Proximal gastrectomy with exclusion of no. 3b lesser curvature lymph node dissection could be indicated for patients with advanced upper-third gastric cancer

Comparison of the efficacy, safety and postoperative quality of life between modified side overlap anastomosis and double-tract anastomosis after laparoscopic proximal gastrectomy

PURPOSE

To compare the surgical safety and postoperative quality of life (QOL) between side overlap anastomosis (SOA) and double-tract anastomosis (DTA) after laparoscopic proximal gastrectomy (LPG).

METHODS

This retrospective cohort study included 43 patients with proximal gastric cancer (PGC) who underwent LPG and were admitted to the Second Affiliated Hospital of Fujian Medical University between August 2020 and December 2022 were in. Their clinical and follow-up data were collected. The patients were divided into the modified SOA (mSOA) (n = 20) and DTA (n = 23) groups based on the anastomosis methods used. The main outcome measures included the QOL of patients 1 year after surgery, and the evaluation criteria were based on the postgastrectomy syndrome assessment scale. Secondary outcome measures included intraoperative and postoperative conditions, postoperative long-term complications and nutritional status 3, 6 and 12 months after surgery.

RESULTS

No significant differences were observed in intraoperative and postoperative conditions (P > 0.05) between the mSOA and DTA groups. The mSOA group showed a decreased incidence of reflux esophagitis 1 year after surgery compared with the DTA group (P < 0.05), and no statistically significant differences were noticed between the two groups in terms of other postoperative complications (P > 0.05). The mSOA group showed better QOL when compared with the DTA group (P < 0.05). No significant differences were recorded in postoperative nutritional status between the two groups (P > 0.05).

CONCLUSION

The efficacy and safety of LPG with mSOA for PGC were comparable. When compared with the DTA group, the mSOA group seems to show reduced incidence of gastroesophageal reflux and improved QOL, which makes mSOA one of the ideal surgical methods for PGC.

Comparison of short-term clinical efficacy between modified Kamikawa anastomosis and double tract anastomosis after laparoscopic proximal gastrectomy

Objective

This study aimed to explore the short-term clinical efficacy of modified Kamikawa anastomosis and double tract anastomosis after laparoscopic proximal gastrectomy.

Methods

A retrospective analysis was carried out by collecting the clinical and pathological data of 42 patients who underwent laparoscopic proximal gastrectomy after admission in our centre from May 2020 to October 2022. Among the 42 enrolled patients, 22 underwent modified Kamikawa anastomosis (modified Kamikawa group), and the other 20 underwent double tract anastomosis (double tract group). Outcome measures included intraoperative condition, postoperative recovery, postoperative quality of life, postoperative nutritional status and gastroesophageal reflux. The patients were followed up using outpatient examination and telephone interviews to identify their nutritional status, reflux esophagitis and anastomotic status.

Results

(1) Intraoperative condition: Compared with the double tract group, the modified Kamikawa group had significantly prolonged time for operation and digestive tract reconstruction. However, no statistically significant difference in intraoperative blood loss was found between the two groups. (2) Postoperative recovery: Compared with the double tract group, the modified Kamikawa group had a significantly shorter time for the first postoperative intake of fluids, drainage tube placement and postoperative hospital stay. No statistically significant difference in the time to first postoperative anal exhaust and postoperative complications was found between the two groups. (3) Postoperative quality of life: Compared with the double tract group, the modified Kamikawa group showed better quality of life at 12 months after surgery. (4) Postoperative nutritional status and gastroesophageal reflux: No statistically significant difference in hemoglobin, total serum albumin, albumin, body mass index, MUST score, PG-SGA score, grading of reflux esophagitis using the Los Angeles classification system and GERD score was found between the two groups at 6 and 12 months after surgery. All patients did not experience anastomotic stenosis and tumour recurrence or metastasis.

Conclusions

Modified Kamikawa anastomosis is a safe and feasible treatment in laparoscopic proximal gastrectomy, which can ensure good postoperative anti-reflux effect and nutritional status. It has the advantage of better postoperative recorvery and quality of life compared with double tract anastomosis.

Useful of proximal gastrectomy with double-tract reconstruction in preventing glucose spikes

BACKGROUND

Volatile glucose levels after gastrectomy induce dumping syndrome, which adversely affects patient quality of life. This study aimed to evaluate the glycemic variability of proximal gastrectomy with double-tract reconstruction (PGDTR) as a function-preserving procedure.

METHODS

This study used a continuous glucose monitoring (CGM) system to record glycemic profiles of patients who underwent PGDTR or total gastrectomy (TG) and compared them. Moreover, this study evaluated postgastrectomy syndrome, including dumping symptoms, between the PGDTR and TG groups using the 37-item Postgastrectomy Syndrome Assessment Scale (PGSAS-37) questionnaire.

RESULTS

Of note, 44 patients underwent PGDTR, and 42 patients underwent TG, which included more advanced cases. CGM results showed that the SD, relative SD, and maximum drop in glucose level between 30 min and 2 h after a meal were smaller in the PGDTR group than in the TG group (14.81 vs 22.40 mg/dL [P < .001], 0.14 vs 0.20 mg/dL [P < .001], and 42.06 vs 117.67 mg/dL [P < .001], respectively). For nocturnal glucose levels, SD and percentage time below the range were smaller in the PGDTR group than in the TG group (11.76 vs 15.16 mg/dL [P = .005] and 11.25% vs 35.27% [P < .001]). The PGDTR group generally performed better than the TG group on all the PGSAS-37 questionnaire items. Patients in the PGDTR group without food inflow into the remnant stomach showed similar CGM results as those in the TG group but with stronger dumping symptoms.

CONCLUSION

Food inflow into the remnant stomach is essential for PGDTR to be a function-preserving procedure as it leads to the control of dumping symptoms and lower glucose level spikes.

Study of Short-Term and Long-Term Outcomes Between Esophagogastrostomy and Double-Tract Reconstruction After Proximal Gastrectomy

BACKGROUND

As the opportunities for proximal gastrectomy (PG) for early gastric cancer in the upper third stomach have been increasing, the safety and feasibility of PG have been a great concern in recent years. This study aimed to compare the short-term and long-term outcomes between patients who underwent esophagogastrostomy (EG) and those who underwent double-tract reconstruction (DTR) after PG.

METHODS

We retrospectively reviewed the medical records of 34 patients who underwent EG and 39 who underwent DTR at our hospital between 2011 and 2022. We compared the procedure data and postoperative complications including anastomotic complications within 1 year after surgery as short-term outcomes and the rates of change in nutritional status, skeletal muscle mass, and 3-year survival as long-term outcomes.

RESULTS

Although operation time of the DTR group was significantly longer than that of the EG group, there were no significant differences in postoperative complications between 2 groups. Regarding the endoscopic findings, the incidence of anastomotic stenosis and reflux esophagitis was significantly higher in the EG group than in the DTR group (26.5% vs 0%, p < 0.001; 15.2% vs 0%, p = 0.020). In long-term outcomes, there were no significant differences in body weight, BMI, laboratory data, and skeletal muscle mass index between 2 groups for 3 years. The 3-year overall survival rates of 2 groups were similar.

CONCLUSION

DTR after PG could prevent the occurrence of anastomotic complications in comparison to EG. The long-term outcomes were similar between these 2 types of reconstruction.

Food passage following proximal gastrectomy with double-tract reconstruction and its effect on nutritional status in early gastric cancer: a prospective single-center cohort study

Purpose

Laparoscopic proximal gastrectomy with double-tract reconstruction (LPG-DTR) expectedly results in improved nutritional status and less body weight loss than conventional total gastrectomy in upper-third gastric cancer. This study aimed to investigate the food passage patterns following LPG-DTR and its effect on nutritional outcomes up to 1 year after surgery.

Methods

This prospective cohort study recruited 10 patients with early gastric cancer scheduled for LPG-DTR. Nutritional indices and body composition were assessed every 3 months up to 12 months. Liquid and solid food transits were evaluated with fluoroscopic upper gastrointestinal study and radionuclide scintigraphy, respectively.

Results

At 12 months, patients exhibited a body weight loss of 14.5% ± 3.6%. The main passage routes for liquid and solid foods differed, primarily via the interposed jejunum for liquids, whereas via both tracts for solids. The median half-life of solid food emptying from the remnant distal stomach was 105.1 minutes (range, 50.8-2,194.2 minutes), and duodenal passage of solid food was noted in 9 of 10 patients. Those with gastric half-emptying time >3 hours demonstrated greater weight loss (19.5% ± 1.4% vs. 12.5% ± 1.1%, P = 0.024) and more pronounced reduction in serum albumin levels (-0.5 ± 0.3 g/dL vs. 0.0 ± 0.2 g/dL, P = 0.024) after 12 months.

Conclusion

LPG-DTR demonstrated varying food passage patterns depending on the food contents and delayed solid food emptying from the remnant stomach was associated with more substantial weight loss.

Oncological relevance of proximal gastrectomy in advanced gastric cancer of upper third of the stomach

Background

The oncological relevance of proximal gastrectomy in advanced gastric cancer remains unclear. We aimed to examine the frequency of lymph node metastasis in advanced gastric cancer to determine the oncological validity of proximal gastrectomy selection.

Materials and methods

This study included consecutive 71 patients with locally advanced gastric cancer in the upper third of the stomach who underwent total gastrectomy at our institution between 2001 and 2017. Lymph node metastasis and its therapeutic value index were examined to identify candidates for proximal gastrectomy. Metastatic and 3-year overall survival rates of numbers 3a and 3b lymph nodes were examined from 2010 to 2019.

Results

The metastatic rate and therapeutic value index of numbers 4d, 5, 6, and 12a lymph nodes were zero or low. The number 3 lymph node had a metastatic rate and therapeutic value index of 36.6 % and 31.1, respectively. The metastatic and 3-year overall survival rates of the number 3a lymph node were 32.7 % and 89 %, respectively, whereas those of the number 3b lymph node were 3.8 % and 100 %, respectively. All patients with positive metastasis to the number 3b lymph node received adjuvant chemotherapy. Histopathological findings of positive metastasis to the number 3b lymph node were located in the lesser curvature, and the tumor diameter exceeded 40 mm.

Conclusion

For advanced gastric cancer of the upper third of the stomach, the indications of localization to the lesser curvature and a tumor diameter of >40 mm should be considered cautiously.

Total versus proximal gastrectomy for proximal gastric cancer after neoadjuvant chemotherapy: a multicenter retrospective propensity score-matched cohort study

BACKGROUND

This study aimed to analyze and compare the short-term and long-term outcomes of proximal gastrectomy (PG) and total gastrectomy (TG) in patients with locally advanced proximal gastric cancer (GC) following neoadjuvant chemotherapy (NACT).

METHOD

A multicenter retrospective cohort study and propensity score matching (PSM) were employed. The authors examined 367 patients with proximal GC who received NACT followed by PG ( n =164) or TG ( n =203) at two Chinese medical institutions between December 2009 and December 2022. Clinical and pathological parameters, postoperative complications, and 5-year overall survival (OS) and recurrence-free survival (RFS) were compared between the two groups. The dissection status and metastasis rate of each lymph node station were assessed.

RESULTS

After PSM, 80 patients were enrolled in both TG and PG group, and baseline characteristics were comparable between the groups (all P >0.05). The TG group had a higher total number of lymph nodes retrieved ( P <0.001) and longer operative time ( P =0.007) compared to the PG group. The incidence of Clavien-Dindo grade II or higher postoperative complications was similar between the TG group (21.3%, 17/80) and the PG group (17.5%, 14/80) ( P =0.689). The 5-year OS rates were 68.4 for the PG group and 66.0% for the TG group ( P =0.881), while the 5-year RFS rates were 64.8 and 61.9%, respectively ( P =0.571), with no statistically significant differences. Metastasis rates at lymph node stations #4d, #5, #6, and #12a were notably low in the TG group, with values of 2.74, 0.67, 1.33, and 1.74%, respectively.

CONCLUSION

For proximal GC patients following NACT, PG maintains comparable curative potential and oncological efficacy to TG, making it a safe option.

Clinical efficacy of modified Kamikawa anastomosis in patients with laparoscopic proximal gastrectomy

BACKGROUND

With the increasing incidence of proximal gastric cancer, laparoscopic proximal gastrectomy has been applied. However, reflux esophagitis often occurs after traditional esophagogastric anastomosis. In order to solve this problem, several methods of digestive tract reconstruction have emerged, but the most satisfying method remains to be discussed. Therefore, we modified traditional Kamikawa anastomosis to investigate the appropriate digestive tract reconstruction in laparoscopic proximal gastrectomy.

AIM

To discuss the clinical efficacy of modified Kamikawa anastomosis in laparoscopic proximal gastrectomy.

METHODS

A retrospective case series was adopted. Clinicopathological data were collected from 26 patients who underwent laparoscopic proximal gastrectomy and modified Kamikawa anastomosis at our hospital from January 2020 to September 2022. The operation conditions, postoperative recovery, postoperative complications, and follow-up data were collected and analyzed.

RESULTS

All the patients were successfully operated on without conversion to laparotomy. The duration of operation and digestive tract reconstruction were 203.500 (150-224) min and 87.500 (73-111) min, respectively. The intraoperative amount of bleeding was 20.500 mL ± 0.696 mL. The time of postoperative first flatus, the first postoperative fluid intake, and the postoperative length of stay were 2 (1-3) d, 4 (3-5) d, and 9 (8-10) d, respectively. All the patients were followed up for 12-23 months. The body mass index at 6 and 12 months after surgery were 22.577 kg/m2 ± 3.098 kg/m2 and 22.594 kg/m2 ± 3.207 kg/m2, respectively. The nutrition risk screening 2002 score, the patient-generated subjective global assessment score, and the gastroesophageal reflux disease scale score were good at 6 and 12 months after surgery. Reflux esophagitis and anastomotic stenosis were not observed in any of the patients during their 12-month postoperative gastroscopy or upper gastrointestinal tract visits. All the patients exhibited no tumor recurrence or metastasis.

CONCLUSION

The modified Kamikawa anastomosis is safe and feasible for laparoscopic proximal gastrectomy and has good antireflux effects and nutritional status.

Current status of gastrectomy and reconstruction types for patients with proximal gastric cancer in Japan

BACKGROUND

Surgical procedures for proximal gastric cancer remain a highly debated topic. Total gastrectomy (TG) is widely accepted as a standard radical surgery. However, subtotal esophagectomy, proximal gastrectomy (PG) or even subtotal gastrectomy, when a small upper portion of the stomach can technically be preserved, are alternatives in current clinical practice.

METHODS

Using a cohort of the PGSAS NEXT trial, consisting of 1909 patients responding to a questionnaire sent to 70 institutions between July 2018 and December 2019, gastrectomy type, reconstruction method, and furthermore the remnant stomach size and the anti-reflux procedures for PG were evaluated.

RESULTS

TG was the procedure most commonly performed (63.0%), followed by PG (33.4%). Roux-en-Y was preferentially employed following TG irrespective of esophageal tumor invasion, while jejunal pouch was adopted in 8.5% of cases with an abdominal esophageal stump. Esophagogastrostomy was most commonly selected after PG, followed by the double-tract method. The former was preferentially employed for larger remnant stomachs (≧3/4), while being used slightly less often for tumors with as compared to those without esophageal invasion in cases with a remnant stomach 2/3 the size of the original stomach. Application of the double-tract method gradually increased as the remnant stomach size decreased. Anti-reflux procedures following esophagogastrostomy varied markedly.

CONCLUSIONS

TG is the mainstream and PG remains an alternative in current Japanese clinical practice for proximal gastric cancer. Remnant stomach size and esophageal stump location appear to influence the choice of reconstruction method following PG.

Korean Practice Guidelines for Gastric Cancer 2022: An Evidence-based, Multidisciplinary Approach

Gastric cancer is one of the most common cancers in Korea and the world. Since 2004, this is the 4th gastric cancer guideline published in Korea which is the revised version of previous evidence-based approach in 2018. Current guideline is a collaborative work of the interdisciplinary working group including experts in the field of gastric surgery, gastroenterology, endoscopy, medical oncology, abdominal radiology, pathology, nuclear medicine, radiation oncology and guideline development methodology. Total of 33 key questions were updated or proposed after a collaborative review by the working group and 40 statements were developed according to the systematic review using the MEDLINE, Embase, Cochrane Library and KoreaMed database. The level of evidence and the grading of recommendations were categorized according to the Grading of Recommendations, Assessment, Development and Evaluation proposition. Evidence level, benefit, harm, and clinical applicability was considered as the significant factors for recommendation. The working group reviewed recommendations and discussed for consensus. In the earlier part, general consideration discusses screening, diagnosis and staging of endoscopy, pathology, radiology, and nuclear medicine. Flowchart is depicted with statements which is supported by meta-analysis and references. Since clinical trial and systematic review was not suitable for postoperative oncologic and nutritional follow-up, working group agreed to conduct a nationwide survey investigating the clinical practice of all tertiary or general hospitals in Korea. The purpose of this survey was to provide baseline information on follow up. Herein we present a multidisciplinary-evidence based gastric cancer guideline.

Mediastinal Lymph Node Dissection in Gastroesophageal Junction Adenocarcinoma

Currently, the prevalence of gastroesophageal junction adenocarcinoma (GEJAC) is increasing in both Asian and Western countries, although the increasing rate in Asian countries is much slower than in Western countries. With these current trends, concerns regarding the surgical treatment method are also increasing among gastrointestinal surgeons. However, the surgical treatment for GEJAC has been a controversial issue for a long time due to the relative scarcity of this tumor and its characteristics from its borderline location. Recently, a large-scale prospective study of this tumor has been conducted in Japan, and the results are now available. The results of this study will be helpful for understanding this tumor. In this article, the pattern of lymph node metastasis of GEJAC is reviewed, and the extent and method of lymph node dissection for this tumor are discussed and proposed based on the review.

Indications and technical aspects of proximal gastrectomy

According to the World Health Organization, gastric cancer is the fifth most common type of tumor, and is the third most common cause of tumor-associated death. Although gastric cancer incidence rates have decreased in the past few decades, the prevalence of proximal gastric cancer has been steadily rising in developed countries. Techniques regarding the improvement of treatment options must thus be developed. This can be achieved through incorporating both a wider use of endoscopic surgery (endoscopic mucosal resection-EMR, endoscopic submucosal dissection-ESD) and a review of applied surgical interventions. Even though there is no single international consensus available, the Japanese Gastric Cancer Association (JGCA) recommends proximal gastrectomy with D1+ lymphadenectomy in early gastric tumors. Despite recommendations from Asian guidelines and the short term outcomes of the KLASS 05 trial, surgical treatments in Western countries still rely on total gastrectomy. This is mostly due to technical and oncological challenges regarding surgical interventions in a proximal gastrectomy. However, the residual stomach after a proximal gastrectomy has been shown to diminish the incidence of dumping syndrome and anemia, and even improve postoperative quality of life (QoL). Therefore, it is necessary to define the place of proximal gastrectomy in the treatment of gastric cancers.

Long-term nutritional status after total gastrectomy was comparable to proximal gastrectomy but with much less reflux esophagitis and anastomotic stenosis

AIM

To compare the long-term nutritional status, reflux esophagitis and anastomotic stenosis, between total gastrectomy (TG) and proximal gastrectomy (PG).

METHODS

Patients who underwent PG or TG in this single institution between January 2014 and December 2016 were included in this study. The inclusion and exclusion criteria were defined. One-to-one propensity score matching (PSM) by the demographic and pathological characteristics was performed to compare the long-term outcomes between the two groups. The primary endpoint was long-term nutritional status, and the second endpoints were reflux esophagitis and anastomotic stenosis. Long-term nutritional status was valued by percentage of body mass index (%BMI), body weight, and blood test including total protein, prealbumin, hemoglobin and total leukocytes.

RESULTS

Totally 460 patients received PG or TG in our institution for the treatment between January 2014 and December 2016 and according to the inclusion and exclusion criteria 226 cases were included in this study finally. There was no significant difference as to nutritional status in the end of first 5 years after PG or TG. While reflux esophagitis and anastomotic stenosis were significantly higher in the PG group than in the TG group (54.4% versus 26.8%, p < 0.001; 14.9% versus 4.5%, p=0.015; respectively). Overall survival rates were similar between the two groups after PSM (5-year survival rates: 65.4% versus 61.5% in the PG and TG groups, respectively; p = 0.54). The rate of carcinoma of remnant stomach after PG was 3.5% in this group of patients.

CONCLUSIONS

TG should be more aggressively recommended for the similar nutritional status, significantly lower reflux esophagitis and anastomotic stenosis, and free of carcinoma of remnant stomach compared with PG.

Signature and Prediction of Perigastric Lymph Node Metastasis in Patients with Gastric Cancer and Total Gastrectomy: Is Total Gastrectomy Always Necessary?

Simple Summary

The signature and prediction of perigastric lymph node metastasis (pLNM) is clinically important, but evidence is still lacking. Here, we aimed to identify an informative signature for the prediction of pLNMs in gastric cancer patients after total gastrectomy, and reassess the current indications for proximal gastrectomy and pylorus-preserving gastrectomy (PPG). We found that proximal gastrectomy may be expanded to patients with stage T1–T2 GC and/or tumor diameter < 4 cm in the upper-third stomach, while PPG may be expanded to include T1–T2/N0 and/or tumors < 4 cm in the middle-third stomach. Furthermore, we developed a new predictive factor, the shortest distance from the pylorus ring to the distal edge of the tumor, which showed good predictive performance for pLNMs.

Abstract

Background: A growing number of studies suggest that the current indications for partial gastrectomy, including proximal gastrectomy and pylorus-preserving gastrectomy (PPG), may be expanded, but evidence is still lacking. Methods: We retrospectively analyzed 300 patients with gastric cancer (GC) who underwent total gastrectomy. We analyzed the incidence of pLNMs in relation to tumor location, tumor size and T stage. We further identified predictive factors for perigastric lymph node metastasis (pLNM) in stations 1, 2, 3, 4sa, 4sb, 4d, 5, and 6. Results: No patients with upper-third T1–T2 stage GC had pLNMs in stations 4sa, 4sb, 4d, 5, or 6, but 3.8% of patients with stage T3 had 4d pLNM. No patients with upper-third GC < 4 cm in diameter had pLNMs in 2, 4sa, 4d, 5, or 6, and 2.3% of patients had pLNMs in 4sb. For middle-third GCs, 2.9% of patients with T1 stage had pLNMs in 4sa and 5, but no patients with T2 stage or tumors < 4 cm had pLNMs in 2, 4sa, or 5. The shortest distance from pylorus ring to distal edge of tumor (sDPD) was a new predictive factor for pLNMs in 2, 4d, 5, and 6. Conclusions: Proximal gastrectomy may be expanded to patients with stage T1–T2 GC and/or tumor diameter < 4 cm in the upper-third stomach, whereas PPG may be expanded to include T1–T2/N0 and/or tumors < 4 cm in the middle-third stomach. A new predictive factor, sDPD, showed good predictive performance for pLNMs, especially in stations 4d, 5, and 6.

Function-Preserving Gastrectomy for Early Gastric Cancer

Recently, minimally invasive (endoscopic or laparoscopic) treatment for early gastric cancer (EGC) has been widely accepted. However, a standard gastrectomy with radical lymphadenectomy is generally performed in patients with EGC who have no indications for endoscopic resection, and postgastrectomy dysfunction is one of the problems of standard gastrectomy. Function-preserving gastrectomy, such as proximal gastrectomy and pylorus-preserving gastrectomy, can be considered when attempting to preserve the patient's quality of life (QOL) postoperatively. In addition, sentinel node navigation surgery for EGC has been applied in clinical practice in several prospective studies on function-preserving personalized minimized gastrectomy. In the near future, the sentinel lymph node concept is expected to form the basis for establishing an ideal, personalized, minimally invasive function-preserving treatment for patients with EGC, which will improve their postoperative QOL without compromising their long-term survival. In this review article, we summarize the current status, surgical techniques, and postoperative outcomes of function-preserving gastrectomy for EGC.

Indication of Proximal Gastrectomy for Advanced Proximal Gastric Cancer Based on Lymph Node Metastasis at the Distal Part of the Stomach

Objective

To suggest the possible indication of proximal gastrectomy for advanced gastric cancer located at the upper third of the stomach.

Background

Proximal gastrectomy has been an alternative surgical procedure for early proximal gastric cancer due to its benefits for quality of life while maintaining oncological outcomes. However, the oncological safety of proximal gastrectomy for advanced tumors remains unclear.

Methods

We retrospectively reviewed data from 878 patients who underwent radical total gastrectomy from 2003 to 2018 for pathologic T2-T4 gastric cancer in the upper third of the stomach. We identified risk factors for lymph node metastasis at the distal part of the stomach, which was not dissected in proximal gastrectomy. Subsequently, we evaluated the metastasis rate and therapeutic value index of lymph nodes at the distal part of the stomach in patients with none of these risk factors.

Results

Multivariable analysis revealed that esophagogastric junction (EGJ)-tumor epicenter distance >30 mm, tumor size >70 mm, macroscopic type IV tumor, and serosal invasion were risk factors for lymph node metastasis at the distal stomach. In patients without risk factors, the therapeutic value index for any lymph nodes at the distal stomach was 0.8, suggesting that lymph node dissection could be omitted in these patients.

Conclusions

EGJ-tumor epicenter distance ≤ 30 mm, tumor size ≤ 70 mm, not a macroscopic type IV tumor, and no serosal invasion could be an indication of proximal gastrectomy for advanced gastric cancer located at the upper third of the stomach.

Is proximal gastrectomy indicated for locally advanced cancer in the upper third of the stomach?

AIM

To treat upper third gastric cancer, proximal gastrectomy (PG), a function-preserving procedure, is recommended for early lesions when at least half the distal stomach can be preserved, while total gastrectomy (TG) is standard for locally advanced lesions. Oncological feasibility, when applying PG for such lesions, remains unknown.

METHODS

We reviewed patients undergoing TG for clinical (c) T2-T4 upper third gastric cancer between 2006 and 2015. Preoperative tumor locations were further classified into the cardia, fornix, and gastric body based on endoscopic findings. The metastatic rate and therapeutic value index for lymph node (LN) dissection were determined, and characteristics of patients with distal LN (No. 4d, 5, and 6) metastasis (DLNM) were reviewed. In addition, patients with pathological tumor invasion to the middle third (M) region were investigated.

RESULTS

We studied 167 patients. There were 8 (4.8%) with DLNM and 41 (24.6%) with pathological tumor invasion to the M region. As to regional stations, therapeutic indices for LN dissection at stations No. 4d, 5, 6, and 12a were zero or extremely low. No DLNM was detected in cT2 lesions or cT3/T4 lesions located within the cardia and/or the fornix. In addition, none of the lesions located within the cardia and/or the fornix by preoperative endoscopy extended to the M region in the pathological specimen.

CONCLUSIONS

For upper third gastric cancer, PG without No. 12a dissection might be acceptable for cT2-T4 lesions located within the cardia and/or the fornix when considering the risk of DLNM and cancer-positivity in the distal stump.

History of the lymph node numbering system in the Japanese Classification of Gastric Carcinoma since 1962

The Japanese Classification of Gastric Carcinoma was established by the Japanese Research Society for Gastric Cancer in 1962. The latest 15th edition was published in 2017. One of its main features is that lymph nodes are numbered as stations. The number of groups has increased from 16 to 36 in 55 years. Seven groups (nos. 1, 2, 5, 7, 9, 10, and 15) were retained from the original classification. Nine groups (nos. 3, 4, 6, 8, 11, 12, 13, 14, and 16) were sub-divided into two or more groups. Furthermore, seven groups (nos. 17, 18, 19, 20, 110, 111, and 112) were added in the 6th, 11th, and 12th editions. This numbering system helps surgeons recognize the exact lymph nodes that need to be dissected. However, the numbering system has become extremely complicated. It is necessary to organize the historical background of each lymph node station and share the definitions clearly. This review focuses on nine anatomical zones around the stomach and summarizes the history of lymph node stations in the Japanese Classification of Gastric Carcinoma. Lymph node stations will continue to be modified in the future, and the historical background may be useful in future revisions.

The Results of Sentinel Node Mapping for Patients with Clinically Early Staged Gastric Cancer Diagnosed with pT2/deeper Tumors

BACKGROUND

Sentinel node (SN) mapping based on the SN concept has been applied to early gastric cancer. However, it is still controversial whether or not the oncological safety is ensured in case pathological stage was advanced in these patients. The aim of this study was to investigate the validity of SN mapping in patients with clinically early staged gastric cancer diagnosed with pT2/deeper tumors.

METHODS

We retrospectively analyzed 40 patients with a diagnosis of cT1N0 or cT2N0 single-lesion gastric cancer who were shown to have pT2 or deeper tumors after gastrectomy with SN mapping. We adopted a dual-tracer method using a radioactive colloid and blue dye to detect SNs. The diagnostic accuracy and distribution of SNs at each tumor site were analyzed.

RESULTS

Of the 40 patients, 24 (60%) were postoperatively diagnosed as pT2, and 16 (40%) as pT3 or T4. SNs were detected in all patients. The false negative rate was 9% (1/11), and in that patient, the non-SN metastasis was observed within the SN basin. Diagnostic accuracy was 98% (39/40). Overall distribution of SNs was similar to that for patients with early gastric cancer. No significant differences in overall and recurrence-free survival were observed between the patients who underwent standard gastrectomy and those who underwent function-preserving gastrectomy, based on the results of SN mapping.

CONCLUSIONS

Our results confirmed validity of SN mapping for patients with clinically early staged gastric cancer diagnosed with pT2/deeper tumors after gastrectomy. Closed surveillance without additional surgical treatment is an option for these patients.

Gastric equivalent of the 'Holy Plane' to standardize the surgical concept of stomach cancer to mesogastric excision: updating Jamieson and Dobson's historic schema

BACKGROUND

Surgery for curable gastric cancer has historically involved dissection of lymph nodes, depending on the risk of metastasis. By establishing the concept of mesogastric excision (MGE), we aim to make this approach compatible with that for colorectal cancer, where the standard is excision of the mesentery.

METHODS

Current advances in molecular embryology, visceral anatomy, and surgical techniques were integrated to update Jamieson and Dobson's schema, a historical reference for the mesogastrium.

RESULTS

The mesogastrium develops with a three-dimensional movement, involving multiple fusions with surrounding structures (retroperitoneum or other mesenteries) and imbedding parenchymal organs (pancreas, liver, and spleen) that grow within the mesentery. Meanwhile, the fusion fascia and the investing fascia interface with adjacent structures of different embryological origin, which we consider to be equivalent to the 'Holy Plane' in rectal surgery emphasized by Heald in the concept of total mesorectal excision. Dissecting these fasciae allows for oncologic MGE, consisting of removing lymph node-containing mesenteric adipose tissue with an intact fascial package. MGE is theoretically compatible with its colorectal counterpart, although complete removal of the mesogastrium is not possible due to the need to spare imbedded vital organs. The celiac axis is treated as the central artery of the mesogastrium, but is peripherally ligated by tributaries flowing into the stomach to feed the spared organs.

CONCLUSION

The obscure contour of the mesogastrium can be clarified by thinking of it as the gastric equivalent of the 'Holy Plane'. MGE could be a standard concept for surgical treatment of stomach cancer.

Evaluation of Lymph Node Metastasis Among Adults With Gastric Adenocarcinoma Managed With Total Gastrectomy

IMPORTANCE

It is unclear whether proximal gastrectomy (PG) can replace total gastrectomy (TG), even in cases of advanced gastric carcinoma.

OBJECTIVES

To evaluate the oncologic safety of PG based on the lymph node (LN) metastasis rate and develop a selection diagram for PG eligibility.

DESIGN, SETTING, AND PARTICIPANTS

In this cohort study, a retrospective analysis of a prospective database of gastric carcinoma surgery was performed including procedures that took place between December 1, 2000, and December 31, 2015, in the National Cancer Center, Korea, a high-volume carcinoma center with a structured database and accurate long-term follow-up. Among 9952 patients who underwent surgery for gastric carcinoma, 2347 underwent TG. Six-hundred fifty-five (564 in a second statistical analysis) had gastric carcinoma in the upper third of the stomach. The inclusion criteria were age 18 to 85 years, histologically proven adenocarcinoma (any size or differentiation) located in the upper third of the stomach, curative R0 TG performed, and postoperative follow-up for at least 3 years. Exclusion criteria included Borrmann type 4 carcinoma, T4 category, use of neoadjuvant chemotherapy, and a history of other carcinomas. Data analysis was performed from December 1, 2019, to May 30, 2020.

EXPOSURES

Total gastrectomy and LN dissection.

MAIN OUTCOMES AND MEASURES

The primary end point was the rate of LN metastasis at LN stations 4d, 5, and 6, which are usually not dissected during PG.

RESULTS

Among the 655 study patients, the mean (SD) age was 57.7 (11.9) years, and 462 (70.5%) were men. Only those with poorly differentiated cT3 category carcinomas had an increased incidence of LN metastasis at stations 4d (2 of 32 [6.3%]) and 11d (T3N0: 2 of 22 [9.1%], T3N1: 3 of 27 [11.1%]), independent of tumor size. For cT1-T3N0/1M0 category carcinomas, the incidence of station 5 LN metastasis was 0, irrespective of tumor size and differentiation. The LN metastasis rate at stations 4d and 6 for cT1-T3N0/1M0 differentiated tumors was also 0. Tumor size greater than or equal to 4.1 cm was associated with significantly increased LN metastasis compared with tumors less than 4.1 cm (40.0% vs 20.4%, P = .001).

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that PG can be safely performed for cT1-T2N0/1M0 tumors less than 4.1 cm in diameter that are located in the upper third of the stomach. The cT3N0/1M0-differentiated tumors less than 4.1 cm may also be eligible for PG, whereas poorly differentiated cT3 tumors and any cT4 or cN2/3 diseases require TG.

Double Tract Reconstruction Reduces Reflux Esophagitis and Improves Quality of Life after Radical Proximal Gastrectomy for Patients with Upper Gastric or Esophagogastric Adenocarcinoma

Purpose

The aim of the present study was to compare the difference between double tract reconstruction and esophagogastrostomy.

Materials and Methods

Patients who underwent radical proximal gastrectomy with esophagogastrostomy or double tract reconstruction were included in this study.

Results

Sixty-four patients were included in this study and divided into two groups according to reconstruction method. The two groups were well balanced in perioperative safety and 3-year overall survival (OS). The rates of postoperative reflux esophagitis in the double tract reconstruction group and esophagogastrostomy group were 8.0% and 30.8%, respectively (p=0.032). Patients in the double tract reconstruction group had a better global health status (p < 0.001) and emotional functioning (p < 0.001), and complained less about nausea and vomiting (p < 0.001), pain (p=0.039), insomnia (p=0.003), and appetite loss (p < 0.001) based on the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 questionnaire. Regarding the EORTC QLQ-STO22 questionnaire, patients in the double tract reconstruction group complained less about dysphagia (p=0.030), pain (p=0.008), reflux (p < 0.001), eating (p < 0.001), anxiety (p < 0.001), dry mouth (p=0.007), and taste (p=0.001). The multiple linear regression analysis showed that reconstruction method, postoperative complications, reflux esophagitis, and operation duration had a linear relationship with the global health status score.

Conclusion

Double tract reconstruction could better prevent reflux esophagitis and improve quality of life without scarifying perioperative safety or 3-year OS.

True esophagogastric junction adenocarcinoma: background of its definition and current surgical trends

The definition of true esophagogastric junction (EGJ) adenocarcinoma and its surgical treatment are debatable. We review the basis for the current definition and the Japanese surgical strategy in managing true EGJ adenocarcinoma. The Siewert classification is a well-known anatomical classification system for EGJ adenocarcinomas: type II tumors in the region 1 cm above and 2 cm below the EGJ are described as "true carcinoma of the cardia". Coincidentally, this range matches gastric cardiac gland distribution. Conversely, Nishi's classification is generally used to describe EGJ carcinomas, defined as tumors with the center located within 2 cm above and 2 cm below the EGJ, regardless of their histological subtype. This range coincides with the extent of the lower esophageal sphincter combined with gastric cardiac gland distribution. The current Japanese surgical strategy focuses on the tumor range from the EGJ to the esophagus and stomach. According to previous studies, the strategy can be roughly classified into three types. The optimal surgical procedure for true EGJ adenocarcinoma is controversial. However, an ongoing Japanese nationwide prospective trial will help confirm the appropriate standard surgery, including the optimal extent of lymph node dissection.

15-year experience of laparoscopic gastrectomy in advanced gastric cancer: analysis on short-term and long-term oncologic outcome

BACKGROUND

Laparoscopic gastrectomy (LG) is now a widely accepted treatment option for gastric cancer. However, there is insufficient evidence for LG for advanced gastric cancer (AGC). Many retrospective studies have shown that LG for AGC is safe and feasible, but very few studies have shown the actual outcome in general practice. The aim of this study is to analyze our last 15 years of experience in LG for AGC.

METHODS

This is a retrospective review from May 2003 to May 2017 in Seoul National University Bundang Hospital. A total of 1592 patients who had LG for AGC were enrolled of which 109 patients with open conversion were excluded. We evaluated the short-term and long-term oncologic outcomes of LG for AGC.

RESULTS

A total of 1483 patients were analyzed. There were 432 cases of total gastrectomy, 982 cases of distal gastrectomy, and 69 cases of proximal gastrectomy. The total complication rate was 9.1% (135/1483), which included wound-related complications (0.7%), postoperative bleeding (0.5%), anastomosis or stump leakage (2.2%), intestinal obstruction (0.9%), pancreatic fistula (0.1%), intra-abdominal abscess (1.6%), and lung morbidity (3.0%). The rate of Clavien-Dindo grade 3 and above complications was 4.9%. Age was the only significant risk factor in multivariate analysis (OR 1.02; 95% CI, 1.01-1.04, P = 0.01). 5-year overall survival stratified by stage was as follows: stage IB 88.9%, stage IIA 88.7%, stage IIB 84.2%, stage IIIA 71.7%, stage IIIB 56.8%, stage IIIC 45.4%, and stage IV 25%. Total recurrence rate was 14.4%, which included local recurrence (1.1%) and distant metastases (13.3%).

CONCLUSIONS

During our 15 years of experience, we have successfully performed 1483 cases of AGC with laparoscopy. Our results showed short-term and long-term oncologic outcomes that were comparable with other studies. LG is safe and feasible in general practice for advanced gastric cancer when performed by experienced surgeons.

Oncological safety of proximal gastrectomy for T2/T3 proximal gastric cancer

BACKGROUND

It remains unclear whether total gastrectomy is necessary for patients with proximal T2/T3 gastric cancer. To explore the oncological safety of proximal gastrectomy for proximal T2/T3 gastric cancer, in this study, we evaluated the metastatic rates in and the therapeutic effect of dissection of key distal lymph node stations that are usually excluded in proximal gastrectomy.

METHODS

In this study, we examined 202 patients seen between January 2000 and December 2012, who underwent total gastrectomy with lymph node dissection (D1/D1+/D2; 2/17/183) and was pathologically diagnosed as T2/T3 gastric cancer exclusively located in the upper third of the stomach. The theoretical therapeutic necessity of dissecting lymph nodes at each lymph node station was evaluated based on the therapeutic index calculated by multiplying the frequency of metastasis at each station and the 5-year survival rate of patients with metastasis to that station.

RESULTS

The 5-year overall survival rate (95% confidence interval) was 72.9% (65.5-80.3). The metastatic rates at #4d and #12a were very low (0.99% and 0.006%, respectively), and those at #5 and #6 were zero, and therapeutic indices for #4d, #5, #6 and #12a were zero. On the other hand, the most frequent metastatic station was #3, followed by #1, #2 and #7 (overall metastatic rate > 12%), which was consistent with the order of the therapeutic indices.

CONCLUSIONS

Considering the nodal stations that need to be dissected, proximal gastrectomy would be the choice and oncologically safe for patients with T2/T3 proximal gastric cancer.

Universalization of the operative strategy by systematic mesogastric excision for stomach cancer with that for total mesorectal excision and complete mesocolic excision colorectal counterparts

Gastrointestinal cancer surgery aims at en bloc removal of the primary tumor with its lymphatic drainage by excising organ-specific mesentery as an "intact package". This concept was advocated in colorectal cancer surgery as total mesorectal excision (TME) or complete mesocolic excision (CME) procedures, but is not directly applicable to stomach cancer as a result of the morphological complexities of the gastric mesentery. In this review, we discuss the unique anatomical features of the mesogastrium by introducing its embryology, disclose its similarity to the mesosigmoid, and then propose a theoretical concept to mesentery-based D2 gastrectomy, namely systematic mesogastric excision, which can universalize the operative strategy of stomach cancer with that of TME and CME colorectal counterparts.