Changes in clinicopathological features and survival after gastrectomy for gastric cancer over a 20-year period

Changing trends of clinicopathologic features and survival duration after surgery for gastric cancer in Northeast China

BACKGROUND

Through analyzing the data from a single institution in Northeast China, this study revealed the possible clinicopathologic characteristics that influence the prognosis of patients with gastric cancer (GC).

AIM

To evaluate the changing trends of clinicopathologic features and survival duration after surgery in patients with GC in Northeast China, which is a high-prevalence area of GC.

METHODS

The study analyzed the difference in clinicopathologic features and survival duration after surgery of 5887 patients who were histologically diagnosed with GC at the Harbin Medical University Cancer Hospital. The study mainly analyzed the data in three periods, 2000 to 2004 (Phase 1), 2005 to 2009 (Phase 2), and 2010 to 2014 (Phase 3).

RESULTS

Over time, the postoperative survival rate significantly increased from 2000 to 2014. In the past 15 years, compared with Phases 1 and 2, the tumor size was smaller in Phase 3 (P < 0.001), but the proportion of high-medium differentiated tumors increased (P < 0.001). The proportion of early GC gradually increased from 3.9% to 14.4% (P < 0.001). A surprising improvement was observed in the mean number of retrieved lymph nodes, ranging from 11.4 to 27.5 (P < 0.001). The overall 5-year survival rate increased from 24% in Phase 1 to 43.8% in Phase 3. Through multivariate analysis, it was found that age, tumor size, histologic type, tumor-node-metastasis stage, depth of invasion, lymph node metastasis, surgical approach, local infiltration, radical extent, number of retrieved lymph nodes, and age group were independent risk factors that influenced the prognosis of patients with GC.

CONCLUSION

The clinical features of GC in Northeast China changed during the observation period. The increasing detection of early GC and more standardized surgical treatment effectively prolonged lifetimes.

Current status of laparoscopic proximal gastrectomy in proximal gastric cancer: Technical details and oncologic outcomes

The incidence of proximal gastric cancer has been increasing continuously. This status has prevailed despite the application of laparoscopic proximal gastrectomy as a surgical treatment for early proximal gastric cancer. The widespread adoption and standardization of this surgical procedure as the primary treatment for the abovementioned cancer has been hampered by the lack of consensus on the optimal reconstruction method after proximal gastrectomy. In addition, the oncological safety of proximal gastrectomy for advanced gastric disease remains unclear. We reviewed the English-language literature to clarify the current status of laparoscopic proximal gastrectomy in proximal gastric cancer. Japanese gastric cancer guidelines have suggested three types of reconstructions for proximal gastrectomy, namely, esophagogastrostomy, double-tract reconstruction, and jejunal interposition. Optimal reconstruction methods remain to be determined because of the lack of adequately performed and well-designed randomized controlled trials. The technical complexity and challenging implementation of reconstruction procedures have resulted in several complications with anastomoses. Multicenter randomized controlled trials are necessary to evaluate the various reconstruction methods and the oncological safety of laparoscopic proximal gastrectomy for advanced gastric disease.

Current status of proximal gastrectomy for gastric and esophagogastric junctional cancer: A review

Proximal gastrectomy (PG) is one of the function-preserving surgical methods for the treatment of upper gastric cancer. Favorable postoperative results have been reported in comparison with total gastrectomy. However, because there are challenges, such as postoperative reflux esophagitis, anastomotic stenosis, and residual food, appropriate selection of a reconstruction method is crucial. Some methods include esophagogastric anastomosis, including simple esophagogastrostomy, tube-like stomach esophagogastrostomy, side overlap with fundoplication by Yamashita, and double-flap technique, and reconstruction using the small intestine, including double-tract methods, jejunal interposition, and jejunal pouch interposition. However, standard reconstruction methods are yet to be established. PG has also been employed in early gastric cancer of the upper third of the stomach, and indications have also been extended to esophagogastric junction cancer, which has shown an increase in recent years. Although many retrospective studies have revealed the functional benefits or oncological safety of PG, the characteristics of each surgical procedure should be understood so that an appropriate reconstruction method, with a reflux prevention mechanism and minimal postoperative injury, can be selected.

Validation of a novel reconstruction method of laparoscopic gastrectomy for proximal early gastric cancer: a systematic review and meta-analysis

Background

Recently, a novel surgical procedure, named as laparoscopic proximal gastrectomy (LPG) with double-tract reconstruction (DTR), has been reported to provide surgical benefits in the treatment of proximal early gastric cancer (EGC) over traditional laparoscopic total gastrectomy (LTG). These benefits include a lower incidence of some surgical complications and better postoperative nutritional status. However, the number of relevant studies is still too low to validate such benefits. Therefore, this systematic review and meta-analysis aimed to assess the surgical features, complications, and postoperative nutritional status of LPG with DTR in comparison to those of LTG.

Methods

Online databases (PubMed, Web of Science, Cochrane Library, and EMBASE) were scoured for relevant studies published by April 2020. The quality assessment of the included articles was evaluated using the Newcastle-Ottawa scale. Egger’s test was utilized to assess publication bias.

Results

Nine studies (687 patients) were enrolled for this meta-analysis, and we found that LPG with DTR and LTG had similar surgical features. However, LPG with DTR was superior to LTG in the incidence of reflux syndrome [OR = 0.185; 95%CI 0.083, 0.414; P = 0.000], postoperative nutritional status (hemoglobin [WMD = − 2.326; 95%CI − 4.491, − 0.160; P = 0.035], vitamin B12 [WMD = − 13.072; 95%CI − 22.850, − 3.294; P = 0.009], and body weight [WMD = − 3.514; 95%CI − 5.579, − 1.449; P = 0.001]).

Conclusions

LPG with DTR has better performance in the incidence of reflux syndrome and postoperative nutritional status compared with LTG. This surgical procedure may therefore have more benefits for patients with proximal EGC.

Effects of reconstruction techniques after proximal gastrectomy: a systematic review and meta-analysis

BACKGROUND

Additional studies comparing several reconstruction methods after proximal gastrectomy have been published; of note, it is necessary to update systematic reviews and meta-analysis from the current evidence-based literature.

AIM

To expand the current knowledge on feasibility and safety, and also to analyze postoperative outcomes of several reconstructive techniques after proximal gastrectomy.

METHODS

PubMed, Google Scholar, and Medline databases were searched for original studies, and relevant literature published between the years 1966 and 2019 concerning various reconstructive techniques on proximal gastrectomy were selected. The postoperative outcomes and complications of the reconstructive techniques were assessed. Meta-analyses were performed using Rev-Man 5.0. A total of 29 studies investigating postoperative outcomes of double tract reconstruction, jejunal pouch interposition, jejunal interposition, esophagogastrostomy, and double flap reconstruction were finally selected in the quantitative analysis.

RESULT

Pooled incidences of reflux esophagitis for double tract reconstruction, jejunal pouch interposition, jejunal interposition esophagogastrostomy, and double flap reconstruction were 8.6%, 13.8%, 13.8%, 19.3%, and 8.9% respectively. Meta-analysis showed a decreased length of hospital in the JI group as compared to the JPI group (heterogeneity: Chi2 = 1.34, df = 1 (P = 0.25); I2 = 26%, test for overall effect: Z = 2.22 (P = 0.03). There was also a significant difference between JI and EG in length of hospital stay with heterogeneity: Chi2 = 1.40, df = 3 (P = 0.71); I2 = 0%, test for overall effect: Z = 5.04 (P < 0.00001). Operative time was less in the EG group as compared to the JI group (heterogeneity: Chi2 = 31.09, df = 5 (P < 0.00001); I2 = 84%, test for overall effect: Z = 32.35 (P < 0.00001).

CONCLUSION

Although current reconstructive techniques present excellent anti-reflux efficacy, the optimal reconstructive method remains to be determined. The double flap reconstruction proved to lower the rate of complication, but the DTR, JI, JPI, and EG groups showed higher incidence of complications in anastomotic leakage, anastomotic stricture, and residual food. In the meta-analysis result, the complications between the JI, JPI, and EG were comparable but the EG group showed to have better postoperative outcomes concerning the operative time, blood loss, and length of hospital stay.

RON and RONΔ160 promote gastric cancer cell proliferation, migration, and adaption to hypoxia via interaction with β-catenin

Aberrant accumulation of the receptor tyrosine kinase recepteur d’origine nantais (RON) has been verified in gastric adenocarcinoma. Upregulation of RON and its splice variant RONΔ160 contribute to the growth and migration in gastric cancer cells in vitro. However, the mechanisms of RON/RONΔ160-mediated gastric cancer growth and metastasis remain vague. We therefore examined the actions of RON, RONΔ160, and β-catenin in gastric cancer cells and tissue samples, and their effects on cell growth in vitro and in vivo. We found that in gastric cancer samples and cell lines, there was positive correlation between RON/RONΔ160 and β-catenin levels, and that they formed a RON/RONΔ160-β-catenin complex which was translocated to the nucleus. Hypoxia led the binding of hypoxia-inducible factor-1α to the RON/RONΔ160-β-catenin complex, which increased nuclear translocation and expression of downstream oncogenic signaling molecules. Overexpression of RON/RONΔ160 promoted the proliferation and migration of gastric cancer cells, which were also enhanced by hypoxia. Suppression of RON using siRNA or anti‑RON monoclonal antibody diminished gastric cancer cell and tumor growth in vitro and in vivo. These findings establish a link between the receptor tyrosine kinase RON and β-catenin and provide insight into the mechanism by which they contribute to gastric cancer progression.

D1-plus vs D2 nodal dissection in gastric cancer: a propensity score matched comparison and review of published literature

Background

The results of D1-plus lymphadenectomy following gastric resection are seldom investigated. The aim of this study was to compare results of D1-plus vs D2 resections and to provide a literature review.

Methods

Patients who underwent upfront R0 gastrectomy for adenocarcinoma from 2000 to 2016 in three Institutions were selected using propensity scores and categorized according to lymphadenectomy. Statistical analyses were performed for the nodal harvest (LNH) and survival. Published literature comparing D1-plus and D2 was reviewed and analyzed according to PICO and PRISMA guidelines.

Results

Two matched groups of 93 D1-plus and 93 D2 resections were selected. LNH was significantly greater in D2 vs D1-plus dissections (mean 31.2 vs 27.2, p 0.04), however LNH distribution was similar. The cumulative incidence curves for overall survival, disease free and disease specific events did not report significant differences, however Cox regression analysis disclosed that total gastrectomies (HR 1.8; 95% 1.0–2.9), advanced stages (HR 5.9; 95% 3.4–10.3) and D1-plus nodal dissection (HR 2.1; 95% 1.26–3.50) independently correlated with disease free survival. Literature review including 297 D1-plus and 556 D2 lymphadenectomies documented LNH in favor of D2 sub-group (SMD -0.772; 95%CI -1.222- -0.322).

Conclusion

D2 provided greater LNH than D1-plus dissections; prospective studies should aim to investigate long-term survival of D1-plus lymphadenectomy.

Non-flap hand-sewn esophagogastrostomy as a simple anti-reflux procedure in laparoscopic proximal gastrectomy for gastric cancer

AIMS

No ideal and generally accepted method of reconstruction for laparoscopic proximal gastrectomy (LPG) has been established because of a high incidence of postoperative reflux and anastomotic stenosis. The aim of this study was to evaluate the short-term outcomes of LPG with a non-flap hand-sewn technique as a simple anti-reflux procedure for the upper part of clinical Stage I gastric cancer.

METHODS

Between November 2016 and June 2019, 23 consecutive gastric cancer patients, who underwent curative LPG with lymphadenectomy, were enrolled in the study. In this study, we devised a simple hand-sewn technique for esophagogastrostomy, which comprises a 5-cm pseudo-fornix as a fundoplication, the posterior pressure mechanism by the remnant stomach and bilateral crus, and a flat-shaped anastomotic hole as a valvuloplasty.

RESULTS

The median operation time and hospital stay was 325 min and 10 days, respectively. There was no patient with anastomotic leakage and delayed gastric empting. No patient had symptoms of gastroesophageal reflux, but two patients (8.6% (2/23): Grade M and Grade A) had endoscopic findings during a follow-up period of more than 6 months. There was no patient with Grade B or more severe reflux esophagitis. One patient (4.3%, 1/23) developed anastomotic stenosis, which was resolved with endoscopic dilatation. The mean body weight loss at 6 months after surgery was 7.5% in comparison with the preoperative body weight.

CONCLUSION

Our non-flap hand-sewn technique for esophagogastrostomy had favorable outcomes and might be one of reliable techniques as an anti-reflux procedure in LPG for gastric cancer.

Functional and nutritional outcomes after gastric cancer surgery

Recent improvements in diagnostic techniques and national screening programs have resulted in increasing number of patients diagnosed with early gastric cancer (EGC). The low incidence rate of lymph node metastasis and excellent survival rates after surgical treatment for EGC enabled the reduction in the extent of lymphadenectomy and the range of gastric resection for function-preserving gastrectomy. Thus, the quality of life (QOL) of patients with gastric cancer (GC) in the curative stage can be maintained. Moreover, these function-preserving procedures have been widely performed by less invasive procedures, such as laparoscopic and robotic approaches. Pylorus-preserving gastrectomy (PPG) and proximal gastrectomy (PG) represent the two main function-preserving surgical procedures for GC. PPG is an alternative to distal gastrectomy (DG) for cT1 N0 EGC located in the middle part of the stomach. Preservation of the pyloric function is expected to prevent post-gastrectomy syndromes such as dumping syndrome. PG is an alternative to total gastrectomy (TG) and can thus be performed for cT1 N0 EGC located in the upper part of the stomach. Preservation of the residual stomach is expected to work as a reservoir for ingested food. The optimal reconstruction method after PG among the three most commonly performed procedures (esophagogastrostomy, jejunal interposition, and double-tract reconstruction) remains controversial. In addition to these three reconstruction methods, the novel double-flap technique (DFT) of esophagogastrostomy has gained attention recently because of its potential usefulness to prevent postoperative esophageal reflux. In this review article, we summarize the current evidence of PPG and PG with esophagogastrostomy by the DFT, focusing on postoperative nutrition and QOL.

Double-Tract Reconstruction Designed to Allow More Food Flow to the Remnant Stomach After Laparoscopic Proximal Gastrectomy

PURPOSE

Laparoscopic proximal gastrectomy (LPG) is a function-preserving surgery performed on patients with cancer of the upper third of the stomach. However, if much of the ingested food passes through the jejunum, LPG might function broadly like a total gastrectomy. We devised a jejunogastrostomy with double-tract reconstruction (DTR) to ensure that most food flows easily to the remnant stomach.

METHODS

A side-to-side jejunogastrostomy was created between the remnant stomach's posterior wall and the jejunum 10 cm below the esophagojejunostomy, and the common stab incision was also closed with a linear stapler. The jejunogastrostomy was created as a delta-shaped anastomosis by using only linear staplers. The 15 patients who underwent delta-shaped anastomosis from 2017 to 2018 were retrospectively reviewed to collect and analyze their surgical and postoperative outcomes, including nutritive conditions, in comparison to the reconstruction that was performed before then.

RESULTS

Operative times and postoperative complications were not significantly different compared to the previous reconstruction. We confirmed significant differences in operative bleeding and passage of food through the remnant stomach. The level of nutritional indicators at the end of postoperative year one did not tend to be lower, but total weight loss (TWL) and %TWL were significantly lower. As expected, there was a correlation between differences in jejunogastrostomy type and postoperative malnutrition.

CONCLUSIONS

This method devised for intracorporeal DTR provided patients with improved postoperative nutritional status by directing more food through the remnant stomach after LPG.

Graphene-based stochastic sensors for pattern recognition of gastric cancer biomarkers in biological fluids

This paper proposes pattern recognition of gastric cancer biomarkers CEA, CA19-9 and p53 in whole blood and urine samples using a stochastic sensor based on exfoliated graphene (E-NGr) paste modified with protoporphyrin IX. The proposed sensor covered large ranges of concentrations: 1 × 10[Formula: see text]–1 × 10[Formula: see text]g/mL for CEA, 1 × 10[Formula: see text]–1 × 102 U/mL for CA19-9, and 0.2–5.0 [Formula: see text]g/mL for p53. These ranges allowed the determination of the three biomarkers from early to latest stages of gastric cancer. Validation of the pattern recognition of gastric cancer biomarkers was accomplished using biological samples: whole blood and urine.

Overlap method versus functional method for esophagojejunal reconstruction using totally laparoscopic total gastrectomy

BACKGROUND

Laparoscopic intracorporeal esophagojejunostomy (EJ) is a useful method in totally laparoscopic total gastrectomy (TLTG) for treating upper-third gastric cancer. The two methods of laparoscopic intracorporeal EJ-functional and overlap-have not been compared side-by-side in terms of safety and feasibility.

METHODS

Retrospective review and analysis of the data of 490 consecutive patients who underwent TLTG by either functional method (n = 365) or overlap (n = 125) method for upper- or middle-third gastric cancer was conducted between January, 2011 and May, 2018 at Asan Medical Center (Seoul, Korea). One-to-one propensity score matching (PSM) was performed to compare age, sex, body mass index, American Society of Anesthesiologist score, the presence of comorbidity, number of comorbidities, clinical T stage, clinical nodal stage, clinical TNM stage, history of previous abdominal surgery, and combined surgery. After PSM, 244 patients were divided into functional method group and overlap method group (n = 122, each). The surgical outcomes and EJ-related complications were compared between the two groups.

RESULTS

No significant difference was found between the two groups in terms of early surgical outcomes such as operative time, time to first flatus, postoperative hospital stay, transfusion during surgery, transfusion after surgery, and administration of analgesics. However, the pain score was significantly lower in overlap method group (6.21 ± 1.83) than functional method group (6.97 ± 2.09, p < 0.05). The overlap method was also associated with significantly fewer late complications (3.28% vs. 12.30%; p < 0.05), lower Clavien-Dindo classification grade (p < 0.05), and fewer EJ-related complications (0.82% vs. 6.56%; p < 0.05), as compared with the functional method.

CONCLUSION

The overlap method was safer and more feasible than the functional method for TLTG in gastric cancer patients, based on the finding of significantly lower incidence of EJ-related complications.

Thirty-year trends in clinicopathologic characteristics and prognosis after gastrectomy for gastric cancer: A single institution in Northern China

Background: We integrated changes in the trends in clinicopathologic characteristics and postoperative prognosis in patients with gastric cancer Northern China over a 30-year period. Methods: A retrospective analysis of patients undergoing gastric cancer resection and complete follow-up information from January 1981 to December 2010 in the first affiliated Hospital of China Medical University was carried out. We divided the patients into three consecutive periods. Results: A total of 3,520 patients were included in this study. The proportion of lower tumors increased (from 58.8 to 66.9%), while that of upper tumors decreased (from 21.3 to 13.4%). The proportion of tumors > 5cm decreased (from 58.6 to 41.1 %), but the increasing trend of poorly differentiated gastric cancer was obvious (from 60.1 to 75.7%). The percentage of early gastric cancer increased from 10.0 to 15.5 during the study periods, and that of TNM stage Ⅳ cancer decreased from 38.6 to 28.1. In surgery treatment, the rate of radical resection increased to 92.1% in recent period, and the average number of retrieved lymph nodes increased. The 5-year survival rate gradually increased from 36.5% to 48.5% (p<0.001). The Multivariate analysis showed that age, tumor size, T stage, N stage, number of retrieved lymph nodes and resection type were independent prognostic factors for gastric cancer. Conclusion: The patterns of clinicopathologic features for gastric cancer changed during the 30-year period in North China. Overall survival (OS) could be increased by early detection of tumors and standard surgical treatment.

Laparoscopic proximal gastrectomy with double-flap technique versus laparoscopic subtotal gastrectomy for proximal early gastric cancer

Background

Laparoscopic proximal gastrectomy with double‐flap technique (LPG‐DFT) and laparoscopic subtotal gastrectomy (LSTG) may replace laparoscopic total gastrectomy (LTG) for proximal early gastric cancer. The aim of this study was to evaluate short‐ and long‐term outcomes after LPG‐DFT and LSTG.

Methods

Patients who underwent LPG‐DFT or LSTG at the Cancer Institute Hospital in Tokyo between January 2006 and April 2015 were included in this retrospective study. Operative procedures were selected based on the distance from the cardia to the proximal boundary of the tumour, tumour location and predicted remnant stomach volume. Patient characteristics, surgical data, markers of postoperative nutritional status, such as blood chemistry and bodyweight loss, and endoscopic findings were compared between procedures. The main study outcome was nutritional status.

Results

A total of 161 patients (LPG‐DFT 51, LSTG 110) were included. Types of postoperative complication occurring more than 30 days after surgery differed between the two procedures. Remnant stomach ulcers, including anastomotic ulcers, were observed only after LPG‐DFT, whereas complications involving the small intestine, such as internal hernia or small bowel obstruction, occurred more frequently after LSTG. Values for total protein, albumin, prealbumin and bodyweight loss were comparable between the two procedures at 36 months after surgery. Haemoglobin concentrations were higher after LPG‐DFT than after LSTG at 24 months (13·4 versus 12·8 g/dl respectively; P = 0·045) and 36 months (13·5 versus 12·8 g/dl; P = 0·007) after surgery. The rate of Los Angeles grade B or more severe reflux oesophagitis was comparable.

Conclusion

LPG‐DFT and LSTG for proximal early gastric cancer have similar outcomes, but different types of complication.

Safety and feasibility of laparoscopic spleen-preserving No. 10 lymph node dissection for locally advanced upper third gastric cancer: a prospective, multicenter clinical trial

BACKGROUND

Previous retrospective studies have shown that laparoscopic spleen-preserving D2 total gastrectomy (LSTG) for advanced upper third gastric cancer (AUTGC) is safe. However, all previous studies were underpowered. We therefore conducted a prospective, multicenter study to evaluate the technical safety and feasibility of LSTG for patients with AUTGC.

METHODS

Patients diagnosed with AUTGC (cT2-4a, N-/+, M0) underwent LSTG at 19 institutions between September 2016 and October 2017 were included. The number of No. 10 lymph node (LN) dissections, metastasis rates, intraoperative and postoperative complications were investigated.

RESULTS

A total of 251 patients were enrolled in the study, and 242 patients were eligible for the per protocol analysis. The average numbers of No. 10 LN dissections and metastases were 2.4 and 0.1, respectively. Eighteen patients (7.4%) had No. 10 LN metastases, and among patients with advanced gastric cancer, the rate of No. 10 LN metastasis was 8.1% (18/223). pN3 status was an independent risk factor for No. 10 LN metastasis. Intraoperative complications occurred in 7 patients, but no patients required conversion to open surgery or splenectomy. The overall postoperative complication rate was 13.6% (33/242). The major complication and mortality rates were 3.3% (8/242) and 0.4% (1/242), respectively. The number of retrieved No. 10 LNs, No. 10 LN metastasis and TNM stage had no significant influence on postoperative complication rates.

CONCLUSION

LSTG for AUTGC was safe and effective when performed by very experienced surgeons, this technique could be used in patients who needed splenic hilar lymph node dissection.

Risk Factors for Gallbladder Stone Formation after Gastric Cancer Surgery

Purpose

Although an increased incidence of gallbladder (GB) stone formation after gastrectomy has been reported, its etiology remains uncertain. The goal of this study was to explore the incidence of gallstone formation after gastrectomy in gastric cancer patients and investigate the risk factors therein.

Materials and Methods

Medical records of patients who underwent curative gastrectomy, performed by a single surgeon between August 2012 and December 2015 at the Asan Medical Center, were retrospectively reviewed. Baseline characteristics and surgical outcomes, including GB stone gallstone formation after gastrectomy, were analyzed.

Results

Of 561 patients included in the study, 36 presented with GB stone formation after gastrectomy for gastric cancer. The incidence of gallstone formation was 6.4%. The mean interval between gallstone formation and gastrectomy was 21.9 months. In multivariate analyses, the incidence of gallstone formation increased in patients 63 years or older, with greater than 6.2 kg weight loss in the first 6 months after the procedure, a preoperative serum total bilirubin level greater than 0.5 mg/dL, and in patients who did not receive adjuvant chemotherapy.

Conclusions

This study presented risk factors for GB stone formation after gastric cancer surgery, and special attention should be afforded to patients with such risk factors.

Surgical outcomes and risk assessment for anastomotic complications after laparoscopic proximal gastrectomy with double-flap technique for upper-third gastric cancer

BACKGROUND

Double-flap technique (DFT) has received increased attention as an anastomotic procedure preventing reflux esophagitis after laparoscopic proximal gastrectomy (LPG) for upper-third gastric cancer. However, incidence of anastomotic stricture still remains high. This study was a retrospective review aimed to demonstrate details of surgical outcomes and to assess risk factors for anastomotic complications using pre-operative CT image after LPG with DFT (LPG-DFT).

METHODS

Patient background data, surgical outcomes, post-operative courses, and complications for patients who underwent LPG-DFT from January 2013 to June 2017 were collected. In addition to the details of short-term outcomes, risk factors for anastomotic stricture and gastroesophageal reflux were analyzed.

RESULTS

The study sample was 147 patients, including 139 patients with upper-third gastric cancer and 8 patients with submucosal tumor of the upper-third stomach. The overall morbidity rate was 12.2% (18/147), and 97.3% (143/147) of the patients achieved R0 resection. Twelve (8.3%) patients required endoscopic balloon dilatation for anastomotic stenosis, and six (4.2%) suffered regurgitation grade ≥ B in the Los Angeles classification. Multivariate analysis revealed that diameter of the esophagus < 18 mm on pre-operative CT image and the presence of short-term complications were found to be independent risk factors for post-operative anastomotic stenosis. No specific risk for gastroesophageal reflux was identified.

CONCLUSIONS

The incidence rate of anastomotic complications after LPG-DFT was far lower than that reported after conventional esophagogastrostomy. Alternative anastomotic method may be considered for patients with diameter of the esophagus < 18 mm on pre-operative CT image. Prevention of short-term complications may lessen post-operative stricture.

Oncological feasibility of laparoscopic subtotal gastrectomy compared with laparoscopic proximal or total gastrectomy for cT1N0M0 gastric cancer in the upper gastric body

BACKGROUND

The upper gastric body is of particular interest in relation to gastrectomy because this area includes a border; that is, both distal and proximal gastrectomy for early gastric cancer can involve this area. Laparoscopic subtotal gastrectomy (LsTG) is reported to be suitable procedure compared with laparoscopic proximal and total gastrectomy (LPG, LTG), regarding postoperative nutritional status and surgical safety. However, whether LsTG is an oncologically acceptable procedure for early gastric cancer in the upper gastric body is unclear.

METHODS

We analyzed 215 patients with cT1N0M0 gastric cancer limitedly located in the upper gastric body. The frequency of conversion from each intended procedure to an alternative procedure, the width of the pathological margin, the incidence of lymph node metastasis at each station and the 3-year overall survival (OS) and relapse-free survival (RFS) were evaluated.

RESULTS

LsTG was planned for 65 patients, and LPG for 72 and LTG for 78, respectively. Conversion to other procedures was required in about 10% of patients for whom LsTG or LPG was planned. The width of the pathological margin in patients who underwent LsTG was significantly shorter than patients who underwent the others. No patients who underwent LsTG, LPG or LTG had metastases in station no. 2 or 4sa lymph node. The 3-year OS and RFS rates of patients for whom each procedure was planned were not different.

CONCLUSIONS

LsTG could be an oncologically acceptable procedure for cT1N0M0 gastric cancer in the upper gastric body. LsTG could be one option for such disease.

A meta-analysis of comparison of proximal gastrectomy with double-tract reconstruction and total gastrectomy for proximal early gastric cancer

Background

In theory, proximal gastrectomy with double-tract reconstruction (PG-DT) was superior to total gastrectomy (TG) in hematologic and nutritional outcomes. However, its clinical effects in proximal early gastric cancer (EGC) have been controversial.

Methods

The purpose of this study was to investigate the outcomes of laparoscopic proximal gastrectomy with double-tract reconstruction (LPG-DT) for proximal EGC. For this systematic review and meta-analysis, we searched for articles published before December of 2018 in the following databases: PubMed, Web of Science, EBSCO, Medline, and Cochrane Library.

Results

The results showed no significant difference in the anastomotic stenosis (OR = 0.91, 95%CI = 0.33–2.50, p = 0.85) and reflux esophagitis (OR = 1.87, 95%CI = 0.62–5.65, p = 0.27) between LPG-DT and laparoscopic total gastrectomy (LTG). The vitamin B12 supplementation rate in the LPG-DT group was lower than the LTG group (OR = 0.06, 95%Cl = 0.01–0.59, p = 0.02).

Conclusions

Due to comparable clinical effect, PG-DT is comparable to TG for patients with proximal EGC. In addition, LPG-DT not only appears superior to TG in terms of preventing vitamin B12 deficiency, but also does not increase the risk of anastomotic stricture and reflux esophagitis.

Electronic supplementary material

The online version of this article (10.1186/s12893-019-0584-7) contains supplementary material, which is available to authorized users.

Integrated Glycome Strategy for Characterization of Aberrant LacNAc Contained N-Glycans Associated With Gastric Carcinoma

Aberrant glycosylation is not only a feature of malignant cell transformation, but also plays an important role in metastasis. In the present study, an integrated strategy combining the lectin microarrays and lectin cytochemistry was employed to investigate and verify the altered glycopatterns in gastric cancer (GC) cell lines as well as resected tumor specimens from matched tissue sets of 46 GC patients. Subsequently, lectin-mediated affinity capture glycoproteins, and MALDI-TOF/TOF-MS were employed to further acquire precise structural information of the altered glycans. According to the results, the glycopatterns recognized by 10 (e.g., ACA, MAL-I, and ConA) and 3 lectins (PNA, MAL-I, and VVA) showed significantly variations in GC cells and tissue compared to their corresponding controls, respectively. Notably, the relative abundance of Galβ-1,4GlcNAc (LacNAc) recognized by MAL-I exhibited a significant increase in GC cells (p < 0.001) and tissue from patients at stage II and III (p < 0.05), and a significant increase in lymph node positive tumor cases, compared with lymph node negative tumor cases (p < 0.05). More LacNAc contained N-glycans were characterized in tumor sample with advanced stage compared to corresponding control. Moreover, there were 10 neo-LacNAc-contained N-glycans (e.g., m/z 1625.605, 1803.652, and 1914.671) only presented in GC tissue with advanced stage. Among these, six N-glycans were modified with sialic acid or fucose based on LacNAc to form sialylated N-glycans or lewis antigens, respectively. Our results revealed that the aberrant expression of LacNAc is a characteristic of GC, and LacNAc may serve as a scaffold to be further modified with sialic acid or fucose. Our findings provided useful information for us to understand the development of GC.

Systematic review and meta-analysis of splenectomy in gastrectomy for gastric carcinoma

BACKGROUND

The role of splenectomy for patients with gastric cancer still remains controversial. We performed this meta-analysis to evaluate the safety and long-term oncological outcomes of splenectomy for patients with gastric cancer.

METHODS

A systematic literature search was performed using PubMed, EMBASE, Cochrane Library, and Web of Science from January 1997 to October 2018. The results were analyzed according to predefined criteria. All statistical analyses were performed using RevMan 5.3 software.

RESULTS

In total, 16 studies with 4457 patients, including 3 randomized controlled trials (RCTs) and 13 non-randomized controlled trials (nRCTs), were analyzed. The meta-analysis showed the splenectomy group was associated with higher rates of overall postoperative complication, anastomosis leakage, abdominal abscess, and pancreatic fistula. Regarding long-term oncological outcomes, the splenectomy group showed lower 5-year overall survival (OS) and higher recurrence rates on subgroup analysis for the nRCTs. No significant difference was observed in the 5-year OS and recurrence rates between the two groups on subgroup analysis for the RCTs.

CONCLUSIONS

Splenectomy increases postoperative complications without clearly improving long-term prognosis.

Clinicopathological Characteristics and Prognosis of Proximal and Distal Gastric Cancer during 1997-2017 in China National Cancer Center

Background

The prognostic relevance of gastric tumor location has been reported and debated. Our study was conducted to examine the differences in clinicopathological features, prognostic factors, and overall survival (OS) between patients with proximal gastric cancer (PGC) and distal gastric cancer (DGC).

Patients and Methods

Patients with PGC or DGC were identified from the China National Cancer Center Gastric Cancer Database (NCCGCDB) during 1997–2017. Survival analysis was performed via Kaplan-Meier estimates and Cox proportional hazards models.

Results

We reviewed 16,119 cases of gastric cancer patients, including 6,479 of PGC and 9,640 of DGC. PGC patients presented as older patients (61.5 versus 56.4 years, P<0.001) and more males (82.9% versus 68.2%, P<0.001). Compared with DGC, PGC was more likely to be in later pT stage (pT3 and pT4, 65.0% versus 52.8%, P<0.001) and lymph node metastasis (54.8% versus 50.9%, P<0.001). In univariate analysis, PGC patients had a worse survival outcome in stage I (Hazard ratio [HR] = 2.04, 95% CI: 1.42-2.94) but a better prognosis in stage IV (HR = 0.85, 95% CI: 0.73-0.98) when compared to DGC patients. However, multivariate analysis demonstrated that PGC was not an independent predictor for poor survival (HR = 1.07, 95% CI: 1.00-1.14). Results from multivariate analysis also revealed that pT4, lymph node metastasis, distant metastasis, no gastrectomy, and Borrmann IV were independent predictors associated with poor survival for both PGC and DGC patients. Additional prognostic factors for PGC patients included underweight (BMI < 18.5) (HR = 1.29, 95% CI: 1.06-1.58), linitis plastica (HR = 2.13, 95% CI: 1.25-3.65), and overweight (23 ≤ BMI <27.5) (HR = 0.80, 95% CI: 0.71-0.90). During the 20-year study period, the 5-year OS increased significantly for both PGC and DGC, with the increase rate of 91.7% and 67.7%, respectively.

Conclusion

In China, PGC significantly differed from DGC in clinicopathological characteristics and prognostic factors. However, there was no significant relationship between survival outcome and gastric tumor location.

Objective evaluation of clinical outcomes of laparoscopy-assisted pylorus-preserving gastrectomy for middle-third early gastric cancer

Background

Laparoscopic-assisted pylorus-preserving gastrectomy (LAPPG) is a minimally invasive function-preserving surgery for early gastric cancer. This study was designed to investigate the clinical outcomes between LAPPG and laparoscopy-assisted distal gastrectomy (LADG) by objective evaluation.

Methods

A total 167 pT1N0M0 gastric cancer patients underwent LAPPG(n = 70) and LADG(n = 97) were retrospectively analyzed. By evaluating the functional advantages, objective short-term and one year follow-up outcomes were compared.

Results

There is no significant difference in perioperative clinical characteristics as well as pathologic results between LAPPG and LADG group while the cost is higher in latter(p = 0.004). The Clavien–Dindo grade II or higher complications were 15.7 and 13.4% in LAPPG and LADG group respectively(p = 0.824). In one year follow-up, nutritional status was significantly better in LAPPG group accompanied by better pylorus function preserving.

Conclusion

LAPPG is an acceptable surgical procedure for pT1N0M0 middle portion gastric cancer patients in terms of nutritional and economic advantage.

Trial registration

Chinese Clinical Trial Registry (ChiCTR-PIC-17012358, Date of Registration:2017-08-14).

HOXC10 overexpression promotes cell proliferation and migration in gastric cancer

Homeodomain‑containing gene 10 (HOXC10) is a member of the homeobox transcription factors that plays an important role in the development of multicellular organisms. HOXC10 is overexpressed in a variety of human cancers, and recent studies have revealed that HOXC10 is upregulated in gastric cancer as well. However, its mechanism of action is not fully understood, thus, the role of HOXC10 was investigated in the present study in human gastric cancer. First, HOXC10 expression was revealed to be significantly increased in gastric cancer tissues compared to normal tissues (TCGA dataset), and HOXC10 upregulation was associated with decreased recurrence‑free survival in gastric cancer patients in a public gene expression dataset. HOXC10 promoted cell proliferation and metastasis in two gastric cancer cell lines (AGS and MKN74). Analyzing TCGA 450K DNA methylation dataset, it was revealed that HOXC10 CpG sites were hypomethylated in gastric cancer tissues. Bisulfite sequencing revealed that CpG sites in the HOXC10 first intronic region were hypomethylated in three gastric cancer tissues, and HOXC10 expression was increased in gastric cancer cell lines (AGS and SNU620) in response to 5‑azacytidine treatment. By RNA‑sequencing of AGS cells with ectopic HOXC10 expression, it was revealed that many genes were upregulated by HOXC10 overexpression. Among them, CST1 was predicted to be a HOXC10 direct target gene via prediction of HOXC10 binding sites from the JASPAR database. A chromatin immunoprecipitation assay revealed that HOXC10 directly bound to CST1 promoter regions. The present study proposes HOXC10 is a potential prognostic marker or therapeutic target in human gastric cancer.

Tumor blood supply may predict neoadjuvant chemotherapy response and survival in patients with gastric cancer

Objectives

We investigated the prognostic value of tumor blood supply in patients with advanced gastric cancer (GC) receiving neoadjuvant chemotherapy.

Methods

We retrospectively reviewed 53 patients with advanced GC treated with FLEEOX chemotherapy. The tumor computed tomography (CT) enhancement value was measured before chemotherapy (CT1; arterial phase CT–plain phase CT). The liver parenchyma CT enhancement value (CT2) was also measured using the same method, to eliminate individual differences. Tumor blood supply was defined as good or poor based on the median CT1/CT2 values. We evaluated the relationships between tumor blood supply and response to chemotherapy, clinicopathologic characteristics, and overall survival (OS).

Results

A good blood supply (GBS) was associated with significantly better clinical and pathological responses to chemotherapy than a poor blood supply (PBS). The 3-year OS was 65.8% for the entire cohort. Patients with a GBS had a significantly higher OS (78.57%) than those with a PBS (54.44%). Additionally, patients with Bormann type III GC had a better blood supply than those with type II GC.

Conclusion

Patients with advanced GC and a GBS are more likely to benefit from neoadjuvant chemotherapy than those with a PBS. Blood supply may thus be a predictor for chemotherapy response.

Long noncoding RNA AOC4P regulates tumor cell proliferation and invasion by epithelial-mesenchymal transition in gastric cancer

BACKGROUND

The clinical relevance and biological role of tissular AOC4P in gastric cancer (GC) remains to be clarified.

METHODS

The association between AOC4P expression and clinicopathological characteristics was investigated. In vitro, 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT), colony formation, wound healing and terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assays were performed to explore the biological effects of AOC4P on GC cell proliferation, migration, invasion, and apoptosis in MGC-803 and BGC-823 cell lines. In vivo, animal experiments were conducted to confirm the in vitro findings. Quantitative real-time polymerase chain reaction, western blotting, and immunofluorescence were used to investigate the potential mechanisms.

RESULTS

Expression levels of AOC4P were significantly higher in tumor tissues than in noncancerous tissues, and patients with high levels of AOC4P had poor overall and disease-free survival. AOC4P expression was correlated with lymphovascular invasion. In vitro, knockdown of AOC4P inhibited tumor cell proliferation, migration, and invasion, and promoted apoptosis of MGC-803 and BGC-823 cells. In vivo, BGC-823 cells transfected with AOC4P siRNA formed smaller and lighter tumors than BGC-823 cells transfected with negative control siRNA in severe combined immunodeficiency mice. Additionally, the si-AOC4P group had less proliferating cells and more apoptotic cells in tumor xenografts compared with the negative control. Mechanistically, knockdown of AOC4P decreased the expression of vimentin and MMP9, while increasing the expression of E-cadherin. Immunofluorescence confirmed the relationship between AOC4P expression and E-cadherin, vimentin, and MMP9 levels in clinical GC specimens.

CONCLUSIONS

AOC4P promotes tumorigenesis and progression partly through epithelial-mesenchymal transition in GC. Additionally, AOC4P may serve as a prognostic biomarker for clinical decision making.

Should Pyloric Lymph Nodes Be Dissected for Siewert Type II and III Adenocarcinoma of the Esophagogastric Junctions: Experience from a High-Volume Center in China

BACKGROUND

The optimal extent of lymph node (LN) dissection remains controversial in adenocarcinoma of the esophagogastric junction (AEG), especially in Siewert types II and III. The aim of this study was to analyze clinicopathological characteristics of patients with Siewert type II and III AEGs to clarify whether pyloric (no. 5 and no.6) lymphadenectomy is essential in these patients.

METHODS

A retrospective analysis was performed in the Third Affiliated Hospital of Soochow University from September 2008 to December 2012, and clinicopathological characteristics on all patients with Siewert type II and III AEGs, who underwent curative total gastrectomy with lymphadenectomy were collected. The index of estimated benefit from lymph node dissection (IEBLD) was used to evaluate the efficacy of lymph node dissection of no. 5 and no. 6. Both clinicopathological characteristics and IEBLDs were set as the standards in the assessment of the value of pyloric lymph nodes dissection.

RESULTS

A total of 216 patients with AEG (Siewert type II: 141, Siewert type III: 75) were included into the study. Type III AEG had a larger tumor size and relatively advanced T stage compared to Type II AEG. The 5-year overall survival (OS) rates in type II and type III AEGs were almost similar (type II 50.4% vs. type III 46.7%, p = 0.782). There was a very low incidence of pyloric lymph nodes metastases in type II AEG (no. 5 is 1.4% and no. 6 is 0.7%). Hence, the IEBLDs of no. 5 and no. 6 lymph node were negligible regardless of the T stage and tumor differentiation. In type III AEG, metastasis rates of no. 5 and no. 6 lymph node were 9.3 and 5.3%, respectively. The IEBLDs of no. 5 and no. 6 lymph node were 2.7 and 1.3, respectively.

CONCLUSIONS

Based on the IEBLDs of pyloric lymph nodes, dissection of no. 5 and no. 6 lymph nodes were worthwhile for Siewert type III AEG but not essential for Siewert type II AEG.

Feasibility of laparoscopic total gastrectomy in overweight patients: Implications of less impact of overweight on laparoscopic versus open approach

AIM

To investigate safety and oncological feasibility of laparoscopic total gastrectomy (LTG) in overweight (OW) patients.

METHODS

Patients who underwent total gastrectomy (110 laparoscopic, 211 open) for gastric cancer between January 1999 and July 2016 were included. Propensity score matching selected 152 patients (76 laparoscopic, 76 open), which were subsequently divided into the OW (≥ 25) or non-OW (< 25) group by body mass index. Postoperative outcomes of laparoscopic versus open approaches were compared between OW and non-OW groups.

RESULTS

In the propensity-matched population, baseline characteristics were comparable between the OW and non-OW groups for the laparoscopy and open groups. In the laparoscopy group, operative time was longer (P = 0.01) in the OW group, however, other perioperative results including complication rates were comparable between the non-OW and OW groups. In the open group, number of retrieved lymph nodes were less (P = 0.03) and local complication rate was more frequent (P = 0.03) in the OW group.

CONCLUSION

LTG in OW patients remains technically challenging but can be performed safely. Our findings imply that OW has a lesser effect on the laparoscopic versus open approach to total gastrectomy.

Laparoscopic Proximal Gastrectomy Maintains Body Weight and Skeletal Muscle Better Than Total Gastrectomy

BACKGROUND

Laparoscopic proximal gastrectomy (LPG) is performed as a function-preserving surgery for patients with early proximal gastric malignant tumors; however, whether LPG has advantages postoperatively compared with laparoscopic total gastrectomy (LTG) is debatable, especially with regard to nutritional outcomes.

METHODS

We evaluated 20 patients who underwent LTG and 10 patients who underwent LPG with double tract reconstruction (LPG-DT) who were diagnosed preoperatively with T1a or T1b N0 Stage IA gastric cancer in our department in the same time period. The statistical relevance of complications, surgical maneuvers, clinical factors and changes in weight, skeletal muscle index (SMI) and serum albumin levels after surgery was compared between the LPG-DT group and the LTG group.

RESULTS

No differences between groups were observed in patient demographics, operation time, blood loss, complications, number of dissected lymph nodes and pathological stage. The body weight reduction rate was significantly lower in the LPG-DT group compared with the LTG group at 6 months (5.7 vs. 14.9%, respectively; p = 0.0045) and 1 year after surgery (9.6 vs. 17.9%, respectively; p = 0.0042). The SMI reduction rate of the LPG-DT group in the first postoperative year was significantly lower than that of the LTG group (9.3 vs. 18.3%, respectively; p = 0.0057).

CONCLUSIONS

Patients with early gastric cancer who underwent LPG-DT had acceptable morbidity and mortality, similar to those who underwent LTG. Body weight and SMI reduction rates were lower in the LPG-DT group than in the LTG group. Thus, LPG-DT is an appropriate procedure for patients with clinical Stage IA proximal gastric cancer.

Robot-Assisted Versus Laparoscopy-Assisted Proximal Gastrectomy for Early Gastric Cancer in the Upper Location: Comparison of Oncological Outcomes, Surgical Stress, and Nutritional Status

Background:

An increasing amount of attention has been paid to minimally invasive function-preserving gastrectomy, with an increase in incidence of early gastric cancer in the upper stomach. This study aimed to compare oncological outcomes, surgical stress, and nutritional status between robot-assisted proximal gastrectomy (RAPG) and laparoscopy-assisted proximal gastrectomy (LAPG).

Methods:

Eighty-nine patients were enrolled in this retrospective study between November 2011 and December 2013. Among them, 27 patients underwent RAPG and 62 underwent LAPG. Perioperative parameters, surgical stress, nutritional status, disease-free survival, and overall survival were compared between the 2 groups.

Results:

Sex, age, and comorbidity were similar in the RAPG and LAPG groups. There were also similar perioperative outcomes regarding operation time, complications, and length of hospital stay between the groups. The reflux esophagitis rates following RAPG and LAPG were 18.5% and 14.5%, respectively (P = .842). However, patients in the RAPG group had less blood loss (P = .024), more harvested lymph nodes (P = .021), and higher costs than those in the LAPG group (P < .001). With regard to surgical stress, no significant differences were observed in C-reactive protein concentrations and white blood cell count on postoperative days 1, 3, and 7 between the groups (Ps > .05). There appeared to be higher hemoglobin levels at 6 months (P = .053) and a higher body mass index at 12 months (P = .056) postoperatively in patients in the RAPG group compared with those in the LAPG group, but this difference was not significant. Similar disease-free survival and overall survival rates were observed between the groups.

Conclusions:

RAPG could be an alternative to LAPG for patients with early gastric cancer in the upper stomach with comparable oncological safety and nutritional status. Further well-designed, prospective, large-scale studies are needed to validate these results.

Body mass index and mortality in patients with gastric cancer: a large cohort study

BACKGROUND

The effects of obesity on prognosis in gastric cancer are controversial.

AIMS

To evaluate the association between body mass index (BMI) and mortality in patients with gastric cancer.

METHODS

A single-institution cohort of 7765 patients with gastric cancer undergoing curative gastrectomy between October 2000 and June 2016 was categorized into six groups based on BMI: underweight (< 18.5 kg/m²), normal (18.5 to < 23 kg/m²), overweight (23 to < 25 kg/m²), mildly obese (25 to < 28 kg/m²), moderately obese (28 to < 30 kg/m²), and severely obese (≥ 30 kg/m²). Hazard ratios (HRs) for overall survival (OS) and disease-specific survival (DSS) were calculated using Cox proportional hazard models.

RESULTS

We identified 1279 (16.5%) all-cause and 763 (9.8%) disease-specific deaths among 7765 patients over 83.05 months (range 1.02-186.97) median follow-up. In multivariable analyses adjusted for statistically significant clinicopathological characteristics, preoperative BMI was associated with OS in a non-linear pattern. Compared with normal-weight patients, underweight patients had worse OS [HR 1.42; 95% confidence interval (CI) 1.15-1.77], whereas overweight (HR 0.84; 95% CI 0.73-0.97), mildly obese (HR 0.77; 95% CI 0.66-0.90), and moderately obese (HR 0.77; 95% CI 0.59-1.01) patients had better OS. DSS exhibited a similar pattern, with lowest mortality in moderately obese patients (HR 0.58; 95% CI 0.39-0.85). Spline analysis showed the lowest all-cause mortality risk at a BMI of 26.67 kg/m².

CONCLUSION

In patients undergoing curative gastric cancer surgery, those who were overweight or mildly-to-moderately obese (BMI 23 to < 30 kg/m²) preoperatively had better OS and DSS than normal-weight patients.

Study on safety of laparoscopic total gastrectomy for clinical stage I gastric cancer: the protocol of the CLASS02-01 multicenter randomized controlled clinical trial

BACKGROUND

The safety of laparoscopic total gastrectomy (LTG) for the treatment of gastric cancer remains lack of clinical evidence. The Chinese Laparoscopic Gastrointestinal Surgery Study (CLASS) Group recently launched a multicenter randomized clinical trial (CLASS02-01) to compare the safety of LTG for clinical stage I gastric cancer with the conventional open total gastrectomy (OTG).

METHODS

This CLASS02-01 trial is a prospective, multicenter, randomized, controlled, open, and non-inferiority trial. Two hundred patients who met the inclusion criteria and did not accord with the exclusion criteria will be randomly divided into LTG group (n = 100) and OTG group (n = 100). The primary purpose of this study is to evaluate the early operative morbidity and mortality of LTG compared with OTG for clinical stage I gastric adenocarcinoma. The second purpose is to evaluate the recovery course and compare the postoperative hospital stay of the patients enrolled in this study.

DISCUSSION

This CLASS02-01 trial is the first prospective randomized two-arm controlled study to determine the safety of LTG compared with OTG. Through this trial, we hope to show that experienced surgeons can safely perform LTG with lymphadenectomy for gastric cancer.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT03007550 . December 30, 2016.

Comparison of laparoscopic proximal gastrectomy with double-tract reconstruction and laparoscopic total gastrectomy in terms of nutritional status or quality of life in early gastric cancer patients

BACKGROUND

This study aimed to evaluate the surgical outcomes of laparoscopic proximal gastrectomy (LPG) reconstructed by the double-tract method in comparison to those of laparoscopic total gastrectomy (LTG).

METHODS

A retrospective review of the prospectively established database identified early gastric cancer patients who underwent LPG (n = 34) or LTG (n = 46) between January 2011 and December 2015. Baseline characteristics and surgical outcomes including postoperative complications, changes in body composition, nutritional status, and quality of life (QOL) after surgery were compared between the LPG and LTG patients.

RESULTS

Operating time was significantly longer in the LTG group (240.7 ± 43.9 vs. 211.7 ± 32.8 min, p = 0.007). The incidence of grade II or more complications and the hospital stay were comparable between the groups. There was no significant difference between the groups in terms of body composition using a bioelectrical impedance method in 1 year postoperatively. Nutritional status assessed by serum hemoglobin, iron, vitamin B12, albumin, total protein, and total cholesterol levels and postoperative changes in quality of life up to 2 years after surgery were also similar between the groups. Vitamin B12 supplementation was required in 75.4% of the patients in the LTG group and 46.5% in the LPG group within 2 years after surgery (p = 0.005).

CONCLUSION

LPG with double-tract reconstruction appears superior in preventing vitamin B12 deficiency compared to LTG, particularly after 1 year after the surgery, although it offered little benefit in terms of postoperative body composition changes and QOL.

A novel classifier based on three preoperative tumor markers predicting the cancer-specific survival of gastric cancer (CEA, CA19-9 and CA72-4)

Several studies have highlighted the prognostic value of the individual and the various combinations of the tumor markers for gastric cancer (GC). Our study was designed to assess establish a new novel model incorporating carcino-embryonic antigen (CEA), carbohydrate antigen 19-9 (CA19-9), carbohydrate antigen 72-4 (CA72-4). A total of 1,566 GC patients (Primary cohort) between Jan 2000 and July 2013 were analyzed. The Primary cohort was randomly divided into Training set (n=783) and Validation set (n=783). A three-tumor marker classifier was developed in the Training set and validated in the Validation set by multivariate regression and risk-score analysis. We have identified a three-tumor marker classifier (including CEA, CA19-9 and CA72-4) for the cancer specific survival (CSS) of GC (p<0.001). Consistent results were obtained in the both Training set and Validation set. Multivariate analysis showed that the classifier was an independent predictor of GC (All p value <0.001 in the Training set, Validation set and Primary cohort). Furthermore, when the leave-one-out approach was performed, the classifier showed superior predictive value to the individual or two of them (with the highest AUC (Area Under Curve); 0.618 for the Training set, and 0.625 for the Validation set), which ascertained its predictive value. Our three-tumor marker classifier is closely associated with the CSS of GC and may serve as a novel model for future decisions concerning treatments.

Risk factors for early metachronous tumor development after endoscopic resection for early gastric cancer

BACKGROUND

Metachronous gastric tumor (MGT) is one of major concerns after endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). Optimal follow-up strategy has not been yet well-established. The aim of this study was to identify the different clinical features of the patients according to the time interval to development of MGT.

METHODS

Among 1,780 consecutive patients with EGC who underwent ESD between 2005 and 2014, 115 patients with MGT were retrospectively reviewed. MGT was defined as secondary gastric cancer or dysplasia detected > 1 year after initial ESD. Clinicopathological factors associated with early development of MGT were evaluated.

RESULTS

The median interval to development of MGT was 37 months. In univariate analysis, the median interval to MGT was shorter if EGC lesion was non-elevated type (39.4 vs 57.0 months, p = 0.011), or synchronous primary lesion was absent (39.8 vs 51.4 months, p = 0.050). In multivariate Cox's proportional hazards analysis, the hazard ratios for early occurrence of MGT were 1.966 (95% CI: 1.141-3.386, p = 0.015) and 1.911 (95% CI: 1.163-3.141, p = 0.011), respectively. There was no significant difference in overall survival after diagnosis of MGT between the early occurrence group and the late occurrence group.

CONCLUSIONS

Non-elevated gross type and absence of synchronous gastric tumor were independent risk factors for early development of MGT. Meticulous endoscopic inspection is especially important for the detection of MGT during the early follow-up period in patients with these initial tumor characteristics.

Function-preserving surgery for gastric cancer: current status and future perspectives

The number of early gastric cancer (EGC) cases has been increasing because of improved diagnostic procedures including endoscopy and screening systems. Therefore, function-preserving gastrectomy (FPG) for EGC with the expectation of better quality of life (QOL) after surgery may be increasingly utilized, due to its association with low rate of lymph node metastasis and excellent survival and the possibility of employing less invasive procedures such as laparoscopic gastrectomy in combination. Pylorus-preserving gastrectomy (PPG) with curative intent lymph node dissection is a representative FPG that has been used in EGC, and its superiorities, indications, limitations, and survival benefits have already been reported in several retrospective studies. Laparoscopic proximal gastrectomy (LAPG) has also been employed in EGC of the upper third of the stomach; however, LAPG was found to be associated with major issues in achieving a balance between swallowing and reflux prevention. In patients with EGC in the upper third of the stomach, laparoscopy-assisted subtotal gastrectomy with a preserved, albeit very small, stomach may provide a better QOL and fewer postoperative complications. FPG is recommended as a surgical treatment for EGC if the indication is accurately diagnosed and strictly confirmed; however, these techniques in laparoscopic surgery present technical difficulties to surgeons without a certain degree of skills. Although many retrospective studies revealed the functional benefits or oncological safety with FPG, further prospective studies using large case series are necessary to reveal the value of FPG compared with the conventional procedures.

A nomogram to predict lymph node metastasis in patients with early gastric cancer

Background

Lymph node status is crucial to determining treatment for early gastric cancer (EGC). We aim to establish a nomogram to predict the possibility of lymph node metastasis (LNM) in EGC patients.

Methods

Medical records of 952 EGC patients with curative resection, from 2002 to 2014, were retrospectively retrieved. Univariate and multivariate analysis were performed to examine risk factors associated with LNM. A nomogram for predicting LNM was established and internally validated.

Results

Five variables significantly associated with LNM were included in our model, these are sex (Odd ratio [OR] = 1.961, 95% confidence index [CI], 1.334 to 2.883; P = 0.001), depth of tumor (OR = 2.875, 95% CI, 1.872 to 4.414; P = 0.000), tumor size (OR = 1.986, 95% CI, 1.265 to 3.118; P = 0.003), histology type (OR = 2.926, 95% CI, 1.854 to 4.617; P = 0.000) and lymphovascular invasion (OR = 4.967, 95% CI, 2.996 to 8.235; P = 0.000). The discrimination of the prediction model was 0.786.

Conclusions

A nomogram for predicting lymph node metastasis in patients with early gastric cancer was successfully established, which was superior to the absolute endoscopic submucosal dissection (ESD) indication in terms of the clinical performance.

Gastric cancer treatment: similarity and difference between China and Korea

Chinese populations have many demographic similarities to Korean populations. However, the long-term survival rates of gastric cancer patients in China are still not satisfactory when compared with Korea, especially for the advanced cases. In this article, we discuss about the similarity and difference of gastric cancer treatment in terms of screening, surgical approach, stomach resection, digestive tract reconstruction, lymphadenectomy, harvested lymph nodes, operative morbidity and mortality, postoperative chemotherapy as well as follow-up between China and Korea. Given that a variety of factors ranging from tumor characteristics to different treatment strategies are seen between the two countries, the reasons accounting for the differences in survival should be focused and the corresponding strategy should be considered and finally promote to improve the prognosis of gastric cancer.

Double-tract reconstruction after laparoscopic proximal gastrectomy using detachable ENDO-PSD

BACKGROUND

Proximal gastrectomy (PG) is widely performed in Japan as a function-preserving surgical approach. Since esophagogastrostomy (EG) was associated with increased reflux symptoms and anastomotic strictures, we have chosen double-tract reconstruction (DTR) as the standard reconstruction method since March 2013. In this study, we described a novel method of laparoscopic DTR using detachable ENDO-PSD and compared its 1-year outcome with EG performed formerly in our institution.

METHODS

Patients who underwent laparoscopic PG between May 2005 and July 2014 were retrospectively divided into two groups based on the type of reconstruction and were subsequently analyzed (19 patients in the DTR group and 22 in the EG group). All of them underwent a laparoscopic PG with regional lymph node dissection. In the DTR group, the lower left port site was extended to 4 cm, and an intracorporeal purse-string suture was performed using the detachable ENDO-PSD. The jejunogastrostomy was fashioned on the anterior side of the remnant stomach parallel to the transection line, 2 cm from the cut end. The EG group used the conventional purse-string suture instrument through the 6 cm upper midline mini-laparotomy incision. Patient characteristics, operative data, early operative complications and 1-year postoperative follow-up findings were compared between the two groups.

RESULTS

The frequencies of reflux symptoms (10.5 vs. 54.5%, P = 0.003), usage of proton pump inhibitors (31.6 vs. 72.7%, P = 0.008), and anastomotic strictures (0 vs. 27%, P = 0.014) were significantly lower in the DTR group as compared to the EG group. There were no significant differences between the two groups with regard to operation time, blood loss, postoperative hospital stay, postoperative complications, average postoperative/preoperative weight loss ratio, and postoperative/preoperative ratio of biochemical markers (hemoglobin, total protein, albumin, cholesterol).

CONCLUSION

Our results indicate that DTR is a useful reconstruction method after PG, especially in terms of preventing reflux esophagitis and anastomotic strictures.

Laparoscopic proximal gastrectomy with double tract reconstruction is superior to laparoscopic total gastrectomy for proximal early gastric cancer

BACKGROUND

Laparoscopic proximal gastrectomy (LPG) with double tract reconstruction (DTR) is known to reduce reflux symptoms, which is a major concern after proximal gastrectomy. The aim of this study is to compare retrospectively the clinical outcomes of patients undergoing LPG with DTR with those treated by laparoscopic total gastrectomy (LTG).

METHODS

Ninety-two and 156 patients undergoing LPG with DTR and LTG for proximal stage I gastric cancer were retrospectively analyzed for short- and long-term clinical outcomes.

RESULTS

There were no significant differences in the demographics, T-stage, N-stage, and complications between the groups. The LPG with DTR group had a shorter operative time and lower estimated blood loss than the LTG group (198.3 vs. 225.4 min, p < 0.001; and 84.7 vs. 128.3 mL p = 0.001). The incidence of reflux symptoms ≥ Visick grade II did not significantly differ between the groups during a mean follow-up period of 37.2 months (1.1 vs. 1.9%, p = 0.999). The hemoglobin change was significantly lower in the LPG with DTR group compared to in the LTG group in the first and second postoperative years (5.03 vs. 9.18% p = 0.004; and 3.45 vs. 8.30%, p = 0.002, respectively), as was the mean amount of vitamin B₁₂ supplements 2 years after operation (0.1 vs. 3.1 mg, p < 0.001). The overall survival rate was similar between the groups.

CONCLUSIONS

LPG with DTR maintained comparable oncological safety and anastomosis-related late complications compared to LTG and is preferred over LTG in terms of preventing postoperative anemia and vitamin B₁₂ deficiency.

Clinical Outcomes and Evaluation of Laparoscopic Proximal Gastrectomy with Double-Flap Technique for Early Gastric Cancer in the Upper Third of the Stomach

BACKGROUND

A novel double-flap esophagogastrostomy technique developed to prevent reflux after proximal gastrectomy was applied to laparoscopic proximal gastrectomy (LPG), and the clinical outcomes of this technique (LPG-DFT) were evaluated and compared to those of laparoscopic total gastrectomy (LTG).

METHODS

This retrospective study of 90 patients with early gastric cancer (EGC) in the upper third of the stomach compared surgical outcomes, postoperative endoscopic findings, and nutritional status between two procedure groups, LPG-DFT (n = 43) and LTG (n = 47). The association between morbidity and surgical procedure was analyzed by controlling for body mass index (BMI).

RESULTS

Mean operation time was significantly higher for LPG-DFT than LTG (386.5 vs. 316.3 min, P < 0.001). The morbidity and the frequency of anastomotic complications were lower, although not significantly, for LPG-DFT than LTG (7.0 vs. 21.3%, P = 0.073; and 4.7 vs. 17.2%, P = 0.093). Median postoperative hospital stay was significantly shorter for LPG-DFT than LTG (10 vs. 13 days, P = 0.002). The LPG-DFT procedure was identified as the most significant independent predictor of low morbidity after adjustment for BMI (P = 0.028, OR = 0.232, 95% CI 0.047-0.862). LTG induced more severe reflux esophagitis than LPG-DFT (14.9% vs. 2.3%, P = 0.06). The mean baseline weight, total protein, and hemoglobin were significantly higher with LPG-DFT than with LTG (P < 0.05).

CONCLUSIONS

LPG-DFT is a better surgical procedure for treating upper-third EGC than LTG in terms of morbidity, postoperative hospital stay, and postoperative nutritional status.

Genome-Wide lncRNA Microarray Profiling Identifies Novel Circulating lncRNAs for Detection of Gastric Cancer

Long non-coding RNAs (lncRNAs) can serve as blood-based biomarkers for cancer detection. To identify novel lncRNA biomarkers for gastric cancer (GC), we conducted, for the first time, genome-wide lncRNA screening analysis in two sets of samples: five paired preoperative and postoperative day 14 plasma samples from GC patients, and tissue samples from tumor and adjacent normal tissues. Candidate tumor-related lncRNAs were then quantitated and evaluated in three independent phases comprising 321 participants. The expression levels of lncRNAs were also measured in GC cell lines and the corresponding culture medium. Biomarker panels, lncRNA-based Index I and carcinoembryonic antigen (CEA)-based Index II, were constructed using logistic regression, and their diagnostic performance compared. Fagan's nomogram was plotted to facilitate clinical application. As a result, we identified five novel plasma lncRNAs (TINCR, CCAT2, AOC4P, BANCR and LINC00857), which, when combined in the lncRNA-based Index I, outperformed the CEA-based Index II (P < 0.001) and could distinguish GC patients from healthy controls with an area under the receiver-operating curve (AUC) of 0.91 (95% confidence interval (CI): 0.88-0.95). The lncRNA-based index decreased significantly by postoperative day 14 (P = 0.016), indicating its ability to monitor tumor dynamics. High values of the lncRNA-based index were correlated with tumor size (P = 0.036), depth of invasion (P = 0.025), lymphatic metastasis (P = 0.012) and more advanced tumor stages (P = 0.003). The lncRNA-based index was also able to discriminate GC patients from precancerous individuals and patients with gastrointestinal stromal tumor with AUC values of 0.82 (95% CI: 0.71-0.92) and 0.80 (95% CI: 0.68-0.91), respectively. Taken together, our findings demonstrate that this panel of five plasma lncRNAs could serve as a set of novel diagnostic biomarkers for GC detection.

Effectiveness of postoperative elemental diet (Elental®) in elderly patients after gastrectomy

Background

We aimed to investigate the efficacy of postoperative early intervention with an elemental diet to reduce weight loss and enhance recovery after gastrectomy. Nutritional status and gastrointestinal immune function tend to worsen, and postoperative weight loss is inevitable in these patients; therefore, improvement in their postoperative condition is important, especially in gastric cancer patients aged ≥80 years.

Methods

Clinical outcomes and postoperative nutritional status were compared between 21 and 22 consecutive elderly patients aged ≥80 years who underwent distal gastrectomy before and after the introduction of postoperative oral elemental diet (Elental®, 300 kcal/day), respectively, between October 2011 and June 2016.

Results

A significant reduction in postoperative complications was noted in the nutrition support group (N-group) as compared with the control group (C-group). In particular, the prevalence of systemic complications was significantly lower in the N-group (33.3 vs. 4.5 %, p = 0.015), whereas no significant difference was observed in the prevalence of locoregional complications. The percentage of weight loss and reduction in BMI from 1 month to 1 year after surgery was significantly lower in the N-group (p = 0.012 each). The nutrition status (albumin, total protein, hemoglobin, and C-reactive protein levels) at 1 month after surgery showed improvements (p = 0.005, p = 0.048), and hospital stay was decreased in the N-group as compared to the C-group (16.0 vs. 12.5 days, p = 0.041).

Conclusions

Early intervention with an elemental diet after distal gastrectomy is valuable for reducing perioperative weight loss and improving nutritional management and may be associated with enhanced postoperative recovery in elderly patients.

Laparoscopic proximal gastrectomy for early gastric cancer

The incidence of proximal early gastric cancer (EGC) is increasing, and while laparoscopic proximal gastrectomy (LPG) has been performed as a surgical option, it is not yet the standard treatment, because there is no established common reconstruction method following proximal gastrectomy (PG). We reviewed the English-language literature to clarify the current status and problems associated with LPG in treating proximal EGC. This procedure is considered indicated for EGC located in the upper third of the stomach with clinical T1N0, but not when it can be treated endoscopically. No operative mortality or conversion to open surgery was reported in our review, suggesting that this procedure is technically feasible. The most frequent postoperative complication involved problems with anastomoses, possibly caused by the technical complexity of the reconstruction. Although various reconstruction methods following open PG (OPG) and LPG have been reported, there is no standard reconstruction method. Well-designed multicenter, randomized, controlled, prospective trials to evaluate the various reconstruction methods are necessary.

The effects of laparoscopic spleen-preserving splenic hilar lymphadenectomy on the surgical outcome of proximal gastric cancer: a propensity score-matched, case-control study

BACKGROUND

The evidence regarding the long-term results of laparoscopic spleen-preserving splenic hilar lymphadenectomy (LSPL) has only been rarely reported. The aim of this study was to investigate the feasibility and oncologic efficacy of LSPL for locally advanced proximal gastric cancer.

METHODS

From May 2007 to December 2012, we prospectively collected and retrospectively analyzed the data of 548 patients who underwent laparoscopic radical total gastrectomy due to proximal gastric cancer. The patients were grouped according to spleen-preserving splenic hilar lymphadenectomy (200 in the D2 group and 348 in the D2-group). The short- and long-term outcomes were compared between the two groups after propensity score matching.

RESULTS

Before matching, TNM stages were significantly different between the D2 and D2-groups. After propensity score matching, the two groups were well balanced in clinicopathologic characteristics. After matching, the time for lymph node dissection was longer in the D2 group, but a greater number of lymph nodes were dissected; the estimated blood loss, time to first flatus and duration of hospital stay were similar in the two groups. Furthermore, no significant differences in morbidity and mortality were found. Before matching, the 3-year overall survival (OS) and disease-free survival (DFS) rates of the D2 group were comparable with those of the D2-group (62.4 vs. 57.7 %, p = 0.076). After matching, the 3-year OS remained comparable, but the D2 group showed significantly longer 3-year DFS (61.6 vs. 53.7 %, p = 0.034). Stratified analysis showed that, in stage III patients, the D2 group had better 3-year DFS. Multivariate Cox regression showed that age (p = 0.003), operation (p = 0.001) and pN stage (p < 0.001) were independent prognostic factors.

CONCLUSIONS

LSPL is a safe and feasible procedure, and patients with stage III proximal gastric cancer might obtain higher 3-year DFS rates.

Restoration of gastrointestinal motility ameliorates nutritional deficiencies and body weight loss of patients who undergo laparoscopy-assisted proximal gastrectomy

BACKGROUND

Esophagogastrostomy after proximal gastrectomy (PG) is a simple and safe reconstruction, but it leads to a high incidence of reflux esophagitis and impairs postoperative quality of life. We have already reported gastric tube (GT) reconstruction after PG and performed it on more than 100 patients. No studies have reported long-term outcomes after PG-GT. The aim of this study was to investigate long-term outcomes, including nutrition indices, such as body weight, serum albumin, total protein, hemoglobin, and ferritin after PG, and observe recovery of upper gastrointestinal tract motility.

METHODS

We analyzed body weight loss and laboratory findings at our outpatient clinic at 1, 6, 12, 24, 36, 48, and 60 months postoperatively. Manometric recording was carried out at 1, 2, 3, 4, and 5 years after surgery.

RESULTS

The percentage change in body weight in the PG-GT group was significantly larger than that in the PG-JI and TG-RY groups at 2.5, 3, 4, and 5 years after surgery. The levels of hemoglobin and ferritin in the PG-GT and PG-JI groups were significantly higher than those in the TG-RY group at all time points except 6 months after surgery. In the fasted state, the phase III originated at the gastric tube was propagated to the duodenum 3 years after surgery. In the fed state, phasic contractions of the duodenum were in harmony with gastric tube contractions 3 years after surgery.

CONCLUSIONS

PG-GT is the least invasive procedure, and restoration of gastrointestinal motilities in the gastric tube and duodenum may ameliorate body weight loss and nutritional status, including anemia, in patients after PG.