GI Surgery – Stomach and Duodenum
RCT: H. pylori Screening Added to Fecal Immunochemical Testing Did Not Reduce Gastric Cancer Incidence or Mortality
4 Oct, 2024 | 11:00h | UTCBackground: Gastric cancer is a leading cause of cancer-related mortality worldwide, particularly in East Asia. Helicobacter pylori infection is a well-established risk factor for gastric cancer development. While eradication therapy may prevent gastric cancer, the effectiveness of community-based H. pylori screening on gastric cancer incidence and mortality remains uncertain.
Objective: To determine whether adding H. pylori stool antigen (HPSA) testing to fecal immunochemical test (FIT) screening reduces gastric cancer incidence and mortality compared to FIT screening alone.
Methods: In a pragmatic randomized clinical trial conducted in Changhua County, Taiwan (2014–2018), 152,503 residents aged 50 to 69 years eligible for biennial FIT screening were randomized to receive an invitation for HPSA testing plus FIT (n = 63,508) or FIT alone (n = 88,995). Participants in the HPSA + FIT group with positive HPSA results were offered antibiotic eradication therapy. Primary outcomes were gastric cancer incidence and mortality, assessed via national cancer and death registries.
Results: Participation rates were higher in the HPSA + FIT group (49.6%) than in the FIT-alone group (35.7%). In the HPSA + FIT group, 38.5% tested positive for HPSA, and 71.4% of these received antibiotic treatment, achieving a 91.9% eradication rate. Over a median follow-up of approximately 5 years, gastric cancer incidence did not differ significantly between the HPSA + FIT and FIT-alone groups (0.032% vs 0.037%; mean difference –0.005%; 95% CI, –0.013% to 0.003%; P = .23). Gastric cancer mortality rates were also similar (0.015% vs 0.013%; mean difference 0.002%; 95% CI, –0.004% to 0.007%; P = .57). Adjusted analyses accounting for participation rates, follow-up duration, and baseline characteristics showed a lower gastric cancer incidence in the HPSA + FIT group (RR 0.79; 95% CI, 0.63–0.98; P = .04), but no difference in mortality (RR 1.02; 95% CI, 0.73–1.40; P = .91). Adverse effects from antibiotics were mild, with abdominal pain or diarrhea occurring in 2.1%.
Conclusions: An invitation to HPSA testing combined with FIT did not significantly reduce gastric cancer incidence or mortality compared to FIT alone over a median follow-up of about 5 years. Adjusted analyses suggest a potential reduction in gastric cancer incidence but not mortality when accounting for participation rates and follow-up duration.
Implications for Practice: Adding H. pylori screening to existing FIT programs may not significantly reduce gastric cancer incidence or mortality in the short term, possibly due to low participation rates, incomplete eradication, and limited follow-up. Clinicians should consider these factors when implementing community-based H. pylori screening and weigh the benefits against resource utilization and patient adherence.
Study Strengths and Limitations: Strengths include a large sample size and integration of HPSA testing into an existing FIT screening infrastructure. Limitations encompass differences in participation rates and baseline characteristics between groups, a relatively short follow-up period, and only 71.4% of HPSA-positive participants receiving eradication therapy, which may have reduced the ability to detect significant effects.
Future Research: Longer-term studies with higher participation and eradication rates are needed to assess the long-term benefits of H. pylori screening on gastric cancer incidence and mortality. Research should explore strategies to improve screening uptake and treatment adherence.
Randomized Noninferiority Trial: Oral Vonoprazan Noninferior to IV Proton Pump Inhibitors in Preventing Rebleeding of High-Risk Peptic Ulcers – Gastroenterology
18 Aug, 2024 | 18:32h | UTCStudy Design and Population: This multicenter, randomized, open-label, noninferiority trial was conducted in Thailand across six centers, including both university and community hospitals. A total of 194 patients with high-risk peptic ulcer (PU) bleeding who had achieved successful endoscopic hemostasis were randomized to receive either vonoprazan or intravenous proton pump inhibitors (PPI). The study aimed to compare the efficacy of vonoprazan, a potassium-competitive acid blocker, with that of high-dose PPIs in preventing rebleeding.
Main Findings: The trial found that the 30-day rebleeding rate in the vonoprazan group was 7.1%, compared to 10.4% in the PPI group. This demonstrated noninferiority of vonoprazan within a 10% margin (risk difference: -3.3%, 95% CI: -11.2 to 4.7; P < .001). The 3-day and 7-day rebleeding rates were also noninferior. Secondary outcomes, including mortality rates, the need for rescue therapy, blood transfusion requirements, and length of hospital stay, were comparable between the two groups. Adverse events were similar in both groups.
Implications for Practice: Vonoprazan presents a viable alternative to intravenous PPIs for preventing rebleeding in patients with high-risk PU after endoscopic hemostasis. The availability of vonoprazan in oral form could potentially reduce hospital stays. However, further studies in multiethnic populations are needed to confirm these findings and assess the cost-effectiveness of vonoprazan in this setting.
Network Meta-Analysis: Preoperative Chemoradiotherapy and Chemotherapy Equally Improve Survival in Esophagogastric Adenocarcinoma – JAMA Netw Open
17 Aug, 2024 | 19:21h | UTCStudy Design and Population: This network meta-analysis included 17 randomized clinical trials (RCTs) with a total of 2,549 patients, predominantly male (86.5%), with a mean age of 61 years. The study compared the effects of preoperative chemoradiotherapy (CRT) versus preoperative and/or perioperative chemotherapy, and surgery alone on overall survival and disease-free survival in patients with adenocarcinoma of the esophagus and esophagogastric junction (AEG).
Main Findings: Both preoperative CRT plus surgery (HR, 0.75) and preoperative/perioperative chemotherapy plus surgery (HR, 0.78) significantly improved overall survival compared to surgery alone. Disease-free survival was similarly prolonged with both treatments. No significant difference was observed between CRT and chemotherapy in overall survival, though CRT was associated with higher postoperative morbidity.
Implications for Practice: The findings suggest that both preoperative CRT and preoperative/perioperative chemotherapy are effective in extending survival in AEG patients, with no clear superiority of one approach over the other. Clinicians can consider either modality based on patient-specific factors, although the increased morbidity associated with CRT warrants careful consideration.
RCT: Pantoprazole Reduces GI Bleeding in Mechanically Ventilated ICU Patients – N Engl J Med
3 Aug, 2024 | 18:57h | UTCStudy Design and Population: This international, randomized, double-blind trial involved 4,821 critically ill adults undergoing invasive mechanical ventilation across 68 intensive care units (ICUs). Participants were assigned to receive either intravenous pantoprazole (40 mg daily) or a matching placebo. The primary efficacy outcome was the incidence of clinically significant upper gastrointestinal bleeding within 90 days, and the primary safety outcome was mortality from any cause within the same period.
Main Findings: The trial found that upper gastrointestinal bleeding occurred in 1.0% of patients treated with pantoprazole compared to 3.5% in the placebo group (hazard ratio, 0.30; 95% CI, 0.19 to 0.47; P<0.001). Mortality at 90 days was 29.1% in the pantoprazole group and 30.9% in the placebo group, showing no significant difference (hazard ratio, 0.94; 95% CI, 0.85 to 1.04; P=0.25). There were no significant differences in the rates of ventilator-associated pneumonia or Clostridioides difficile infection between the groups.
Implications for Practice: The study demonstrates that pantoprazole significantly reduces the risk of upper gastrointestinal bleeding in critically ill patients on mechanical ventilation without affecting overall mortality. This suggests that pantoprazole can be considered a safe and effective option for stress ulcer prophylaxis in this high-risk population, potentially improving patient outcomes in the ICU.
Post hoc analysis: Laparoscopic spleen-preserving hilar lymphadenectomy may improve 5-year survival in advanced proximal gastric cancer without greater curvature invasion – JAMA Surg
25 May, 2024 | 19:43h | UTCThis study presents the results of a post hoc secondary analysis from the Fuges-02 randomized clinical trial, investigating the effects of laparoscopic total gastrectomy (LTG) with and without spleen-preserving splenic hilar lymphadenectomy (LSPSHL) in 536 patients with resectable advanced proximal gastric cancer (APGC) lacking greater curvature invasion. Conducted from January 2015 to October 2018 with a minimum follow-up of five years, the study reported a significantly improved 5-year disease-free survival (DFS) rate of 63.9% in the LTG with LSPSHL group compared to 55.1% in the LTG alone group. The overall survival (OS) also favored the LSPSHL group at 66.2% versus 57.4% in the LTG group. Furthermore, the recurrence rate was lower in the LSPSHL group, with a notable reduction in recurrence at the No. 10 lymph node area, indicating a protective benefit from the addition of LSPSHL. The findings suggest a potential therapeutic advantage of incorporating LSPSHL in surgical protocols for APGC without greater curvature invasion, warranting further investigation through multicenter studies.
Reference (link to abstract – $ for full-text):
RCT | Hemostatic powder provides better control of gastrointestinal tumor bleeding than standard endoscopic treatment
20 Jun, 2023 | 12:39h | UTCHemostatic powder vs. standard endoscopic treatment for gastrointestinal tumor bleeding: A multicenter randomized trial – Gastroenterology (link to abstract – $ for full-text)
Review | Hereditary colorectal, gastric, and pancreatic cancer
18 May, 2023 | 13:43h | UTCHereditary colorectal, gastric, and pancreatic cancer: comprehensive review – BJS Open
Commentary on Twitter
Have a?at our latest comprehensive review covering all u need to know?about hereditary ?colorectal, gastric & pancreatic?! https://t.co/y1LL0DNRiy@Adductor @DrRABurkhart #SoMe4Surgery #StepUp4CRC #SurgEd #MedTwitter @BJSAcademy @BJSurgery @juliomayol @young_bjs Great read! pic.twitter.com/JmmOmMBydO
— BJS Open (@BjsOpen) May 11, 2023
Review | Helicobacter pylori infection
2 May, 2023 | 13:37h | UTCHelicobacter pylori infection – Nature Reviews Disease Primers (if the link is paywalled, try this one)
Commentary on Twitter
A Primer published by @DiseasePrimers summarizes the epidemiology, pathophysiology, diagnosis and management of Helicobacter pylori infection, and discusses patient quality of life and open research questions. https://t.co/WawWpSGBU9 pic.twitter.com/ghFTbyp0ln
— Nature Portfolio (@NaturePortfolio) April 24, 2023
Cohort Study | Cancer surveillance as an alternative to prophylactic total gastrectomy in hereditary diffuse gastric cancer
17 Apr, 2023 | 12:57h | UTCCancer surveillance as an alternative to prophylactic total gastrectomy in hereditary diffuse gastric cancer: a prospective cohort study – The Lancet Oncology (link to abstract – $ for full-text)
Commentary: Endoscopic Surveillance in Patients at Risk for Hereditary Diffuse Gastric Cancer – The ASCO Post
RCT | Over-the-scope clips show lower rebleeding rates in nonvariceal GI bleeding
6 Apr, 2023 | 12:57h | UTCComparison of Over-the-Scope Clips to Standard Endoscopic Treatment as the Initial Treatment in Patients With Bleeding From a Nonvariceal Upper Gastrointestinal Cause: A Randomized Controlled Trial – Annals of Internal Medicine (link to abstract – $ for full-text)
Commentaries:
Over-the-Scope Clip Beneficial for Nonvariceal Upper GI Bleeding – HealthDay
Commentary on Twitter
A new RCT found that over-the-scope-clips may be more effective than standard treatment for some patients with nonvariceal upper #GastrointestinalBleeding: https://t.co/GWG70CWmlt pic.twitter.com/Foq2qQZTEc
— Annals of Int Med (@AnnalsofIM) March 7, 2023
Brief Review | What every gastroenterologist should know about gastrointestinal neuroendocrine tumors
4 Apr, 2023 | 13:29h | UTC
Gastric Cancer: the combined impact of H. pylori infection and pathogenic gene variants
3 Apr, 2023 | 13:51h | UTCHelicobacter pylori, Homologous-Recombination Genes, and Gastric Cancer – New England Journal of Medicine (link to abstract – $ for full-text)
Commentary: H. Pylori Infection Negatively Modifies Genetically Increased Risk for Gastric Cancer – Physician’s Weekly
Commentary on Twitter
Infection with Helicobacter pylori is known to confer a risk of gastric cancer. In this study, persons who carried certain genetic variants and were infected with H. pylori had an excess risk of gastric cancer. https://t.co/jIcUiYu14G#genetics pic.twitter.com/jY4H1Mq6dO
— NEJM (@NEJM) March 29, 2023
Guidelines for Gastric Cancer | An evidence-based, multidisciplinary approach
22 Mar, 2023 | 13:33h | UTC
RCT | Comparable 5-year relapse-free survival for laparoscopic vs. open distal gastrectomy in advanced gastric cancer
22 Mar, 2023 | 13:27h | UTCSummary: The JLSSG0901 randomized clinical trial aimed to compare the 5-year survival outcomes of laparoscopy-assisted distal gastrectomy (LADG) and open distal gastrectomy (ODG) with D2 lymph node dissection for locally advanced gastric cancer.
The study involved 507 patients from 37 institutes in Japan. The primary endpoint was 5-year relapse-free survival. The results showed that the 5-year relapse-free survival rates were 73.9% and 75.7% for the ODG and LADG groups, respectively, confirming the noninferiority of LADG, and no significant differences were observed in severe postoperative complications between the two groups.
The study concluded that LADG with D2 lymph node dissection, when performed by qualified surgeons, was proven noninferior to ODG, and could become a standard treatment for locally advanced gastric cancer.
Article: Five-Year Survival Outcomes of Laparoscopy-Assisted vs Open Distal Gastrectomy for Advanced Gastric Cancer: The JLSSG0901 Randomized Clinical Trial – JAMA Surgery (link to abstract – $ for full-text)
Related:
Commentary on Twitter
Study results provide robust evidence suggesting that laparoscopic gastrectomy for locally advanced gastric cancer may be an appropriate treatment approach when performed by skilled surgeons. https://t.co/Dvnzk5YI9u pic.twitter.com/GDCdT4DJhp
— JAMA Surgery (@JAMASurgery) March 15, 2023
M-A | Laparoscopic vs. open distal gastrectomy for locally advanced gastric cancer
15 Mar, 2023 | 14:52h | UTCRelated:
Review | Analysis of deprescription strategies of proton pump inhibitors in primary care
7 Mar, 2023 | 12:42h | UTCRelated:
Deprescribing proton pump inhibitors – Australian Journal of General Practice
Review | Platelet aggregation inhibitors and anticoagulants in gastroenterological and visceral surgical procedures
1 Mar, 2023 | 14:03h | UTC
Guideline | Diagnosis and treatment of Helicobacter pylori
24 Feb, 2023 | 13:53h | UTCRelated:
RCT | Laparoscopic proximal gastrectomy with double-tract reconstruction vs. total gastrectomy in upper-third early gastric cancer
23 Feb, 2023 | 13:29h | UTCSummary: This randomized trial examined whether laparoscopic proximal gastrectomy with double-tract reconstruction (LPG-DTR) is a superior surgical treatment compared to laparoscopic total gastrectomy (LTG) for patients with early gastric cancer (GC) in the upper third of the stomach. The study found that LPG-DTR resulted in significantly decreased amounts of vitamin B12 supplementation, but no significant difference in hemoglobin change compared to LTG. The study also found no difference in complication rates or overall and disease-free survival rates between the two groups. The study suggests that LPG-DTR may be a function-preserving procedure for the treatment of patients with upper-third early GC.
Commentary on Twitter
RCT: Proximal gastrectomy with double tract reconstruction had an advantage of less vitamin B12 supplementation than total gastrectomy similar complication rates and survival in patients with upper third early gastric cancer. https://t.co/tdAktJxkpL pic.twitter.com/5miUbb9Ia6
— JAMA Network Open (@JAMANetworkOpen) February 15, 2023
M-A | Efficacy and safety of drugs for gastroparesis
17 Feb, 2023 | 13:05h | UTCCommentaries:
Review finds only two efficacious medications to treat gastroparesis – ACP Gastroenterology
Two drug classes appear effective for gastroparesis treatment – MDedge
Commentary from the author on Twitter (thread – click for more)
Our latest (and definitely last!) paper of 2022 is now published online in @AGA_Gastro and is a network meta-analysis of drugs in gastroparesis:https://t.co/kpz8nH6ekT
— Alexander Ford (@alex_ford12399) December 26, 2022
Complications of diagnostic upper gastrointestinal endoscopy: recognition, assessment and management
7 Feb, 2023 | 13:41h | UTC
Review | Prevention and management of minor complications in percutaneous endoscopic gastrostomy
7 Feb, 2023 | 13:39h | UTC
Rates of antimicrobial resistance in Helicobacter pylori isolates across the US and Europe
6 Feb, 2023 | 13:12h | UTCCommentary: Time to ditch clarithromycin for H. pylori? – MDedge
Commentary on Twitter
New #RedJournal study by Mégraud, et al., shows high antibiotic resistance rates in #Hpylori isolates across the US & EU and the need for antibiotic resistance surveillance and novel treatment strategies for H. pylori.
? Read more: https://t.co/JT6P0MnEdW@umfoodoc @cwhowden pic.twitter.com/5FeV3Wj6Dw
— AJG – The American Journal of Gastroenterology (@AmJGastro) November 14, 2022
M-A | Short-and long-term outcomes of laparoscopic versus open gastrectomy in patients with gastric cancer
2 Feb, 2023 | 14:36h | UTC
M-A | Proximal gastrectomy with double-tract-reconstruction vs. total gastrectomy in gastric and gastroesophageal junction cancer patients
27 Jan, 2023 | 11:54h | UTC