The impact of old age on surgical outcomes of totally laparoscopic gastrectomy for gastric cancer

Prognostic factors associated with gastrointestinal dysfunction after gastrointestinal tumor surgery: A meta-analysis

BACKGROUND

Explore the risk factors of gastrointestinal dysfunction after gastrointestinal tumor surgery and to provide evidence for the prevention and intervention of gastrointestinal dysfunction in patients with gastrointestinal tumor surgery.

AIM

To investigate the potential risk factors for gastrointestinal dysfunction following gastrointestinal tumor surgery and to present information supporting the prevention and management of gastrointestinal dysfunction in surgery patients.

METHODS

Systematically searched the relevant literature from PubMed, Web of Science, Cochrane Library, Embase, CNKI, China Biomedical Database, Wanfang Database, and Weipu Chinese Journal Database self-established until October 1, 2022. Review Manager 5.3 software was used for meta-analysis after two researchers independently screened literature, extracted data, and evaluated the risk of bias in the included studies.

RESULTS

A total of 23 pieces of literature were included, the quality of which was medium or above, and the total sample size was 43878. The results of meta-analysis showed that the patients were male (OR = 1.58, 95%CI: 1.25-2.01, P = 0.002) and ≥ 60 years old (OR = 2.60, 95%CI: 1.76-2.87, P < 0.001), physical index ≥ 25.3 kg/m2 (OR = 1.6, 95%CI: 1.00-1. 12, P = 0.040), smoking history (OR = 1.89, 95%CI: 1.31-2.73, P < 0.001), chronic obstructive pulmonary disease (OR = 1.49, 95%CI: 1.22-1.83, P < 0.001), enterostomy (OR = 1.47, 95%CI: 1.26-1.70, P < 0.001), history of abdominal surgery (OR = 2.90, 95%CI: 1.67-5.03, P < 0.001), surgical site (OR = 1.2, 95%CI: 1.40-2.62, P < 0.001), operation method (OR = 1.68, 95%CI: 1.08-2.62, P = 0.020), operation duration (OR = 2.65, 95%CI: 1.92-3.67, P < 0.001), abdominal adhesion grade (OR = 2.52, 95%CI: 1.90-3.56, P < 0.001), postoperative opioid history (OR = 5.35, 95%CI: 3.29-8.71, P < 0.001), tumor TNM staging (OR = 2.58, 95%CI: 1.84-3.62, P < 0.001), postoperative blood transfusion (OR = 2.92, 95%CI: 0.88-9.73, P = 0.010) is a risk factor for postoperative gastrointestinal dysfunction in patients with gastrointestinal tumors.

CONCLUSION

There are many factors affecting gastrointestinal dysfunction in gastrointestinal patients after surgery. Clinical staff should identify relevant risk factors early and implement targeted intervention measures on the basis of personalized assessment to improve the clinical prognosis of patients.

Non cancer causes of death after gallbladder cancer diagnosis: a population-based analysis

Mortality from non cancer causes in patients with gallbladder cancer (GBC) still unclear. This study evaluated the causes and risk factors of non cancer death during different follow-up periods after GBC diagnosis. Non cancer causes of death for GBC patients diagnosed between 2000 and 2017 in Surveillance, Epidemiology and End Results database were analyzed and standardized mortality rates (SMR) for each non cancer death were calculated. Predictors for non cancer death were identified through multivariate competing risk analysis. A total 11,927 GBC patients were identified for further analysis, 9393 died during follow up. The largest proportion of non cancer deaths occurred > 3 years after diagnosis (39.4%). Most common non cancer cause were cardiovascular disease (43.3%), followed by other cause of death (34.4%) and infectious diseases (8.6%). Compared with US general population, GBC patients has higher risk of death from disease of heart (SMR, 1.58; 95%CI, 1.41-1.75), septicemia (SMR,3.21; 95%CI, 2.27-4.40), diabetes mellitus (SMR,1.97; 95%CI, 1.43-2.63), alone with other causes. Non cancer causes accounted for a significant proportion of deaths during the follow-up period after GBC diagnosis. The risk of non cancer death is higher in GBC patients than in the general population. Our study provides comprehensive assessment of death from non cancer cause in GBC patients, which has important implications for health management in GBC patients.

Robotic-assisted gynecologic surgery in an older population: A comparison study

INTRODUCTION

Robotic-assisted surgery in select patients has been shown to result in less peri-operative morbidity. Few studies have explored the association of robotic-assisted gynecology oncology surgery complication rates and increasing age. Our objective was to evaluate the peri- and postoperative complication rates in patients age 65 years or above in minimally-invasive robotic gynecologic surgery.

MATERIAL AND METHODS

We performed a retrospective review of data from 765 consecutive minimally-invasive robotic-assisted surgeries performed by high-volume gynecologic oncologists. The patients were divided into "younger" patients aged <65 years and "older" patients aged ≥65 years. The primary outcomes were intraoperative and postoperative complications.

RESULTS

Of the 765 patients analyzed, 185 (24%) were ≥ 65. The intraoperative complication rate in patients <65 was 1.9% (11/580) versus 1.62% (3/185) in females ≥65 (p = 0.808). The postoperative complication rate in patients <65 was 15.5% (90/580) versus 22.7% (42/185) in females ≥65 (p = 0.328). We observed more post-operative complications with patients who had intraoperative complications compared to patients who developed post-operative complications without intraoperative complcations in our sample, but it was not statisticaly significant (OR = 2.78, p = 0.097). The average estimated blood loss was 137.5 ml (0-1000) for patients younger than 65 years and 134.81 ml (0-2200) in patients 65 years or older (p = 0.097).

DISCUSSION

Robotic gynecologic oncology surgery is common. When performed by expert surgeons, complications are not associated with increasing age.

Changes in failure to rescue after gastrectomy at a large-volume center with a 16-year experience in Korea

Failure to rescue (FTR), the mortality rate among patients with complications, is gaining attention as a hospital quality indicator. However, comprehensive investigation into FTR has rarely been conducted after radical gastrectomy for gastric cancer patients. This study aimed to assess FTR after radical gastrectomy and investigate the associations between FTR and clinicopathologic factors, operative features, and complication types. From 2006 to 2021, 16,851 gastric cancer patients who underwent gastrectomy were retrospectively analyzed. The incidence and risk factors were analyzed for complications, mortality, and FTR. Seventy-six patients had postoperative mortality among 15,984 patients after exclusion. The overall morbidity rate was 10.49% (1676/15,984 = 10.49%), and the FTR rate was 4.53% (76/1676). Risk factor analysis revealed that older age (reference: < 60; vs. 60-79, adjusted odds ratio [OR] 2.07, 95% confidence interval [CI] 1.13-3.79, P = 0.019; vs. ≥ 80, OR 3.74, 95% CI 1.57-8.91, P = 0.003), high ASA score (vs. 1 or 2, OR 2.79, 95% CI 1.59-4.91, P < 0.001), and serosa exposure in pathologic T stage (vs. T1, OR 2.74, 95% CI 1.51-4.97, P < 0.001) were associated with FTR. Moreover, patients who underwent gastrectomy during 2016-2021 were less likely to die when complications occurred than patients who received the surgery in 2006-2010 (OR 0.35, 95% CI 0.18-0.68, P = 0.002). This investigation of FTR after gastrectomy demonstrated that the risk factors for FTR were old age, high ASA score, serosa exposure, and operation period. FTR varied according to the complication types and the period, even in the same institution.

Comparison of short-term efficacy between totally laparoscopic gastrectomy and laparoscopic assisted gastrectomy for elderly patients with gastric cancer

BACKGROUND

Totally laparoscopic gastrectomy (TLG) entails both gastrectomy and gastrointestinal reconstruction under laparoscopy. Compared with laparoscopic assisted gastrectomy (LAG), TLG has been demonstrated in many studies to require a smaller surgical incision, result in a faster postoperative recovery and less pain and have comparable long-term efficacy, which has been a research hotspot in recent years. Whether TLG is equally safe and feasible for elderly patients remains unclear.

AIM

To compare the short-term efficacy of and quality of life (QOL) associated with TLG and LAG in elderly gastric cancer (GC) patients.

METHODS

The clinicopathological data of 462 elderly patients aged ≥ 70 years who underwent LAG or TLG (including distal gastrectomy and total gastrectomy) between January 2017 and January 2022 at the Department of General Surgery, First Medical Center, Chinese PLA General Hospital were retrospectively collected. A total of 232 patients were in the LAG group, and 230 patients were in the TLG group. Basic patient information, clinicopathological characteristics, operation information and QOL data were collected to compare efficacy.

RESULTS

Compared with those in the LAG group, intraoperative blood loss in the TLG group was significantly lower (P < 0.001), and the time to first flatus and postoperative hospitalization time were significantly shorter (both P < 0.001). The overall incidence of postoperative complications in the TLG group was significantly lower than that in the LAG group (P = 0.01). Binary logistic regression results indicated that LAG and an operation time > 220 min were independent risk factors for postoperative complications in elderly patients with GC (P < 0.05). In terms of QOL, no statistically significant differences in various preoperative indicators were found between the LAG group and the LTG group (P > 0.05). Compared with the laparoscopic-assisted total gastrectomy group, patients who received totally laparoscopic total gastrectomy had lower nausea and vomiting scores and higher satisfaction with their body image (P < 0.05). Patients who underwent laparoscopic-assisted distal gastrectomy were more satisfied with their body image than patients in the totally laparoscopic distal gastrectomy group (P < 0.05).

CONCLUSION

TLG is safe and feasible for elderly patients with GC and has outstanding advantages such as reducing intracorporeal blood loss, promoting postoperative recovery and improving QOL.

Causes of death following small cell lung cancer diagnosis: a population-based analysis

PURPOSE

To examine the distribution of causes of death (CODs) in patients with small cell lung cancer (SCLC).

METHODS

Patients diagnosed with SCLC were identified from the Surveillance, Epidemiology, and End Results Program database during 2004-2015. Standardized mortality rates (SMRs) were performed for each COD to present changes in risk for a particular COD following SCLC diagnosis.

RESULTS

A total of 44,506 patients diagnosed with SCLC were identified in this study, and 42,476 patients died during the follow-up. Of total deaths, 69.5% occurred within the first years after diagnosis, 26% occurred from 1 to 3 years, and 4.5% individuals survived longer than 3 years. In addition, 88.7% of deaths were caused by SCLC, followed by non-cancer causes (7.1%) and other cancers (4.2%). Moreover, non-cancer CODs increased from 6.3 to 30% over time after 3 years of diagnosis. As for non-cancer CODs, cardiovascular diseases, COPD, and septicemia were the most common in SCLC.

CONCLUSION

Non-cancer CODs, such as cardiovascular events, COPD and septicemia, contribute to a considerable proportion of deaths among long-term SCLC survivors, supporting the involvement of multidisciplinary care for the follow-up strategy in SCLC.

Novel temperature-responsive hydrogel injected to the incision site for postoperative pain relief in laparoscopic abdominal surgery: a single-blind, randomized, pivotal clinical trial

BACKGROUND

A temperature-responsive hydrogel (PF-72; TGel Bio, Inc., Ltd, Seoul, Korea), developed as a sustained drug delivery device, can be mixed with ropivacaine to reduce pain in the incision area. The hydrogel is soluble at low temperatures (2-8 °C) and is converted into a gel at high temperatures (> 30 °C). We aimed to evaluate whether the administration of ropivacaine using PF-72 at incision sites reduces pain until 72 h postoperatively in patients undergoing laparoscopic stomach or colorectal surgery.

METHODS

Patients were randomly assigned to the control group (0.75% ropivacaine) or PF-72 group (PF-72 mixed with 0.75% ropivacaine). Before surgical incision closure, 0.75% ropivacaine or PF-72 mixed with 0.75% ropivacaine was injected into the subcutaneous fat and muscle of all incisions. Postoperative pain was evaluated by the Numerical Rating Scale (NRS, 0 = no pain, 10 = most severe pain) for wound pain at 3, 6, 24, 48, and 72 h after the end of surgery.

RESULTS

Ninety-nine patients (control, n = 51; PF-72, n = 48) were included in the analysis. The areas under the curve of NRS for wound pain until 72 h in the control group and the PF-72 group were 188.7 ± 46.1 and 135.3 ± 49.9 h, respectively (P < 0.001). The frequency of the administration of rescue analgesics in the general ward was similar between the two groups.

CONCLUSION

PF-72 mixed with 0.75% ropivacaine reduced postoperative pain until 72 h in patients undergoing laparoscopic surgery. Although the study population was not large enough for safety evaluation, no adverse events associated with PF-72 were observed.

Gastric cancer in older adult patients: a retrospective study and literature review

Background

With increasing life expectancy, the incidence of gastric cancer (GC) in older adults is increasing. This study analyzed differences in GC characteristics according to age and sex among patients who underwent surgical treatment for GC.

Methods

A total of 2,983 patients diagnosed with gastric adenocarcinoma who underwent surgical treatment at Seoul National University Bundang Hospital between 2003 and 2017 were classified into three groups: I (<65 years, n=1,680), II (60–74 years, n=919), and III (≥75 years, n=384). We compared the baseline clinical characteristics, pathological characteristics of the tumor, overall and GC-specific survival rates, and associated risk factors between the groups.

Results

Cancer of the distal third of the stomach (p<0.001), with intestinal-type histology (p<0.001), and with p53 overexpression (p=0.004) were more common in groups II and III than in group I, and the proportion of intestinal-type GC increased with age. The cancer type, lymph node metastasis, and cancer stage did not differ significantly. In terms of overall survival, survival decreased with increasing age (p<0.001), but this difference decreased significantly for GC-specific survival. Cox multivariate analyses revealed age, histologic type (diffuse or mixed type), and advanced cancer stage (p=0.002, 0.001, and <0.001, respectively) as risk factors for GC-related mortality.

Conclusion

Age itself was found to be one of the most important prognostic factors for overall and disease-specific survival in elderly GC patients, along with cancer stage.

Preoperative Prognostic Nutrition Index as a Prognostic Indicator of Survival in Elderly Patients Undergoing Gastric Cancer Surgery

Purpose

Gastric cancer is a common tumor type associated with nutritional and immune status. The aim of the current study was to investigate the prognostic value of a preoperative prognostic nutritional index (PNI), composed of nutritional factors and immune factors in elderly patients undergoing gastric cancer surgery.

Patients and Methods

A total of 454 patients undergoing gastric cancer surgery were divided into two groups based on preoperative PNI scores: ≤45.1 (n = 307) and >45.1 (n = 147). Survival analysis was performed using the Kaplan-Meier method and Log rank tests. Univariate and multivariate analyses were conducted to identify independent prognostic factors using a Cox proportional hazards model.

Results

According to the X-tile program, the optimal cutoff value for predicting overall survival (OS) with the PNI was 45.1. The receiver operating characteristic analysis revealed that PNI exhibited 70.6% sensitivity and 56.5% specificity for predicting death during long-term follow-up. The cumulative incidence of postoperative 4-year mortality indicated that the risk of death increased significantly for PNI ≤45.1. In multivariate analysis, preoperative PNI was a significant independent predictor of mortality. In the age-stratified subgroup analysis, preoperative PNI was more sensitive for the old elderly subgroup than for the young elderly subgroup.

Conclusion

Preoperative PNI is a sensitive and specific prognostic predictor among elderly patients undergoing gastric cancer surgery.

Laparoscopic mechanical latero-lateral oesophagojejunostomy after total gastrectomy for cancer in the elderly: technical notes and results

BACKGROUND

The realization of a oesophagojejunostomy is a critical step in total gastrectomy. Several techniques based on a Roux-En-Y restoration of gastrointestinal continuity were described with similar results. We here report our laparoscopic experience in intracorporeal oesophagojejunostomy.

METHODS

Adults who underwent laparoscopic total gastrectomy for cancer with laterolateral (functional termino-terminal) Roux en Y intracorporeal oesophagojejunostomy with linear stapler from January 2014 to December 2018 were included. Demographics, intra and postoperative outcomes including 30-day readmissions and mortality were considered.

RESULTS

32 patients were included. Nodal dissection D1's were 16. Median operative time was 280'. median blood loss was 200 mL. Fluid oral intake is usually resumed on the second postoperative day and soft solid diet is started on the third postoperative day. Three patients had minimal anastomotic leakage and they underwent Non Operative Management. Median postoperative stay was 8.5 days.

CONCLUSIONS

This technique may improve the ergonomics of oesophagojejunostomy creation. The procedure is suitable for experienced laparoscopic surgeons.

Body mass index affects postoperative daily activities of older patients after gastrectomy

PURPOSE

This study aimed to examine the impact of preoperative body mass index (BMI) on postoperative activities of daily living (ADL) and clinical outcomes in older patients who underwent curative gastrectomy.

METHODS

This was a retrospective observational study using a nationwide inpatient database in Japan. The study included 1769 patients with gastric cancer, aged ≥ 65 years old, who underwent gastrectomy. BMI was defined as per the World Health Organization classifications for Asian populations. Primary outcome was ADL at discharge, assessed by Barthel index. Secondary outcomes included postoperative complications and length of hospital stay.

RESULTS

Patients analyzed included 890 (50.3%) aged 65-74 years, 745 (42.1%) aged 75-84 years, and 134 (7.6%) aged ≥ 85 years; 71.5% were male. According to BMI classification, 11.9% patients were considered underweight (< 18.5 kg/m²), 46.7% were in the standard range (18.5 to < 23 kg/m²), 34.1% were classified as overweight (23-27.5 kg/m²), and 7.3% were in the obese group (≥ 27.5 kg/m²). In multivariate analysis, a significant association was observed between BMI and Barthel index scores (underweight group: standardized coefficient, - 0.040; compared with standard group; p = 0.013), postoperative complication (obese group: odds ratio, 1.562; compared with standard group; p = 0.034), and length of hospital stay (obese group: standardized coefficient, 0.047; compared with standard group; p = 0.019).

CONCLUSION

Perioperative management with a focus on BMI is important in older patients undergoing elective curative gastrectomy.

Combining the Fibrinogen-to-Pre-Albumin Ratio and Prognostic Nutritional Index (FPR-PNI) Predicts the Survival in Elderly Gastric Cancer Patients After Gastrectomy

Background

Inflammation and nutrition are important causes contributing to the progression and poor survival of gastric cancer (GC). The objective of this study is to investigate the prognostic significance of the preoperative fibrinogen-to-pre-albumin ratio (FPR) and the prognostic nutritional index (PNI) in GC patients who have undergone gastrectomy.

Methods

A total of 274 patients with resected pathological GC from January 2007 to December 2013 were enrolled in this retrospective study. Survival analysis was performed using Kaplan–Meier and log rank tests. Univariate and multivariate analyses were established to identify independent prognostic factors of 5-year survival. A predictive nomogram was used to predict prognosis of overall survival (OS), and its accuracy was determined by Harrell’s concordance index (C index).

Results

A high preoperative FPR-PNI score was significantly correlated with age, bigger tumor size, more lymphatic metastases and advanced TNM stage. Univariate analysis revealed that the GC patients with high FPR, low PNI and high FPR-PNI scores had shorter survival time. Multivariate analysis showed that FPR-PNI was an independent prognostic factor for OS in GC patients, especially in elderly patients. In the sub-analysis by age, the FPR-PNI score could significantly increase the accuracy of prognosis compared with the FPR and PNI alone in elderly GC patients.

Conclusion

The preoperative FPR-PNI score is an effective independent prognostic index for GC patients after surgery, especially in elderly patients.

Laparoscopic versus open resection for elderly patients with gastric cancer: a double-center study with propensity score matching method

PURPOSE

The applicability of laparoscopic-assisted radical gastrectomy for elderly patients with gastric cancer is still not well clarified. The aim of this double-center study was to explore the feasibility and effectiveness of laparoscopic-assisted radical gastrectomy on elderly patients with gastric cancer.

METHODS

We prospectively collected data of patients who underwent gastrectomy for cancer in two centers from June 2016 to December 2019. Propensity score matching was performed at a ratio of 1:1 to compare the laparoscopic-assisted radical gastrectomy group and open radical gastrectomy group. Univariate analyses and multivariate logistic regression analyses evaluating the risk factors for total, surgical, and medical complications were performed.

RESULTS

A total of 481 patients with gastric cancer met the inclusion criteria and were included in this study. After propensity score analysis, 258 patients were matched each other (laparoscopic-assisted radical gastrectomy (LAG) group, n = 129; open radical gastrectomy (OG) group, n = 129). LAG group had lower rate of surgical complications (P = 0.009), lower rate of severe complications (P = 0.046), shorter postoperative hospital stay (P = 0.001), and lower readmission rate (P = 0.039). Multivariate analyses revealed that anemia, Charlson comorbidity index, and combined resection were independent risk factors in the LAG group, whereas body mass index and American Society of Anesthesiology grade in the OG group.

CONCLUSION

Laparoscopic-assisted radical gastrectomy was relative safe even effective in elderly gastric cancer patients. We should pay attention to the different risk factors when performing different surgical procedures for gastric cancer in elderly patients.

A systematic review and meta-analysis of baseline risk factors for the development of postoperative ileus in patients undergoing gastrointestinal surgery

INTRODUCTION

Postoperative ileus occurs frequently following abdominal surgery. Identification of groups at high risk of developing ileus before surgery may allow targeted interventions. This review aimed to identify baseline risk factors for ileus.

METHODS

A systematic review was conducted with reference to PRISMA and MOOSE guidelines. It was registered on PROSPERO (CRD42017068697). Searches of MEDLINE, EMBASE and CENTRAL were undertaken. Studies reporting baseline risk factors for the development of postoperative ileus based on cohort or trial data and published in English were eligible for inclusion. Dual screening of abstracts and full texts was undertaken. Independent dual extraction was performed. Bias assessment was undertaken using the quality in prognostic studies tool. Meta-analysis using a random effects model was undertaken where two or more studies assessed the same variable.

FINDINGS

Searches identified 2,430 papers, of which 28 were included in qualitative analysis and 12 in quantitative analysis. Definitions and incidence of ileus varied between studies. No consistent significant effect was found for association between prior abdominal surgery, age, body mass index, medical comorbidities or smoking status. Male sex was associated with ileus on meta-analysis (odds ratio 1.12, 95% confidence interval 1.02-1.23), although this may reflect unmeasured factors. The literature shows inconsistent effects of baseline factors on the development of postoperative ileus. A large cohort study using consistent definitions of ileus and factors should be undertaken.

Long-Term Outcomes in Laparoscopic D2 Gastrectomy for Gastric Cancer: a Large Comprehensive Study Proposing Novel Hypotheses

BACKGROUND

The long-term outcomes of laparoscopic gastrectomy (LG) versus open gastrectomy (OG) for gastric cancer (GC) remain obscure, especially for advanced cancer and disease affecting the upper stomach and in older patients. This study aimed to comprehensively assess the long-term efficacy of LG for GC using a large prospective database.

METHODS

Totally, 1877 consecutive patients (1186 receiving LG and 691 OG) operated in 2004-2016 were analyzed, with a median follow-up of 63 months. Association of LG versus OG with disease-specific survival (DSS) and disease-free survival (DFS) overall and in various subgroups were investigated using multivariable Cox regression. Propensity score matching (PSM) was performed for sensitivity analysis.

RESULTS

Before PSM, overall, there was no significant association of LG versus OG with survival after multivariable adjustment; however, in subgroup analyses, LG was associated with superior DSS in patients aged ≥ 70 years and those with upper GC. No significant associations regarding DFS were observed overall or in stratifications. PSM analyses revealed that LG was associated with better DSS also in patients aged ≥ 70 years (hazard ratio (HR) = 0.33, 95% confidence interval (CI) = 0.15-0.72) and in those with upper GC (HR = 0.51, 95% CI = 0.29-0.91), and with better DFS in those with upper GC (HR = 0.60, 95% CI = 0.37-0.99). Multivariable analysis showed that age, hepatitis B, performance status, tumor histology, stage, and vascular invasion were significantly associated with post-LG survival. LG-specific nomograms were then constructed with concordance indexes of 0.814 (DSS) and 0.809 (DFS) and excellent calibration.

CONCLUSIONS

In this large institutional analysis, while LG for GC was associated with DSS and DFS similar to those for OG overall, non-inferior LG-associated survival especially DSS was observed in some subgroups rarely investigated in prospective or randomized settings. There could still be biases even after PSM due to confounders not accounted for in this observational study. However, these findings offer novel hypotheses for further validation.

Long-term survival estimates in older patients with pathological stage I gastric cancer undergoing gastrectomy: Duocentric analysis of simplified scoring system

BACKGROUND

Our aim was to determine factors predictive of long-term post-gastrectomy outcomes in older adults with pathological stage I gastric cancer (GC).

METHODS

A total of 175 patients with resected pathological stage I GC at two institutions were reviewed, each ≥75 years old at the time of gastrectomy and full participants in a 5-year follow-up program. The procedures were undertaken between January 2006 and December 2011. Patients were divided into two groups: survivors and non-survivors at postoperative Year 5. Univariate and multivariate analyses were applied to identify independent predictors of 5-years survival, including preoperative, surgical, and histopathologic variables.

RESULTS

Multivariate analysis of overall survival (OS) at 5 years indicated that prognostic nutritional index (PNI) <45 and the American Society of Anesthesiologists physical status (ASA-PS) 3 were independently associated with unfavorable outcomes. A clinical score consisting of 1-point each for these two variables proved useful in predicting survival after gastrectomy (5-year OS: 0 point, 86.6%; 1-point, 51.6%; 2-point, 33.3%; p < .001, area under the curve [AUC] = 0.757).

CONCLUSIONS

Long-term survival of older adults with pathological stage I GC is unfavorable in patients displaying both ASA-PS 3 and PNI < 45. A simple scoring method, based on combined ASA-PS/PNI determinations, provides an accurate prognostic prediction for these patients.

Morbidity and mortality of elderly patients with advanced gastric cancer after laparoscopy-assisted or open distal gastrectomy: a randomized-controlled trial

Laparoscopy-assisted distal gastrectomy (LDG) combined with D2 lymphadenectomy may be safely performed in patients with advanced gastric cancer (AGC) by experienced surgeons at specialized high-volume institutions as shown in the Chinese Laparoscopic Gastrointestinal Surgery Study (CLASS)-01. However, studies focusing on the use of LDG in patients with gastric cancer older than 65 years are rare. This study was designed to investigate the morbidity and mortality of elderly patients with gastric cancer who underwent laparoscopic-assisted or open distal gastrectomy (ODG). In this prospective, randomized, open, parallel controlled trial, patients older than 65 years with tumor located at the middle or lower part of the stomach will be enrolled in this study. Patients will be randomly divided into a laparoscopic group and an open surgery group. The early post-operative complications, intra-operative complications and post-operative recovery will be compared between the two groups. This trial will provide valuable clinical evidence for the objective assessment of the feasibility, short-term safety, and potential benefits of LDG compared with ODG for gastric cancer in the elderly patients. This trial has been registered on ClinicalTrials.gov. (Identifier: NCT02246153.) in September 22, 2014.

Postoperative mechanical bowel obstruction after pharyngolaryngectomy for hypopharyngeal cancer: Retrospective analysis using a Japanese inpatient database

BACKGROUND

Data have been limited on donor-site mechanical bowel obstruction after pharyngolaryngectomy with free jejunum graft reconstruction.

METHODS

Using a nationwide Japanese inpatient database, we extracted data on patients who underwent pharyngolaryngectomy for hypopharyngeal cancer between July 2007 and March 2014. A Cox proportional hazard model was used to determine the association between background characteristics and the occurrence of mechanical bowel obstruction.

RESULTS

Among the 3320 eligible patients from 332 hospitals, 108 patients (3.3%) developed mechanical bowel obstruction after a median 88 (interquartile range 26-217) postoperative days. Multivariable Cox regression analysis revealed that older age (≥60 years old) was independently associated with an increased risk of mechanical bowel obstruction, whereas sex, body mass index [BMI], smoking status, comorbidity at admission, blood transfusion, history of surgery, and hospital type were not.

CONCLUSION

In pharyngolaryngectomy, careful attention should be paid to the risk of abdominal complications and, thus, to the graft choice, especially in elderly patients.

NDRG4 hypermethylation is a potential biomarker for diagnosis and prognosis of gastric cancer in Chinese population

In order to assess whether N-Myc downstream regulated gene 4 (NDRG4) methylation was associated with the diagnosis and prognosis of gastric cancer, we measured the methylation of NDRG4 promoter and gene body regions among 110 gastric cancer patients using quantitative methods (MethyLight and pyrosequencing). Both NDRG4 promoter and gene body methylation levels were increased in tumor tissues than paired adjacent normal tissues (P < 0.001). NDRG4 gene body methylation was found to be significantly associated with age and tumor differentiation. NDRG4 promoter hypermethylation was proved to be a predictor of poor overall survival. However, opposite result was observed among The Cancer Genome Atlas (TCGA) cohort. The findings from gastric cell lines and public databases have suggested that NDRG4 methylation level was inversely associated with NDRG4 transcription level. Subsequent luciferase reporter gene assay showed that promoter CpG island but not gene body CpG island was able to upregulate gene expression. Collectively, NDRG4 promoter hypermethylation contributed to the risk of gastric cancer and predicted a poor prognosis in Chinese gastric cancer patients. Moreover, the combined methylation levels of NDRG4 promoter and gene body served as diagnostic biomarkers in gastric cancer.

Characteristics of advanced gastric cancer with negative or only perigastric lymph node metastasis in elderly patients

OBJECTIVES

After gastrectomy with extended lymph node (LN) dissection, the damage of celiac plexus seems to cause of disorder of eating habits. To clarify the indication of gastrectomy with limited LN dissection for elderly patients, the pathological characteristics of advanced gastric cancer in elderly patients were examined in this study.

METHODS

Forty-seven patients aged ≥80 years with advanced gastric cancer (deeper than pT2) who underwent curative gastrectomy from 1998 to 2015 were enrolled. Patients were classified into two groups by extent of LN metastasis: Group A, with N0 or only perigastric LN metastasis (n = 33); Group B, LN metastasis beyond the perigastric area (n = 14). Pathological factors were then evaluated.

RESULTS

No significant differences were observed in age, sex, body mass index, American Society of Anesthesiologists physical status classification, serum level of carcinoembryonic antigen, surgical procedure, extent of LN dissection, and number of dissected LNs. Pathological findings showed no significant differences in tumor location, macroscopic type, histologic type, and lymphovascular invasion. However, significant differences were observed in tumor maximum diameter at the cut-off level of 40 mm (Group A: ≤40 mm, n = 10 and >40 mm, n = 23; Group B: ≤40 mm, n = 0 and >40 mm, n = 14; P = 0.02).

CONCLUSION

In the elderly patients, LN metastasis in advanced gastric cancer of ≤40 mm in diameter was limited to be within the perigastric area. Gastrectomy with only perigastric LN dissection may be adopted in these patients.

Feasibility of laparoscopic gastrectomy for elderly gastric cancer patients: meta-analysis of non-randomized controlled studies

The aim of this meta-analysis was to determine the feasibility of laparoscopic gastrectomy (LG) for elderly gastric cancer patients by comparing laparoscopic and conventional open gastrectomies (OG). Comprehensive search of the PubMed, EMBASE, and Cochrane Library databases revealed nine non-randomized controlled studies that compared LG and OG in elderly gastric cancer patients We then analyzed dichotomous or continuous parameters using odds ratios (ORs) or weighted mean differences (WMDs). Overall survival was estimated using hazard ratios (HRs) with a fixed effects or random effects model. We observed that the age distribution was similar between the LG and OG patient groups (WMD -0.22 95% CI, -1.26-0.82). LG patients experienced less blood loss (WMD -119.14 95% CI, -204.17--34.11) and had shorter hospital stays (WMD -3.48 95% CI, -5.41--1.56), but endured longer operation times (WMD 10.87 95% CI, 2.50-19.24). Postoperatively, LG patients exhibited lower incidences of postoperative morbidities (OR 0.59 95% CI, 0.43-0.79), surgery related morbidities (OR 0.58 95% CI, 0.41-0.81) and systemic morbidities (OR 0.56 95% CI, 0.38-0.82). We observed no differences between the LG and OG patient groups regarding anastomotic leakage (OR 0.69 95% CI, 0.34-1.41), mental disease (OR 0.72 95% CI, 0.37-1.41) and long term effects (HR 0.98 95% CI, 0.74-1.32). We therefore conclude that laparoscopic gastrectomy might be technically feasible for elderly gastric cancer patients.

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis in the Elderly: A Case-Controlled, Multicenter Study

OBJECTIVE

This study was designed to identify factors associated with morbidity and mortality in patients older than 70 years who underwent cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis (PC).

BACKGROUND

Major surgery is associated with higher morbidity and mortality in elderly patients. For PC, CRS and HIPEC is the only current potential curative therapy, but the risks inherent to this patient population have called its benefits into question.

METHODS

We retrospectively analyzed a multi-center database from 1989 to 2015. All patients who underwent CRS and HIPEC for PC were selected and patients older than 70 years were matched 1:4 with a younger cohort according to cancer origin, peritoneal cancer index (PCI), and completeness of cytoreduction. Major morbidity and mortality were analyzed.

RESULTS

Of 2328 patients, 188 patients older than aged 70 years were matched with 704 younger patients. Patients older than aged 70 years demonstrated a higher American Society of Anesthesiologist score (≥ASA III 10.8 vs. 6.6 %, p = 0.008). There was no difference in overall 90-day morbidity (≥70: 45.7 % vs. <70: 44.5 %; p = 0.171); however, patients older than 70 years had significantly more cardiovascular complications (13.8 vs. 9.2 %, p = 0.044). Differences between the older and younger cohorts failed to reach significance for 90-day mortality (5.4 and 2.7 %, respectively; p = 0.052), and failure-to-rescue (11.6 and 6.1 %, respectively; p = 0.078). In multivariate analysis, PCI > 7 (95 % CI 1.051-5.798, p = 0.038) and HIPEC duration (95 % CI 1.106-6.235, p = 0.028) were independent factors associated with morbidity in elderly patients.

CONCLUSIONS

CRS and HIPEC appear feasible for selected patients older than aged 70 years, albeit with a higher risk of medical complications associated with increased mortality.

Low Serum Albumin Level, Male Sex, and Total Gastrectomy Are Risk Factors of Severe Postoperative Complications in Elderly Gastric Cancer Patients

Purpose

It is well known that old age is a risk factor for postoperative complications. Therefore, this study aimed to explore the risk factors for poor postoperative surgical outcomes in elderly gastric cancer patients.

Materials and Methods

Between January 2006 and December 2015, 247 elderly gastric cancer patients who underwent curative gastrectomy were reviewed. In this study, an elderly patient was defined as a patient aged ≥65 years. All possible variables were used to explore the risk factors for poor early surgical outcomes in elderly gastric cancer patients.

Results

Based on multivariate analyses of preoperative risk factors, preoperative low serum albumin level (<3.5 g/dl) and male sex showed statistical significance in predicting severe postoperative complications. Additionally, in an analysis of surgery-related risk factors, total gastrectomy was a risk factor for severe postoperative complications.

Conclusions

Our study findings suggest that low serum albumin level, male sex, and total gastrectomy could be risk factors of severe postoperative complications in elderly gastric cancer patients. Therefore, surgeons should work carefully in cases of elderly gastric cancer patients with low preoperative serum albumin level and male sex. We believe that efforts should be made to avoid total gastrectomy in elderly gastric cancer patients.

Efficacy of totally laparoscopic distal gastrectomy for gastric cancer in elderly patients

Elderly patients are often considered as high-risk for major abdominal surgery due to reduced functional reserve and increased comorbidities. We herein evaluated the efficacy of totally laparoscopic distal gastrectomy (TLDG) in elderly patients with gastric cancer by measuring the postoperative systemic responses and postoperative analgesic consumption. A total of 102 patients with gastric cancer [57 who underwent TLDG and 45 who underwent laparoscopy-assisted distal gastrectomy (LADG)] were enrolled in this study. The patients were classified as elderly (aged ≥75 years) and non-elderly (aged <75 years) groups. The surgical outcome and postoperative analgesic consumption were evaluated. The elderly group exhibited a higher incidence of comorbidities and a longer postoperative hospital stay compared with those of younger patients, although there was no difference in the incidence of postoperative complications. In addition, the total consumption of additional analgesics until postoperative day 5 in patients who underwent TLDG was significantly lower compared with that in patients who underwent LADG in the elderly group; there was no such difference in the non-elderly group. The results suggested that TLDG was better for the management of postoperative pain in elderly patients with gastric cancer, who exhibit the highest mortality rates in the adult surgical population.

Laparoscopy-assisted versus open distal gastrectomy for gastric cancer in elderly patients: a retrospective comparative study

BACKGROUND

With the current increased longevity in elderly population, surgeons can expect to operate more frequently on elderly patients with both malignancies and comorbid medical conditions. This study aimed to compare the surgical and early postoperative outcomes of laparoscopy-assisted distal gastrectomy (LADG) with those of open distal gastrectomy (ODG) for gastric cancer in patients 70 years of age or older.

METHODS

Retrospective analysis based on a prospectively collected database of elderly patients who underwent laparoscopy-assisted distal gastrectomy or ODG from February 2013 to January 2014. Preoperative patient baseline parameters, surgical and oncological outcomes, postoperative complications and pathologic results were analyzed in this report.

RESULTS

Distal gastrectomy was performed for 50 patients with the age of 70 years or older, using laparoscopic surgery for 23 patients (LADG group) and open surgery for 27 patients (ODG group). The mean age of LADG group was 76.6 years and ODG group 80.0 years. The comparison between the two groups revealed statistically similar results regarding age, gender, BMI, ASA class, history of previous surgeries, CCI and pathologic characteristics. The LADG group was characterized by less intraoperative blood loss (LADG group 100 mL vs. ODG group 250 mL, P < 0.001), less narcotic use (LADG group 1 day vs. ODG group 3 days, P < 0.001), faster bowel function recovery (time to first flatus: LADG group 51.6 h vs. ODG group 67.2 h, P < 0.001; days to oral intake: LADG group 6.1 days vs. ODG group 7.9 days, P = 0.002) and shorter postoperative hospital stay (LADG group 12 days vs. ODG group 16 days, P < 0.001). There was no significant difference in postoperative complication rate (overall complication rate: LADG group 21.7 % vs. ODG group 25.9 %, P = 0.730), survival rate (P = 0.719), postoperative recurrence and metastasis rate between the patients who underwent LADG and ODG.

CONCLUSIONS

LADG for gastric cancer is feasible, efficacious and safe in elderly patients and may be superior to conventional open resection as regards some surgical outcomes.

Short- and Long-Term Outcomes After Laparoscopic Versus Open Total Gastrectomy for Elderly Gastric Cancer Patients: a Propensity Score-Matched Analysis

BACKGROUND

To date, it has been unclear whether laparoscopic-assisted total gastrectomy (LTG) was a suitable treatment for elderly patients (aged 65 years and older) with gastric cancer. The aim of the present study was to clarify the value of LTG in the elderly using a propensity score matching method.

METHODS

We prospectively collected data from 675 elderly gastric cancer patients who underwent total gastrectomies at our institution between January 2002 and February 2012. Propensity score matching was applied at a ratio of 1:1 to compare the LTG and open total gastrectomy (OTG) groups. The operation results, hospital courses, and survival rates were compared between the matched groups.

RESULTS

The LTG group had a significantly shorter mean operating time (194 vs. 267 min, P < 0.001) and significantly less intraoperative blood loss (92 vs. 204 ml, P < 0.001). The total number of collected lymph nodes was similar in the two groups. Postoperatively, the length of hospital stay was shorter in the LTG group than in the OTG group (median 14.4 vs. 16.6 days; P = 0.001); however, no significant intergroup differences were found in morbidity or mortality. Furthermore, the 3-year overall survival (OS) rate was similar between the two groups (P = 0.517).

CONCLUSIONS

LTG for elderly gastric cancer is feasible and safe with acceptable oncologic outcomes. Therefore, patient age alone should not be considered a contraindication in the decision between LTG and OTG treatment options. A high-volume prospective study is needed to confirm this rationale.

Laparoscopic Total Gastrectomy in Elderly Patients (≥70 Years) with Gastric Carcinoma: A Retrospective Study

PURPOSE

To compare the surgical outcomes of laparoscopic total gastrectomy between elderly and non-elderly patients.

MATERIALS AND METHODS

Between 2008 and 2015, a total of 273 patients undergoing laparoscopic total gastrectomy for gastric carcinoma were divided into two age groups: elderly (≥70 years, n=71) vs. non-elderly (<70 years, n=172). Postoperative outcomes, including length of hospital stay, morbidity, and mortality were compared between the groups.

RESULTS

The elderly group showed a significantly higher rate of comorbidities and American Society of Anesthesiologists scores than those in the non-elderly group. No significant differences were found with respect to lymphadenectomy or combined organ resection between the groups. After surgery, the elderly group showed a significantly higher incidence of grade III and above complications than the non-elderly group (15.5% vs. 4.1%, P=0.003). Among the complications, anastomosis leakage was significantly more common in the elderly group (9.9% vs. 2.9%, P=0.044). Univariate and multivariate analyses showed that old age (≥70 years) was an independent risk factor (odds ratio=4.42, 95% confidence interval=1.50~13.01) for postoperative complications of grade III and above.

CONCLUSIONS

Elderly patients are more vulnerable to grade III and above complications after laparoscopic total gastrectomy than non-elderly patients. Great care should be taken to prevent and monitor the development of anastomosis leakage in elderly patients after laparoscopic total gastrectomy.

Role of robot-assisted distal gastrectomy compared to laparoscopy-assisted distal gastrectomy in suprapancreatic nodal dissection for gastric cancer

PURPOSE

Despite theoretical advantages, no clear benefit was proven for initial application of robotic surgery for gastric cancer so far. The aim of this analysis was to examine the role of robotic surgery regarding nodal dissection technically demanding areas compared to conventional laparoscopic surgery.

METHODS

This analysis included 87 patients who underwent robot-assisted distal gastrectomy (RADG) and 288 patients who underwent laparoscopy-assisted distal gastrectomy (LADG) at the National Cancer Center, Korea, between February 2009 and September 2011. Clinicopathologic data, surgery-related data, postoperative morbidity, and pathologic data for each nodal station were analyzed.

RESULTS

Time to flatulence was 3.5 ± 0.8 days for RADG and 3.8 ± 0.8 days for LADG (P = 0.01). Postoperative hospital stay was 6.7 ± 1.0 days in RADG and 7.4 ± 2.4 days in LADG (P < 0.001).The number of dissected lymph nodes was 37.1 ± 12.9 in the RADG group and 34.1 ± 12.1 in the LADG group (P = 0.044). In patients undergoing D2 gastrectomy, the number of dissected lymph nodes in the N2 area was 16.3 ± 7.7 for RADG and 13.2 ± 5.3 for LADG (P = 0.001). The number of dissected lymph nodes around the splenic artery area was 2.9 ± 2.9 in RADG and 2.2 ± 2.0 in LADG (P = 0.04). Regarding postoperative complications, there was no statistically significant difference [five patients (5.7%) in RADG and 26 patients (9%) in LADG) (P = 0.330)].

CONCLUSION

RADG could provide an advantage over LADG in the dissection of the N2 area lymph nodes, especially around the splenic artery area.

Evaluation of Clavien-Dindo classification in patients undergoing total gastrectomy for gastric cancer

The Clavien-Dindo classification for postoperative complications has been established as a standardized system and applied in many fields of surgery. The aim of our study was to assess the complications after total gastrectomy using the Clavien-Dindo classification and identify risk factors related to them. Four hundred and fifteen patients who underwent total gastrectomy for gastric cancer between April 2009 and September 2014 were enrolled in this study. Postoperative complications were graded, and possible risk factors related to complications were analyzed. The overall complication rate was 13.3 %, with the severe complications classified as grade III or above accounting for 3.1 %. Age of 65 years old or more, higher TNM staging, and open surgery were identified as independent risk factors for overall complications. Age of 65 years old or more, ASA score of 3 or more, multiorgan resection, and retrieved lymph nodes of 30 or more were identified as independent risk factors for severe complications. The Clavien-Dindo system has a broad applicability and facilitates the assessment on the incidence and severity of complications. Large-scaled, prospective clinical trials using the classification are necessary to evaluate the postoperative complications of total gastrectomy for gastric cancer.

Cytoreductive surgery and HIPEC for peritoneal carcinomatosis in the elderly

Background. The combined treatment of peritoneal carcinomatosis with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy is a rigorous surgical treatment, most suitable for young and good performance status patients. We evaluated the outcomes of elderly patients undergoing CRS and HIPEC for peritoneal carcinomatosis with careful perioperative care. Methods. All consecutive patients 70 years of age or older who were treated for peritoneal carcinomatosis over the past five years were included. Primary outcomes were perioperative morbidity and mortality. Secondary outcomes were disease-free survival and overall survival. Results. From a pool of 100 patients, with a diagnosis of PC who underwent CRS and HIPEC in our center, we have included 30 patients at an age of 70 years or older and the results were compared to the patients younger than 70 years. The total morbidity rate was 50% versus 41.5% in the group younger than 70 years (NSS). The mortality rate was 3.3% in the elderly group versus 1.43% in the younger group (NSS). Median overall survival was 30 months in the older group versus 38 months in the younger group. Conclusion. Cytoreductive surgery and HIPEC for peritoneal carcinomatosis may be safely performed with acceptable morbidity in selected elderly patients.

Robotic gastrectomy versus laparoscopic gastrectomy for gastric cancer: comparison of surgical performance and short-term outcomes

PURPOSE

This study was designed to compare robot-assisted gastrectomy with laparoscopy-assisted gastrectomy in surgical performance and short-term clinical outcomes for gastric cancer and evaluate the safety and feasibility of robotic surgery.

METHODS

A retrospective database of patients who underwent robotic or laparoscopic gastrectomy for gastric cancer between March 2010 and May 2013 was examined. After screening, 514 patients who underwent gastrectomy for gastric cancer were enrolled in this study: 120 robotic and 394 laparoscopic surgery. Patient demographics, surgical performance, and short-term clinical outcomes were examined.

RESULTS

All operations were performed successfully. The clinicopathologic characteristics were similar between the two groups. Compared with the laparoscopic group, the robotic group had less intraoperative blood loss (118.3 ± 55.8 vs. 137.6 ± 61.6 ml, P < 0.001), more lymph nodes dissection (34.6 ± 10.9 vs. 32.7 ± 11.2, P = 0.013), and longer operation time (234.8 ± 42.4 vs. 221.3 ± 44.8 min, P = 0.003). The survival rates were 90.2% at 1 year, 78.1% at 2 years, and 67.8% at 3 years in the RAG group compared with 87.3% at 1 year, 77.1% at 2 years, and 69.9% at 3 years in the LAG group. The difference in overall survival rate between the two groups was not statistically significant (P = 0.812). In view of lymph node involvement, the 3-year survival rates for patients with negative nodal metastasis were 84.4% in the RAG group versus 82.6% in the LAG group (P = 0.972) and 57.5% in the RAG group versus 60.3% in the LADG group (P = 0.653) for those with positive nodal metastasis.

CONCLUSIONS

Comparing well with laparoscopic gastrectomy, robot-assisted gastrectomy is a feasible and safe surgical procedure with clear operation field, precise dissection, minimal trauma, and fast recovery. Longer follow-up time and randomized, clinical trials are needed to evaluate the clinical benefits and long-term oncological outcomes of this new technology.