A randomized controlled trial of Roux-en-Y gastrojejunostomy vs. gastroduodenostomy with respect to the improvement of type 2 diabetes mellitus after distal gastrectomy in gastric cancer patients

The Metabolic Effects and Effectiveness of the Different Reconstruction Methods used in Gastric Cancer Surgery: A Systematic Review and Meta-Analysis

Gastric Cancer (GC) is the fifth most common cancer worldwide. Early stages of GC began being detected, giving rise to a new concern, Quality of Life. This study aimed to systematically assess the effects of different GC reconstruction techniques on postoperative type 2 diabetes mellitus (T2DM), hypertension (HBP), and body mass index (BMI) reduction rate and to provide an overview of recent research on oncometabolic surgery (OS). We performed a systematic review and meta-analysis by searching three databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We performed a meta-analysis of risk ratios and mean differences to estimate the impact of duodenal bypass, Roux-en-Y reconstruction, and residual stomach on T2DM, HBP, and BMI reduction rate. Heterogeneity was assessed using the I2 statistics. At the end of the follow-up, the duodenal bypass group compared to Billroth I had a significantly higher postoperative remission of T2DM and HBP, with a relative risk (RR) of 1.43 (95% confidence interval (95% CI) [1.27; 1.62]) and 1.3 (95% CI [1.00; 1.69]), respectively. Compared with the Billroth II group, Roux-en-Y reconstruction had significantly greater T2DM remission after gastrectomy (RR = 1.19; 95% CI [1.08; 1.31]), while HBP showed no significant differences. Regarding the improvement of HBP, total gastrectomy was significantly superior to subtotal gastrectomy (95% CI [1.01; 2.64]). A trend towards Roux-en-Y Esophagojejunostomy as the best option for T2DM remission was observed (95% CI [0.98; 2.77]; p = 0.06). Gastrectomy with Roux-en-Y reconstruction appears to be the most effective treatment for T2DM remission. Further research is needed to assess the impact of OS on metabolic diseases.

Diabetes Mellitus and Gastric Cancer: Correlation and Potential Mechanisms

This review summarizes the correlation between diabetes mellitus (DM) and gastric cancer (GC) from the perspectives of epidemiology, drug use, and potential mechanisms. The association between DM and GC is inconclusive, and the positive direction of the association reported in most published meta-analyses suggests that DM may be an independent risk factor for GC. Many clinical investigations have shown that people with DM and GC who undergo gastrectomy may have better glycemic control. The potential link between DM and GC may involve the interaction of multiple common risk factors, such as obesity, hyperglycemia and hyperinsulinemia, H. pylori infection, and the use of metformin. Although in vitro and in vivo data support that H. pylori infection status and metformin can influence GC risk in DM patients, there are conflicting results. Patient survival outcomes are influenced by multiple factors, so further research is needed to identify the patients who may benefit.

Postoperative Remission of Diabetes Mellitus After Gastrectomy in Patients With Diabetes Mellitus and Gastric Cancer

BACKGROUND/AIM

We investigated the postoperative treatment status for diabetes mellitus and perioperative HbA1c levels in patients with diabetes mellitus and examined the effects of clinical factors on the remission of diabetes mellitus.

PATIENTS AND METHODS

In this study, 126 patients with gastric cancer were considered to have diabetes mellitus preoperatively, of whom 79 were treated with oral antidiabetic drugs and/or insulin treatment. We compared diabetic treatment status and HbA1c values between the preoperative and postoperative periods in patients who underwent gastrectomy and examined the effects of clinical factors on improving diabetes mellitus.

RESULTS

Of the 79 patients treated preoperatively for diabetes mellitus, 34 (43%) discontinued all medications for diabetes mellitus and for 37 (47%) the therapeutic dose was reduced or switched from insulin to oral antidiabetic drugs. Total gastrectomy was an independent factor for remission of antidiabetic treatments after gastrectomy. Concerning HbA1c levels, only the absence of preoperative insulin use was an independent factor for improvement. However, reconstruction was not a significantly correlated factor for the improvement of postoperative HbA1c levels and reduction of antidiabetic medications after distal gastrectomy.

CONCLUSION

Almost all patients discontinued or had their dose of antidiabetic medications reduced after gastrectomy in clinical practice, and special attention should be paid in the management methods for diabetes mellitus in patients who underwent total gastrectomy for gastric cancer.

Effectiveness and safety of self-pulling and latter transected Roux-en-Y reconstruction in totally laparoscopic distal gastrectomy

BACKGROUND

Self-pulling and latter transection (SPLT) reconstruction has been applied in total laparoscopic total gastrectomy and BI reconstruction (known as Delta SPLT) in total laparoscopic distal gastrectomy (TLDG) in some previous studies. This approach can reduce the technical difficulty of the surgery as well as the quantity of cartridges required, with manageable safety. Here, we used SPLT to complete Roux-en-Y reconstruction in TLDG and evaluated the safety and effectiveness of this novel method by comparing it with conventional Roux-en-Y reconstruction in laparoscopy-assisted distal gastrectomy (LADG).

METHODS

Patients with gastric cancer who underwent SPLT-TLDG or LADG between June 2019 and September 2021 were retrospectively analyzed. Baseline information and postoperative short-term surgical outcomes of the two groups were compared.

RESULTS

A total of 114 patients with gastric cancer were included in the study. Patients underwent SPLT-TLDG (n = 73, 64.0%) or LADG (n = 41, 36.0%). No patient underwent open surgery. There were no differences in patient demographics or tumor characteristics between the two groups. The mean intraoperative blood loss was 47.1 ± 34.3 ml in the SPLT-TLDG group, which was significantly less than that in the LADG group (P = 0.022). There were no significant differences in operation time, harvested lymph nodes, time to first flatus, time to liquid intake, or postoperative hospital stay between the two groups. Nine and five patients had short-term postoperative complications in the SPLT-TLDG and LADG groups, respectively.

CONCLUSION

We introduced a self-pulling and latter transected Roux-en-Y reconstruction (SPLT-RY) for use in TLDG. We showed that SPLT-RY reconstruction in TLDG is a safe and feasible surgical method in terms of short-term surgical outcomes and has the advantages of simplifying the reconstruction.

Oncometabolic surgery in gastric cancer patients with type 2 diabetes

The rates of early gastric cancer and type 2 diabetes mellitus(T2DM) are sharply increasing in Korea. Oncometabolic surgery in which metabolic surgery is conducted along with cancer surgery is a method used to treat gastric cancer and T2DM in one-stage operation. From 2011 to 2019, a total of 48 patients underwent long-limb Roux-en-Y gastrectomy (LRYG) in Inha University Hospital, and all data were reviewed retrospectively. A 75 g oral glucose tolerance test and serum insulin level test were performed before and 1 week and 1 year after surgery. One year after LRYG operation, 25 of 48 patients showed complete or partial remission and 23 patients showed non-remission of T2DM. The preoperative HbA1c level was significantly lower and the change in HbA1c was significantly greater in the T2DM remission group. Insulin secretion indices(insulinogenic index and disposition index) were increased significantly in the T2DM remission group. In contrast, the insulin resistance indices (homeostatic model assessment of insulin resistance (HOMA-IR) and Matsuda index) changed minimal. In the case of LRYG in T2DM patients, remnant β cell function is an important predictor of favorable glycemic control.

Comparison of the Clinical Outcomes of Reconstruction Methods After Distal Gastrectomy: A Systematic Review and Meta-Analysis Based on Randomized Controlled Trials

BACKGROUND

To analyze the short- and long-term clinical outcomes of 2 reconstruction methods after distal gastrectomy for gastric cancer.

METHODS

Three keywords, "gastric neoplasm," "distal gastrectomy," and "reconstruction," were used to search PubMed. We selected only randomized controlled trial that compared the anastomosis methods. A total of 11 papers and 8 studies were included in this meta-analysis. All statistical analyses were performed using the R software.

RESULTS

Among short-term clinical outcomes, a shorter operation time, reduced morbidity, and shorter hospital stay were found for Billroth type I (B-I) than for Roux-en-Y (RNY) reconstruction in the meta-analysis (P<0.001, P=0.048, P<0.001, respectively). When comparing Billroth type II (B-II) to RNY, the operation time was shorter for B-II than for RNY (P<0.019), but there were no differences in morbidity or length of hospital stay (P=0.500, P=0.259, respectively). Regarding long-term clinical outcomes related to reflux, there were significantly fewer incidents of reflux esophagitis, reflux gastritis, and bile reflux (P=0.035, P<0.001, P=0.019, respectively) for RNY than for B-I in the meta-analysis, but there was no difference between the 2 methods in residual food (P=0.545). When comparing B-II to RNY, there were significantly fewer incidents of reflux gastritis (P<0.001) for RNY than for B-II, but the amount of residual food and patient weight gain showed no difference.

CONCLUSION

B-I had the most favorable short-term outcomes, but RNY was more advantageous for long-term outcomes than for other methods. Surgeons should be aware of the advantages and disadvantages of each type of anastomosis and select the appropriate method.

Impact of Preoperative Type 2 Diabetes Mellitus on the Outcomes of Gastric Cancer Patients Following Gastrectomy: A Propensity Score Matching Analysis

Purpose

The current study aims to explore the outcomes of type 2 diabetes mellitus (T2DM) on gastric cancer patients following gastrectomy through propensity score matching (PSM) analysis.

Methods

A retrospective study of gastric cancer patients following gastrectomy was conducted in a single clinical center from January 2014 to December 2019. The short-term outcomes, overall survival (OS) and disease-free survival (DFS) were analyzed between T2DM group and Non-T2DM group.

Results

A total of 703 patients were enrolled in this study. After 1:1 PSM, 84 patients in T2DM group and 84 patients in Non-T2DM were matched for final analysis. No significant difference was found in terms of operation time, intra-operative blood loss, retrieved lymph nodes, postoperative stay, blood transfusion and complications between T2DM group and Non-T2DM group (p > 0.05). The Kaplan-Meier curve implied that T2DM had no impact on OS or DFS. Cox regression was conducted to identify predictive factors for prognosis. Body mass index (BMI) (p = 0.039 < 0.05, HR = 0.725, 95% CI = 0.534–0.983), pre-operative lymphocyte (p = 0.017 < 0.05, HR = 0.678, 95% CI = 0.493–0.932), pathological tumor node metastasis (pTNM) stage (p = 0.000 < 0.05, HR = 2.619, 95% CI = 2.048–3.349) and complications (p = 0.006 < 0.05, HR = 1.528, 95% CI = 1.132–2.061) were predictive factors for OS, and BMI (p = 0.013 < 0.05, HR = 0.524, 95% CI = 0.315–0.872), pTNM stage (p = 0.000 < 0.05, HR = 2.619, 95% CI = 2.048–3.349) and complications (p = 0.008 < 0.05, HR = 1.892, 95% CI = 1.179–3.036) were independent predictive factors for DFS.

Conclusion

T2DM did not have an impact on gastric cancer patients following gastrectomy in terms of short-term outcomes and prognosis.

Techniques for reconstruction after distal gastrectomy for cancer: updated network meta-analysis of randomized controlled trials

BACKGROUND

The choice of the best reconstruction technique after distal gastrectomy (DG) remains controversial and still not defined. The purpose was to perform a comprehensive evaluation within the major type of intestinal reconstruction after DG for gastric cancer.

METHODS

Systematic review and network meta-analyses of randomized controlled trials (RCTs) to compare Billroth I (BI), Billroth II (BII), Billroth II Braun (BII Braun), Roux-en-Y (RY), and Uncut Roux-en-Y (URY). Risk ratio (RR) and weighted mean difference (WMD) were used as pooled effect size measures while 95% credible intervals (CrI) were used to assess relative inference.

RESULTS

Ten RCTs (1456 patients) were included. Of these, 448 (33.7%) underwent BI, 220 (15.1%) BII, 114 BII Braun (7.8%), 533 (36.6%) RY, and 141 URY (9.6%). No significant differences were found among treatments for 30-day mortality, anastomotic leak, anastomotic stricture, and overall complications. At 12-month follow-up, RY was associated with a significantly reduced risk of remnant gastritis compared to BI (RR=0.56; 95% Crl 0.35-0.76) and BII reconstruction (RR=0.47; 95% Crl 0.22-0.97). Similarly, despite the lack of statistical significance, RY seems associated with a trend toward reduced endoscopically proven esophagitis compared to BI (RR=0.58; 95% Crl 0.24-1.51) and bile reflux compared to BI (RR=0.48; 95% Crl 0.17-1.41), BII (RR=0.74; 95% Crl 0.20-2.81), and BII Braun (RR=0.65; 95% Crl 0.30-1.43).

CONCLUSIONS

This network meta-analysis shows that there are five main options for intestinal anastomosis after DG. All techniques seem equally safe with comparable anastomotic leak, anastomotic stricture, overall morbidity, and short-term outcomes. In the short-term follow-up (12 months), RY seems associated with a reduced risk of remnant gastritis and a trend toward a reduced risk of bile reflux and esophagitis.

Remission of type 2 diabetes after gastrectomy for gastric cancer: diabetes prediction score

BACKGROUND

Although type 2 diabetes (T2D) remission after gastric cancer surgery has been reported, little is known about the predictors of postoperative T2D remission.

METHODS

This study used data from a nationwide cohort provided by the National Health Insurance Service in Korea. We developed a diabetes prediction (DP) score, which predicted postoperative T2D remissions using a logistic regression model based on preoperative variables. We applied machine-learning algorithms [random forest, XGboost, and least absolute shrinkage and selection operator (LASSO) regression] and compared their predictive performances with those of the DP score.

RESULTS

The DP score comprised five parameters: baseline body mass index (< 25 or ≥ 25 kg/m²), surgical procedures (subtotal or total gastrectomy), age (< 65 or ≥ 65 years), fasting plasma glucose levels (≤ 130 or > 130 mg/dL), and antidiabetic medications (combination therapy including sulfonylureas, combination therapy not including sulfonylureas, single sulfonylurea, or single non-sulfonylurea]). The DP score showed a clinically useful predictive performance for T2D remission at 3 years after surgery [training cohort: area under the receiver operating characteristics (AUROC) 0.73, 95% confidence interval (CI), 0.71-0.75; validation cohort: AUROC 0.72, 95% CI 0.69-0.75], which was comparable to that of the machine-learning models (random forest: AUROC 0.71, 95% CI 0.68-0.74; XGboost: AUROC 0.70, 95% CI 0.67-0.73; LASSO regression: AUROC 0.75, 95% CI 0.73-0.78 in the validation cohort). It also predicted the T2D remission at 6 and 9 years after surgery.

CONCLUSIONS

The DP score is a useful scoring system for predicting T2D remission after gastric cancer surgery.

Impact of the different biliopancreatic limb length on diabetes and incretin hormone secretion following distal gastrectomy in gastric cancer patients

The present study aimed to investigate changes in glucose metabolism and incretin hormone response following longer intestinal bypass reconstruction after distal gastrectomy (DG) in low BMI patients with gastric cancer and type 2 diabetes. A total of 20 patients were prospectively recruited and underwent either conventional Billroth I (BI), Billroth II with long-biliopancreatic limb (BII), or Roux-en-Y anastomosis with long-Roux limb (RY) after DG. A 75g-oral glucose tolerance test (OGTT) was given preoperatively; and at 5 days, 3 months, and 6 months postoperatively. Serum glucose, insulin, glucagon, glucagon-like peptide-1 (GLP-1), and glucose-dependent insulinotropic polypeptide (GIP) were serially measured. At 6 months after surgery, complete diabetes remission was achieved in 57.1% of the BII group but in no patients in the other two groups (p = 0.018). BII group showed a significant reduction in glucose concentration during OGTT at 6 months in contrast to the other 2 groups. In the BII group, a significant increase in GLP-1 secretion was observed after surgery but not maintained at 6 months, while postoperative hyperglucagonemia was alleviated along with a reduction in GIP. BII gastrojejunostomy with long biliopancreatic limb achieved better diabetes control with favorable incretin response after DG compared to BI or RY reconstruction.

Letter to editor ‘Gastroenteropathy in gastric cancer patients concurrent with diabetes mellitus’

The present letter to the editor is related to the study titled “Diabetic gastroenteropathy: An underdiagnosed complication”. Diabetic gastroenteropathy contributes to a decline in quality of life. In addition, gastroenteropathy is generally observed in patients with concurrent gastric cancer and diabetes mellitus before surgery, and the occurrence of the symptoms might be due not only to cancer but also to the complications of diabetes mellitus.

Roux-en-Y versus Billroth-I reconstruction after distal gastrectomy for gastric cancer

BACKGROUND

Gastric cancer is the fifth most common cancer diagnosed worldwide. Due to improved early detection rates of gastric cancer and technological advances in treatments, a significant improvement in survival rates has been achieved in people with cancer undergoing gastrectomy. Subsequently, there has been increasing emphasis on postgastrectomy syndrome (e.g. fullness, delayed emptying, and cold sweat, amongst others) and quality of life postsurgery. However, it is uncertain which types of reconstruction result in better outcomes postsurgery.

OBJECTIVES

To assess the evidence on health-related quality of life and safety outcomes of Roux-en-Y and Billroth-I reconstructions after distal gastrectomy for people with gastric cancer.

SEARCH METHODS

We searched the Cochrane Library and the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase on 4 May 2021. We checked the reference lists of the included studies and contacted manufacturers and professionals in the field. There were no language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) allocating participants to Roux-en-Y reconstruction or Billroth-I reconstruction after distal gastrectomy for gastric cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies identified by the search for eligibility and extracted data. The primary outcomes were health-related quality of life after surgery and incidence of anastomotic leakage. The secondary outcomes included body weight loss, incidence of bile reflux, length of hospital stay, and overall morbidity. We used a random-effects model to conduct meta-analyses. We assessed risk of bias of the included studies in accordance with the Cochrane Handbook for Systematic Reviews of Interventions, and the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included eight RCTs (942 participants) in the review. One study included both cancer patients and benign disease patients such as stomach ulcers. Two studies compared Roux-en-Y, Billroth-I, and Billroth-II reconstructions, whilst the other studies compared Roux-en-Y and Billroth-I directly.  For the primary outcomes, the evidence suggests that there may be little to no difference in health-related quality of life between Roux-en-Y and Billroth-I reconstruction (standardised mean difference 0.04, 95% confidence interval (CI) -0.11 to 0.18; I² = 0%; 6 studies; 695 participants; low-certainty evidence due to study limitations and imprecision). The evidence for the effect of Roux-en-Y versus Billroth-I reconstruction on the incidence of anastomotic leakage is very uncertain (risk ratio (RR) 0.63, 95% CI 0.16 to 2.53; I² = 0%; 5 studies; 711 participants; very low-certainty evidence). The incidence of anastomotic leakage was 0.6% and 1.4% in the Roux-en-Y and Billroth-I groups, respectively. For the secondary outcomes, the evidence suggests that Billroth-I reconstruction may result in little to no difference in loss of body weight compared to Roux-en-Y reconstruction (mean difference (MD) 0.41, 95% CI -0.77 to 1.59; I² = 0%; 4 studies; 541 participants; low-certainty evidence). Roux-en-Y reconstruction probably reduces the incidence of bile reflux compared to Billroth-I reconstruction (RR 0.40, 95% CI 0.25 to 0.63; I² = 22%; 4 studies; 399 participants; moderate-certainty evidence). Billroth-I reconstruction may shorten postoperative hospital stay, but the evidence for this outcome is very uncertain (MD 0.96, 95% CI 0.16 to 1.76; I² = 56%; 7 studies; 894 participants; very low-certainty evidence). Billroth-I reconstruction may reduce postoperative overall morbidity compared to Roux-en-Y reconstruction (RR 1.47, 95% CI 1.02 to 2.11; I² = 0%; 7 studies; 891 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

The evidence suggests that there is little to no difference between Roux-en-Y and Billroth-I reconstruction for the outcome health-related quality of life. The evidence for the effect of Roux-en-Y versus Billroth-I reconstruction on the incidence of anastomotic leakage is very uncertain as the incidence of this outcome was low. Although the certainty of evidence was low, we found some possibly clinically meaningful differences between Roux-en-Y and Billroth-I reconstruction for short-term outcomes. Roux-en-Y reconstruction probably reduces the incidence of bile reflux into the remnant stomach compared to Billroth-I reconstruction. Billroth-I reconstruction may shorten postoperative hospital stay compared to Roux-en-Y reconstruction, but the evidence is very uncertain. Billroth-I reconstruction may reduce postoperative overall morbidity compared to Roux-en-Y reconstruction. Future trials should include long-term follow-up of health-related quality of life and body weight loss.

Effect of oncometabolic surgery on gastric cancer: The remission of hypertension, type 2 diabetes mellitus, and beyond

This review summarizes the definition and surgical methods of oncometabolic surgery according to previous studies. Then, the authors discuss the beneficial effects observed after gastrectomy in gastric cancer (GC) patients with concurrent hypertension or type 2 diabetes mellitus (T2DM). The authors summarize the current studies analyzing the remission rate and the hypotheses of the mechanisms underlying these effects. The remission rate ranged from 42.5%-65.4% in T2DM patients and from 11.1%-57.6% among those with hypertension. Furthermore, the remission of T2DM could have an impact on overall survival rates as well. The mechanisms underlying the remission of hypertension and T2DM is unclear in current studies, but oncometabolic surgery is expected to be applied in clinical practice. In addition, the effect of oncometabolic surgery on other chronic metabolic comorbidities is expected to be proven in further studies. Therefore, the purpose of this review is to discuss the effects of oncometabolic surgery reported in current studies with a primary focus on the remission of hypertension and T2DM after gastrectomy in GC patients. The possibility of the remission of other metabolic comorbidities in GC patients who undergo oncometabolic surgery is also discussed.

Metabolic Effects of Gastrectomy and Duodenal Bypass in Early Gastric Cancer Patients with T2DM: A Prospective Single-Center Cohort Study

We evaluated the metabolic effects of gastrectomies and endoscopic submucosal dissections (ESDs) in early gastric cancer (EGC) patients with type 2 diabetes mellitus (T2DM). Forty-one EGC patients with T2DM undergoing gastrectomy or ESD were prospectively evaluated. Metabolic parameters in the patients who underwent gastrectomy with and without a duodenal bypass (groups 1 and 2, n = 24 and n = 5, respectively) were compared with those in patients who underwent ESD (control, n = 12). After 1 year, the proportions of improved/equivocal/worsened glycemic control were 62.5%/29.2%/8.3% in group 1, 40.0%/60.0%/0.0% in group 2, and 16.7%/50.0%/33.3% in the controls, respectively (p = 0.046). The multivariable ordered logistic regression analysis results showed that both groups had better 1-year glycemic control. Groups 1 and 2 showed a significant reduction in postprandial glucose (−97.9 and −67.8 mg/dL), body mass index (−2.1 and −2.3 kg/m²), and glycosylated hemoglobin (group 1 only, −0.5% point) (all p < 0.05). Furthermore, improvements in group 1 were more prominent when preoperative leptin levels were high (p for interaction < 0.05). Metabolic improvements in both groups were also observed for insulin resistance, leptin, plasminogen activator inhibitor-1, and resistin. Gastrectomy improved glycemic control and various metabolic parameters in EGC patients with T2DM. Patients with high leptin levels may experience greater metabolic benefits from gastrectomy with duodenal bypass.

Improvement of Diabetes Mellitus After Colorectal Cancer Surgery: A Retrospective Study of Predictive Factors For Type 2 Diabetes Mellitus Remission and Overall Survival

PURPOSE

The purpose of the current study was to evaluate the impact of colorectal cancer (CRC) surgery on type 2 diabetes mellitus (T2DM) and to analyze the change in T2DM on overall survival after CRC surgery.

METHODS

Patients who underwent CRC surgery were retrospectively enrolled from January 2013 to December 2019. The status of T2DM pre- and 1-year after CRC surgery was recorded, and predictive factors for T2DM remission and overall survival were analyzed.

RESULTS

A total of 296 patients were included in this study. Thirty-eight patients experienced remission of T2DM 1 year after CRC surgery, and the remission rate was 12.8%. Weight loss was significantly higher in the T2DM remission group (p = 0.038), and the T2DM duration was significantly shorter in the T2DM remission group (p = 0.015). In the multivariate logistic regression analysis, higher weight loss (p = 0.046, odds ratio = 1.060, 95% CI = 1.001-1.122) and shorter T2DM duration (p = 0.019, odds ratio = 1007, 95% CI = 1.001-1.014) were predictive factors for remission of T2DM. Furthermore, in multivariate Cox regression analysis, lower TNM stage (p = 0.000, odds ratio = 2.147, 95% CI = 1.474-3.128) and T2DM remission (p = 0.033, odds ratio = 2.999, 95% CI = 1.091-8.243) were the predictive factors for better overall survival.

CONCLUSION

Patients with concurrent CRC and T2DM had a 12.8% remission 1 year after CRC surgery. Higher weight loss and shorter T2DM duration contributed to T2DM remission, and patients with T2DM remission could improve in terms of their overall survival.

Comparison of Billroth I, Billroth II, and Roux-en-Y reconstructions following distal gastrectomy: A systematic review and network meta-analysis

Major surgical treatment for distal gastric cancer include Billroth I (BI), Billroth II (BII), and Roux-en-Y (RY). Since the optimal reconstruction methods remains inconclusive, we aimed to compare these treatments in terms of intraoperative and postoperative course after distal gastrectomy with a systematic review and random-effects network meta-analysis. We searched PubMed, Web of Knowledge, Ovid's database for prospective, randomized, controlled trials comparing the outcomes of BI, BII, and RY reconstruction after distal gastrectomy until January 2020. From the included studies, operative time, intraoperative blood loss, postoperative hospital stay, endoscopic findings and complications were extracted as the short- and long-term outcomes of reconstructions. The network meta-analysis was performed with R 3.5.2 software as well as "gemtc" and "forestplot" packages. Twelve randomized controlled trials (RCTs) involving 1662 patients were included. RY reconstruction has a lower risk and degree of remnant gastritis than BI and BII reconstructions(OR 0.40, 95%Crl: 0.24-0.64; OR 0.36, 95% Crl: 0.16-0.83, respectively). BI reconstruction method took significantly less time to perform as compared to BII and RY reconstruction (WMD 20, 95% Crl: 0.18-41; WMD 30, 95% Crl: 14-25, respectively). No differences in intraoperative blood loss, time to resumed oral intake, postoperative hospital stay, reflux oesophagitis and complications among the three reconstructions. The RY reconstruction after distal gastrectomy was more effective in preventing remnant gastritis than Billroth I and Billroth II reconstruction, although RY reconstruction was considered as technical complexity.

The effects of yam gruel on lowering fasted blood glucose in T2DM rats

There is increasing evidence of the linkage between type 2 diabetes mellitus (T2DM) and gut microbiota. Based on our previous studies, we investigated the hypoglycemic mechanisms of yam gruel to provide a scientific basis for its popularization and application. Wistar rats were randomly divided into control and T2DM model groups. Rats in the model group were stimulated by a high-sugar/high-fat diet combined with an intraperitoneal injection of streptozotocin to induce T2DM. The T2DM rats were further subdivided randomly into three groups: (1) DM, (2) DM + yam gruel, and (3) DM + metformin. After 4 weeks of intervention, the changes in gut microbiota, short-chain fatty acids (SCFAs) (acetic acid, propionic acid, and butyric acid), the expression of G protein-coupled receptor 43 (GPR43), glucagon-like peptide-1 (GLP-1), peptide YY (PYY), and fasted blood glucose (FBG) levels were observed. Yam gruel intervention elevated the abundance of probiotic bacteria and increased the expression of SCFAs, GPR43 receptor, GLP-1, and PYY. It also reduced FBG levels. We conclude that yam gruel can lower FBG by promoting the growth of probiotic bacteria, increasing the content of SCFAs, and enhancing the expression of GPR43 receptor to increase the content of GLP-1 and PYY in serum.

Ghrelin Affects Gastric Cancer Progression by Activating AMPK Signaling Pathway

As the endogenous ligand for the GH secretagogue receptor (GHSR), Ghrelin is aberrant expressed in multiple malignant carcinoma, and involved in regulating a number of progression of cancer, especially in metastasis and proliferation. However, the precise role of Ghrelin in tumorigenesis of gastric cancer (GC) is still poorly understood. In this study, we extensively investigated the roles and mechanisms of Ghrelin in human gastric cancer. Ghrelin levels in cancer tissues and cell lines were analyzed by immunohistochemistry, qRT-PCR, and Western blot. Functional studies were performed after Ghrelin overexpressed or knockdown in AGS cell line. Cell proliferation was evaluated in by MTT and clone formation assays. The wound healing and Transwell system were used to assess the cell migration and invasive ability of GC cells. Cell apoptosis was detected by flow cytometry, and metabolic assays were performed to reveal the function of Warburg effect in the process. Ghrelin was lowly expressed in gastric cancer tissues and cell lines. Overexpression of Ghrelin inhibited gastric cancer cell proliferation, migration, invasion, and promoted apoptosis by activating the AMPK pathway, while D-[lys3]-GHRP-6 (a GHSR agonist) treatment relieved the effect, promoting tumorigenesis. Ghrelin knockdown increased the glucose uptake and lactic acid release, suggesting that Ghrelin elicited an anti-Warburg effect via AMPK pathway to inhibit gastric tumorigenesis. Ghrelin inhibits cell proliferation, migration, and invasion by eliciting an anti-Warburg effect via AMPK signaling pathway in gastric cancer cells.

Does Roux-en-Y Construction Really Bring Benefit of Type 2 Diabetes Mellitus Remission After Gastrectomy in Patients with Gastric Cancer? A Systematic Review and Meta-Analysis

INTRODUCTION

To evaluate whether the extent of gastrectomy or the reconstruction method brings benefit of type 2 diabetes mellitus (T2DM) remission after gastrectomy in patients with gastric cancer.

METHODS

PUBMED, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library were searched to find eligible studies published from inception to July 31, 2020.

RESULTS

A total of nine studies (1424 patients) were included. At the first year and the end of follow-up time after gastrectomy, the total gastrectomy group had better T2DM remission than the subtotal gastrectomy group, and the Roux-en-Y reconstruction (R-Y) group had better T2DM remission compared with the non-R-Y group. There was no difference between R-Y and non-R-Y in terms of subtotal gastrectomy (OR 1.08, 95% CI 0.63-1.84, P = 0.78). However, total gastrectomy with R-Y had better T2DM remission than subtotal gastrectomy with R-Y (OR 2.75, 95% CI 1.19-6.35, P = 0.02).

CONCLUSION

Total gastrectomy with R-Y had better T2DM remission. The extent of gastrectomy rather than the reconstruction method might play an important role in T2DM remission after gastrectomy in patients with gastric cancer.

Comparison of Billroth I, Billroth II, and Roux-en-Y reconstructions following distal gastrectomy: A systematic review and network meta-analysis

Major surgical treatment for distal gastric cancer include Billroth I (BI), Billroth II (BII), and Roux-en-Y (RY). Since the optimal reconstruction methods remains inconclusive, we aimed to compare these treatments in terms of intraoperative and postoperative course after distal gastrectomy with a systematic review and random-effects network meta-analysis. We searched PubMed, Web of Knowledge, Ovid's database for prospective, randomized, controlled trials comparing the outcomes of BI, BII, and RY reconstruction after distal gastrectomy until January 2020. From the included studies, operative time, intraoperative blood loss, postoperative hospital stay, endoscopic findings and complications were extracted as the short- and long-term outcomes of reconstructions. The network meta-analysis was performed with R 3.5.2 software as well as "gemtc" and "forestplot" packages. Twelve randomized controlled trials (RCTs) involving 1662 patients were included. RY reconstruction has a lower risk and degree of remnant gastritis than BI and BII reconstructions(OR 0.40, 95%Crl: 0.24-0.64; OR 0.36, 95% Crl: 0.16-0.83, respectively). BI reconstruction method took significantly less time to perform as compared to BII and RY reconstruction (WMD 20, 95% Crl: 0.18-41; WMD 30, 95% Crl: 14-25, respectively). No differences in intraoperative blood loss, time to resumed oral intake, postoperative hospital stay, reflux oesophagitis and complications among the three reconstructions. The RY reconstruction after distal gastrectomy was more effective in preventing remnant gastritis than Billroth I and Billroth II reconstruction, although RY reconstruction was considered as technical complexity.

Glycemic variability in patients with gastrointestinal cancer: An integrative review

PURPOSE

Glycemic variability is associated with risks for adverse events in patients with cancer. Several studies have evaluated the presence and impact of hyperglycemia and/or hypoglycemia in patients with cancer; however, few studies have evaluated glycemic variability. The purpose of this integrative review of studies in patients with gastrointestinal cancers was to investigate the presence and methods of reporting glycemic variability during and following treatments.

METHODS

A comprehensive review of the literature was conducted. PubMed, CINAHL, EMBASE, and Cochrane databases were searched for publications between 1/1/1969 and 7/24/2019. Studies of patients with gastrointestinal cancer following surgery, during treatment, and <5 years following treatment were included and evaluated by cancer type and method of glucose and glycemic variability measurement.

RESULTS

Among 1526 patients with gastrointestinal cancer across 19 studies, gastric and pancreatic cancers were most prevalent. Timing of glucose testing and methods of analyzing glycemic variability varied. Most analyses used the standard deviation or interquartile range. Glycemic variability was more prevalent among patients with Type 2 Diabetes and among those with pancreatic cancer. In some patients glycemic variability remained notable > one year following surgery despite improvements in glycemic control.

CONCLUSION

Patients with gastrointestinal cancer experience glycemic variability during and up to one year following treatment. There was heterogeneity in methods related to timing of testing and reporting glycemic variability among the 19 studies in this review. Future investigations need to identify the presence and define the methods of measuring glycemic variability in patients with gastrointestinal cancer.

Prognostic impact of the preoperative hemoglobin A1c levels in patients with gastric cancer surgery depends on postoperative complications

Purpose

The long-term prognostic impact of the hemoglobin A1c levels has not yet been evaluated in patients with gastric cancer. The present study investigated the clinical significance of the hemoglobin A1c levels in patients with gastric cancer.

Methods

We enrolled 294 patients with stage II, III, or IV gastric cancer who underwent gastrectomy. The patients were divided into high preoperative hemoglobin A1c (> 6.0%) and low preoperative hemoglobin A1c (≤ 6.0%) groups.

Results

In patients with stage III gastric cancer with severe postoperative complications, the high preoperative hemoglobin A1c group had a significantly worse prognosis than the low preoperative hemoglobin A1c group (p = 0.0409). In patients without severe postoperative complications, the high preoperative hemoglobin A1c group had a significantly favorable prognosis compared with the low preoperative hemoglobin A1c group (p = 0.0348).

Conclusion

The prognosis of patients with stage III gastric cancer having high preoperative hemoglobin A1c levels greatly depended on the presence or absence of postoperative complications. To avoid postoperative complications, optimal perioperative management and personalized treatments are critical, particularly for these patients.

Comparison of Postoperative Nutritional Status after Distal Gastrectomy for Gastric Cancer Using Three Reconstructive Methods: a Multicenter Study of over 1300 Patients

PURPOSE

Perioperative nutritional status has been reported to be associated with short- and long-term outcomes after surgery in gastric cancer patients. This study compared changes in nutritional status after distal gastrectomy using the Billroth I (BI), Billroth II (BII), and Roux-en-Y (RY) reconstruction techniques in gastric cancer patients.

MATERIALS AND METHODS

Data from 1305 gastric cancer patients who underwent distal gastrectomy at two tertiary hospitals from January 2011 to December 2016 were reviewed. The patients were divided into three groups according to reconstruction type: BI, BII, and RY. We evaluated changes in nutritional parameters including body mass index (BMI), biochemical data, the prognostic nutritional index (PNI), nutritional risk index (NRI), and geriatric nutritional risk index (GNRI) preoperatively, and 3, 6, and 12 months after surgery.

RESULTS

Total protein, albumin, PNI, and NRI were significantly lower in the BII group than in the BI and RY groups during follow-up (P < 0.001). In multivariate analysis, reconstruction types were independently related to decreases in BMI (> 10%), low serum protein, albumin, and cholesterol 12 months after surgery. Compared with BI, BII was associated with decreased BMI, low protein, and albumin and RY was associated with decreased BMI and low cholesterol.

CONCLUSION

During the first year after gastric cancer surgery, postoperative nutritional status differed according to the reconstruction type; BI resulted in the least weight and nutritional loss, RY yielded results comparable with BI in the nutritional indexes, and BII resulted in the greatest nutritional loss.

Utility of continuous glucose monitoring following gastrectomy

BACKGROUND

Glucose fluctuation after gastrectomy represented by dumping syndrome is a well-known post-gastrectomy syndrome that negatively impacts patient quality of life. However, the current methods of post-gastrectomy glucose monitoring do not comprehensively capture the postoperative blood glucose fluctuations that characterize this.

METHODS

We used a continuous glucose monitoring (CGM) system to document the glycemic profiles of patients undergoing gastrectomy and compared these between patients undergoing distal gastrectomy (DG) and total gastrectomy (TG). To evaluate post-gastrectomy syndromes, including dumping syndrome, we used the Post-gastrectomy Syndrome Assessment Scale 37-item questionnaire. The glycemic profiles were also compared using this tool.

RESULTS

We studied 57 patients who had undergone DG and 13 who had undergone TG between September 2017 and September 2019. Our results revealed larger diurnal glycemic variability and longer periods of nocturnal hypoglycemia after gastrectomy. The dumping score was worse in the TG than in the DG group (TG 2.4 ± 1.4 vs. DG 1.3 ± 1.2, P = 0.0061). Importantly, 30 of 57 DG patients (52.6%) and 5 of 13 TG patients (38.5%) experienced postprandial hypoglycemia following hyperglycemia without hypoglycemic symptoms. There was no correlation between the dumping symptom score and glycemic variability (ρ = 0.0545, P = 0.6662).

CONCLUSIONS

CGM demonstrated diurnal glycemic variability and nocturnal hypoglycemia in patients undergoing gastrectomy. Because some hypoglycemic patients did not develop symptoms and glycemic variability was not necessarily associated with dumping symptom, dumping syndrome must only partially explain the postoperative glucose fluctuations.

Does Reconstruction Type After Gastric Resection Matters for Type 2 Diabetes Improvement?

BACKGROUND

Gastrointestinal (GI) surgery involving gastric resection and bypass of intestinal segments was reported to facilitate glucose control in obese patients with type 2 diabetes (T2D).

AIM

Our aim was to assess whether the type of post-gastrectomy GI reconstruction also influences glucose control in T2D patients with BMI below 35 kg/m² submitted to gastrointestinal surgery without bariatric intention.

METHODS

A cohort of T2D Caucasian patients (n = 40) with upper GI malignancy (n = 33) or complicated reflux disease (n = 7) were submitted to either a gastrectomy plus Billroth II (BII) gastrojejunal anastomosis (n = 17), a gastrectomy plus Roux-en-Y gastrojejunostomy (RY) reconstruction (n = 18; subtotal gastrectomy n = 7 and total gastrectomy n = 11), or atypical gastrectomy without reconstruction (no-R) (n = 5). Patients were evaluated before and 2 years after surgery for body weight, Hb1Ac, need of glucose lowering drugs, and presence of diabetes.

RESULTS

Body mass index (BMI) decreased after every surgical procedure when compared to baseline (- 0.9 ± 0.8 kg/m² for BII vs - 4.3 ± 2.6 kg/m² for RY vs - 4.6 ± 2.5 kg/m² for no-R, p < 0.05), which was only significantly different after RY surgeries. Diabetes remission occurred in 5.9% of BII patients, in 27.8% of RY patients, and 0% of no-R patients, while in patients with persistent T2D, the needs for glucose-lowering drugs were significantly also decreased after RY (31.3% BII vs 66.7% RY vs 25% no-R, p = 0.03).

CONCLUSIONS

T2D Caucasian patients undergoing post-gastrectomy GI reconstructions without a bariatric intention experience a significant improvement of T2D, in a magnitude that could be influenced by the technical procedure performed in favor of RY reconstruction. Thus, presence of T2D should be taken into consideration when deciding for the type of post-gastrectomy GI reconstruction.

Feasibility of preserving the remnant stomach during distal pancreatectomy after distal gastrectomy

PURPOSE

The safety and feasibility of preserving the remnant stomach during distal pancreatectomy (DP) in patients who have undergone distal gastrectomy (DG) remains unclear.

METHODS

A retrospective review of a prospectively maintained database was performed to identify patients who underwent DP. A propensity score-matched analysis was performed to match post-DG patients with control patients.

RESULTS

Among the 226 patients included in this study, 9 DP patients who had a history of DG were studied (4.0%). These nine patients in the DG group were matched to 45 patients in the control group. There were no significant differences in the incidence of postoperative morbidities, including postoperative pancreatic fistula rate or stomach-related complications. The hemoglobin A1C (HbA1c) levels in the DG group after surgery decreased to the normal range.

CONCLUSION

Our study suggested that the remnant stomach may be safely preserved when performing DP in patients with a history of DG with respect to short-term morbidities. However, there are some concerns about the long-term nutritional status in patients with a history of DG.

The Effect of Metformin on Prognosis in Patients With Locally Advanced Gastric Cancer Associated With Type 2 Diabetes Mellitus

OBJECTIVES

This study examined the effect of metformin use on the prognosis of gastric cancer patients.

MATERIALS AND METHODS

The study population comprised 2187 patients who underwent curative gastrectomy for the treatment of gastric cancer. They were divided into 3 groups: metformin (n=103), non-metformin (n=139), and non-diabetes mellitus (DM) (n=1945) according to their history of type 2 DM and metformin use. Survival, disease recurrence, and the pathologic stage were analyzed.

RESULTS

Overall survival was better in the metformin group than in the non-DM group (P=0.005). Metformin use was an independent prognostic factor of overall survival, cancer recurrence, and peritoneal recurrence. An effect of metformin use was especially notable in patients with T4 or N0 disease.

CONCLUSIONS

Metformin improves the survival of patients with gastric cancer and type 2 DM.

Metabolic effects and safety of Roux-en-Y gastric bypass surgery vs. conventional medication in obese Chinese patients with type 2 diabetes

AIM

To assess metabolic effects and safety of Roux-en-Y gastric bypass (RYGB) versus conventional medication (CM) in obese Chinese patients with type 2 diabetes (T2DM).

METHODS

This retrospective cohort study included 40 patients who underwent RYGB (mean age 44.1 years, body mass index [BMI] 33.3 kg/m² ) and 36 patients administered CM (mean age 49.4 years, BMI 32.1 kg/m² ). The primary endpoint was achievement of the triple endpoint (haemoglobin A1C [HbA1c] < 7.0%, low-density lipoprotein cholesterol < 2.6 mmol/L, and systolic blood pressure < 130 mmHg). Changes in weight, BMI, medication usage, complications, and adverse events were assessed.

RESULTS

After 1-year follow-up, 35% of RYGB patients and 8% of CM patients achieved the triple endpoint (P = 0.005). More patients in the RYGB group achieved complete (48% vs 3%, P < 0.001) and partial (23% vs 0%, P = 0.007) remission of diabetes, and complete remission of hypertension (58% vs 24%, P = 0.019). Patients in the RYGB group had greater weight loss and decrease in BMI, waist circumference, fasting and postprandial of blood glucose and insulin levels, HbA1c, blood pressure, triglycerides, and increased high-density cholesterol (P < 0.001- < 0.05). A lower proportion of the RYGB group received antidiabetics, antihypertensives, or antilipemic treatments, and had non-alcoholic fatty liver disease (NAFLD) than the CM group during follow-up. More patients had nutrient deficiency-related diseases in the RYGB group over 1-year follow-up.

CONCLUSIONS

For obese Chinese patients with T2DM, RYGB resulted in better metabolic control, greater weight loss, and lower medication usage and NAFLD, but more frequently resulted in diseases related to nutrient deficiency.

The Development and Future of Digestive Tract Reconstruction after Distal Gastrectomy: A Systemic Review and Meta-Analysis

Background: Billroth I, Billroth II, Roux-en-Y, and Un-cut Roux-en-Y are common reconstruction techniques of distal gastrectomy. Which of these techniques is better has yet to be established. We performed an indirect comparison to evaluate which technique was optimal for preventing reflux symptoms.

Methods: The PubMed, Cochrane Collaboration, Embase, ClinicalTrials.gov and Web of Science databases were searched to identify clinical trials that compared at least two of the reconstruction skills among Billroth I, Billroth II, Roux-en-Y, and Un-cut Roux-en-Y. Data on reflux gastritis, intraoperative blood loss, bile reflux and postoperative hospital stays were extracted from the included clinical trials for meta-analysis using a random-effects model.

Results: Twenty-four articles that included 5419 individuals were assessed as eligible for meta-analysis. The indirect comparison suggested that Roux-en-Y reconstruction significantly reduces reflux gastritis, and it tended to rank first and had the highest probability of preventing bile reflux. No significant differences were found in intraoperative blood loss and postoperative hospital stays.

Conclusion: This indirect comparison suggested some superiority of Roux-en-Y reconstruction after distal gastrectomy. Further perspective clinical trials are required to provide evidence for the optimal reconstruction skill.

Dissecting the Physiology and Pathophysiology of Glucagon-Like Peptide-1

An aging world population exposed to a sedentary life style is currently plagued by chronic metabolic diseases, such as type-2 diabetes, that are spreading worldwide at an unprecedented rate. One of the most promising pharmacological approaches for the management of type 2 diabetes takes advantage of the peptide hormone glucagon-like peptide-1 (GLP-1) under the form of protease resistant mimetics, and DPP-IV inhibitors. Despite the improved quality of life, long-term treatments with these new classes of drugs are riddled with serious and life-threatening side-effects, with no overall cure of the disease. New evidence is shedding more light over the complex physiology of GLP-1 in health and metabolic diseases. Herein, we discuss the most recent advancements in the biology of gut receptors known to induce the secretion of GLP-1, to bridge the multiple gaps into our understanding of its physiology and pathology.