Long-term quality of life after laparoscopic distal gastrectomy for early gastric cancer: results of a prospective multi-institutional comparative trial

Fewer Feedback Opportunities and Health Perception of Gastric Cancer Survivors: Opportunities for Patient Education

This study aimed to estimate the impact of having fewer opportunities for patient education on health perception of gastric cancer survivors by examining quality-of-life (QoL) responses from patients who had been away for chemotherapy for a year. The full-surveillance (FullSV) group was comprised of gastric cancer survivors with stage I cancer who completed preoperative and postoperative 3-, 6-, 9-, and 12-month surveillances. The returning (RTN) group was comprised of 1-year survivors of stage II cancer who had been away for chemotherapy for a year. Surveillance periods were utilized to provide patient education about expected postoperative weight changes. The European Organisation for Research and Treatment of Cancer QoL questionnaires were used to assess QoL. The study included a total of 278 patients (243 in the FullSV group and 35 in the RTN group). The baseline QoL was not significantly different between the groups. Significant differences in postoperative QoL were revealed by some scales (global health status/QoL, physical functioning, fatigue, financial difficulties, anxiety, dry mouth, and body image), all in favor of the FullSV group. Despite no significant difference in their actual weight changes, stronger weight dissatisfaction was revealed among the RTN group. Patients with fewer educational inputs for postoperative adjustment of weight perception were the ones with stronger dissatisfaction about current weight. The health perception of cancer survivors is under the constant influence of clinician feedback during patient education. For the best cancer survivorship care, sufficient opportunities for adjustment of health perception through patient education need to be ensured.

Chinese national clinical practice guidelines on the prevention, diagnosis, and treatment of early gastric cancer

BACKGROUND

Gastric cancer is one of the most common malignant tumors in the digestive system in China. Few comprehensive practice guidelines for early gastric cancer in China are currently available. Therefore, we created the Chinese national clinical practice guideline for the prevention, diagnosis, and treatment of early gastric cancer.

METHODS

This clinical practice guideline (CPG) was developed in accordance with the World Health Organization's recommended process and with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) in assessing evidence quality. We used the Evidence to Decision framework to formulate clinical recommendations to minimize bias and increase transparency in the CPG development process. We used the Reporting Items for practice Guidelines in HealThcare (RIGHT) statement and the Appraisal of Guidelines for Research and Evaluation II (AGREE II) as reporting and conduct guidelines to ensure completeness and transparency of the CPG.

RESULTS

This CPG contains 40 recommendations regarding the prevention, screening, diagnosis, treatment, and follow-up of early gastric cancer based on available clinical studies and guidelines. We provide recommendations for the timing of Helicobacter pylori eradication, screening populations for early gastric cancer, indications for endoscopic resection and surgical gastrectomy, follow-up interval after treatment, and other recommendations.

CONCLUSIONS

This CPG can lead to optimum care for patients and populations by providing up-to-date medical information. We intend this CPG for widespread adoption to increase the standard of prevention, screening, diagnosis, treatment, and follow-up of early gastric cancer; thereby, contributing to improving national health care and patient quality of life.

Comparison of the effects of open and laparoscopic approach on body composition in gastrectomy for gastric cancer: A propensity score-matched study

Aim

To compare the effects of open (OG) and laparoscopic gastrectomy (LG) on body composition and muscle strength.

Methods

This study performed a propensity score matching analysis using cases from a large-scale, multicenter, phase III randomized controlled trial concerning oral nutritional supplements after gastrectomy and analyzed both the whole and matched cohorts. Measurements of body composition and hand grip strength (HGS) were performed at baseline (preoperatively) and at 1, 2, 3, 6, and 12 months after gastrectomy.

Results

Of 835 patients, 275 and 560 underwent OG and LG, respectively. Skeletal muscle mass (SMM) and HGS loss were significantly lesser in the LG group than in the OG group. The propensity score-matched analysis, including 120 pairs of patients, confirmed that the % SMM loss values at 1, 2, 3, 6, and 12 POM were -4.5%, -4.0%, -4.7%, -4.6%, and -5.8% in the OG group and -3.0%, -1.9%, -2.4%, -2.2%, and -2.7% in the LG group, respectively. The % SMM loss was significantly lesser in the LG group than in the OG group (repeated measures ANOVA p < 0.001). The HGS loss was non-significantly smaller in the LG group than in the OG group.

Conclusion

Skeletal muscle mass loss was significantly lesser in the LG group than in the OG group in both cohorts, indicating that LG may be more effective than OG for maintaining muscle mass.

Impact on quality of life with affirmative feedback on weight loss after gastrectomy

This study investigated the feasibility of improving post-gastrectomy satisfaction/quality of life (QoL) of gastric cancer survivors by readjusting their expectations through patient interviews. Weight loss after gastric cancer surgery is common, and a change in the departmental policy helped in providing cancer survivors with an alternative interpretation of lost weight. Under the new policy, a group of patients who were preoperatively overweight or obese were provided with affirmative feedback, despite their postoperative weight loss. The European Organization for Research and Treatment of Cancer QoL Questionnaire-C30 and -STO22 were used to assess the QoL. The postoperative 1-year QoL was compared before (control) and after policy changes (affirmative-feedback group) in preoperatively overweight (or obese) patients who lost weight. Despite the weight loss, the affirmative-feedback group exhibited a higher percentage of "less worried" responses (90.4%) on low body weight concerns as compared to the control group (76.5%; P = 0.037). Significant QoL advantages were also observed in the affirmative-feedback group on multiple scales (global health status/QoL, nausea/vomiting, diarrhea, dysphagia, dry mouth, and body image). Patient interviews with affirmative feedback on weight loss improved weight satisfaction and QoL in gastric cancer survivors who lost weight.

The Predictive Value of a New Inflammatory-Nutritional Score for Quality of Life after Laparoscopic Distal Gastrectomy for Gastric Cancer

We explored the predictive value of various inflammatory-nutritional indicators for postoperative quality of life (QoL) in gastric cancer (GC) patients undergoing laparoscopic distal gastrectomy (LDG) and developed a novel inflammatory-nutritional score (INS). In this study, 156 GC patients who underwent LDG were included. We used multiple linear regression to analyze the correlation between postoperative QoL and inflammatory-nutritional indicators. Least absolute shrinkage and selection operator (LASSO) regression analysis was performed to construct INS. Hemoglobin was positively correlated with physical functioning (β =8.5; p = 0.003) and cognitive functioning (β = 3.5; p = 0.038) 3 mo, after surgery. Prognostic nutritional index (PNI) was positively associated with global health status (β =5.8; p = 0.043). Albumin-alkaline phosphatase ratio (AAPR) was negatively correlated with emotional functioning 12 mo, after surgery (β = -5.7; p = 0.024). Neutrophil-lymphocyte ratio (NLR), Lymphocyte- monocyte ratio (LMR), AAPR, hemoglobin and PNI were selected using LASSO regression analysis to construct INS. The C-index values of the model in the training group and the validation group were 0.806 (95% CI, 0.719-0.893) and 0.758 (95% CI: 0.591-0.925), respectively. INS had particular predictive value for postoperative QoL in patients undergoing LDG and provided a reference for risk stratification and clinical practice.

Application of Overlap Gastroduodenostomy in Billroth I Anastomosis after Totally Laparoscopic Distal Gastrectomy for Gastric Cancer

Delta-shaped gastroduodenostomy (DSGD) and overlap gastroduodenostomy (OGD) are the two most widely used intracorporeal Billroth I anastomosis methods after distal gastrectomy. In this study, we compared the short-term outcomes of DSGD and OGD in total laparoscopic distal gastrectomy (TLDG). In a retrospective cohort study, we examined 92 gastric cancer patients who underwent TLDG performed by the same surgeon between January 2014 and June 2018. All patients underwent Billroth I reconstruction (OGD, n = 45; DSGD, n = 47) and D2 lymph node dissection. We retrospectively reviewed the surgical outcomes, clinical pathological results, and endoscopy results. Laparoscopic surgery was successfully performed in both groups without conversion to open surgery. The demographic and clinical characteristics were similar between the two groups (P > 0.05). There were no significant differences between the two groups in operation time (158.9 ± 13.6 min vs. 158.8 ± 14.8 min, P=0.955), anastomotic time (19.4 ± 3.0 min vs. 18.8 ± 2.9 min, P=0.354), intraoperative blood loss (88.9 ± 25.4 mL vs. 83.7 ± 24.3 mL, P=0.321), number of lymph node dissections (31.0 ± 7.1 vs. 29.2 ± 7.5, P=0.229), length of hospital stay (8.8 ± 2.7 days vs. 9.1 ± 3.0 days, P=0.636), fluid intake time (3.1 ± 0.7 days vs. 3.2 ± 0.7 days, P=0.914), and morbidity of postoperative complications (6.7% [3/45] vs. 10.6% [5/47], P=0.499). Endoscopy performed 6 months postoperatively showed that the residual food (P=0.033), gastritis (P=0.029), and bile (P=0.022) classification score significantly decreased in the OGD group, and there were no significant differences 12 months postoperatively. OGD is a safe and effective reconstruction technique with comparable postoperative surgical outcomes and endoscopy results when compared with those of DSGD.

Health-Related Quality of Life in Patients With Locally Advanced Gastric Cancer Undergoing Perioperative or Postoperative Adjuvant S-1 Plus Oxaliplatin With D2 Gastrectomy: A Propensity Score-Matched Cohort Study

Background

Some high-quality clinical trials have proven the efficacy and safety of perioperative and postoperative S-1 with oxaliplatin (peri-SOX and post-SOX) for patients with locally advanced gastric cancer (LAGC) undergoing D2 gastrectomy. However, little is known about how health-related quality of life (HRQOL) changes over time in patients receiving peri-SOX or post-SOX chemotherapy.

Methods

A prospective observational cohort (NCT04408859) identified 151 eligible patients with LAGC who underwent D2 gastrectomy with at least six cycles of peri-SOX or post-SOX chemotherapy from 2018 to 2020. HRQOL was assessed using the EROTC QLQ-C30 and its gastric module, QLQ-STO22, at indicated measurements, including the baseline, 1st, 3rd, 6th and 12th month after initiation of therapy. Baseline characteristics, therapeutic effects, and longitudinal HRQOL were compared between the peri-SOX and post-SOX groups after propensity score matching. HRQOL changes over time and the risk factors for scales with severe deterioration were further analyzed.

Results

No statistically significant differences in longitudinal HRQOL were observed between patients in the peri-SOX and post-SOX groups, with comparable surgical outcomes and adverse chemotherapy events. Scales of social functioning, abnormal taste, and anxiety improved earlier in the peri-SOX group than in the post-SOX group. Score changes in both groups indicated that general deterioration and slower recovery usually occurred in the scales of physical, social, and role functioning, as well as symptoms of fatigue, reflux, diarrhea, and anxiety.

Conclusion

Peri-SOX showed a longitudinal HRQOL comparable to post-SOX in patients with LAGC who underwent D2 gastrectomy. The peri-SOX group had better performance in social functioning, abnormal taste, and anxiety at some measurements.

Impact of Body Composition and Physical Function on Quality of Life After Gastrectomy for Gastric Cancer

Purpose

Patients with gastric cancer after gastrectomy often suffer from a decline in their quality of life (QoL), but the relationship between body composition (BC) and physical function on QoL has rarely been studied. This study aims to evaluate and determine the changes in QoL after gastrectomy and the impact of BC and physical function on QoL.

Methods

A total of 311 gastric cancer patients completed EORTC QLQ-C30 and EORTC QLQ-STO22 questionnaires before and 1, 3, 6 months post-surgery. Data including BC, handgrip strength (HGS) and 6-m gait speed (GS) were collected prospectively. Multiple linear regression analysis was used to determine the correlation between QoL and BC, HGS and GS.

Results

Patients had significantly worse scores after surgery on most function and symptom scales (p < 0.001), but most of these scales recovered within 6 months after surgery. A higher subcutaneous fat area (SFA)was associated with increased symptom scores 1 month after surgery. A higher GS is associated with a better global health status symptom.

Conclusion

Patients suffer from a decline in their QoL after gastrectomy for gastric cancer. Intervention strategies aiming at reducing SFA and improving GS may improve the QoL in patients underwent gastrectomy for gastric cancer.

Life prognosis of sentinel node navigation surgery for early-stage gastric cancer: Outcome of lymphatic basin dissection

BACKGROUND

Lymphatic basin dissection is a sentinel node biopsy method that is specific for gastric cancer. In this method, the dyed lymphatic system is dissected en bloc, and sentinel nodes are identified at the back table (ex vivo). Even with lymphatic basin dissection, blood flow to the residual stomach can be preserved, and function-preserving curative gastrectomy can be performed. The oncological safety of function-preserving curative gastrectomy combined with lymphatic basin dissection has not yet been fully investigated. We hypothesized that the oncological safety of sentinel node navigation surgery (SNNS) is not inferior to that of the guidelines.

AIM

To investigate the life prognosis of SNNS for gastric cancer in comparison with guidelines surgery.

METHODS

This was a retrospective cohort study. Patients were selected from gastric cancer patients who underwent sentinel node biopsy from April 1999 to March 2016. Patients from April 1999 to August 2008 were from the Department of Surgery II, Kanazawa University Hospital, and patients from August 2009 to March 2016 were from the Department of Surgical Oncology, Kanazawa Medical University Hospital. Patients who were diagnosed with gastric cancer, which was preoperatively diagnosed as superficial type (type 0), 5 cm or less in length, clinical T1-2 and node negative, and underwent various gastrectomies guided by sentinel node navigation were retrospectively collected. The overall survival (OS) and relapse-free survival (RFS) of these patients (SNNS group) were investigated. Patients with gastric cancer of the same stage and who underwent guidelines gastrectomy with standard nodal dissection were also selected as the control group.

RESULTS

A total of 239 patients in the SNNS group and 423 patients in the control group were included. Pathological nodal metastasis was observed in 10.5% and 10.4% of the SNNS and control groups, respectively. The diagnostic abilities of sentinel node biopsy were 84% and 98.6% for sensitivity and accuracy, respectively. In the SNNS group, 81.6% of patients underwent modified gastrectomy or function-preserving curative gastrectomy with lymphatic basin dissection, in which the extent of nodal dissection was further reduced compared to the guidelines. The OS rate in the SNNS group was 96.8% at 5 years and was significantly better than 91.3% in the control group (P = 0.0014). The RFS rates were equal in both groups. After propensity score matching, there were 231 patients in both groups, and the cumulative recurrence rate was 0.43% at 5 years in the SNNS group and 1.30% in the control group, which was not statistically different.

CONCLUSION

The oncological safety of patients who undergo gastrectomy guided by sentinel node navigation is not inferior to that of the guidelines surgery.

A comparison of quality of life between patients with small and large gastric remnant volumes after gastrectomy for gastric cancer

The impact of gastric remnant volumes (GRVs) after gastrectomy on patients' quality of life (QOL) has not yet been clarified. The aim of the present study was to compare QOL after gastrectomy between small and large gastric remnant volume patients.We prospectively collected clinical data from 78 consecutive patients who underwent distal gastrectomy with Billroth II gastrojejunostomy for gastric cancer. The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Stomach questionnaire and gastric computed tomography scans were performed. The patients were subdivided into 2 groups by remnant stomach volume (the S group ≤110 mL vs L group >110 mL).The worst scores for most items were observed at postoperative month 1 and usually improved thereafter. There was no difference in the STO22 score except for dysphagia between the S and L groups after gastrectomy (P > .05). The QOL score of dysphagia was different at postoperative 6 months (S vs L, 12.4 vs 22.8, P < .03), but there was no difference at postoperative months 1, 3, 12, 24, or 36 (P > .05).The remnant gastric volume after partial gastrectomy affects neither functional differences nor QOL after 6 months following appropriate radical surgery.

Impact of gastric cancer treatment on quality of life of patients

Treatment of gastric cancer is stage specific and ranges from endoscopic resections in early gastric cancer to gastrectomy and multimodal treatment in locally advanced tumour situations. Palliative systemic treatment has the potential to prolong survival in advanced tumour stages. However, tumour-directed therapies and their side-effects potentially worsen the general condition of a patient. Treatment discussions and decisions, especially when trading-off the options with the patient, have widened their focus from 'technical' terms like overall survival, disease-free survival and progression-free survival to patient reported outcomes (PROs) including quality of life (QoL). The assessment of PROs has evolved as important endpoint in clinical studies. A precise definition of QoL seems impossible. Its multiple dimensions can be evaluated by various validated questionnaires like the QLQ-C30 and FACT-G focusing on different priorities. Special additional tools have been developed and validated to assess QoL in gastric cancer patients (QLQ-STO22, FACT-Ga). We herein give an overview on the options to evaluate QoL in patients with gastric cancer and on published data on the impact of tumour-targeted therapy on QoL in these patients.

Influencing Factors and Effects of Treatment on Quality of Life in Patients With Gastric Cancer-A Systematic Review

Background: Gastric cancer (GC) is one of the leading causes of death worldwide. It is associated with several disease-related impairments contributing to the psycho-social burden of those patients, such as deterioration of well-being and overall quality of life (QOL). The aim of this study is to present the wide range of factors potentially impacting patients' overall well-being and possible preventive interventions. Methods: This systematic review was conducted in October 2020 with a search in the PubMed, MedLine, PsycInfo, and Google Scholar databases. We used the keywords "gastric cancer," "gastric neoplasm," and each of them combined with "quality of life," "depression," and "anxiety" to identify all relevant articles reporting about potential impact factors influencing the overall well-being of patients suffering from gastric cancer. Results: Finally, 125,490 articles were found, of which 125,431 were excluded in several steps of screening. Inclusion criteria were studies carried out on human ≥18 years of age, studies in English or German language, clinical trials, registry-based studies, cohort studies, population-based studies, and certain titles and abstracts. After screening for eligibility 35 potential factors influencing overall well-being in patients with GC were identified and classified into 9 important categories: genetic condition, treatment method, blood markers, nutritional status, daily living, state of health, mental state, supportive care, and alternative treatment. Conclusion: Since various factors are involved in the development of patients' overall well-being, timely treatment of psycho-social impairments by physicians and psychologists is of enormous importance. Preventing psycho-social burden by improving patients' QOL should be of high importance in the treatment regimen of patients with GC.

Laparoscopic versus open subtotal gastrectomy for gastric adenocarcinoma: cost-effectiveness analysis

Background

Laparoscopic subtotal gastrectomy (LSG) for cancer is associated with good perioperative outcomes and superior quality of life compared with the open approach, albeit at higher cost. An economic evaluation was conducted to compare the two approaches.

Methods

A cost–effectiveness analysis between LSG and open subtotal gastrectomy (OSG) for gastric cancer was performed using a decision‐tree cohort model with a healthcare system perspective and a 12‐month time horizon. Model inputs were informed by a meta‐analysis of relevant literature, with costs represented in 2016 Canadian dollars (CAD) and outcomes measured in quality‐adjusted life‐years (QALYs). A secondary analysis was conducted using inputs extracted solely from European and North American studies. Deterministic (DSA) and probabilistic (PSA) sensitivity analyses were performed.

Results

In the base‐case model, costs of LSG were $935 (€565) greater than those of OSG, with an incremental gain of 0·050 QALYs, resulting in an incremental cost–effectiveness ratio of $18 846 (€11 398) per additional QALY gained from LSG. In the DSA, results were most sensitive to changes in postoperative utility, operating theatre and equipment costs, as well as duration of surgery and hospital stay. PSA showed that the likelihood of LSG being cost‐effective at willingness‐to‐pay thresholds of $50 000 (€30 240) per QALY and $100 000 (€60 480) per QALY was 64 and 68 per cent respectively. Secondary analysis using European and North American clinical inputs resulted in LSG being dominant (cheaper and more effective) over OSG, largely due to reduced length of stay after LSG.

Conclusion

In this decision analysis model, LSG was cost‐effective compared with OSG for gastric cancer.

Health-related quality of life and health utility score of patients with gastric cancer: A multi-centre cross-sectional survey in China

OBJECTIVE

To evaluate the health-related quality of life (HRQoL) and health state utility scores of gastric cancer patients in daily life at different clinical stages after treatment, and to explore influencing factors associated with HRQoL.

METHODS

Gastric cancer patients discharged from hospitals and healthy controls identified by screening were recruited. The three-level EQ-5D was employed to assess HRQoL and was scored using two Chinese-specific tariffs published in 2014 and 2018.

RESULTS

A total of 1,399 patients and 2,179 healthy controls were recruited. The likelihood of reporting problems in the five dimensions for patients was 4.0-23.8 times higher than controls. Based on the 2014/2018 tariff, the mean EQ-5D utility score was 0.321/0.163 lower than controls, and the mean utility scores of each patient subgroup were 0.077/0.039 (high-grade intraepithelial neoplasia/carcinoma in situ), 0.254/0.121 (Stage I), 0.249/0.123 (Stage II), 0.353/0.182 (Stage III) and 0.591/0.309 (Stage IV) lower than controls (all statistically significant). Age, occupation, duration of illness, other chronic disease status and therapeutic regimen had a significant impact upon different aspects of HRQoL in patients.

CONCLUSIONS

Gastric cancer significantly impaired patients' HRQoL in daily life after treatment. More advanced cancer stages were associated with larger decrements on health state utility.

Multidisciplinary Approach in Improving Survival Outcome of Early-Stage Gastric Cancer

BACKGROUND

The necessity of extensive lymph node (LN) dissection/examination and adjuvant therapy for patients with early gastric cancer (EGC, Tis-T1, any N) remains controversial. We aim to refine treatment recommendations for patients with EGC through a reflective analysis for the survival gap between Eastern and Western countries.

METHODS

EGC patients diagnosed between 2004 and 2014 were identified from the National Cancer Database (NCDB) and a large medical center in China. Adequate LN yield was defined as ≥25 LNs examined.

RESULTS

In the US cohort, 14.4% of (1104/7641) patients with EGC had ≥25 LNs examined. The 5-y overall survival (OS) was significantly better than those with <25 LNs (78.9% versus 68.5%, P < 0.001). Examination of ≥25 LNs was an independent predictor of better OS after adjusting all known prognostic factors. Patients with ≥25 LNs examined had significantly higher chance of having LN-positive disease compared to patients with <25 LNs (14.9% versus 10.7%, P < 0.001). A similar stage migration phenomenon was observed in Chinese cohort (LN positive: 25.2% versus 18.4% in ≥25 LNs and <25 LNs examined group, respectively, P = 0.02). In the US cohort, adjuvant therapy was associated with a significant survival benefit for LN-positive patients (5-y OS: 71.0% versus 43.0% for with/without adjuvant therapy, respectively, P < 0.001) but not in LN-negative patients (5-y OS: 71.2% versus 71.5%, P = 0.90).

CONCLUSIONS

Adequate lymphadenectomy and LN examination are critical components of EGC management. Adjuvant therapy should be strongly encouraged for all EGC patients with LN-positive disease in the United States.

Comparison of subjective quality of life after endoscopic submucosal resection or surgery for early gastric cancer

Quality of life (QoL) has become an important issue after early gastric cancer (EGC) treatment. We aimed to compare the QoL of EGC survivors after ESD (n = 241) or laparoscopic subtotal gastrectomy (n = 241) without recurrence and to evaluate the QoL over the 5-year period after adjusting for various confounding factors related to QoL. QoL related to the gastric cancer subscale (GCS) was significantly higher in the ESD group than surgery group (p < 0.001). After adjusting for all possible confounding factors, survivors who underwent ESD still had higher QoL related to CSG than those who underwent surgery. On the analysis of interaction effects for all QoL subscales, higher QoL related to GCS of ESD group than those of surgery group has been kept over time (p = 0.983). Therefore, we concluded that EGC survivors who undergo ESD have significantly better QoL related to GCS over a 5-year period after treatment than those who undergo surgery. This may be a useful consideration when selecting treatment modalities for patients with EGC.

Detection of indocyanine green fluorescence to determine tumor location during laparoscopic gastrectomy for gastric cancer: Results of a prospective study

INTRODUCTION

In laparoscopic gastrectomy, a method to locate the margin of an early-stage cancerous lesion that is invisible from the serosal surface and impalpable during laparoscopic procedures is needed to determine an appropriate transection line. We conducted a prospective study to develop a new marking method using preoperative submucosal injection of indocyanine green (ICG).

METHODS

Patients undergoing laparoscopic gastrectomy for T1 gastric cancer were recruited. The first 11 patients comprised the learning set and the subsequent 18 patients the validation set. ICG was endoscopically injected in the submucosal layer of the stomach approximately 1 cm away from the tumor edge 1 or 3 days before surgery. The diameters of the visualized ICG were compared with those of a conventional marking method using India ink in 10 historical controls.

RESULTS

In the learning set, the optimal amount of ICG was determined to be 0.1 mL at a concentration of 0.5 mg/mL. In the validation set, the same procedure was repeated. No technical problems or adverse reactions related to ICG injection were observed. In all cases, ICG was successfully detected, and negative surgical margins were pathologically confirmed. The mean long diameter of the visualized ICG fluorescence measured at the mucosal surface of the stomach was significantly smaller in the current study than in the historical controls in whom India ink was used (21 vs 52 mm, P < 0.0001).

CONCLUSIONS

The preoperative submucosal ICG marking was safely performed and successfully detected without excessive blurring during laparoscopic gastrectomy.

Quality of Life After Curative Resection for Gastric Cancer: Survey Metrics and Implications of Surgical Technique

Gastric cancer is one of the most common cancers worldwide, and radical gastrectomy is an integral component of curative therapy. With improvements in perioperative morbidity and mortality, attention has turned to short- and long-term post-gastrectomy quality of life (QoL). This article reviews the common psychometric surveys and preference-based measures used among patients following gastrectomy. It also provides an overview of studies that address associations between surgical decision-making and postoperative health-related QoL. Further attention is focused on reported associations between technical aspects of the operation, such as extent of gastric resection, minimally-invasive approach, pouch-based conduits, enteric reconstruction, and postoperative QoL. While there are several randomized studies that include QoL outcomes, much remains to be explored. The relationship between symptom profiles and preference-based measures of health state utility is an area in need of further research.

Clockwise, Modularized Lymphadenectomy in Laparoscopic Gastric Cancer Surgery: a New Laparoscopic Surgery Model

BACKGROUND

The aim of the study is to present the clockwise, modularized lymphadenectomy model of laparoscopic gastrectomy for gastric cancer patients, which is based on our clinical practice experience in laparoscopic gastric cancer surgery.

METHODS

From Jan 2015 to July 2017, 116 patients who underwent laparoscopic gastrectomy were retrospectively collected and analyzed. According to the different resection models, patients were divided into two groups: traditional laparoscopic lymphadenectomy group (63 patients) and clockwise, modularized lymphadenectomy group (53 patients). Operation-related parameters were compared between the two groups.

RESULTS

The clockwise, modularized lymphadenectomy group had less dissection time (119.8 ± 19.1 min vs. 135.3 ± 23.8 min, p < 0.001) and less intraoperative blood loss (81.7 ± 42.9 ml vs. 91.4 ± 28.7 ml, p = 0.016) compared with the traditional laparoscopic lymphadenectomy group. Meanwhile, the clockwise, modularized lymphadenectomy group had more numbers of examined lymph nodes (40.5 ± 14.3 vs. 33.9 ± 11.0, p = 0.007) than the traditional laparoscopic lymphadenectomy group. Besides, there was no statistically significant difference in the postoperative complication rates between the two groups. The clockwise, modularized lymphadenectomy group had shorter postoperative hospital stay than the traditional laparoscopic lymphadenectomy group (8.7 ± 3.2 days vs. 10.4 ± 3.9 days, respectively, p < 0.001).

CONCLUSIONS

Through the adoption of the fixed sequence of lymphadenectomy, requirements and standard of lymphadenectomy of each lymph node station, and specific surgical skills for intraoperative exposure by the clockwise and modularized lymphadenectomy model, we can optimize and facilitate the laparoscopic gastric cancer surgery.

The Effect of Comedy Films on Postoperative Pain and Anxiety in Surgical Oncology Patients

Objectives: To determine the effect of watching Turkish comedy films on postoperative pain and anxiety in oncology surgical patients. Design: This study was conducted using a pre- and post-test randomized controlled trial model. Materials and Methods: The study was conducted in a general surgery clinic of a hospital in eastern Turkey between January 2016 and January 2017. The sample of the study consisted of 88 patients (44 test, 44 control) selected by using the randomized sampling method. In the experimental group, funny videos from Turkish old comedy movies were watched for 10 min before surgery. Anxiety, measured by the State-Trait Anxiety Inventory, and vital signs were measured before and after the experimental protocol. In the analysis of the data, descriptive statistics, χ2 and t test were used. Results: The state-trait anxiety pre- and post-test mean score of the experimental group was found to be 39.59 ± 3.66 and 37.54 ± 3.52 before and after watching the video, respectively, indicating a statistically significant difference between these two values (p ≤ 0.05). No statistically significant difference was found between the pre- and post-test state-trait anxiety scores of the patients in the control group. The decrease from the pre- to post-test mean pain score was determined as 0.65 ± 1.05 in the experimental group and 0.11 ± 0.96 in the control group. A statistically significant difference was found between the groups’ post-test mean pain scores (p ≤ 0.05). Conclusion: The study results suggest that watching Turkish comedy movie videos has a positive effect on postoperative pain and anxiety in surgical oncology patients.

The role of trait emotional intelligence in quality of life, anxiety and depression symptoms after surgery for esophageal or gastric cancer: A French national database FREGAT

OBJECTIVE

The main objective was to test the indirect effects of emotional competence (EC) after diagnosis (T1) on the health-related quality of life (HRQoL) after surgery (T2) of esogastric cancer patients via fewer anxiety and depression symptoms (T2).

METHODS

Data were collected from 30 French centers via the clinicobiological database French EsoGastric Tumors (FREGAT). Two hundred and twenty-eight participants completed a self-reported questionnaire at T1 and T2, assessing their EC (Profile of Emotional Competence (PEC)), HRQoL (EORTC Quality of Life Questionnaire-Core (QLQ-C30)), and anxiety and depression symptoms (Hospital Anxiety and Depression Scale (HADS)). Regression analyses were used to test the direct effects of intrapersonal and interpersonal EC on their anxiety/depression symptoms and HRQoL at T1 and T2. The PROCESS Macro in SPPS v.22 with bootstrap methods was used to test the indirect effects of intrapersonal and interpersonal EC at T1 on HRQoL at T2 via anxiety and depression symptoms.

RESULTS

EC predicted fewer anxiety and depression symptoms of patients at T1 and T2 and better HRQoL at T1. EC at T1 also predicted a better HRQoL at T2 via fewer anxiety and depression symptoms at T2.

CONCLUSIONS

Patients who tended to use their EC in daily life could be more effective in regulating the emotional impact of the cancer diagnosis and surgery. This explains why they reported fewer anxiety and depression symptoms, which in turn enabled a better perceived HRQoL after surgery. Therefore, reinforcing the use of patients' EC in daily life following their diagnosis could decrease their emotional distress and, in this way, improve their HRQoL in the preoperative and postoperative stages.

Background factors influencing postgastrectomy syndromes after various types of gastrectomy

BACKGROUND

Postgastrectomy syndromes (PGS) after curative gastrectomy for gastric cancer are influenced by not only gastrectomy type but also by background factors. Recently, a nationwide PGS study was performed using the Postgastrectomy Syndrome Assessment Scale-45 (PGSAS-45) questionnaire.

AIM

To determine the influence of each background factor on PGS for each gastrectomy type using PGS assessment study (PGSAS) data as an additional analysis.

METHODS

The data of 2368 patients were obtained from the PGSAS. This included patients undergoing distal gastrectomy (DG) with Billroth I reconstruction, DG with Roux-en-Y reconstruction, total gastrectomy with Roux-en-Y, proximal gastrectomy, pylorus-preserving gastrectomy (PPG), and local resection. Multiple regression analysis was performed to explore the independent effects of each background factor on the main outcome measures (MOMs) of PGSAS-45 for each gastrectomy type. The background factors included postoperative period, age, sex, surgical approach (laparoscopic or open), and the status of the celiac branch of the vagal nerve.

RESULTS

The MOMs of DG and PPG were highly affected by background factors, whereas those of total gastrectomy with Roux-en-Y, proximal gastrectomy, and local resection were not. Worse PGS were found in females, whereas a longer postoperative period alleviated some of the MOMs. For DG and PPG, a laparoscopic approach and preservation of the celiac branch improved several MOMs.

CONCLUSION

Various background factors affected PGS, and their influence varied with the type of gastrectomy performed. Laparoscopic surgery and celiac branch preservation can improve PGS in patients undergoing DG and PPG.

Laparoscopic surgery for gastric cancer: where are we now and where are we going?

INTRODUCTION

Minimally-invasive surgery is gaining increasing popularity for the management of gastric cancer (GC). Areas covered: The authors hereby comprehensively and systematically reviewed the randomized and/or prospective evidence on laparoscopic gastrectomy (LG) for GC. For early GC located in the distal stomach, various randomized trials have demonstrated the superiority/non-inferiority of LG especially in reducing surgical trauma and enhancing postoperative recovery without compromising surgical safety and oncologic efficacy. For advanced GC, while multicenter large-scale randomized evidence has demonstrated the safety and feasibility of LG by experienced hands, the long-term survival which is to be clarified by several ongoing trials are crucial to determine whether a more widespread application is acceptable. Randomized evidence regarding the application of laparoscopic total or proximal gastrectomy, which is technically challenging, is scarce. Various attempts in modification of the traditional laparoscopic approach to further reduce the trauma have been evaluated, such as single-incision and totally LG. LG is becoming increasingly individualized and precise. Expert commentary: The current randomized and/or prospective evidence supports the non-inferiority of laparoscopic surgery especially for the management of early GC located in the distal stomach, while the definitive efficacy of the laparoscopic approach for more surgically challenging situations remains largely explorative and investigative.

Comparison of Coping, Psychological Distress, and Level of Functioning in Patients With Gastric and Colorectal Cancer Before Adjuvant Chemotherapy

CONTEXT

Patients with gastrointestinal cancers are at high risk for functional problems that are generally accompanied by a decline in their overall status and intense psychological distress.

OBJECTIVES

This study compares the level of functioning in individuals with gastric cancer (GC) and colorectal cancer (CRC) and analyzes whether improved functioning can be explained by patients' psychological status and coping strategies.

METHODS

This is a prospective, transversal, multicenter study in patients with nonmetastatic GC and CRC before initiating adjuvant chemotherapy. Participants answered questionnaires evaluating quality of life, including functioning (European Organization for Research and Treatment of Cancer Quality of Life questionnaire), coping strategies (Mini-Mental Adjustment to Cancer), and psychological distress (Brief Symptom Inventory-18).

RESULTS

Between December 2015 and July 2017, 266 patients with CRC and 69 patients with GC were consecutively recruited. A pathological level of functioning was more prevalent in people with GC than in those with CRC (20% vs. 5%). Individuals with GC presented worse functioning and more psychological distress and displayed more hopelessness, anxious preoccupation, and cognitive avoidance as coping strategies than those with CRC. Psychological distress and fighting spirit accounted for 40% of the functional status in GC patients, whereas psychological distress and hopelessness represented 58% of CRC patients' functional status.

CONCLUSION

Our findings suggest that level of functioning affects many subjects with GC and reveals the importance of developing interventions targeted at enhancing adaptive coping strategies before initiating adjuvant cancer treatment.

Feasibility and Effects of a Postoperative Recovery Exercise Program Developed Specifically for Gastric Cancer Patients (PREP-GC) Undergoing Minimally Invasive Gastrectomy

PURPOSE

Exercise intervention after surgery has been found to improve physical fitness and quality of life (QOL). The purpose of this study was to investigate the feasibility and effects of a postoperative recovery exercise program developed specifically for gastric cancer patients (PREP-GC) undergoing minimally invasive gastrectomy.

MATERIALS AND METHODS

Twenty-four patients treated surgically for early gastric cancer were enrolled in the PREP-GC. The exercise program comprised sessions of In-hospital Exercise (1 week), Home Exercise (1 week), and Fitness Improvement Exercise (8 weeks). Adherence and compliance to PREP-GC were evaluated. In addition, body composition, physical fitness, and QOL were assessed during the preoperative period, after the postoperative recovery (2 weeks after surgery), and upon completing the PREP-GC (10 weeks after surgery).

RESULTS

Of the 24 enrolled patients, 20 completed the study without any adverse events related to the PREP-GC. Adherence and compliance rates to the Fitness Improvement Exercise were 79.4% and 99.4%, respectively. Upon completing the PREP-GC, patients also exhibited restored cardiopulmonary function and muscular strength, with improved muscular endurance and flexibility (P<0.05). Compared to those in the preoperative period, no differences were found in symptom scale scores measured using the European Organization for Research and Treatment of Cancer (EORTC) Core Quality of Life Questionnaire (QLQ-C30) and Quality of Life Questionnaire-Stomach Cancer-Specific Module (QLQ-STO22); however, higher scores for global health status and emotional functioning were observed after completing the PREP-GC (P<0.05).

CONCLUSIONS

In gastric cancer patients undergoing minimally invasive gastrectomy, PREP-GC was found to be feasible and safe, with high adherence and compliance. Although randomized studies evaluating the benefits of exercise intervention during postoperative recovery are needed, surgeons should encourage patients to participate in systematic exercise intervention programs in the early postoperative period (Registered at the ClinicalTrials.gov NCT01751880).

Reevaluation of laparoscopic versus open distal gastrectomy for early gastric cancer in Asia: A meta-analysis of randomized controlled trials

BACKGROUND

The benefits and risks of laparoscopic distal gastrectomy (LADG) are not yet sufficiently clear for acceptance as a standard treatment of early gastric cancer. Previous meta-analyses were not powered to reach definitive conclusions.

MATERIALS AND METHODS

Randomized controlled trials comparing LADG with open distal gastrectomy (ODG) for early gastric cancer in Asia and published between January 1994 and January 2018 were retrieved from PubMed, Embase, the Cochrane Library, and Google Scholar. Patient characteristics, oncological safety and efficacy, and surgical safety were evaluated following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Grading of Recommendations Assessment, Development and Evaluation guidelines (GRADE) guidelines. Trial Sequential Analysis (TSA) reduced random error and reinforced the reliability and strength of evidence.

RESULTS

Eight trials including 2666 participants were selected. LADG benefits were an 11.6 cm shorter incision (95% CI: -13.31 to -9.88 cm; P < 0.0001), 103.81 ml less blood loss (95% CI: -133.68 to -73.94; P < 0.0001), 1.73 times less analgesic use (95% CI: -2.21 to -1.24; P < 0.0001), 0.51 days shorter time to first flatus (95% CI: -0.88 to -0.15 days; P = 0.006), lower risk of wound dehiscence (RR = 0.24, 95% CI: 0.08-0.78; P = 0.02), lower risk of surgical adverse events (RR = 0.69, 95% CI: 0.53-0.91; P = 0.008), and lower risk of respiratory complications (RR = 0.40; 95% CI: 0.20-0.79; P = 0.009) than ODG. LADG had 2.22 fewer resected lymph nodes (95% CI: -4.33 to -0.12; P = 0.04) and 76.61 min longer procedures (76.61 min, 95% CI: 57.74-95.47 min; P < 0.0001).

CONCLUSIONS

In Asian patients, LADG had similar mortality and oncological safety, better surgical safety, less operative morbidity, less trauma, and faster recovery than ODG. It has a high role to play in node-negative cases due to better short-term outcomes but less nodal harvest. It is a recommended alternative treatment for experienced surgeons in high-volume centers.

Long-term outcomes of laparoscopic versus open D2 gastrectomy for advanced gastric cancer

BACKGROUND

Technical safety and short-term surgical outcomes of laparoscopy-assisted gastrectomy (LAG) for advanced gastric cancer (AGC) have been investigated in many clinical trials. However, studies with large sample size and sufficient follow-up comparing LAG and open gastrectomy (OG) for AGC have seldom been reported. The purpose of this study was to compare the long-term outcomes of LAG versus open OG for AGC using a propensity score matching analysis.

METHODS

We retrospectively evaluated 459 and 856 patients who underwent LG or OG with D2 lymph node dissection, respectively, for AGC between June 2007 and June 2012. One-to-one propensity score matching was performed to compensate for heterogeneity between groups. We compared long-term outcomes between the two groups after propensity score matching.

RESULTS

In the propensity score-matched cohort, no significant differences were observed in 5-year overall survival (OS) (52.0% vs. 53.4%; P = 0.805) and disease-free survival (DFS) (46.8% vs. 47.3%; P = 0.963) between the LAG group and OG group. Stratified analysis showed that the 5-year OS and DFS rates were comparable between the two groups in each tumor stage (P > 0.05). Multivariate analysis revealed that the operation method was not an independent prognostic factor for OS or DFS. Further analysis showed that the recurrence pattern was similar between the LAG group the OG group (P > 0.05).

CONCLUSION

LAG is a feasible surgical procedure for AGC in terms of long-term prognosis, although the results should be confirmed by the ongoing randomized controlled trials.

Utility analysis and calibration of QOL assessment in disease management

In clinical trials, the assessment of health-related quality of life (QOL) (or patient-reported outcome [PRO] measure) has become very popular especially for clinical studies conducted for evaluating clinical benefits of patients with chronic, severe, and/or life threatening diseases. Health-related QOL information and PRO measures are useful for disease management for achieving best clinical practice. In this article, we will focus on health-related QOL assessment. The concept, design, and analysis of health-related QOL in clinical trials are reviewed. Validation of the use of health-related QOL instrument in terms of some key performance characteristics such as accuracy, reliability, sensitivity, and responsibility for assuring quality, integrity, and validity of collected QOL data are discussed. The concept of utility analysis and calibration (e.g., with respect to life events) for achieving the optimization of disease management are proposed. The change of the QOL could be translated into different life events for effective disease management. These translations could evaluate the treatment effect by more directly displaying the change of the QOL.

Impact of Body Mass Index on the Quality of Life after Total Gastrectomy for Gastric Cancer

Purpose

We evaluated the impact of postoperative body mass index (BMI) shifts on the quality of life (QoL) following total gastrectomy in patients with gastric cancer.

Materials and Methods

QoL data collected from the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ)-C30 and QLQ-STO22 questionnaires were obtained from 417 patients preoperatively and 1 year after surgery. Patients were divided into two groups based on changes in BMI: group 1 comprised patientswhose BMIrange category dropped, and group 2 included patients who maintained or rose to a higher category compared to their preoperative BMI category.

Results

There were 276 patients in group 1 and 141 in group 2. QoLs with respect to the global health status and functional scales were not significantly different between the groups 1 year after surgery. However, there were significantly greater decreases in QoL in group 1 due to gastrointestinal symptoms, such as nausea and vomiting (p=0.008), appetite loss (p=0.001), and constipation (p=0.038). Of the QLQ-STO22 parameters, dysphagia (p=0.013), pain (p=0.012), reflux symptoms (p=0.017), eating restrictions (p=0.007), taste (p=0.009), and body image (p=0.009) were associated with significantly worse QoL in group 1 than in group 2 1 year after surgery.

Conclusion

Patients have significantly different QoLs depending on the BMI shift after total gastrectomy. Efforts to reduce the gap in QoL should include intensive nutritional support and restoration of dietary behaviors. Appropriate clinical and institutional approaches, plus active medical interventions, are required for maintaining patients' BMIs after surgery.

Chronological Changes in Quality of Life after Distal Gastrectomy for Gastric Cancer

PURPOSE

Patient quality of life (QoL) may be severely disrupted following distal gastrectomy for gastric cancer. This issue should be addressed to improve postoperative care.

MATERIALS AND METHODS

QoL data from the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, and its gastric cancer-specific module, were administered to 202 patients preoperatively, and 5 years postoperatively. Patients were classified into subgroups based on their answers to each questionnaire item: group I (good), answering "not at all"; group II (fair), answering "a little"; group III (poor), answering "quite a bit" or "very much."

RESULTS

At 5 years post-operation, the proportion of patients in group III on the functional scales ranged from 4.3% to 5.7%. The proportions of patients in group III with fatigue, insomnia, diarrhea, and financial difficulties were 8.9%, 9.0%, 11.5%, and 9.1%, respectively. The proportions of patients in group III with anxiety, dry mouth, body image concerns, and hair loss were 12.8%, 10.5%, 9.9%, and 12.6%, respectively. These proportions were less than 5% for other QoL symptom scales/items and for the gastric cancer-specific module.

CONCLUSIONS

Most patients reported good or fair QoL following surgery. However, symptom management of fatigue, insomnia, diarrhea, anxiety, dry mouth, body image, and hair loss should be specifically targeted for long-term patient care in approximately 10% of patients.

Robotic surgery for gastric tumor: current status and new approaches

Surgical techniques have evolved tremendously over this past century. To maximize the efficacy and minimize the invasiveness of laparoscopic surgery, researchers have sought to implement wider application of robotics. Nevertheless, both optimism without sound evidence and fear of new technology obscure the appropriate uses of robotic surgery. In the present review, we attempted to provide a balanced perspective on the current state of robotic gastrectomy, outlining evidence and opportunities for the use thereof. Although evidence is limited, the use of robotics is feasible for gastric cancer surgery, and less than 10 cases of robotic surgery are needed to become proficient therein. Compared to the clinical impact of laparoscopy on gastric cancer surgery, the additional benefits of robotic surgery to patients seem to be limited. Despite additional costs and longer surgeries, robotic surgery reportedly does not offer surgical outcomes superior to those for laparoscopic surgery, according to a recent multicenter study. Meanwhile, however, our in-depth review of retrospective and prospective reports revealed that robots could expand the indications of minimally invasive gastrectomy for patients requiring total gastrectomy and D2 lymph node dissection. Moreover, we found that robotic gastrectomy is associated with a higher number of retrieved lymph nodes, less bleeding, fewer complications, and shorter hospital stay, compared to laparoscopic gastrectomy. Accordingly, new surgical approaches using advanced technologies, such as near infrared detectors, the Tilepro^® multi-input display, dual consoles, and the Single-Site^® system, are under investigation. In conclusion, measuring the additional benefits of robotic over laparoscopic surgery would be difficult and clinically insignificant. Thus, developing new surgical procedures that extend the benefits of conventional laparoscopic surgery to patients in whom minimally invasive surgery would not be possible is necessary to justify the greater use of robotic surgery.

Chronological Changes of Quality of Life in Long-Term Survivors after Gastrectomy for Gastric Cancer

Purpose

A few studies have prospectively evaluated changes in quality of life (QoL) after surgery in short-term survivors; however, no prospective study has evaluated the longitudinal changes in QoL in long-terms survivors. We prospectively evaluated the chronological changes in QoL after a gastrectomy over a 5-year postoperative period in a large group of patients.

Materials and Methods

QoL data from the European Organization for Research and Treatment of Cancer QLQ-C30 and the QLQ-STO22 questionnaires were obtained from 254 patients who completed the entire series of QoL assessments preoperatively and at 1, 2, 3, 4, and 5 years after surgery.

Results

There was no statistically significant change in global health status/QoL during the 5-year postoperative period. Decreases in QoL from upper gastrointestinal symptoms including diarrhea (p < 0.001), dysphagia (p < 0.001), reflux symptoms (p=0.029), and eating restrictions (p < 0.001) were observed among the long-term survivors. Decreased physical functioning (p < 0.001), role functioning (p < 0.001), and cognitive functioning (p < 0.001), along with fatigue (p=0.045) and a poor body image (p=0.003), negatively impacted the patients’ QoL for a long time.

Conclusion

Management of gastrointestinal symptoms should be specifically targeted as a part of long-term patient care after a gastrectomy. Proper nutritional care will improve food intake resulting in weight gain and improved physical functioning, role functioning, and body image. In addition, patients should be encouraged to preserve self-esteem and maintain social activity.

[Spectrum of laparoscopic surgery for gastric tumors]

Minimally invasive operative procedures are increasingly being used for treating tumors of the upper gastrointestinal tract. While minimally invasive surgery (MIS) has become established as a standard procedure for benign tumors and gastrointestinal stromal tumors (GIST) based on current studies, the significance of MIS in the field of gastric cancer is the topic of heated debate. Until now the majority of studies and meta-analyses on gastric cancer have come from Asia and these indicate the advantages of MIS in terms of intraoperative blood loss, minor surgical complications and swifter convalescence although without any benefits in terms of long-term oncological results and quality of life. Unlike in Germany, gastric cancer in Asia with its unchanged high incidence rate, 50 % frequency of early carcinoma and predominantly distal tumor localization is treated at high-volume centres. Due to the proven marginal advantages of MIS over open resection described in the published studies no general recommendation for laparoscopic surgery of gastric cancer can currently be given.

A systematic review of laparoscopic total gastrectomy for gastric cancer

BACKGROUND

Laparoscopic total gastrectomy (LTG) has been performed since 1999. Although surgical outcomes have been reported from Japan, Korea, China, and many Western countries, the effectiveness of this technique has not been conclusively established. This study therefore aimed to review the literature systematically.

METHODS

Our search of the research literature identified 150 studies, which were mostly retrospective and from single institutions.

RESULTS

There has recently been a remarkable increase in the number of studies from Korea, and the number of patients included in studies has increased since 2009. In most studies, the surgical procedures were longer, blood loss was reduced, and the number of retrieved lymph nodes was the same in the LTG group as in the open total gastrectomy group. The incidence of postoperative complications and that of inflammation during postoperative recovery were the same in these two groups.

CONCLUSIONS

During LTG, the method used for esophagojejunostomy is important for surgical reliability and to reduce postoperative complications. There has been rapid development of new techniques from the level of esophagojejunostomy through a small skin incision to the high level of intracorporeal esophagojejunostomy using various techniques. A nationwide prospective phase II study is urgently needed to establish the value of LTG.