Surgical outcomes of laparoscopic distal gastrectomy compared to open distal gastrectomy: A retrospective cohort study based on a nationwide registry database in Japan

Assessment of diagnostic value of indocyanine green for lymph node metastasis in laparoscopic subtotal gastrectomy with D2 lymphadenectomy for gastric cancer: a prospective single-center study

PURPOSE

Evaluation of diagnostic value for lymph node (LN) metastasis and LN identification using indocyanine green (ICG) fluorescence in laparoscopic subtotal gastrectomy for gastric cancer.

METHODS

A prospective study on 79 patients who underwent radical subtotal gastrectomy with the use of ICG-guided LN dissection. The sensitivity and specificity of the ICG fluorescence lymphography method in detecting metastatic LNs were evaluated.

RESULTS

A total of 79 patients underwent surgery. The number of LNs was retrieved: 2992 LNs, of which 2392 were fluorescent (79.9%) and 600 were nonfluorescent (20.1%). The average number of LNs dissected was 37.7 ± 11.8 LNs, and the average number of fluorescent LNs was 30.3 ± 11.1; the LN metastasis rates in the total LNs and in the ICG group were 6.79% and 7.34%, respectively. The median number of retrieved LNs in patients with LN metastases (37 [IQR, 33-47]) was higher than in patients without LN metastases (36 [IQR, 27-43]), (P = .348). The median number of fluorescent LNs was significantly higher in patients with LN metastases (32 [IQR, 26-44]) than in those without LN metastases (26 [IQR, 21-36]; P < .001). The sensitivity of ICG in metastasis detection was 75.86% (22 of 29 patients), with a false-negative rate of 24.14% (7 of 29 patients). For the identification of metastatic LNs, the sensitivity of ICG was 90.7%, with the specificity of 20.8%. The negative predictive value of nonfluorescent LNs was 97%.

CONCLUSION

ICG fluorescence lymphography-guided lymphadenectomy can clearly visualize the lymphatic system and the LNs alongside the tumor. The high sensitivity in detecting metastatic LNs and the high negative predictive value of a nonfluorescent LNs suggest that this is an effective method for clinically radical gastrectomy for gastric cancer.

A Path to High-Value Gastric Cancer Surgery Care Delivery

Objective

To evaluate the feasibility, safety, and effectiveness of a comprehensive regional program, including the Minimally Invasive Recovery and Empowerment Care (MIREC) pathway, that can significantly reduce hospital stays after laparoscopic gastrectomy without increasing adverse events.

Background

Cost-effectiveness and improving patient outcomes are crucial in providing quality gastric cancer care worldwide.

Methods

To compare the outcomes of gastric cancer surgery using 2 different models of care within an integrated healthcare system from February 2012 to March 2023. The primary endpoint was the length of hospital stay. The secondary endpoints were the need for intensive care unit care, emergency room (ER) visits, readmission, reoperation, and death within 30 days after surgery.

Results

There were 553 patients, 167 in the pre-(February 2012-April 2016) and 386 in the post-MIREC period (May 2016-March 2023). Perioperative chemotherapy utilization increased from 31.7% to 76.4% (P < 0.0001). Laparoscopic gastrectomy increased from 17.4% to 97.7% (P < 0.0001). Length of hospitalization decreased from 7 to 2 days (P < 0.0001), with 32.1% and 88% of patients discharged home on postoperative day 1 and postoperative day 2, respectively. When comparing pre- and post-MIREC, intensive care unit utilization (10.8% vs. 2.9%, P < 0.0001), ER visits (34.7% vs. 19.7%, P = 0.0002), and readmission (18.6% vs. 11.1%, P = 0.019) at 30 days were also considerably lower. In addition, more patients received postoperative adjuvant chemotherapy (31.4% to 63.5%, P < 0.0001), and the time between gastrectomy and starting adjuvant chemotherapy was also less (49-41 days; P = 0.002).

Conclusion

This comprehensive regional program, which encompasses regionalization care, laparoscopic approach, modern oncologic care, surgical subspecialization, and the MIREC pathway, can potentially improve gastric cancer surgery outcomes. These benefits include reduced hospital stays and lower complication rates. As such, this program can revolutionize how gastric cancer surgery is delivered, leading to a higher quality of care and increased value to patients.

The development of a risk assessment tool for patients with postoperative pneumonia after gastrectomy for gastric cancer

BACKGROUND

Although frail patients are known to experience increased postoperative complications, this is unclear for postoperative pneumonia (POP). We investigated associations between frailty and POP in patients with gastric cancer (GC) undergoing gastrectomy.

METHODS

In this prospective study conducted between August 2016 and December 2022, we preoperatively assessed frailty in 341 patients with GC undergoing gastrectomy using a frailty index (FI). Patients were divided into high FI vs low FI groups to examine frailty and pneumonia rates after gastrectomy for GC.

RESULTS

Of 327 patients, 18 (5.5%) experienced POP after gastrectomy. Multivariate analyses showed that a high FI and total or proximal gastrectomy (TG/PG) were independent risk factors for POP (high FI: odds ratio [OR], 5.00; 95% CI, 1.77-15.54; TG/PG: OR, 3.07; 95% CI, 1.09-8.78). The proportion of patients with POP was 2.4% in those with nonhigh FI and non-TG/PG, 5.3% in those with nonhigh FI and TG/PG, 7.1% in those with high FI and non-TG/PG, and 28.0% in those with high FI and TG/PG (P < .001). The area under the receiver operating characteristic curve for this risk assessment for predicting POP was 0.740.

CONCLUSION

In patients with GC undergoing gastrectomy, POP was independently associated with preoperatively high FI and TG/PG. Our simple POP risk assessment method, which combines these factors, may effectively predict and prepare patients for POP.

A multi-institutional prospective observational study to compare postoperative quality of life of patients who undergo total or proximal gastrectomy for early gastric cancer (CCOG1602)

BACKGROUND

Proximal gastrectomy (PG) has become an increasingly preferred procedure for treating early cancer in the upper third of the stomach. However, advantages of PG in postoperative quality of life (QOL) over total gastrectomy (TG) has not fully proven.

METHODS

We conducted a multi-institutional prospective observational study (CCOG1602) of patients who undergo TG or PG for cStage I gastric cancer. We used the PGSAS-37 and EORTC-QLQ-C30 to evaluate the changes in body weight and QOL over a 3-year postoperative period. The primary endpoint was the weight loss rate 3 years after surgery.

RESULTS

We enrolled 109 patients from 18 institutions and selected 65 and 19 patients for inclusion in the TG and PG groups, respectively. Mean postoperative weight loss rates were 16.0% and 11.7% for the TG and PG groups, respectively (p = 0.056, Cohen's d 0.656) during postoperative year 1% and 15.0% and 10.8% for TG and PG (p = 0.068, Cohen's d 0.543), respectively, during postoperative year 3, indicating that the PG group achieved a better trend with a moderate effect size. According to the PGSAS-37, the PG group experienced a better trend in the indigestion subscale (p < 0.001, Cohen's d -1.085) and total symptom score (p = 0.050, Cohen's d -0.59) during postoperative year 3 compared with the TG group. In contrast, the EORTC-QLQ-C30 detected no difference between the groups at any time point during 3-year postoperative period.

CONCLUSIONS

This prospective study demonstrates that PG tended to be more favorable compared with TG with respect to postoperative weight loss and QOL, particularly regarding indigestion.

Book-Binding Technique in Totally Laparoscopic Distal Gastrectomy with Billroth I Reconstruction: Clinical Results and Outcomes in 188 Patients with Gastric Cancer

BACKGROUND

Laparoscopic gastrectomy is widely used as a curative treatment for gastric cancer. Although delta-shaped anastomosis is commonly used for Billroth I anastomosis after totally laparoscopic distal gastrectomy (TLDG), it has some drawbacks. The book-binding technique (BBT) was developed as an alternative, and this study aimed to examine its short-term results in 188 consecutive cases.

STUDY DESIGN

This retrospective study included patients who underwent BBT reconstruction after TLDG for gastric malignancy between 2011 and 2020. BBT is a technique for intracorporeal gastroduodenostomy, which is a triangular anastomosis with a linear stapler that does not require additional dissection or rotation of the duodenum. The short-term outcomes of BBT reconstruction and postoperative endoscopic findings were analyzed.

RESULTS

This study evaluated 188 patients who underwent TLDG and BBT reconstruction. Anastomotic stenosis and leakage occurred in 1.1% and 0.5% of the patients, respectively. The median time to the first diet was 3.1 days, and the median postoperative hospital stay was 11.9 days. BBT anastomoses were performed by 19 surgeons and took an average of 32.8 minutes to complete, with completion times decreasing as the surgical team became more proficient. On endoscopy performed 1 year postoperatively, 5.2% had reflux esophagitis (grade A or higher), 67.8% had gastritis (grade 1 or higher), 37.4% had residual food (grade 1 or higher), and 37.4% had bile reflux (grade 1).

CONCLUSIONS

BBT is a safe and feasible method for intracorporeal gastroduodenostomy in TLDG for patients with gastric malignancy and demonstrates good surgical outcomes.

Effectiveness of preserved vagal nerve in totally laparoscopy radical distal gastrectomy: a matched-paired cohort analysis

BACKGROUND

The aim of this retrospective matched-paired cohort study was to clarify the effectiveness of preserving the vagus nerve in totally laparoscopic radical distal gastrectomy (TLDG).

METHODS

One hundred eighty-three patients with gastric cancer who underwent TLDG between February 2020 and March 2022 were included and followed up. Sixty-one patients with preservation of the vagal nerve (VPG) in the same period were matched (1:2) to conventional sacrificed (CG) cases for demographics, tumor characteristics, and tumor node metastasis stage. The evaluated variables included intraoperative and postoperative indices, symptoms, nutritional status, and gallstone formation at 1 year after gastrectomy between the two groups.

RESULTS

Although the operation time was significantly increased in the VPG compared with the CG (198.0 ± 35.2 vs. 176.2 ± 35.2 min, P < 0.001), the mean time of gas passage in the VPG was significantly lower than that in the CG (68.1 ± 21.7 h vs. 75.4 ± 22.6 h, P = 0.038). The overall postoperative complication rate was similar between the two groups (P = 0.794). There was no statistically significant difference between the two groups hospital stay, total number of harvested lymph nodes, and mean number of examined lymph nodes at each station. During follow-up, the morbidity of gallstones or cholecystitis (8.2% vs. 20.5%, P = 0.036), chronic diarrhea (3.3% vs. 14.8%, P = 0.022), and constipation (4.9% vs. 16.4%, P = 0.032) were significantly lower in the VPG than in the CG in this study. Moreover, injury to the vagus nerve was found to be an independent risk factor for gallstone formation or cholecystitis and chronic diarrhea in univariate analysis and multivariate analysis.

CONCLUSION

The vagus nerve plays an imperative role in gastrointestinal motility, and hepatic and celiac branch preservation mainly exerts efficacy and safety in patients who undergo TLDG.

Effect of blood product transfusion on the prognosis of patients undergoing hepatectomy for hepatocellular carcinoma: a propensity score matching analysis

BACKGROUND

Hepatectomy, the most common treatment for hepatocellular carcinoma, is associated with greater intraoperative blood loss than is resection of other malignancies. The effect of blood product transfusion (red blood cell [RBC], platelet, fresh frozen plasma [FFP], 5 and 25% albumin) on prognosis remains unclear. This study examined effects of blood product transfusion on prognoses of patients who underwent hepatectomy for hepatocellular carcinoma.

METHODS

We included 2015 patients with pathologically confirmed hepatocellular carcinoma who underwent hepatectomy at our institution during 1990-2019. Patients (n = 534) who underwent repeat hepatectomy, non-curative hepatectomy, those with synchronous cancer in other organs, those who died within 1 month of surgery, and those with missing data were excluded. Finally, 1481 patients (1142 males, 339 females; median age: 68 years) with curability A or B were included.

RESULTS

Intraoperative blood loss (> 500 mL) was an independent predictor of RBC transfusion (odds ratio, 8.482; P < 0.001). All transfusion groups had poorer recurrence-free survival (RFS) and overall survival (OS) than non-transfusion groups. After propensity score matching, the 5 year RFS rate was 13.4 and 16.3% in the RBC and no-RBC groups, respectively (P = 0.020). The RBC group had a significantly lower 5 year OS rate than the no-RBC group (42.1 vs. 48.8%, respectively; P = 0.035) and the FFP group (57.0%) than the no-FFP group (63.9%) (p = 0.047). No significant between-subgroup differences were found for other blood transfusion types.

CONCLUSIONS

RBC transfusion promotes hepatocellular carcinoma recurrence and RBC/FFP transfusions reduced long-term survival and RFS and OS in patients who underwent radical liver resection of HCC.

Comprehensive evaluation of three-dimensional anatomy of perigastric vessels using enhanced multidetector-row computed tomography

BACKGROUND

To perform laparoscopic gastrectomy safely, we aimed to comprehensively re-evaluate perigastric vessel anatomies using a three-dimensional angiography reconstructed from enhanced multidetector-row computed tomography data.

METHODS

Perigastric vessel anatomy was preoperatively analyzed using a multidetector-row computed tomography-based three-dimensional angiography reconstructed in 127 patients undergoing gastric surgery.

RESULTS

Of the 67 left gastric veins that ran along the dorsal side of the arteries, 59 (88.1%) ran along the dorsal side of the common hepatic artery and flowed into the portal vein. In 18 cases, a common trunk of one to three left gastric arteries and the replaced left hepatic artery was observed. The left inferior phrenic artery ramified from the left gastric artery in 5.5% of the cases. The right gastric artery was classified into distal (73.2%), caudal (18.1%), and proximal (8.7%) types. The infra-pyloric artery was also classified into distal (64.6%), caudal (26.0%), and proximal (9.4%) types. The posterior gastric artery branched as a common trunk with the superior polar artery in the proximal (37.9%) and distal (18.4%) regions of the splenic artery. The left gastroepiploic artery ramified from the splenic (18.1%) and inferior terminal arteries (81.9%). No, one, and two gastric branches of the left gastroepiploic artery, which ramified between the roots of the left gastroepiploic artery and its omental branch, were found in 36.5%, 49.2%, and 14.3% of the cases, respectively.

CONCLUSIONS

Preoperative 3D angiography is useful for the precise evaluation of perigastric vessel anatomies, and may help us to perform laparoscopic gastrectomy and robotic surgery safely.

Phase 2 trial of neoadjuvant docetaxel, oxaliplatin, and S‐1 for clinical stage III gastric or esophagogastric junction adenocarcinoma

Background

Although perioperative treatment has been the standard of care for resectable gastric cancer in the West, postoperative adjuvant chemotherapy is still the standard in Japan. We conducted the first phase 2 trial to investigate the efficacy and safety of neoadjuvant docetaxel, oxaliplatin, and S-1 (DOS) chemotherapy for cStage III gastric or esophagogastric junction (EGJ) adenocarcinoma in Japan.

Methods

Eligibility criteria included cStage III adenocarcinoma of the stomach or EGJ. Patients received docetaxel (40 mg/m², day 1), oxaliplatin (100 mg/m², day 1), or S-1 (80 mg/m², days 1-14) during a 3-week cycle. After two or three cycles of DOS, patients underwent surgical resection. The primary endpoint was progression-free survival (PFS).

Results

Between June 2015 and March 2019, 50 patients were enrolled from four institutions. Of 48 eligible patients (37 gastric and 11 EGJ adenocarcinoma), 42 (88%) completed two or three DOS cycles. Grade 3-4 neutropenia and diarrhea occurred in 69% and 19% of patients, respectively, but there were no treatment-related deaths. R0 resection was achieved in 44 (92%) patients, and the pathological response rate (≥ grade 1b) was 63% (30/48). The 3-year PFS, overall survival, and disease-specific survival rates were 54.2%, 68.7%, and 75.8%, respectively.

Conclusion

Neoadjuvant DOS chemotherapy had a sufficient antitumor effect and tolerable safety profile in patients with gastric or EGJ adenocarcinoma. The survival benefit of a neoadjuvant strategy using our DOS regimen should be validated in phase 3 trials.

Ingenuity and tips for laparoscopic local resection for local recurrence of early gastric cancer after endoscopic submucosal dissection: A case report

INTRODUCTION AND IMPORTANCE

The presence of severe comorbidities is associated with poor surgical outcomes in patients who undergo curative resection for gastric cancer. Herein, we present a report of laparoscopic local resection (LLR) for the local recurrence of gastric cancer in a patient with severe comorbidities.

CASE PRESENTATION

A 73-year-old man underwent endoscopic submucosal dissection (ESD) for an early gastric cancer located at the greater curvature of the gastric antrum. One year after the ESD, follow-up gastroscopy revealed a local recurrence.

CLINICAL DISCUSSION

LLR was performed owing to severe comorbidities such as chronic heart failure, severe chronic obstructive pulmonary disease, and diabetes mellitus. We confirmed the location of the tumor with an endoscope, and full-thickness stitches were placed outside the tumor to prevent displacement between the submucosal and serosal muscular layers. Full-thickness resection of the stomach wall was performed along the stitch points using an ultrasonic shear. The edge of the resection line was closed using a laparoscopic stapling system. The patient had an uneventful postoperative course and was discharged 8 days after the operation. The patient had no disease recurrence and late complications such as digestive symptom and weight loss at the 9-month follow-up after the operation.

CONCLUSION

LLR might be a suitable treatment option for high-risk patients with gastric cancer. During full-thickness resection of the stomach wall, our method enables the maintenance of a negative margin without the need for ESD.

Postoperative Pyoderma Gangrenosum in a Laparoscopic Gastrectomy Port Site: A Case Report

Background

Postoperative pyoderma gangrenosum (PPG) is a rare inflammatory skin disease of unknown etiology characterized by blistering and ulcerative lesions in postoperative wounds. Untreated pyoderma gangrenosum (PG) is potentially life-threatening; therefore, immediate and appropriate treatment is essential. Although PPG and surgical site infection (SSI) present similar clinical findings, they should be differentiated because of their conflicting treatment modalities.

Case presentation

An 82-year-old man with comorbidities of pulmonary tuberculosis, chronic obstructive pulmonary disease, and diabetes underwent laparoscopic gastrectomy for gastric cancer. On postoperative day 6, fever exceeding 39°C, port wound redness, and pain was observed. Laboratory tests revealed severe inflammatory reactions: white blood cell, 42,800/μL and C-reactive protein, 30.2 mg/mL. The patient was diagnosed with SSI and treatment with antibiotics and drainage was started; however, his general and wound conditions also worsened. Therefore, he was diagnosed with PG because painful skin findings were exacerbated by external stimuli and no significant bacteria were detected in the culture test. Treatment with oral prednisolone was started, which significantly improved his skin and inflammatory conditions.

Conclusion

We managed a rare case of PPG that occurred in a port wound after laparoscopic gastrectomy. If atypical clinical findings of postoperative SSI are observed, general surgeons should recognize and consider PPG as a differential diagnosis.

Quantitative Comparison of Surgical Device Usage in Laparoscopic Gastrectomy Between Surgeons' Skill Levels: an Automated Analysis Using a Neural Network

BACKGROUND

Whether surgical device usage in laparoscopic gastrectomy differs with respect to operator's skill levels is unknown. Further, device usage analysis using artificial intelligence has not been reported to date. Herein, we compared the patterns of surgical device usage during laparoscopic gastrectomy for gastric cancer among surgeons at different skill levels. The data of device usage was acquired from laparoscopic video recordings using an automated surgical-instrument detection system.

METHODS

In total, 100 video recordings of infrapyloric lymphadenectomy and 33 of D2 suprapancreatic lymphadenectomy during laparoscopic gastrectomy for gastric cancer were analyzed in this retrospective study. The system's accuracy was evaluated by comparing the automatic and the manual usage time. Surgical device usage patterns were compared between qualified and nonqualified surgeons of The Japan Society for Endoscopic Surgery Endoscopic Surgical Skill Qualification System.

RESULTS

For every device, the automatic detection time and manual detection time were consistent with each other. In infrapyloric lymphadenectomy, the usage time proportions of dissector forceps and clip applier were higher among nonqualified operators than among qualified operators (dissector, 5.1% vs. 2.3%, P < 0.001; clip applier, 1.6% vs. 1.3%, P < 0.01). In suprapancreatic lymphadenectomy, the usage time proportions of energy devices, clip applier, and grasper forceps were significantly different (energy devices, 59.6% vs. 50.6%, P < 0.001; clip applier, 1.4% vs. 0.9%, P < 0.001; only grasper forceps; 18.3% vs. 27.9%, P = 0.022).

CONCLUSIONS

Quantitative analysis of laparoscopic device usage using the automated surgical device detection system showed that the patterns of device usage during laparoscopic gastrectomy differed depending on surgeons' skill levels. These differences could suggest how the qualified and nonqualified surgeons performed the procedures.

Comparison of postoperative pancreatic fistula between open and laparoscopic surgery in patients with gastric cancer: A meta-analysis

Background

Open gastrectomy"OG" compared with laparoscopic gastrectomy"LG" in patients with gastric cancer"GC" has been widely discussed over the past years. However, the lack of comparative analysis in postoperative pancreatic fistula "POPF" hinders its severity as surgical procedures developed rapidly. Therefore, there are still moot on whether one of these surgical options is superior in POPF.

Objective

To compare the incidence of POPF in patients undergoing OG and LG for gastric cancer "GC".

Methods

Articles from January 2011 to August 2021 that compared LG and OG for GC were reviewed. Cohort studies were included in our study. The quality of enrolled studies was evaluated. Outcomes regarding POPF complication and relative operation results were analyzed. Statistical analysis portrayed the Weighted mean difference"WMD"and the odds ratio"OR"with a 95% confidence interval "CI". The curative effect was analyzed using RevMan 5.4.1 software.

Results

Totally 7 articles met the inclusion criteria, including 3194 patients with treatment of gastrectomy surgeries for gastric cancer "GC". There was no significant difference observed in POPF incidence (OR, 95% CI = 1.04 [0.74,1.46], P = 0.81) between OG group and LG group in patients undergoing GC gastrectomy.

Conclusion

We stringently explored the current incidence of POPF after GC gastrectomy, comparing its incidence during LG and OG, there was no significant difference between OG and LG in the incidence of POPF, and surgeons should give more concern for improvement in surgical techniques. Further research is still needed to explore the risk of causes and surgical techniques should be considered cautiously in a clinical procedure.

Comparison of estimated treatment effects between randomized controlled trials, case-matched, and cohort studies on laparoscopic versus open distal gastrectomy for advanced gastric cancer: a systematic review and meta-analysis

PURPOSE

In actual surgical research, case-matched studies are frequently conducted as an alternative to randomized controlled trials (RCTs). However, it is still unclear what differences there are between RCTs and case-matched studies in upper gastrointestinal surgery, and clarifying them is a very important clinical issue. Thus, the purpose of this study was to investigate estimated treatment effects between RCTs, case-matched studies, and cohort studies regarding laparoscopic distal gastrectomy (LDG) for advanced gastric cancer (AGC).

METHODS

We searched the PubMed, Cochrane Central Register of Controlled Trials, and Web of Science databases for studies that compared LDG versus open distal gastrectomy for AGC published from the inception of the databases until July 2021. A meta-analysis was performed using the Review Manager version 5.3 software program from the Cochrane Collaboration, and six short-term outcomes and three long-term outcomes were assessed.

RESULTS

Twenty-three studies with 13698 patients were included. There was no difference in estimated treatment effects between RCTs and case-matched studies for all outcomes except for the number of retrieved lymph nodes and postoperative complications. In terms of intraoperative blood loss, postoperative hospital stay, number of retrieved lymph nodes, and recurrence, observational studies tended to overestimate the treatment effects.

CONCLUSION

The estimated treatment effects of LDG for AGC in the case-matched study were almost the same as in the RCTs. However, to assess the true magnitude of the treatment effect, the design and actual implementation of the analysis must be critically evaluated.

Incidence and risk factors for postoperative pancreatic fistula in 2089 patients treated by radical gastrectomy: A prospective multicenter cohort study in China

OBJECTIVE

To determine the incidence of clinically relevant postoperative pancreatic fistula (CR-POPF) following radical gastrectomy and to identify independent risk factors of CR-POPF.

BACKGROUND

CR-POPF and its sequelae are potential complications following radical gastrectomy. The reported incidence of CR-POPF was quite different across various regions, and no consensus was reached.

METHODS

Between December 2017 to November 2018, patients who underwent radical gastrectomy from 22 centers across 13 regions in China were prospectively recruited. The primary endpoint was the occurrence of CR-POPF, defined by the International Study Group of Pancreatic Fistula (ISGPF) in 2016. Clinically relevant change and short-term outcomes were recorded to diagnose and grade the POPF. Multivariate regression analyses were performed to identify independent risk factors of clinically relevant postoperative pancreatic fistula (CR-POPF).

RESULTS

A total of 2089 cases were analyzed. The incidence of biochemical leakage (BL) and CR-POPF were 19.6% and 1.1% respectively. All CR-POPF patients recovered well after appropriate treatment and no Grade C POPF were recorded. Logistic regression analysis showed pTNM III (OR, 2.940; 95% CI 1.180-7.325; P = 0.021) and LigaSure usage (OR, 6.618; 95% CI 1.847-23.707; P = 0.004) were independent risk factors of CR-POPF. LigaSure usage (OR, 4.817; 95% CI 1.184-19.598; P = 0.028), the drain amylase content (D-AMY) on postoperative day 3 (POD3) ≥5 times the upper limit of normal amylase (OR, 3.476; 95% CI 1.240-9.744; P = 0.018) and open surgery (OR, 2.463; 95% CI 1.003-6.050; P = 0.049) were independent predictors for identifying CR-POPF from BL.

CONCLUSION

In rich-experienced gastric cancer centers, there is high prevalence of BL secondary to radical gastrectomy without clinical impact. Fewer patients suffered Grade B POPF, and Grade C POPF was less common. The patients with pTNM III or LigaSure usage were prone to suffer CR-POPF. Surgery procedure, LigaSure usage combined with D-AMY measurement on POD3 are promising for early identification of CR-POPF.

Safe implementation of robotic gastrectomy for gastric cancer under the requirements for universal health insurance coverage: a retrospective cohort study using a nationwide registry database in Japan

BACKGROUND

Robotic gastrectomy (RG) has increased since being covered by universal health insurance in 2018. However, to ensure patient safety the operating surgeon and facility must meet specific requirements. We aimed to determine whether RG has been safely implemented under the requirements for universal health insurance in Japan.

METHODS

Data of consecutive patients with primary gastric cancer who underwent minimally invasive total or distal gastrectomy-performed by a surgeon certified by the Japan Society for Endoscopic Surgery (JSES) endoscopic surgical skill qualification system (ESSQS) between October 2018 and December 2019-were extracted from the gastrointestinal surgery section of the National Clinical Database (NCD). The primary outcome was morbidity over Clavien-Dindo classification grade IIIa. Patient demographics and hospital volume were matched between RG and laparoscopic gastrectomy (LG) using propensity score-matched analysis (PSM), and the short-term outcomes of RG and LG were compared.

RESULTS

After PSM, 2671 patients who underwent RG and 2671 who underwent LG were retrieved (from a total of 9881), and the standardized difference of all the confounding factors reduced to 0.07 or less. Morbidity rates did not differ between the RG and LG patients (RG, 4.9% vs. LG, 3.9%; p = 0.084). No difference was observed in 30-day mortality (RG, 0.2% vs. LG, 0.1%; p = 0.754). The reoperation rate was greater following RG (RG, 2.2% vs. LG, 1.2%; p = 0.004); however, the duration of postoperative hospitalization was shorter (RG, 10 [8-13] days vs. LG, 11 [9-14] days; p < 0.001).

CONCLUSIONS

Insurance-covered RG has been safely implemented nationwide.

The impact of pancreas compression time during minimally invasive gastrectomy on the postoperative complications in gastric cancer

AIM

Pancreas compression during minimally invasive gastrectomy causes blunt injury to the pancreas and leads to postoperative complications. However, the extent of practical compression associated with the incidence of postoperative complications remains unknown. This study aimed to evaluate the impact of pancreas compression, particularly the duration of compression, on short-term outcomes in minimally invasive gastrectomy for gastric cancer.

METHODS

This study included 178 patients who underwent laparoscopic or robotic gastrectomy at the Shizuoka Cancer Center in 2018. The total time of pancreas compression during gastrectomy was measured using video-reviews, and the correlation between the time and surgical outcomes was evaluated.

RESULTS

A duration of 3 min was selected as the cutoff value of pancreas compression time to predict high drain amylase concentration on postoperative day 1 (≥1000 U/L). The incidence of clinically relevant pancreatic fistula (1.5% vs 12.4%, P = .011) and all postoperative complications (12.3% vs 30.1%, P = .010) were significantly higher in the longer-compression group than in the shorter-compression group. The multivariable analysis identified longer compression as the only independent risk factor for postoperative complications.

CONCLUSION

More than a few minutes of pancreas compression during minimally invasive gastrectomy was associated with a higher incidence of postoperative complications.

Increasing rates of laparoscopic gastrointestinal surgery and decreasing rates of surgical site infections: an observational study in Japan from 2012-2017

BACKGROUND

Surgical site infections (SSI) are the most common healthcare-associated infection, and gastrointestinal surgery is frequently followed by a high incidence of SSI. Epidemiological analysis of the temporal trends in SSI following gastrointestinal surgery has yet to be performed in Japan. Our purpose was to descriptively investigate these trends.

METHODS

Extracting national surveillance data from the Japan Nosocomial Infections Surveillance (JANIS) system, we analyzed the frequency of SSI events following gastrointestinal surgery, which consisted of seven surgical procedures, from 2012-2017. We calculated the standardized infection ratio to compute risk-adjusted SSI frequency, and used the trend test to detect time-dependent changes.

RESULTS

The frequency of SSI events, except for those associated with surgery of the upper gastrointestinal tract, revealed a decreasing time-dependent trend. The use of laparoscopic surgery increased dramatically over time (p < 0.01 for the six applicable surgical sites), while the frequency of SSI events during laparoscopic surgery remained unchanged.

CONCLUSIONS

The increasing use of laparoscopic surgery was identified, and the observation coincided with the decreasing trend in SSI, especially in lower gastrointestinal tract surgery. If the relationship is causal, the overall SSI incidence among previously healthy individuals is expected to decrease, because the use of laparoscopic surgery has large growth potential in Japan.

Superiority trial comparing intraoperative wound irrigation with aqueous 10% povidone-iodine to saline for the purpose of reducing surgical site infection after elective gastrointestinal surgery: study protocol for a randomised controlled trial

INTRODUCTION

Surgical site infection (SSI) is one of the most common complications after gastrointestinal surgery, with a reported incidence of approximately 10%-25%, which is higher than the rates after other types of surgery. Intraoperative wound irrigation (IOWI) is a simple intervention for SSI prevention, and recent studies have reported that IOWI with aqueous povidone-iodine (PVP-I) is significantly more effective at reducing the incidence of SSI than saline. However, the evidence level of previous trials evaluating the efficacy of aqueous PVP-I solution for preventing SSI has been low.

METHODS AND ANALYSES

We propose a single-institute, prospective, randomised, blinded-endpoint trial to assess the superiority of IOWI with aqueous 10% PVP-I solution compared with normal saline for reducing SSI in clean-contaminated wounds after elective gastrointestinal surgery. In the study group, IOWI with 40 mL of aqueous 10% PVP-I solution is performed for 1 min before skin suture, and in the control group, IOWI with 100 mL of saline is performed for 1 min before skin suture. We hypothesise that IOWI with aqueous 10% PVP-I solution will achieve a 50% reduction in the incidence of SSIs. The target number of cases is set at 950. The primary outcome is the incidence of incisional SSI up to postoperative day 30 and will be analysed in the modified intention-to-treat set.

ETHICS AND DISSEMINATION

This trial was designed and is being conducted by Saitama Medical Center, Jichi Medical University, with approval from the Bioethics Committee for Clinical Research, Saitama Medical Center, Jichi Medical University. Participant recruitment began in June 2019. The final results will be reported in international peer-reviewed journals immediately after trial completion.

TRIAL REGISTRATION NUMBER

UMIN000036889.

Advantages of Laparoscopic Surgery for Gastric Cancer in Elderly Patients Aged Over 80 Years: A Propensity Score Matching Analysis

BACKGROUND

The short- and long-term efficacy of laparoscopic surgery for elderly patients with gastric cancer has not been evaluated. We aimed to use propensity score matching to clarify the efficacy of laparoscopic gastrectomy (LG) for elderly patients with gastric cancer aged ≥80 years.

METHODS

We retrospectively collected data from 159 consecutive patients with gastric cancer aged ≥80 years who underwent gastrectomy with curative intent at our institution between 2004 and 2015. Propensity score matching was applied to compare the open gastrectomy (OG) and LG. Short- and long-term outcomes were evaluated between the propensity-matched groups.

RESULTS

Patients' backgrounds and surgical factors were similar in both groups except for blood loss. The median time to first flatus was significantly shorter in the LG group than in the OG group (P = 0.002). The postoperative hospital stay was significantly shorter in the LG group (P = 0.014). The complication rate of Clavien-Dindo grade III or higher was significantly lower in the LG group (3% vs. 23%, P = 0.023). The 5-year overall survival and 5-year disease-specific survival rates were better in the LG group than in the OG group, but the differences were not significant (45% vs. 42% and 67% vs 57%, respectively).

CONCLUSION

LG was associated with good short-term outcomes and acceptable oncologic outcomes compared with OG in these propensity-matched patients aged ≥80 years.

The 140 years' journey of gastric cancer surgery: From the two hands of Billroth to the multiple hands of the robot

After the initial achievement by Billroth in 1881, surgery for gastric cancer has become increasingly extended. However, it turned out to be limited in Western countries after the publication that denied the role of extended surgery in the 1960s. While surgeons in Japan were still enthusiastic about extended surgery, the Japan Clinical Oncology Group (JCOG) conducted clinical trials to validate the role of extended surgery. Contrary to expectations, the efficacy of extended surgery was not demonstrated. In gastric cancer surgery, postoperative complications were reported to be associated with poor survival. A survival benefit could not be obtained by extended surgery, with high morbidity. Therefore, the paradigm had been changed from extended surgery to minimally invasive surgery (MIS). As an MIS for gastric cancer, laparoscopic surgery has been considered a practical method. Initial laparoscopic gastrectomy (LG) was first performed by Kitano in 1991. Thereafter, LG became increasingly common. Several clinical trials demonstrated the noninferiority of LG to open gastrectomy. LG is now regarded as the standard for cStage I gastric cancer, and the indication is expanding to advanced cancer. However, LG has some drawbacks owing to the restriction of movement caused by straight-shaped forceps. Robotic gastrectomy (RG) is considered a major breakthrough to circumvent the drawbacks in LG using articulated devices. However, the solid evidence demonstrating the advantage of RG has not been proved yet. The JCOG is now conducting a randomized controlled trial to evaluate the superiority of RG to LG in terms of reducing morbidity.

Impact of chronic kidney disease on the short- and long-term outcomes of laparoscopic gastrectomy for gastric cancer patients

BACKGROUNDS

This study was undertaken to investigate the impact of coexisting chronic kidney disease (CKD) on short- and long-term outcomes of laparoscopic gastrectomy in patients with gastric cancer (GC).

METHODS

We reviewed the data of 798 patients treated for GC by laparoscopic gastrectomy. All procedures took place between January 2010 and December 2017. Patients were divided into three groups according to their estimated glomerular filtration rate (eGFR): severe CKD group, 44 patients with eGFR < 45 mL/min/1.73 m2; moderate CKD group, 117 patients with 45 ≤ eGFR < 60; control group, 637 patients with eGFR ≥ 60.

RESULTS

Based on multivariate analysis, severe CKD (eGFR < 45) emerged as an independent predictor of anastomotic leak (Hazard ratio 4.63, 95% confidence interval [CI] 1.62-11.54). The 5-year overall survival (OS) rates by group were 46.3% (severe CKD), 76.6% (moderate CKD), and 81.5% (control). Multivariate analysis likewise identified severe CKD (eGFR < 45) as an independent correlate of poor 5-year OS. The 5-year cancer-specific survival (CSS) rates did not differ significantly by group.

CONCLUSIONS

An eGFR value less than 45 mL/min/1.73 m2 is a useful factor for predicting both anastomotic leak and 5-year OS in GC patients undergoing laparoscopic gastrectomy. Clinical care to improve eGFR should be reinforced before and after gastrectomy for GC patients with severe CKD.

[Evidence in minimally invasive oncological gastric surgery]

BACKGROUND

The aim of this study was to systematically review the current evidence on laparoscopic and robotic distal and total gastrectomy in comparison to open surgery.

MATERIAL AND METHODS

A systematic search of EMBASE and PubMed was conducted and 197 randomized (RCT) and non-randomized (non-RCT) studies were identified. An evaluation of early gastric cancer (EGC) and advanced (AGC) gastric cancer was carried out.

RESULTS

For EGC and laparoscopic distal resection (LDG) and total gastrectomy (LTG) a total of 10 RCT and 6 non-RCT, including 4329 patients (laparoscopic 2010 vs. open 2319) were identified. At a high evidence level (1+, 1++) there was no significant difference in terms of feasibility, intraoperative outcome and oncological quality, mortality and long-term oncological outcome compared to open gastrectomy (OG). After LDG and LTG patients showed a significantly faster early postoperative recovery and lower total morbidity. In contrast, the operation times were significant longer compared to ODG and OTG. For distal AGC and LDG in 6 RCT, including 2806 patients (LDG 1410 vs. ODG 1369) comparable results could be found also with a high evidence level (1++). The evidence for LTG in cases of AGC was lower (2-, 2+). Currently ,only 6 non-RCT with a total of 1090 patients (LTG 539 vs. OTG 551) are available, which showed comparable results to LDG but further high-quality RCTs are necessary. Robotic gastrectomy (RG) is currently being evaluated. According to the first studies RG for EGC seems to be equivalent to LDG; however, the evidence is currently low (3 to 2-).

Efficacy of minimally invasive distal gastrectomy for elderly patients with clinical stage I/IIA gastric cancer: a propensity-score matched analysis

BACKGROUND

Phase III trials have shown the non-inferiority of minimally invasive distal gastrectomy (MIDG) comparison with open distal gastrectomy (ODG) in patients with gastric cancer; however, it remains unclear whether MIDG is also effective in the elderly. This study aimed to clarify the efficacy of MIDG in elderly gastric cancer patients.

PATIENTS AND METHODS

This study included 316 patients older than 75 years with clinical stage I/IIA gastric cancer who underwent distal gastrectomy from August 2008 to December 2016 at the Shizuoka Cancer Centre. The long-term outcomes between MIDG and ODG were compared after propensity score matching.

RESULTS

After propensity score matching, there were 97 patients each in the MIDG and ODG groups, with an improved balance of confounding factors between the two groups. MIDG was associated with significantly longer operative time and a lower level of blood loss than ODG. The incidence of complications was comparable between the two groups. Survival outcomes were better in the MIDG group than in the ODG group (overall survival; P = 0.034, relapse-free survival; P = 0.027). In the multivariable analysis, ODG [hazard ratio (HR) 1.971, P = 0.046], being 80 years or older (HR 2.285, P = 0.018), male sex (HR 2.428, 95% P = 0.024), and poor physical status (HR 2.324, P = 0.022) were identified as independent prognostic factors for overall survival.

CONCLUSIONS

We found that MIDG showed better efficacy than ODG in elderly gastric cancer patients. MIDG is an acceptable option for elderly patients.

Assessment of diagnostic value of fluorescent lymphography-guided lymphadenectomy for gastric cancer

BACKGROUND

Indocyanine green fluorescent lymphography helps visualize the lymphatic drainage pattern in gastric cancer; however, it is unknown whether fluorescent lymphography visualizes all metastatic lymph nodes. This study aimed to evaluate the sensitivity of fluorescent lymphography to detect metastatic lymph node stations and lymph nodes and the risk of false-negative findings.

METHODS

Patients with clinical T1-4a gastric cancer were included. Indocyanine green was peritumorally injected the day prior to surgery by endoscopy. Gastrectomy with systematic D1+ or D2 lymphadenectomy was performed. Stations and lymph nodes were retrieved at the back-table using near-infrared imaging and classified as "fluorescent" or "non-fluorescent" and later matched with histopathological findings.

RESULTS

Among 592 patients who underwent minimally invasive gastrectomy from September 2013 until December 2016, lymph node metastases were present in 150. The sensitivity of fluorescent lymphography in detecting all metastatic lymph node stations was 95.3% (143/150 patients), with a false-negative rate of 4.7% (7/150 patients) and the sensitivity in detecting all metastatic lymph nodes was 81.3% (122/150 patients). The negative predictive value was 99.3% for non-fluorescent stations and 99.2% for non-fluorescent LNs. For detecting all metastatic LN stations, subgroup analysis revealed 100% sensitivity for pT1a, 96.8% for pT1b, 100% for pT2, 91.3% for pT3, and 93.6% for pT4a tumors.

CONCLUSIONS

Fluorescent lymphography-guided lymphadenectomy can be a useful method for radical lymphadenectomy by facilitating the complete dissection of all potentially positive LN stations. Fluorescent lymphography-guided lymphadenectomy appears to be a reasonable alternative to conventional systematic lymphadenectomy for gastric cancer.

Comparison of short-term outcomes between robotic and laparoscopic gastrectomy for gastric cancer: a propensity score-matching analysis

Robotic gastrectomy (RG) is increasingly performed based on expected benefits in short-term outcomes. However, it is still unclear if RG has any advantages over laparoscopic gastrectomy (LG). A retrospective cohort study was performed in patients who underwent minimally invasive gastrectomy between January 2012 and January 2020. A total of 366 patients were enrolled and short-term outcomes were compared between RG and LG. Propensity score matching was conducted to reduce selection bias based on age, sex, body mass index, performance status, physical status, clinical T, clinical N, clinical M, tumor location, neoadjuvant chemotherapy, type of gastrectomy, and extent of lymphadenectomy. A propensity score-matching algorithm was used to select 93 patients for each group. Estimated blood loss was smaller (0 vs. 37 mL, P = 0.001), length of hospital stay was shorter (10 vs. 12 days, P = 0.012), and the time until starting a soft diet was shorter (3 vs. 4 days, P = 0.001) in RG compared to LG. The overall complication rate was also lower in RG (9.7% vs 14.0%), but the difference was not significant. There was no mortality in either group. Total gastrectomy was an independent risk factor for postoperative complications. RG can be safely performed with a similar complication rate to that in LG and may permit faster postoperative recovery and a shorter hospital stay.

Preoperative risk factors for postoperative intra-abdominal infectious complication after gastrectomy for gastric cancer using a Japanese web-based nationwide database

BACKGROUND

Postoperative intra-abdominal infectious complication (PIIC) after gastrectomy for gastric cancer worsens in-hospital death or long-term survival. However, the methodology for PIIC preoperative risk assessment remains unestablished. We aimed to develop a preoperative risk model for postgastrectomy PIIC.

METHODS

We collected 183,936 patients' data on distal or total gastrectomy performed in 2013-2016 for gastric cancer from the Japanese National Clinical Database and divided into development (2013-2015; n = 140,558) and validation (2016; n = 43,378) cohort. The primary outcome was the incidence of PIIC. The risk model for PIIC was developed using 18 preoperative factors: age, sex, body mass index, activities of daily living, 12 comorbidity types, gastric cancer stage, and surgical procedure in the development cohort. Secondarily, we developed another model based on the new scoring system for clinical use using selected factors.

RESULTS

The overall incidence of PIIC was 4.7%, including 2.6%, 1.7%, and 1.3% in anastomotic leakage, pancreatic fistula, and intra-abdominal abscess, respectively. Among the 18 preoperative factors, male [odds ratio, (OR) 1.92], obesity (OR, 1.52-1.96), peripheral vascular disease (OR, 1.55), steroid use (OR, 1.83), and total gastrectomy (OR, 1.89) strongly correlated with PIIC incidence. The entire model using the 18 factors had good discrimination and calibration in the validation cohort. We selected eight relevant factors to create a simple scoring system, using which we categorized the patients into three risk groups, which showed good calibration.

CONCLUSION

Using nationwide clinical practice data, we created a preoperative risk model for postgastrectomy PIIC for gastric cancer.

Clinical impact of Endoscopic Surgical Skill Qualification System (ESSQS) by Japan Society for Endoscopic Surgery (JSES) for laparoscopic distal gastrectomy and low anterior resection based on the National Clinical Database (NCD) registry

AIM

This study aimed to evaluate the association between surgeons certified via the Endoscopic Surgical Skill Qualification System (ESSQS) of the Japan Society for Endoscopic Surgery (JSES) and surgical outcomes of laparoscopic distal gastrectomy (LDG) and laparoscopic low anterior resection (LLAR).

METHODS

Japanese National Clinical Database data on the patients undergoing LDG and LLAR between 2014-2016 were analyzed retrospectively. The proportion of cases performed by ESSQS-certified surgeons was calculated for each procedure, and clinicopathological factors with or without participation of ESSQS-certified surgeons as an operator were assessed. Then, effects of operations performed by ESSQS-certified surgeons on short-term patient outcomes were analyzed using generalized estimating equations logistic regression analysis.

RESULTS

There were 110 610 and 65 717 patients who underwent LDG and LLAR, respectively. The operations performed by ESSQS-certified surgeons in each procedure totaled 28 467 (35.3%) and 12 866 (31.2%), respectively. A multivariable logistic regression model showed that odds ratios of mortality for LDG and LLAR performed by ESSQS-certified surgeons were 0.774 (95% CI, 0.566-1.060, P = 0.108) and 0.977 (0.591-1.301, P = 0.514), respectively. Odds ratios for secondary endpoints of anastomotic leakage in LDG and LLAR performed by ESSQS-certified surgeons were 0.835 (95% CI, 0.723-0.964, P = 0.014) and 0.929 (0.860-1.003, P = 0.059), respectively, whereas that of ileus/bowel obstruction for LLAR performed by ESSQS-certified surgeons was 1.265 (1.132-1.415, P < 0.001). There were no significant associations between the two operations performed by ESSQS-certified surgeons and other factors such as mortality and overall complications.

CONCLUSIONS

ESSQS certification did not affect postoperative mortality following LDG and LLAR, but annual experience of laparoscopic surgery was associated with it. ESSQS certification may contribute to favorable outcomes regarding anastomotic leakage following LDG and LLAR.

Laparoscopic versus open distal gastrectomy for advanced gastric cancer: A meta-analysis of randomized controlled trials and high-quality nonrandomized comparative studies

BACKGROUND

Controversy persists about the effects of laparoscopic distal gastrectomy (LDG) versus open distal gastrectomy (ODG) on short-term surgical outcomes and long-term survival within the field of advanced gastric cancer (AGC).

METHODS

Studies published from January 1994 to February 2020 that compare LDG and ODG for AGC were identified. All randomized controlled trials (RCTs) were included. The selection of high-quality nonrandomized comparative studies (NRCTs) was based on a validated tool (Methodological Index for Nonrandomized Studies, MINORS). The short- and long-term outcomes of both procedures were compared.

RESULTS

Overall, 30 studies were included in this meta-analysis, which comprised of 8 RCTs and 22 NRCTs involving 16,029 patients (7864 LDGs, 8165 ODGs). The recurrence, 3-year disease-free survival (DFS), 3-year overall survival (OS), and 5-year OS rates for LDG and ODG were comparable. LDG was associated with a lower postoperative complication rate (OR 0.79; P < 0.00001), lower estimated volume of blood loss (WMD -102.21 mL; P < 0.00001), shorter postoperative hospital stay (WMD -1.96 days; P < 0.0001), shorter time to first flatus (WMD -0.54 day; P = 0.0007) and shorter time to first liquid diet (WMD -0.66 day; P = 0.001). The number of lymph nodes retrieved, mortality, intraoperative complications, intraoperative blood transfusion, and time to ambulation were similar. However, LDG was associated with a longer surgical time (WMD 33.57 min; P < 0.00001).

CONCLUSIONS

LDG with D2 lymphadenectomy is a safe and effective technique for patients with AGC when performed by experienced surgeons at high-volume specialized centers.

Postoperative pancreatic fistula after gastrectomy for gastric cancer

Postoperative pancreatic fistula is one of the most severe complications after gastric cancer surgery, and can cause critical patient conditions leading to surgery-related death. Fortunately, the incidence of postoperative pancreatic fistula after gastrectomy seems to be decreasing with changes in operative procedures. The rate was reported at about 30% after open gastrectomy with Appleby's method in 1997, but lately has improved below 1% for robotic gastrectomy in 2019. For the diagnosis of postoperative pancreatic fistula, drain amylase concentration has been demonstrated to be beneficial and some reports have proposed the optimal cut-off values of drain amylase to predict major postoperative pancreatic fistula. There have been many reports identifying risk factors for postoperative pancreatic fistula, including overweight patients, pancreatic anatomy, blunt trauma from compression of the pancreas, and thermal injuries caused by the continuous use of energy devices. And importantly, laparoscopic gastrectomy has been shown to be more often associated with postoperative pancreatic fistula than open gastrectomy in the prospective national clinical database in Japan. Hence, further sophistication of surgical techniques to reduce pancreas compression would have great promise in reducing postoperative pancreatic fistula after laparoscopic gastrectomy.

Impact of the Endoscopic Surgical Skill Qualification System on the safety of laparoscopic gastrectomy for gastric cancer

BACKGROUND

We hypothesized that the Endoscopic Surgical Skill Qualification System (ESSQS) can shorten operative time, resulting in a decrease in postoperative morbidity. Here, we aimed to clarify whether ESSQS-qualified surgeons could decrease the incidence of complications.

METHODS

Between January 2009 and June 2019, 1042 patients diagnosed with both clinical and pathological Stage ≤ III gastric cancer and undergoing LG were enrolled. In all LG procedures involving ESSQS-qualified surgeons, these served as the operator or the instructive assistant. The short-term outcomes were retrospectively compared between the ESSQS-qualified and the non-ESSQS-qualified surgeons using a propensity-score matched analysis.

RESULTS

After propensity-score matching, 321 patients were included in each group. No significant differences were observed in morbidity rate, and length of hospitalization following surgery, although the non-ESSQS-qualified surgeon group had a significantly longer total operative time (Non-ESSQS-qualified group, 368 [170-779] min vs. ESSQS-qualified group, 316 [147-772] min; p < 0.001), and larger estimated blood loss (Non-ESSQS-qualified group, 28 [0-702] mL vs. ESSQS-qualified group 25, [0-1069] mL; p = 0.042). Multivariate analysis revealed that operative time ≥ 360 min (OR 1.818 [1.069-3.094], p = 0.027) was identified as the only significant independent risk factor determining morbidity.

CONCLUSIONS

The incidence of postoperative morbidity did not differ between patients operated by the qualified and nonqualified surgeons, as long as ESSQS-qualified surgeons provide intraoperative instructions.

Development of gastroenterological surgery over the last decade in Japan: analysis of the National Clinical Database

The National Clinical Database (NCD) of Japan was established in 2010 with the board certification system. A joint committee of 16 gastroenterological surgery database-affiliated organizations has been nurturing this nationwide database and utilizing its data for various analyses. Stepwise board certification systems have been validated by the NCD and are used to improve the surgical outcomes of patients. The use of risk calculators based on risk models can be particularly helpful for establishing appropriate and less invasive surgical treatments for individual patients. Data obtained from the NCD reflect current developments in the surgical approaches used in hospitals, which have progressed from open surgery to endoscopic and robot-assisted procedures. An investigation of the data acquired by the NCD could answer some relevant clinical questions and lead to better surgical management of patients. Furthermore, excellent surgical outcomes can be achieved through international comparisons of the national databases worldwide. This review examines what we have learned from the NCD of gastroenterological surgery and discusses what future developments we can expect.

Evaluation of negative-pressure wound therapy for surgical site infections after ileostomy closure in colorectal cancer patients: a prospective multicenter study

PURPOSE

Surgical site infection (SSI) occurs at a high rate after ileostomy closure. The effect of preventive negative-pressure wound therapy (NPWT) on SSI development in closed wounds remains controversial. We conducted a prospective multicenter study to evaluate the usefulness of preventive NPWT for SSI after ileostomy closure.

METHODS

From January 2018 to November 2018, 50 patients who underwent closure of ileostomy created after surgery for colorectal cancer participated in this study. An NPWT device was applied to each wound immediately after surgery and then treatment was continued for 3 days. The primary endpoint was 30-day SSI, and the secondary endpoints were the incidence of seroma, hematoma, and adverse events related to NPWT.

RESULTS

No patients developed SSI, seroma, or hematoma. Adverse events that may have been causally linked with NPWT were contact dermatitis in two patients and wound pain in one patient, and there were no cases of discontinuation or decompression of NPWT.

CONCLUSION

The use of NPWT following ileostomy closure may be useful for reducing the development of SSI in colorectal cancer patients. This is a prospective multicenter pilot study and we are planning a comparative study based on these successful results.

TRAIL REGISTRATION

Registration number: UMIN000032053 ( https://www.umin.ac.jp/ ).

Propensity-score-matched analysis of a multi-institutional dataset to compare postoperative complications between Billroth I and Roux-en-Y reconstructions after distal gastrectomy

BACKGROUND

Few well-controlled studies have compared postoperative complications between Billroth I (B-I) and Roux-en-Y (R-Y). The aim of the present study was to compare the incidence of overall and severe postoperative complications by reconstruction method after distal gastrectomy.

METHODS

We performed a multi-institutional dataset study of patients who underwent distal gastrectomy with B-I or R-Y reconstruction from 2010 to 2014. Using propensity scores to strictly balance the significant variables, we compared postoperative complications between the techniques.

RESULTS

After matching, we enrolled 1014 patients (n = 507 in each group). The incidence of postoperative complications in the R-Y group was significantly higher vs the B-I group (29% vs 17%, P < 0.0001). The incidence of intra-abdominal abscess (4.3% vs 1.8%, P = 0.0177), bowel obstruction (2.6% vs 0.6%, P = 0.0203), and delayed gastric emptying (5.3% vs 1.0%, P < 0.0001) in the R-Y group was significantly higher vs the B-I group, respectively; we saw no significant difference in leakage (3.4% vs 4.1%, P = 0.5084). The incidence of grade ≥ III severe postoperative complications in the R-Y group was significantly higher vs the B-I group (13% vs 7.1%, P = 0.0013). Multivariable analysis showed that R-Y reconstruction was a strong independent risk factor for overall postoperative complications (odds ratio 1.58, P = 0.0044) and grade ≥ III severe postoperative complications (odds ratio 1.75, P = 0.0127). A forest plot revealed that R-Y reconstruction was associated with a greater risk of both overall and grade ≥ III severe postoperative complications in any subgroups.

CONCLUSIONS

R-Y reconstruction was associated with increasing overall postoperative complications, as well as severe postoperative complications.

Surgical outcomes in gastroenterological surgery in Japan: Report of the National Clinical Database 2011-2018

The National Clinical Database (NCD) of Japan grew rapidly, harvesting over 11 million cases of data between 2011 and 2018 from more than 5000 facilities. This is the Report of the NCD based upon gastrointestinal surgery information in 4 420 175 cases from 2011 to 2018. More than 70% of all gastrointestinal surgeries were performed at certified institutions, and the percentage of surgeries performed at certified institutions was particularly high for the esophagus (93.8% in 2018), liver (89.4%), pancreas (91.3%), and spleen (86.9%). Also, more than 70% of the surgeries were performed with the participation of the board-certified surgeon. As the patients have been getting older, the morbidities have been increasing. However, the mortalities have been kept at a low level. The rates of endoscopic surgery have been increasing year by year, especially high in low anterior resection (67.0%) and esophagectomy (61.0%). Nationwide, this database is surely expecting to ensure the quality of board certification system and surgical outcomes in gastroenterological surgery.

Minimally invasive approaches for early gastric cancer in East Asia: current status and future perspective

East Asia is well known as a region with higher incidences of gastric cancer compared with the rest of the world. This region has also experienced a rise in the detection of early gastric cancer (EGC) for the past three decades. The success of nationwide screening programs conducted in Japan or South Korea, increasing public awareness of gastric cancer, improved diagnostic ability of gastroenterologists and the aging population of modern societies may all contribute to the increase in EGC detection rates. Along with the increasing diagnosis of EGC, several key advances in the minimally invasive approach to EGC treatment have been made. Endoscopic resection is an ideal procedure for lesions without lymph node involvement, and its indications have expanded based on the results of prospective studies. Laparoscopic surgery with lymph node dissection has been becoming a standard treatment for EGC patients. Additionally, robot-assisted surgery is penetrating the field of gastric cancer surgery as surgeons pursue a more accurate minimally invasive approach with reduced morbidity rates. However, prolonged operation time and high cost remain problems to be solved for robot-assisted surgery. In this context, function-preserving surgery has become ever more important and should be considered as a method to enhance patients' quality of life after a gastrectomy for EGC. Pylorus-preserving gastrectomy or proximal gastrectomy is more frequently employed in East Asia and strategies that employ sentinel node (SN) navigation to personalize function-preserving surgery in clinical practice are emerging as several prospective studies investigate its efficacy.

Non-robotic minimally invasive gastrectomy as an independent risk factor for postoperative intra-abdominal infectious complications: A single-center, retrospective and propensity score-matched analysis

BACKGROUND

Minimally invasive surgery for gastric cancer (GC) has gained widespread use as a safe curative procedure especially for early GC.

AIM

To determine risk factors for postoperative complications after minimally invasive gastrectomy for GC.

METHODS

Between January 2009 and June 2019, 1716 consecutive patients were referred to our division for primary GC. Among them, 1401 patients who were diagnosed with both clinical and pathological Stage III or lower GC and underwent robotic gastrectomy (RG) or laparoscopic gastrectomy (LG) were enrolled. Retrospective chart review and multivariate analysis were performed for identifying risk factors for postoperative morbidity.

RESULTS

Morbidity following minimally invasive gastrectomy was observed in 7.5% of the patients. Multivariate analyses demonstrated that non-robotic minimally invasive surgery, male gender, and an operative time of ≥ 360 min were significant independent risk factors for morbidity. Therefore, morbidity was compared between RG and LG. Accordingly, propensity-matched cohort analysis revealed that the RG group had significantly fewer intra-abdominal infectious complications than the LG group (2.5% vs 5.9%, respectively; P = 0.038), while no significant differences were noted for other local or systemic complications. Multivariate analyses of the propensity-matched cohort revealed that non-robotic minimally invasive surgery [odds ratio = 2.463 (1.070–5.682); P = 0.034] was a significant independent risk factor for intra-abdominal infectious complications.

CONCLUSION

The findings showed that robotic surgery might improve short-term outcomes following minimally invasive radical gastrectomy by reducing intra-abdominal infectious complications.

Prediction of postoperative complications and survival after laparoscopic gastrectomy using preoperative Geriatric Nutritional Risk Index in elderly gastric cancer patients

BACKGROUND

Preoperative nutritional assessment of cancer patients is important to reduce postoperative complications. Several studies have reported the Geriatric Nutritional Risk Index (GNRI) to be useful in assessing underlying diseases and long-term outcomes of hospitalized patients. The present study aimed to evaluate the impact of preoperative GNRI on short- and long-term outcomes in elderly gastric cancer patients who underwent laparoscopic gastrectomy.

METHODS

We retrospectively reviewed consecutive patients aged ≥ 65 years who underwent laparoscopy-assisted gastrectomy and had R0 resection for histologically confirmed gastric adenocarcinoma. The cutoff value for preoperative GNRI was determined to be 85.7 based on the incidence of postoperative complications. Patients were categorized into two groups: low GNRI group and normal GNRI group.

RESULTS

Univariate analyses of the 303 patients revealed that the incidence of postoperative complications was significantly associated with the American Society of Anesthesiologists Physical Status classification (ASA-PS), C-reactive protein (CRP), GNRI (p < 0.001), and operative procedure. Multivariate analyses revealed that preoperative GNRI (odds ratio [OR] 2.716; 95% confidence interval [CI] 1.166-6.328; p = 0.021) and operative procedure (OR 2.459; 95% CI 1.378-4.390; p = 0.002) were independently associated with the incidence of postoperative complications. Univariate analyses showed that overall survival (OS) was significantly associated with ASA-PS, tumor size, tumor differentiation, pathological tumor node metastasis (TNM) stage, carcinoembryonic antigen (CEA), CRP, GNRI, and postoperative complications. Multivariate analysis demonstrated that ASA-PS (hazard ratio [HR], 3.755; 95% CI 2.141-6.585; p < 0.001), tumor differentiation (HR 1.898; 95% CI 1.191-3.025; p = 0.007), CEA (HR 1.645; 95% CI 1.024-2.643; p = 0.040), and GNRI (HR 2.093; 95% CI 1.105-3.963; p = 0.023) independently predicted OS.

CONCLUSION

GNRI is an important predictor of postoperative complications and overall survival in elderly gastric cancer patients. It is a reliable and cost-effective prognostic indicator that should be routinely evaluated.

Short-term outcomes and prognosis of laparoscopy-assisted total gastrectomy in elderly patients with stomach cancer

BACKGROUND

The aim of this study was to evaluate the short-term outcomes and prognosis of laparoscopy-assisted total gastrectomy (LTG) in elderly patients with gastric cancer.

METHODS

The clinical data of 275 patients aged over 65 years undergoing open total gastrectomy (OTG, n = 184) or laparoscopy-assisted total gastrectomy (LTG, n = 91) were reviewed from January 2015 to August 2017 at the First Affiliated Hospital of the University of Science and Technology of China. Short-term outcomes were compared between the two groups, and risk factors for postoperative complications were explored. In addition, the 2-year overall survival (OS) and disease-free survival (DFS) were investigated for both groups.

RESULTS

Except for the ASA score (P = 0.01), there was no significant difference regarding patient baselines between the two groups. Patients in the LTG group had a longer operative time (P < 0.001), less intraoperative blood loss (P = 0.004), a shorter time of resumption to a semi-liquid diet (P < 0.001) and a shorter postoperative hospital stay (P = 0.001). The incidence of pulmonary complications was significantly lower in the LTG group than in the OTG group (4.4% vs. 13%, P = 0.026). The number of lymph nodes harvested in the LTG group was higher than that in the OTG group (20.7 ± 7.4 vs. 17.5 ± 6.9, P = 0.001), and the proportion of patients with TNM stage III gastric cancer was higher in the LTG group than in the OTG group (P = 0.035). There was no significant difference in the 2-year OS rate or 2-year DFS rate between the two groups (P = 0.057 and P = 0.344). Sex, age, preoperative comorbidity, intraoperative blood loss, and TNM stage were identified as independent prognostic factors for postoperative survival.

CONCLUSION

Comparing with OTG, LTG is feasible and contributes to less surgical trauma and a faster recovery after total gastrectomy. In addition, LTG contributes to a lower risk of postoperative pulmonary complications. Regarding oncological results, LTG is more effective for lymph node dissection and has a comparable long-term prognosis as OTG.

Should robotic gastrectomy become a standard surgical treatment option for gastric cancer?

Robotic gastrectomy (RG) using the da Vinci Surgical System for gastric cancer was approved for national medical insurance coverage in Japan in April, 2018, and has been used increasingly since. We reviewed the current evidence on RG, open gastrectomy (OG), and conventional laparoscopic gastrectomy (LG) to identify differences in surgical outcomes between Japan and other countries. Briefly, three independent reviewers systematically reviewed the data collected from a comprehensive literature search by an independent organization and focused on the following nine endpoints: mortality, morbidity, operative time, estimated volume of blood loss, length of postoperative hospital stay, long-term oncologic outcome, quality of life, learning curve, and cost. Overall, the mortality rate of the three approaches did not differ, but RG and LG had less intraoperative blood loss and resulted in a shorter postoperative hospital stay than OG. RG had longer operative times and incurred higher costs than LG and OG. However, in Japan, RG may be more effective than LG and OG for decreasing morbidity. Further studies are needed to establish the specific indications for RG, optimal robotic setup, and dissection methods to best utilize the surgical robot.

Surgical outcomes of gastroenterological surgery in Japan: Report of the National Clinical Database 2011-2017

BACKGROUND

The Japanese National Clinical Database (NCD) is a large-scale, nationwide, web-based data entry system that is linked to the surgical board certification system and covers almost all surgical cases carried out in Japan.

AIM

To evaluate outcomes according to the gastroenterological section of the NCD.

METHODS

The 115 surgical procedures stipulated by the "Training Curriculum for Board-Certified Surgeons in Gastroenterology" were registered from 2011 to 2017. The number of surgeries, preoperative comorbidities, and short-term outcomes were compared between registration periods.

RESULTS

In total, 3 818 414 cases have been registered. More than 70% of all surgeries were carried out at certified institutions. The annual number of cases has been increasing year after year, and the aged population has also been increasing. Although the rates of preoperative comorbidities and postoperative complications have been increasing, the postoperative mortality rate has remained relatively low; in 2017, the 30-day mortality rate was 1.0% among those who underwent esophagectomy, 0.7% among those who underwent distal gastrectomy, 1.1% among those who underwent total gastrectomy, 1.3% among those who underwent right hemicolectomy, 0.5% among those who underwent low anterior resection, 1.3% among those who underwent hepatectomy, and 1.3% among those who underwent pancreaticoduodenectomy. The annual rate of endoscopic surgery dramatically increased over 7 years between 2011 and 2017, especially for low anterior resection (29.5%-62.6%) and esophagectomy (31.0%-56.1%).

CONCLUSION

This database is expected to ensure the quality of the board-certification system and surgical outcomes in gastroenterological surgery.

Surgical risk and benefits of laparoscopic surgery for elderly patients with gastric cancer: a multicenter prospective cohort study

BACKGROUND

Laparoscopic gastrectomy (LG) might have greater clinical benefits for elderly patients as less invasive surgery; however, there is still little evidence to support its benefit. We evaluated the surgical outcomes of elderly patients in a nationwide prospective cohort study.

METHODS

One hundred and sixty-nine participating institutions were identified by stratified random sampling, and were adjusted for hospital volume, type and location. During 1 year from 2014 to 2015, consecutive patients who underwent gastrectomy for gastric cancer were prospectively enrolled. 'Elderly' was defined as ≥ 75 years of age, based on the prevalence of comorbidities and the activities of daily living of patients of this age. We compared the surgical outcomes of LG to those of open gastrectomy (OG) in non-elderly and elderly patients. The primary outcome was the incidence of severe morbidities (Grade ≥ 3).

RESULTS

Eight thousand nine hundred and twenty-seven patients were enrolled [non-elderly, n = 6090 (OG, n = 2602; LG, n = 3488); elderly, n = 2837 (OG, n = 1471; LG, n = 1366)]. Grade ≥ 3 complications occurred in 161 (10.9%) patients who underwent OG and 98 (7.2%) who underwent LG (p < 0.001). After adjusting for confounding factors, we confirmed that laparoscopic surgery was not an independent risk factor (odds ratio = 0.81, 0.60-1.09). OG was associated with a significantly longer median length of postoperative stay in comparison to LG (16 versus 12 days, p < 0.001). There were no significant differences in the incidence of other postoperative comorbidities.

CONCLUSION

The safety of LG in elderly patients was demonstrated. LG shortened the length of postoperative hospital stay.

Current status of postoperative infections after digestive surgery in Japan: The Japan Postoperative Infectious Complications Survey in 2015

AIM

To survey postoperative infections (PI) after digestive surgery.

METHODS

This survey, conducted by the Japan Society of Surgical Infection, included patients undergoing digestive surgery at 28 centers between September 2015 and March 2016. Data collected included patient background characteristics, type of surgery, contamination status, and type of PI, including surgical site infection (SSI), remote infection (RI), and antimicrobial-resistant (AMR) bacterial infections and colonization.

RESULTS

Postoperative infections occurred in 10.7% of 6582 patients who underwent digestive surgery (6.8% for endoscopic surgery and 18.7% for open surgery). SSI and RI, including respiratory tract infection, urinary tract infection, antibiotic-associated diarrhea, drain infection, and catheter-related bloodstream infection, occurred in 8.9% and 3.7% of patients, respectively. Among all PI, 13.2% were overlapping infections. The most common overlapping infections were incisional and organ/space SSI, which occurred in 4.2% of patients. AMR bacterial infections occurred in 1.2% of patients after digestive surgery and comprised 11.5% of all PI. Rate of AMR bacterial colonization after digestive surgery was only 0.3%.

CONCLUSION

Periodic surveillance of PI, including AMR bacteria, is necessary for a detailed evaluation of nosocomial infections.

Safety and Feasibility of Linear Stapling Device with Bioabsorbable Polyglycolic Acid Sheet for Duodenal Closure in Gastric Cancer Surgery: A Multi-institutional Phase II Study

BACKGROUND

Duodenal stump fistula (DSF) after gastrectomy is of low frequency but a critical complication in gastric cancer surgery. Manual oversewing for reinforcement of the duodenal stump is not applicable when free longitudinal margin is short and has technical difficulties in laparoscopic surgery. This trial evaluated the safety and feasibility of using a linear stapler with bioabsorbable polyglycolic acid (PGA) sheet for duodenal stump closure and reinforcement in gastric cancer surgery.

METHODS

This multi-institutional, prospective phase II trial included gastric cancer patients who were scheduled to undergo distal or total gastrectomy with R-Y reconstruction. In all cases, duodenum was transected using a linear stapler with PGA sheet. The primary endpoint was the incidence of postoperative DSF. Sample size was set at 100 patients considering an expected value of 3% and threshold value of 8% with one-sided testing at a 10% significance level.

RESULTS

Between June 2014 and June 2015, a total of 100 patients were registered in this trial. Postoperative DSF was observed in two cases (2.0%, 90% CI 0.4-6.2%) which was developed on postoperative days 13 and 20. Intraoperative bleeding at the duodenal stump staple line was observed in one case but was easily controlled without additional suturing. Postoperative bleeding was not observed in any of the cases.

CONCLUSION

This study suggested that the use of PGA sheet as a reinforcement material for closure of the duodenal stump during gastrectomy for gastric cancer is both safe and feasible. Trial registration number UMIN 000014398.

Effect of hospital and surgeon volume on postoperative outcomes after distal gastrectomy for gastric cancer based on data from 145,523 Japanese patients collected from a nationwide web-based data entry system

BACKGROUND

Despite interest in surgeon and hospital volume effects on distal gastrectomy, clinical significance has not been confirmed in a large-scale population. We studied to clarify the effects of surgeon and hospital volume on postoperative mortality after distal gastrectomy for gastric cancer among Japanese patients in a nationwide web-based data entry system.

METHODS

We extracted data on distal gastrectomy for gastric cancer from the National Clinical Database between 2011 and 2015. The primary outcome was operative mortality. Hospital volume was divided into 3 tertiles: low (1-22 cases per year), medium (23-51) and high (52-404). Surgeon volume was divided into the 5 groups: 0-3, 4-10, 11-20, 21-50, 51 + cases per year. We calculated the 95% confidence interval (CI) for the mortality rate based on odds ratios (ORs) estimated from a hierarchical logistic regression model.

RESULTS

We analyzed 145,523 patients at 2182 institutions. Operative mortality was 1.9% in low-, 1.0% in medium- and 0.5% in high-volume hospitals. The operative mortality rate decreased definitively with surgeon volume, 1.6% in the 0-3 group and 0.3% in the 51 + group. After risk adjustment for surgeon and hospital volume and patient characteristics, hospital volume was significantly associated with operative morality (medium: OR 0.64, 95% CI 0.56-0.73, P < 0.001; high: OR 0.42, 95% CI 0.35-0.51, P < 0.001).

CONCLUSIONS

We demonstrate that hospital volume can have a crucial impact on postoperative mortality after distal gastrectomy compared with surgeon volume in a nationwide population study. These findings suggest that centralization may improve outcomes after distal gastrectomy.

Introducing laparoscopic total gastrectomy for gastric cancer in general practice: a retrospective cohort study based on a nationwide registry database in Japan

BACKGROUND

Although laparoscopic total gastrectomy (LTG) is considered a technically demanding procedure with safety issues, it has been performed in several hospitals in Japan. Data from a nationwide web-based data entry system for surgical procedures (NCD) that started enrollment in 2011 are now available for analysis.

METHODS

A retrospective cohort study was conducted using data from 32,144 patients who underwent total gastrectomy and were registered in the NCD database between January 2012 and December 2013. Mortality and morbidities were compared between patients who received LTG and those who underwent open total gastrectomy (OTG) in the propensity score-matched Stage I cohort and Stage II-IV cohort.

RESULTS

There was no significant difference in mortality rate between LTG and OTG in both cohorts. Operating time was significantly longer in LTG while the blood loss was smaller. In the Stage I cohort, LTG, performed in 33.6% of the patients, was associated with significantly shorter hospital stay but significantly higher incidence of readmission, reoperation, and anastomotic leakage (5.4% vs. 3.6%, p < 0.01). In the Stage II-IV cohort, LTG was performed in only 8.8% of the patients and was associated with significantly higher incidence of leakage (5.7% vs. 3.6%, p < 0.02) although the hospital stay was shorter (15 days vs. 17 days, p < 0.001).

CONCLUSION

LTG was more discreetly introduced than distal gastrectomy, but remained a technically demanding procedure as of 2013. This procedure should be performed only among the well-trained and informed laparoscopic team.