Survival impact of postoperative body mass index in gastric cancer patients undergoing gastrectomy

Changes in Skeletal Muscle Mass in the First 3 Months Following Gastrointestinal Cancer Surgery: A Prospective Study

BACKGROUND

Surgical resection is the primary treatment for gastrointestinal (GI) cancers, but postoperative skeletal muscle loss (SML) is common and linked to poor prognosis. This study aims to identify patterns of muscle change, examine its association with quality of life (QoL), and explore predictors of SML in the first 3 months.

PATIENTS AND METHODS

A prospective cohort study was conducted on patients newly diagnosed with GI cancer and undergoing surgery in China between September 2021 and May 2022. Skeletal muscle mass (SMM) and QoL were assessed at admission, 7 days, 1 month, and 3 months post-surgery. Demographic, clinical data, and biomarkers were collected. Missing data were imputed using multiple imputation. Data were analyzed using growth mixture modelling, bivariate analyses, and logistic regression.

RESULTS

A total of 483 patients completed baseline assessment. Of the 242 patients with complete muscle assessments, 92% experienced SML. Three distinct patterns of muscle change were identified: 57% had normal preoperative SMM with mild postoperative SML, 16% had low preoperative SMM with moderate SML, and 27% had normal preoperative mass but severe postoperative SML. Moderate/severe SML was associated with more postoperative complications, poorer health, and higher symptom burden. Independent predictors included advanced age, preoperative sarcopenia, advanced cancer stage, and low prognostic nutrition index (PNI ≤ 45). The results did not change when using imputed values.

CONCLUSIONS

Although SML is prevalent, patterns of muscle change are heterogeneous among patients. Advanced age, preoperative sarcopenia, advanced cancer stage, and cancer-related inflammation are predictors for moderate/severe SML, highlighting the need for early detection and management.

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.

The efficacy of simple oral nutritional supplements versus usual care in postoperative patients with gastric cancer: study protocol for a multicenter, open-label, parallel, randomized controlled trial

BACKGROUND

Body weight loss (BWL) after gastrectomy impact on the short- and long-term outcomes. Oral nutritional supplement (ONS) has potential to prevent BWL in patients after gastrectomy. However, there is no consistent evidence supporting the beneficial effects of ONS on BWL, muscle strength and health-related quality of life (HRQoL). This study aimed to evaluate the effects of ONS formulated primarily with carbohydrate and protein on BWL, muscle strength, and HRQoL.

METHODS

This will be a multicenter, open-label, parallel, randomized controlled trial in patients with gastric cancer who will undergo gastrectomy. A total of 120 patients who will undergo gastrectomy will be randomly assigned to the ONS group or usual care (control) group in a 1:1 ratio. The stratification factors will be the clinical stage (I or ≥ II) and surgical procedures (total gastrectomy or other procedure). In the ONS group, the patients will receive 400 kcal (400 ml)/day of ONS from postoperative day 5 to 7, and the intervention will continue postoperatively for 8 weeks. The control group patients will be given a regular diet. The primary outcome will be the percentage of BWL (%BWL) from baseline to 8 weeks postoperatively. The secondary outcomes will be muscle strength (handgrip strength), HRQoL (EORTC QLQ-C30, QLQ-OG25, EQ-5D-5L), nutritional status (hemoglobin, lymphocyte count, albumin), and dietary intake. All analyses will be performed on an intention-to-treat basis.

DISCUSSION

This study will provide evidence showing whether or not ONS with simple nutritional ingredients can improve patient adherence and HRQoL by reducing BWL after gastrectomy. If supported by the study results, nutritional support with simple nutrients will be recommended to patients after gastrectomy for gastric cancer.

TRIAL REGISTRATION

jRCTs051230012; Japan Registry of Clinical Trails. Registered on Apr. 13, 2023.

Impact of malnutrition and nutritional support after gastrectomy in patients with gastric cancer

Malnutrition, characterized by altered body composition and impaired function, is particularly prevalent among gastric cancer patients, affecting up to 60% of them. Malnutrition in these patients can manifest both before and after surgery, due to factors such as gastric outlet obstruction, cancer cachexia, and anatomical changes. Notably, total gastrectomy (TG) presents the most significant nutritional challenges. However, function-preserving gastrectomy, such as pylorus-preserving gastrectomy (PPG) and proximal gastrectomy (PG), have shown promise in improving nutritional outcomes. Effective nutritional risk screening and assessment are vital for identifying patients at risk. Nutritional support not only improves nutritional parameters but also reduces complications, enhances quality of life (QoL) and survival rates. Those unable to maintain more than 50% of the recommended intake for over 7 days are recommended for nutritional support. Common methods of nutritional support include oral nutrition supplements (ONS), enteral nutrition (EN), or parenteral nutrition (PN) depending on the patient's status. Effect of perioperative nutritional support remains controversial. Preoperative interventions including ONS and PN have shown mixed results, with selective benefits in patients with sarcopenia or hypoalbuminaemia, while impact of EN in gastric outlet obstruction patients have been positive. In contrast postoperative support appears to be consistent. Tube feeding after TG has shown improvements, and ONS have been effective in reducing weight loss and improving nutritional biomarkers. PN was also associated with benefits such as weight maintenance and QoL. This review explores the mechanisms, assessment, and clinical impact of malnutrition, emphasizing the importance of nutritional support in gastric cancer patients undergoing gastrectomy.

Enteral Nutrition in Operated-On Gastric Cancer Patients: An Update

It is well established that the preoperative nutritional status of gastric cancer (GC) patients significantly affects the prognosis of the operated patients, their overall survival, as well as the disease-specific survival. Existing data support that preoperative assessment of nutritional status and early correction of nutritional deficiencies exert a favorable effect on early postoperative outcomes. A variety of relevant indices are used to assess the nutritional status of GC patients who are candidates for surgery. The guidelines of almost all international organizations recommend the use of oral enteral nutrition (EN). Oncologically acceptable types of gastrectomy and methods of patient rehabilitation should take into account the expected postoperative nutritional status. The majority of data support that perioperative EN reduces complications and hospital stay, but not mortality. Oral EN in the postoperative period, albeit in small amounts, helps to reduce the weight loss that is a consequence of gastrectomy. Iron deficiency with or without anemia and low serum levels of vitamin B12 are common metabolic sequelae after gastrectomy and should be restored. EN also significantly helps patients undergoing neoadjuvant or adjuvant antineoplastic therapy. The occurrence of the so-called "postgastrectomy syndromes" requires dietary modifications and drug support. This review attempts to highlight the benefits of EN in GC patients undergoing gastrectomy and to emphasize the type of necessary nutritional management, based on current literature data.

Perioperative and Postoperative Continuous Nutritional Counseling Improves Quality of Life of Gastric Cancer Patient Undergoing Gastrectomy

Post-gastrectomy syndrome (PGS) and body weight loss (BWL) decrease quality of life (QOL) and survival of the patient undergoing gastrectomy. We have introduced perioperative and post-discharge continuous nutritional counseling (CNC) to prevent BWL and improve QOL after gastrectomy. In the present study, we evaluated the effect of CNC on QOL using the Post-gastrectomy Syndrome Assessment Scale-45 (PGSAS-45). Eighty-three patients with gastric cancer (GC) who underwent curative gastrectomy between March 2018 and July 2019 were retrospectively analyzed. Patients received either pre-discharge nutritional counseling alone (control group, n = 45) or CNC (CNC group, n = 38) after gastrectomy. QOL at 12 months after gastrectomy was compared between the two groups. In QOL assessment, change in body weight (-7.98% vs. -12.77%, p = 0.0057), ingested amount of food per meal (7.00 vs. 6.07, p = 0.042) and ability for working (1.89 vs. 2.36, p = 0.049) were significantly better in CNC group than control group. Multiple regression analysis showed that CNC was a significantly beneficial factor for abdominal pain subscale (p = 0.028), diarrhea subscale (p = 0.047), ingested amount of food per meal (p = 0.012), Ability for working (p = 0.031) and dissatisfaction at the meal (p = 0.047). Perioperative and postoperative CNC could improve QOL in the patient undergoing gastrectomy in addition to preventing postoperative BWL.

Effects of postoperative oral elemental nutritional supplement on skeletal muscle loss after gastrectomy for gastric cancer

BACKGROUND

We previously showed that daily nutritional intervention with an oral elemental diet (ED) at 300 kcal/day for 6-8 weeks postoperatively decreased the percentage of body weight loss (%BWL), and that the effect was maintained for 1 year. This post hoc analysis aimed to determine whether this intervention decreased skeletal muscle mass loss 1-year post-gastrectomy.

METHODS

Data from consecutive, untreated patients with histopathologically confirmed stage I-III gastric adenocarcinoma who planned to undergo total gastrectomy (TG) or distal gastrectomy (DG) and were enrolled in a previously published randomized trial were used. The primary endpoint was the percentage of skeletal muscle mass index (%SMI) loss from baseline at 1 year postoperatively, based on abdominal computed tomography images obtained preoperatively and at 1 year postoperatively.

RESULTS

The overall median %SMI loss was lower in the ED versus control group, but the difference was not significant. The difference in %SMI loss in the ED and control groups was greater in patients with TG (10.1 vs. 13.0; P = 0.12) than in those with DG (5.5 vs. 6.8; P = 0.69). A correlation was observed between %BWL and %SMI loss in both groups (ED group, coefficient 0.591; control group, coefficient 0.644; P < 0.001 for both). Type of gastrectomy (coefficient 7.38; P = 0.001) and disease stage (coefficient - 6.43; P = 0.04) were independent predictors of postoperative skeletal muscle mass loss.

CONCLUSION

ED administration for 6-8 weeks following gastrectomy had no inhibitory effect on skeletal muscle loss at 1 year postoperatively.

CLINICAL TRIAL REGISTRATION

UMIN000023455.

Long-term late effects in older gastric cancer survivors: Survival analysis using Cox hazard regression model by retrospective electronic health records

PURPOSE

Because the population of older gastric cancer survivors (GCSs) is growing, understanding the long-term late effects experienced by these GCSs and their impact on survival outcomes is crucial for optimizing survivorship care. This study aims to identify and characterize these effects and investigate their association with survival outcomes.

METHODS

A retrospective analysis of electronic health records was conducted on 9,539 GCSs diagnosed between 2011 and 2017. The GCSs were divided into two age groups (< 65 and ≥ 65 years) and the long-term late effects were categorized by age using Cox proportional hazard models. The impact of clinical factors and age-specific late effects on survival was evaluated in the older GCSs.

RESULTS

Among the total GCSs, 37.6% were over and 62.4% were under 65 years of age. Significant differences between the age groups were observed in the cumulative hazard ratios (HRs) for iron and vitamin B12 levels and prognostic nutritional index (PNI) scores. In older GCSs, abnormal iron levels (HR 1.98, 95% CI 1.16-3.41, p = .013) and poor PNI scores (HR 1.59, 95% CI 1.03-2.47, p = .038) were associated with poorer survival outcomes. Additionally, being female was identified as a risk factor for lower survival rates (if male, HR 0.42, 95% CI 0.18-0.98, p = .045).

CONCLUSION

This study highlights the typical long-term late effects experienced by older GCSs. By tailoring survivorship care to address nutritional-, age-, and gender-related factors, the overall survival and quality of life of older GCSs can be improved.

BMI trajectories, associations with outcomes and predictors in elderly gastric cancer patients undergoing radical gastrectomy: a prospective longitudinal observation study

OBJECTIVES

Elderly gastric cancer patients undergoing radical gastrectomy are prone to experience unexpected weight loss. Preoperative weight risk prediction may be a promising way to prevent weight loss and improve prognosis. The objectives of this study were to explore the BMI trajectory of elderly gastric cancer patients one year after surgery, evaluate theirs the association with outcomes, and explore their related predictors, so as to provide evidence for weight management and prognosis improvement.

METHODS

412 gastric cancer patients were included and recorded BMI at 6 time points. The trajectories of BMI were analyzed by growth mixture modeling, and the associations of BMI trajectories with outcomes as well as their predictors were investigated by regression models.

RESULTS

We identified 3 classes of BMI trajectories: the "slow-decreasing BMI", "rapid-decreasing BMI" and "maintaining BMI". Compared with class1, patients in class 2 were more likely to have a higher frequency of readmission within 1-year(β = 0.59, 95%CI: 0.29, 0.89, P < 0.001) and a higher rate of mortality within 1-year(β = 24.74, 95%CI: 9.60, 63.74, P < 0.001) ; patients in class 3 were more likely to have a higher quality of life (β=-10.46, 95%CI: -17.70, -3.22, P = 0.005) and fewer readmission times within one year (β=-0.43, 95%CI: -0.77, -0.09, P = 0.015). Predictors of decreasing BMI trajectories were TNM stage, comorbidity, anxiety, family cohesion and social support(P < 0.05).

CONCLUSIONS

Our findings can provide a basis for screening high-risk elderly gastric cancer patients with poor prognosis, implementing risk stratification, formulating accurate weight management programs and improving prognosis.

IMPLICATIONS FOR CANCER SURVIVORS

The results of our study can provide gastric cancer survivors with preoperative risk screening based on predictive factors so that nutritional support and weight management can be implemented in a timely manner to improve prognosis.

Surgical outcomes of laparoscopic proximal gastrectomy for upper-third gastric cancer: esophagogastrostomy, gastric tube reconstruction, and double-tract reconstruction

BACKGROUND

There is no consensus on the optimal reconstruction technique after proximal gastrectomy. The purpose of this study was to retrospectively compare the surgical outcomes among esophagogastrostomy (EG) anastomosis, gastric tube (GT) reconstruction and double-tract (DT) reconstruction in patients who underwent laparoscopic proximal gastrectomy (LPG) to clarify the superior reconstruction method.

METHODS

This study enrolled 164 patients who underwent LPG at the Northern Jiangsu People's Hospital in Jiangsu between January 2017 to January 2022 (EG: 51 patients; GT: 77 patients; DT: 36 patients). We compared the clinical and pathological characteristics, surgical features, postoperative complications, nutritional status, and quality of life (QOL) among the above three groups.

RESULTS

Mean operative time was longer with the DT group than the remaining two groups (p = 0.001). With regard to postoperative complications, considerable differences in the postoperative reflux symptoms (p = 0.042) and reflux esophagitis (p = 0.040) among the three groups were found. For the nutritional status, total protein, hemoglobin and albumin reduction rates in the GT group were significantly higher than the other two groups at 12 months postoperatively. In the PGSAS-45, three assessment items were better in the DT group significantly compared with the esophageal reflux subscale (p = 0.047, Cohen's d = 0.44), dissatisfaction at the meal (p = 0.009, Cohen's d = 0.58), and dissatisfaction for daily life subscale (p = 0.012, Cohen's d = 0.56).

CONCLUSIONS

DT after LPG is a valuable reconstruction technique with satisfactory surgical outcomes, especially regarding reduced reflux symptoms, improving the postoperative nutritional status and QOL.

Effect of Patient-Participation Continuous Nutritional Counseling in Gastric Cancer Patients who Underwent Gastrectomy

BACKGROUND

Body weight loss (BWL) and skeletal muscle loss (SML) are inevitable after gastrectomy for gastric cancer (GC) and can decrease patients' quality of life (QOL) and survival.

OBJECTIVE

The aim of this retrospective study was to evaluate the effect of perioperative and post-discharge patient participation in continuous nutritional counseling (CNC) on post-gastrectomy BWL and SML.

METHODS

Ninety-three patients with GC who underwent curative gastrectomy between March 2018 and July 2019 were analyzed. Patients received either pre-discharge nutritional counseling alone (control group, n = 49) or patient-participation CNC (CNC group, n = 44) after gastrectomy. Differences between percentage BWL (%BWL), percentage SML (%SML), and nutrition-related blood parameters between the preoperative values and those at 12 months after surgery were compared between the groups.

RESULTS

Compared with the control group, %BWL was significantly lower in the CNC group at 1 month (-6.2 ± 2.5% vs. -7.9 ± 3.3%, p = 0.005), 6 months (-7.8 ± 6.6% vs. -12.3 ± 6.4%, p = 0.001) and 12 months (-7.9 ± 7.6% vs. -13.2 ± 8.2%, p = 0.002), and %SML was significantly lower in the CNC group at 12 months (-5.3 ± 10.3% vs. -12.8 ± 12%, p = 0.002). Regarding nutrition-related blood parameters, change in total cholesterol was significantly lower in the CNC group than the control group at 12 months after surgery (p = 0.02). Multivariate analysis identified no CNC as an independent risk factor for severe BWL (p = 0.001) and SML (p = 0.006) at 12 months after surgery.

CONCLUSIONS

Following gastrectomy, patient-participation CNC prevented postoperative BWL and SML after surgery. These results support the induction of such a CNC program in these patients.

Advantages of Function-Preserving Gastrectomy for Older Patients With Upper-Third Early Gastric Cancer: Maintenance of Nutritional Status and Favorable Survival

PURPOSE

The incidence of early gastric cancer is increasing in older patients alongside life expectancy. For early gastric cancer of the upper third of the stomach, laparoscopic function-preserving gastrectomy (LFPG), including laparoscopic proximal gastrectomy (LPG) and laparoscopic subtotal gastrectomy (LSTG), is expected to be an alternative to laparoscopic total gastrectomy (LTG). However, whether LFPG has advantages over LTG in older patients remains unknown.

MATERIALS AND METHODS

We retrospectively analyzed data of consecutive patients aged ≥75 years who underwent LTG, LPG, or LSTG for cT1N0M0 gastric cancer between 2005 and 2019. Surgical and nutritional outcomes, including blood parameters, percentage body weight (%BW) and percentage skeletal muscle index (%SMI) were compared between LTG and LPG or LSTG. Survival outcomes were also compared between LTG and LFPG groups.

RESULTS

A total of 111 patients who underwent LTG (n=39), LPG (n=48), and LSTG (n=24) were enrolled in this study. To match the surgical indications, LTG was further categorized into "LTG for LPG" (LTG-P) and "LTG for LSTG" (LTG-S). No significant differences were identified in the incidence of postoperative complications among the procedures. Postoperative nutritional parameters, %BW and %SMI were better after LPG and LSTG than after LTG-P and LTG-S, respectively. The survival outcomes of LFPG were better than those of LTG.

CONCLUSIONS

LFPG is safe for older patients and has advantages over LTG in terms of postoperative nutritional parameters, body weight, skeletal muscle-sparing, and survival. Therefore, LFPG for upper early gastric cancer should be considered in older patients.

TOMOGRAPHIC SARCOPENIA PREDICTS ANASTOMOTIC LEAKS AND LONG-TERM SURVIVAL IN GASTRIC CANCER PATIENTS OPERATED WITH CURATIVE INTENT

BACKGROUND

The preoperative nutritional state has prognostic postoperative value. Tomographic density and area of psoas muscle are validated tools for assessing nutritional status. There are few reports assessing the utility of staging tomography in gastric cancer patients in this field.

AIMS

This study aimed to determine the influence of sarcopenia, measured by a preoperative staging computed tomography scan, on postoperative morbimortality and long-term survival in patients operated on for gastric cancer with curative intent.

METHODS

This retrospective study was conducted from 2007 to 2013. The definition of radiological sarcopenia was by measurement of cross-sectional area and density of psoas muscle at the L3 (third lumbar vertebra) level in an axial cut of an abdominopelvic computed tomography scan (in the selection without intravascular contrast media). The software used was OsirixX version 10.0.2, with the tool "propagate segmentation", and all muscle seen in the image was manually adjusted.

RESULTS

We included 70 patients, 77% men, with a mean cross-sectional in L3 of 16.6 cm2 (standard deviation+6.1) and mean density of psoas muscle in L3 of 36.1 mean muscle density (standard deviation+7.1). Advanced cancers were 86, 28.6% had signet-ring cells, 78.6% required a total gastrectomy, postoperative surgical morbidity and mortality were 22.8 and 2.8%, respectively, and overall 5-year long-term survival was 57.1%. In the multivariate analysis, cross-sectional area failed to predict surgical morbidity (p=0.4) and 5-year long-term survival (p=0.34), while density of psoas muscle was able to predict anastomotic fistulas (p=0.009; OR 0.86; 95%CI 0.76-0.96) and 5-year long-term survival (p=0.04; OR 2.9; 95%CI 1.04-8.15).

CONCLUSIONS

Tomographic diagnosis of sarcopenia from density of psoas muscle can predict anastomotic fistulas and long-term survival in gastric cancer patients treated with curative intent.

Body composition dynamics and impact on clinical outcome in gastric and gastro-esophageal junction cancer patients undergoing perioperative chemotherapy with the FLOT protocol

PURPOSE

Perioperative chemotherapy with FLOT constitutes a standard of care approach for locally advanced, resectable gastric or gastro-esophageal junction (GEJ) cancer. We aimed at investigating anthropometric, CT-based and FDG-PET-based body composition parameters and dynamics during this multidisciplinary approach and the impact on clinical outcomes.

METHODS

This retrospective, single-center study was based on medical records and (FDG-PET)-CT images among gastric/GEJ cancer patients undergoing perioperative FLOT chemotherapy.

RESULTS

Between 2016 and 2021, 46 gastric/GEJ cancer patients started perioperative FLOT at our tertiary cancer center (Salzburg, Austria). At a median follow-up of 32 months median PFS was 47.4 months and median OS was not reached. The skeletal muscle index (SMI, cm²/m²) turned out to be the only body composition parameter with a statistically significant decrease during pre-operative FLOT (51.3 versus 48.8 cm²/m², p = 0.02). Neither pre-FLOT body mass index (BMI), nor SMI had an impact on the duration of pre-operative FLOT, the time interval from pre-operative FLOT initiation to surgery, the necessity of pre-operative or post-operative FLOT de-escalation or the likelihood of the start of postoperative chemotherapy. Pre-FLOT BMI (overweight versus normal, HR: 0.11, 95% CI: 0.02-0.65, p = 0.02) and pre-FLOT SMI (sarcopenia versus no sarcopenia, HR: 5.08, 95% CI: 1.27-20.31, p = 0.02) were statistically significantly associated with PFS in the multivariable analysis.

CONCLUSION

The statistically significant SMI loss during pre-operative FLOT and the meaningful impact of baseline SMI and BMI on PFS argue for the implementation of a nutritional screening and support program prior to the initiation of pre-operative FLOT in clinical routine.

Nutritional Status and Related Factors in Patients with Gastric Cancer after Gastrectomy: A Cross-Sectional Study

Patients after gastrectomy for gastric cancer are at risk of malnutrition, and poor nutritional status negatively affects patients’ clinical outcomes. Knowledge of the factors influencing patients’ nutritional status can inform interventions for improving patients’ nutrition. A cross-sectional study was conducted to describe nutritional status and related factors in gastric cancer patients after gastrectomy. A convenience sample of gastric cancer patients with gastrectomy was recruited from general surgery or oncology clinics of a medical center in northern Taiwan. Data were collected with self-reported questionnaires, including the Functional Assessment Cancer Therapy—Gastric Module version 4, the Concerns in Meal Preparation scale, the Center for Epidemiologic Studies Depression Scale, and the Mini Nutrition Assessment. One hundred and one gastric cancer patients participated in the study. There were 81 cases of subtotal gastrectomy and 20 cases of total gastrectomy. Most patients (52.5%) were malnourished or at risk. Linear regression showed that symptom severity (β = −0.43), employment status (β = 0.19), and difficulty in diet preparation (β = −0.21) were significant predictors of nutritional status. Together, these three variables explained 35.8% of the variance in patient nutritional status (F = 20.3, p < 0.001). More than 50% of our participants were malnourished or at risk for malnutrition, indicating a need for continued monitoring and support after discharge from hospitals. Special attention should be given to patients with severe symptoms, unemployment, and difficulties in diet preparation.

Advanced lung cancer inflammation index (ALI) predicts prognosis of patients with gastric cancer after surgical resection

Introduction

Advanced lung cancer inflammation index (ALI) has been implicated in the prognosis of many types of tumors. But few studies elucidate its role in gastric cancer (GC).

Materials and methods

We consecutively recruited 615 GC patients who underwent radical gastrectomy. Patients were grouped according to ALI status. Risk factors for overall survival (OS) and disease-free survival (DFS) in overall and sex-stratified cohorts were determined using multivariate cox regression analysis. We also compared survival differences between the two groups after one-to-one propensity score matching (PSM).

Results

Patients with low ALI showed larger tumor size, more advanced TNM staging, shorter OS (median: 37 vs 42 months) and DFS (median: 37 vs 42 months) (all P < 0.001). Multivariate analysis showed that elevated ALI was independently associated with longer OS and DFS. After stratification by sex, low ALI was an independent risk factor for OS and DFS in male patients but not in female patients. But our further PSM analysis showed prognostic value of ALI in both male and female subgroups.

Conclusion

Preoperative ALI is an independent prognostic factor for GC patients undergoing curative gastrectomy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09774-z.

Correlation Between Components of Malnutrition Diagnosed by Global Leadership Initiative on Malnutrition Criteria and the Clinical Outcomes in Gastric Cancer Patients: A Propensity Score Matching Analysis

Objective

Malnutrition is recognized as a risk factor for poor outcome in patients with gastric cancer (GC). In 2018, the Global Leadership Initiative on Malnutrition (GLIM) published standardized criteria for the diagnosis of malnutrition. Our aim was to investigate whether any of the components of the GLIM diagnostic criteria were related to worse clinical outcomes in patients with GC.

Methods

This study analyzed patients with GC who underwent radical gastrectomy in our hospital between 2014 and 2019. A preoperative nutritional assessment was performed for each patient. Matching was based on the presence of three GLIM components: high weight loss (WL), low body mass index (BMI), and low skeletal muscle index (SMI).

Results

The analysis included 1,188 patients, including 241 (20.3%) with high WL, 156 (13.1%) with low BMI, and 355 (29.9%) with low SMI. Before matching, patients who met the GLIM component criteria were mostly associated with older age, low nutritional reserves, and late tumor progression. After matching, the clinical characteristics of the three cohorts were balanced. In the matched queue, the survival prognosis of the high WL group was worse than that of the non-WL group, and the postoperative complication rate was higher in the low SMI group than in the normal SMI group (P <0.05). In addition, the clinical outcomes in the low and normal BMI groups were similar (P >0.05).

Conclusion

Of the GLIM criteria, high WL and low SMI may be associated with poor clinical outcomes in patients with GC, while a low BMI may not be associated with outcome.

Risk factors for cancer-specific survival in elderly gastric cancer patients after curative gastrectomy

BACKGROUND/OBJECTIVES

This study aimed to investigate cancer-specific survival (CSS) and associated risk factors in elderly gastric cancer (EGC) patients.

SUBJECTS/METHODS

EGC patients (≥ 70 yrs) who underwent curative gastrectomy between January 2013 and December 2017 at our hospital were included. Clinicopathologic characteristics and survival data were collected. Receiver operating characteristic (ROC) analysis was used to extract the best cutoff point for body mass index (BMI). A Cox proportional hazards model was used to determine the risk factors for CSS.

RESULTS

In total, 290 EGC patients were included, with a median age of 74.7 yrs. The median follow-up time was 31 (1–77) mon. The postoperative 1-yr, 3-yr and 5-yr CSS rates were 93.7%, 75.9% and 65.1%, respectively. Univariate analysis revealed risk factors for CSS, including age (hazard ratio [HR] = 1.08; 95% confidence interval [CI], 1.01–1.15), intensive care unit (ICU) admission (HR = 1.73; 95% CI, 1.08–2.79), nutritional risk screening (NRS 2002) score ≥ 5 (HR = 2.33; 95% CI, 1.49–3.75), and preoperative prognostic nutrition index score < 45 (HR = 2.06; 95% CI, 1.27–3.33). The ROC curve showed that the best BMI cutoff value was 20.6 kg/m². Multivariate analysis indicated that a BMI ≤ 20.6 kg/m² (HR = 2.30; 95% CI, 1.36–3.87), ICU admission (HR = 1.97; 95% CI, 1.17–3.30) and TNM stage (stage II: HR = 5.56; 95% CI, 1.59–19.43; stage III: HR = 16.20; 95% CI, 4.99–52.59) were significantly associated with CSS.

CONCLUSIONS

Low BMI (≤ 20.6 kg/m²), ICU admission and advanced pathological TNM stages (II and III) are independent risk factors for CSS in EGC patients after curative gastrectomy. Nutrition support, better perioperative management and early diagnosis would be helpful for better survival.

Case reports of new-onset eating disorders in older adult cancer survivors

BACKGROUND

It is unusual for a de novo eating disorder to emerge in late adulthood. Across a number of years, a number of patients were identified who experienced severe and unexpected weight loss post curative management of an upper abdominal cancer (i.e., cancer survivors). Each of the patients was readmitted to the tertiary surgical hospital due to complications of severe malnutrition. Each presentation was initially considered to have a major physical health problem (such as cancer recurrence). Each required extensive investigations and multidisciplinary team involvement and were later conceptualised as a new-onset (in later adulthood) eating disorder that emerged post curative cancer treatment. The team wished to better understand this group and/or characterise and/or inform the scientific community of this phenomena if not already well described.

LITERATURE REVIEW

The review identified that the re-emergence of pre-existing eating disorders at the time of cancer treatment was described; however, there was no identification of similar new-onset in later adulthood cases of eating disorders in cancer survivors in the medical literature.

REVIEW OF THE CASES

Once ethics and consent was obtained, then the clinical course of four complex individuals were reviewed, including the use of a multidisciplinary Delphi review process, to understand commonalities and then plot a common care pathway with potential intervention points.

CASE PRESENTATIONS

Common factors identified among the four patients included the lack of a physical health (organic) cause to the weight loss and ongoing weight loss despite intense multidisciplinary care. All had abnormal attitudes and behaviours relating to food, nutritional rehabilitation and/or recovery. None returned to a healthy weight and/or healthy eating despite extensive team input. The presentations were ultimately conceptualised as having severe disordered eating behaviours and in at least three cases met criteria for a formal eating disorder. The cohort had similar psychosocial characteristics including low socioeconomic status and complex family dynamics. None had prior formal psychiatric care. The outcomes were poor; one patient died, another required admission to a specialist eating disorder admission with a subsequent relapsing remitting course, and the remaining two had complicated chronic courses.

CONCLUSION

Similar cases may be underreported. If identified earlier, there may be a role for intervention to prevent high morbidity and mortality and to support clinical teams managing similar complex patients.

The clinical effectiveness of the method by establishing a proximal jejunum pouch after laparoscopic total gastrectomy: A propensity score-based analysis

BACKGROUND

In this study, we propose an improved Roux-en-Y (RY) surgical method by constructing a proximal jejunum pouch (PP-RY). Postoperative results were evaluated among patients with gastric cancer who underwent PP-RY and standard RY anastomosis.

METHODS

The clinical data of patients with gastric cancer who underwent laparoscopic total gastrectomy (LTG) in our center from May 2019 to May 2020 were collected retrospectively. We compared the short-term results of patients in the PP-RY and RY groups using 1:1 propensity score matching (PSM).

RESULTS

A total of 317 patients were selected, including those who received RY (n = 249) or PP-RY (n = 68) after LTG. After PSM, both groups had a sample size of 68. During the one-year follow-up period, the incidences of postoperative dumping syndrome (5.6%) and reflux esophagitis (14.8%) were significantly lower in the PP-RY group (P = 0.001 and P = 0.010, respectively). Weight loss (6.5 ± 2.0 kg) and albumin decrease (0.2 ± 0.1 g/dl) were significantly lower (P = 0.038 and P < 0.001, respectively), and the prognostic nutritional index (PNI) was significantly higher in the PP-RY group (P = 0.009). In the QLQ-C30 scale, the degree of anorexia in the PP-RY group was significantly lower than that in the RY group (P＜0.05). In the QLQ-STO22 scale, chest and abdomen pain, dietary restriction, and anxiety were significantly lower in the PP-RY group (all P＜0.05).

CONCLUSION

PP-RY can lead to obvious improvements in nutritional status, reduce short-term complications, and improve quality of life (QoL) for patients after LTG.

Prognostic implications of visceral obesity on gastric adenocarcinoma: does it really matter?

PURPOSE

To evaluate the association of visceral adiposity measured on computed tomography (CT) in preoperative period with lymph node (LN) metastasis and overall survival in gastric adenocarcinoma patients.

METHODS

Preoperative CT scans of 246 gastric adenocarcinoma patients who did not receive neoadjuvant chemoradiotherapy were evaluated. Visceral fat area (VFA), subcutaneous fat area (SFA) and Total fat area (TFA), VFA/TFA ratio were quantified by CT. VFA/TFA > 29% was defined as visceral obesity. The differentiation, t-stage, n-stage and the number of harvested-metastatic LNs were noted. The maximum thickness of tumor and localization were recorded from CT. Chi-square, Student's t-test, multiple Cox regression, Spearman's correlation coefficient, and Kaplan-Meier algorithm were performed.

RESULTS

The overall survival (OS) rates and N-stage were not different significantly between viscerally obese and non-obese group (p = 0.994, p = 0.325). The number of metastatic LNs were weakly inversely correlated with VFA (r = -0.144, p = 0.024). Univariate analysis revealed no significant association between visceral obesity and OS or LN metastasis (p = 0.377, p = 0.736). In multivariate analyses, OS was significantly associated with poorly differentiation (HR = 1.72, 95% CI =1.04-2.84, p = 0.035), higher pathologic T and N stage (T4 vs T1 + T2 HR = 2.67, 95% CI =1.18-6.04, p = 0.019; T3 vs T1 + T2 HR = 1.98, 95% CI = 0.90-4.33, p = 0.089; N3b vs N0 HR = 2.97, 95% CI1.45-6.0, p = 0.003; N3 (3a+ 3b) vs N0 HR = 2.24 95% CI =1.15-4.36, p = 0.018).

CONCLUSION

Visceral obesity may not be a prognostic factor in resectable gastric adenocarcinoma patients.

The different survival impacts of body mass index in elderly and non-elderly patients with gastric carcinoma

BACKGROUND

The age-dependent survival impact of body mass index (BMI) remains to be fully addressed in patients with gastric carcinoma (GC). We investigated the prognostic impacts of BMI in elderly (≥70 years) and non-elderly patients undergoing surgery for GC.

METHODS

In total, 1168 GC patients were retrospectively reviewed. Patients were stratified into 3 groups according to BMI; low (<20), medium (20-25) and high (>25). The effects of BMI on overall survival (OS) and cancer-specific survival (CSS) were assessed using univariate and multivariate Cox hazards models.

RESULTS

There were 242 (20.7%), 685 (58.7%) and 241 (20.6%) patients in the low-, medium- and high-BMI groups, respectively. The number of patients with high BMI but decreased muscle mass was extremely small (n = 13, 1.1%). Patients in the low-BMI group exhibited significantly poorer OS than those in the high- and medium-BMI group (P < 0.001). Notably, BMI classification significantly demarcated OS and CSS curves (both P < 0.001) in non-elderly patients, while did not in elderly patients (OS; P = 0.07, CSS; P = 0.54). Furthermore, the survival discriminability by BMI was greater in pStage II/III disease (P = 0.006) than in pStage I disease (P = 0.047). Multivariable analysis focusing on patients with pStage II/III disease showed low BMI to be independently associated with poor OS and CSS only in the non-elderly population.

CONCLUSIONS

BMI-based evaluation was useful for predicting survival and oncological outcomes in non-elderly but not in elderly GC patients, especially in those with advanced GC.

Clinical outcomes of proximal gastrectomy for gastric cancer: A comparison between the double-flap technique and jejunal interposition

Background

The optimal reconstruction method after proximal gastrectomy (PG) has been debatable. Recent reports have shown that the double-flap technique (DFT) provides good outcomes in terms of postoperative nutritional status and quality of life. However, no study has compared the clinical outcomes of the DFT with other reconstruction methods. Here, we evaluated and compared the clinical outcomes between the DFT and jejunal interposition (JI) after PG for gastric cancer.

Materials and methods

The medical records of 34 consecutive patients who had undergone PG for upper third gastric cancer between January 2011 and October 2016 were reviewed retrospectively. The main factors investigated were surgical outcomes, postoperative nutritional status, symptoms, and endoscopic findings 1 year after surgery.

Results

Thirty-four patients were enrolled (DFT, 14; JI, 20). The operation time was similar between the two techniques (228 and 246 minutes for DFT and JI, respectively, P = 0.377), as were the rates of anastomotic complications (7% and 0% for DFT and JI, respectively, P = 0.412). Body weight loss was significantly lower in the DFT group than in the JI group (-8.1% vs -16.1%, P = 0.001). Total protein and albumin levels were higher in the DFT group than in the JI group (0% vs -2.9%, P = 0.053, and -0.3% vs -6.1%, P = 0.077, respectively). One patient in the DFT group and no patients in the JI group experienced reflux esophagitis (≥ grade B) (P = 0.393). Anastomotic strictures were not observed as postoperative complications in either group.

Conclusions

Surgical outcomes revealed that the DFT was safe and feasible, similar to JI. In terms of controlling postoperative body weight loss, the DFT is a better reconstruction technique than JI after PG.

Prediction Model for Screening Patients at Risk of Malnutrition After Gastric Cancer Surgery

BACKGROUND

Malnutrition after gastrectomy is associated with a poor prognosis; however, no accurate model for predicting post-gastrectomy malnutrition exists. Hence, we conducted a retrospective study to develop a prediction model identifying gastric cancer patients at high risk of malnutrition after gastrectomy.

METHOD

Gastric cancer patients who underwent curative gastrectomy with more than one weight measurement during a 3-year follow-up period were included. Malnutrition was defined as body mass index (BMI) < 18.5 kg/m² according to the European Society of Clinical Nutrition and Metabolism diagnostic criteria. BMI-loss pattern was analyzed using a group-based trajectory model. A prediction model for malnutrition 6 months after gastrectomy was developed based on significant risk factors, and then validated.

RESULTS

Overall, 1421 patients were examined. The BMI-loss trajectory model showed significant BMI loss at 6 months after gastrectomy. Severe BMI loss (mean 21.5%; n = 109) was significantly associated with the elderly, female sex, higher preoperative BMI, advanced cancer stage, open surgery, total gastrectomy, Roux-en-Y reconstruction, chemotherapy, and postoperative complications (all p < 0.05). Malnutrition 6 months after gastrectomy was observed in 152 (11.9%) of 1281 patients. Preoperative BMI, sex, and type of operation were included in the final prediction model as predictive factors (p < 0.05). The C-index of the developmental set and bootstrap validation of the prediction model was 0.91 (95% confidence interval 0.89-0.94) and 0.91, respectively.

CONCLUSION

The prediction model for the risk of malnutrition 6 months after gastrectomy was accurately developed, with three independent risk factors: low preoperative BMI, female sex, and total or proximal gastrectomy.

Nutritional and Clinical Factors Affecting Weight and Fat-Free Mass Loss after Gastrectomy in Patients with Gastric Cancer

After a gastrectomy, the nutritional status of patients with gastric cancer has great effect on the treatment outcome and patients' quality of life. We investigated the changes in body composition and nutrient intake after gastrectomy in 288 gastric cancer patients. A multiple linear regression analysis was used for each time period to verify the effects of nutritional and clinical factors on weight and fat-free mass loss rates. Gastric cancer patients who underwent a gastrectomy continued to experience weight and fat-free mass loss until three months after surgery and became stagnant at six months. The marginal mean of calorie intake per weight was 24.5, 26.8, and 29.4 kcal at one, three, and six months. The protein intake per kg lean mass was 1.14, 1.14, and 1.16 g at one, three, and six months, respectively. One month after surgery, the rate of weight loss increased significantly in females who received chemotherapy (p < 0.001). At one to three months postoperative, females who had undergone chemotherapy tended to significantly lose weight (p = 0.016). Females with a history of chemotherapy also showed a reduction in fat-free mass for one to three months (p = 0.036). Calorie intake was a significant factor in preventing fat-free mass weight loss at one month after surgery. Chemotherapy was an independent factor affecting the weight and fat-free mass loss rate up to six months after gastrectomy. Careful monitoring of weight and muscle mass changes following active nutritional intervention for sufficient nutrition support could be helpful for patients after gastrectomy.

Delaying adjuvant chemotherapy in advanced gastric cancer patients: Risk factors and its impact on survival outcome

Adjuvant chemotherapy following the curative resection could improve the survival outcome of advanced gastric cancer (GC) patients. However, it is unclear whether delayed initiation of adjuvant chemotherapy had a negative impact on survival outcome in GC patients. The purpose of this study was to review current published literature about the impact of delaying adjuvant chemotherapy on survival outcome and summarize risk factors for delaying adjuvant chemotherapy. Delayed initiation of adjuvant chemotherapy was quite frequent in GC patients who underwent gastrectomy due to postoperative complications, poor nutritional status, comorbid diseases and socioeconomic status. Therefore, it is important for these patients to have a sufficient and smooth transition from surgery to initiation of adjuvant chemotherapy. Based on current available evidence, there is no specific timing interval for the initiation of adjuvant chemotherapy in GC patients. Earlier initiation of adjuvant chemotherapy (<4 weeks) may not be mandatory for GC patients who underwent curative resection. However, the patients should be recommended to receive adjuvant chemotherapy within 6-8 weeks if their performance status and nutritional status were deemed to be appropriate. Minimizing postoperative complications and providing requisite nutritional advice may be helpful for timely initiation of adjuvant chemotherapy.

Functional jejunal interposition versus Roux-en-Y anastomosis after total gastrectomy for gastric cancer: A prospective randomized clinical trial

BACKGROUND

Nutritional status and quality of life deteriorate significantly after total gastrectomy for patients with gastric cancer. The numerous types of reconstruction proposed by medical researchers around the world have limited effect. This prospective, randomized clinical trial compared functional jejunal interposition with Roux-en-Y anastomosis to identify the optimal reconstruction procedure.

METHODS

This was a multi-center, prospective, randomized control trial. The enrolled patients were randomly assigned into the functional jejunal interposition group and the Roux-en-Y group. All patients were followed up at regular intervals after surgery. The endpoints were postoperative nutritional status, quality of life, and long-term postoperative complications.

RESULTS

A total of 113 patients were enrolled from August 2012 to September 2017. Until March 2018, the median follow-up period was 18 months. At 12 months after surgery, food intake per meal (P = 0.021), Prognosis Nutritional Index (P = 0.015), weight loss (P = 0.019), and Gastrointestinal Symptom Rating Scale score (P = 0.015) of the functional jejunal interposition group were significantly worse than those of the Roux-en-Y group. There was no significant difference in operative time, intraoperative blood loss, perioperative complications, time of first flatus and defecation after surgery, postoperative plasma nutritional parameters, Visick score, Eastern Cooperative Group physical condition score, and survival rate.

CONCLUSION

For patients with long-term survival after total gastrectomy for gastric cancer, the Roux-en-Y anastomosis is a better choice compared with functional jejunal interposition.

Lifestyle factors and long-term survival of gastric cancer patients: A large bidirectional cohort study from China

BACKGROUND

Lifestyle factors such as body mass index (BMI), alcohol drinking, and cigarette smoking, are likely to impact the prognosis of gastric cancer, but the evidence has been inconsistent.

AIM

To investigate the association of lifestyle factors and long-term prognosis of gastric cancer patients in the China National Cancer Center.

METHODS

Patients with gastric cancer were identified from the China National Cancer Center Gastric Cancer Database 1998-2018. Survival analysis was performed via Kaplan-Meier estimates and Cox proportional hazards models.

RESULTS

In this study, we reviewed 18441 cases of gastric cancer. Individuals who were overweight or obese were associated with a positive smoking and drinking history (P = 0.002 and P < 0.001, respectively). Current smokers were more likely to be current alcohol drinkers (61.3% vs 10.1% vs 43.2% for current, never, and former smokers, respectively, P < 0.001). Multivariable results indicated that BMI at diagnosis had no significant effect on prognosis. In gastrectomy patients, factors independently associated with poor survival included older age (HR = 1.20, 95%CI: 1.05-1.38, P = 0.001), any weight loss (P < 0.001), smoking history of more than 30 years (HR = 1.14, 95%CI: 1.04-1.24, P = 0.004), and increasing pTNM stage (P < 0.001).

CONCLUSION

In conclusion, our results contribute to a better understanding of lifestyle factors on the overall burden of gastric cancer and long-term prognosis. In these patients, weight loss (both in the 0 to 10% and > 10% groups) but not BMI at diagnosis was related to survival outcomes. With regard to other factors, smoking history of more than 30 years conferred a worse prognosis only in patients who underwent gastrectomy. Extensive efforts are needed to elucidate mechanisms targeting the complex effects of lifestyle factors.

Pre- and post-operative low prognostic nutritional index influences survival in older patients with gastric carcinoma

OBJECTIVES

The survival impact of the preoperative prognostic nutritional index (PNI) has been investigated in older patients with gastric carcinoma (GC), while that of the postoperative PNI has yet to be addressed. We evaluated the significance of PNI before and after surgery in older GC patients (≥75 years).

MATERIALS AND METHODS

In total, 309 older GC patients undergoing radical gastrectomy between 2006 and 2016 were retrospectively reviewed. The PNI was evaluated before and at six months after gastrectomy. Patients were divided into low (<45) and high (≥45) PNI groups. The impact of low PNI on overall survival (OS), cancer-specific survival (CSS), and non-GC-related death were investigated.

RESULTS

Low PNI was present in 134 patients (43.4%) preoperatively and 121 (39.2%) postoperatively. Low pre-PNI was independently associated with poor overall survival (P < .001). Similarly, OS was significantly stratified by post-PNI (P < .001). The significant survival difference according to post-PNI was present only in pStage I disease (P < .001). Low post-PNI independently increased the risk of non-GC-related death in a multivariable analysis (P = .002). In contrast, CSS was not stratified by post-PNI (P = .45). In the high pre-PNI group, total gastrectomy and super-older age (≥80 years) independently increased the risk of low post-PNI, which was significantly associated with poor survival outcomes.

CONCLUSIONS

Pre- and post-operative PNI are useful for predicting long-term outcomes in older patients with GC. Low postoperative PNI is a powerful determinant of mortality due to other diseases. Optimal perioperative management is required for those at high risk of malnutrition postoperatively.

Long-term effects of an oral elemental nutritional supplement on post-gastrectomy body weight loss in gastric cancer patients (KSES002)

AIM

The present study aimed to evaluate the efficacy of short-term nutritional intervention with an oral elemental diet (ED; Elental; EA Pharma Co., Ltd, Tokyo, Japan) at 300 kcal/day for 6-8 weeks in the early post-gastrectomy period on postoperative long-term body weight loss (BWL).

METHODS

We analyzed consecutive patients who were randomly divided to receive the regular diet with or without ED. The control group received regular diet alone post-gastrectomy, whereas the ED group received 300 kcal ED plus regular diet for 6-8 weeks. Primary endpoint was percentage (%) BWL (body weight loss; body weight before surgery minus that at postoperative 1 year) by surgical type. Secondary endpoints included changes in nutrition-related blood parameters.

RESULTS

Of the patients in the original trial, 106 were eligible for efficacy analyses. %BWL at postoperative 1 year was significantly lower in the ED group than in the control group among patients who underwent total gastrectomy (TG) (n = 19 and n = 17, respectively; 9.66 ± 5.98% [95% confidence interval, CI: 6.77-12.54] vs 15.11 ± 6.78% [95% CI: 11.63-18.60], P = .015), but not in patients who underwent distal gastrectomy (n = 38 and n = 32, respectively; 5.81 ± 7.91% [95% CI: 3.21-8.41] vs 5.96 ± 6.20% [95% CI: 3.72-8.19], P = .933). In multivariate analysis, ED was the only factor affecting %BWL at postoperative 1 year among patients who underwent TG.

CONCLUSIONS

Daily nutritional intervention (300 kcal/day ED) for 6-8 weeks reduced %BWL not only at postoperative 6-8 weeks but also at 1 year in patients who underwent TG.

Prognostic significance of body mass index and prognostic nutritional index in stage II/III gastric cancer

INTRODUCTION

Preoperative body weight and nutritional status are related to prognosis in patients with gastric cancer; however, the prognostic impact of postoperative in these variables is unclear. We aimed to investigate the association of preoperative/postoperative body mass index (BMI) and prognostic nutritional index (PNI) with prognosis in patients with gastric cancer.

MATERIALS AND METHODS

We retrospectively 1868 patients with stage II/III gastric cancer treated with gastrectomy between January 2006 and December 2010. We divided the populations into 3 groups according to BMI; underweight, normal, and overweight. Patients were divided into 3 groups according to BMI (underweight, normal-weight, overweight). PNI was classified into low and high (cutoff value; 49.7). The association of preoperative BMI/PNI and their changes (6 months postoperatively) with clinicopathologic characteristics were evaluated.

RESULTS

Preoperative underweight and low PNI were related to poor prognosis (log-rank p < 0.001 for both). There was a positive correlation between preoperative BMI and PNI (mean preoperative PNI: 51.13 [underweight], 53.37 [normal-weight], and 55.16 [overweight]; p < 0.001). Preoperative BMI and PNI were independent prognostic factors for disease-free survival along with age and TNM stage (p < 0.001 for both). BMI changes from normal-weight to underweight and from overweight to normal/underweight were related to poor prognosis (log-rank p = 0.021 and p = 0.013, respectively). PNI changes were related to prognosis in both the preoperative low and high PNI groups (p < 0.001 and p = 0.019, respectively).

CONCLUSION

Preoperative BMI and PNI and their postoperative changes are related to prognosis in patients with stage II/III gastric cancer. Careful nutritional intervention after gastrectomy can improve prognosis.

Influence of body mass index on outcomes in patients undergoing surgery for diverticular disease

BACKGROUND

We hypothesized that increasing body mass index is a risk factor for surgical complications in surgery for diverticulitis. We assessed the relationship of body mass index and surgical complications following surgery for diverticular disease.

METHODS

We used National Surgical Quality Improvement Program database from 2005 to 2015. Patients undergoing surgery for diverticular disease during that period were included and stratified into 9 groups based on their body mass index (< 18.5, 18.6-24.9, 25.0-29.9, 30.0-34.9, 35.0-39.9, 40.0-44.9, 45.0-49.9, 50.0-54.9, > 55). Outcomes of interest were complications of superficial surgical site infection, deep incisional surgical site infection, organ space surgical site infection, wound disruption complications, pneumonia, ventilator dependence > 48 hours, acute renal failure, myocardial infarction, return to operating room, and 30-day mortality.

RESULTS

Morbidly obese patients had higher rates of diabetes, hypertension, and steroid use. They had higher American Society of Anesthesiologists classification and were more likely to have emergency and open cases. Interestingly, increased body mass index was inversely associated with age. Increasing body mass index was associated with worse outcomes including superficial surgical site infection, deep incisional surgical site infection, organ space surgical site infection, wound disruption complications, ventilator dependence > 48 hours, acute renal failure, and return to operating room. Risk of developing pneumonia didn't have similar correlation with body mass index. Overweight status had protective effect on mortality. No statistically significant differences in increased rates of myocardial infarction were noted. Underweight patients also developed worse outcomes.

CONCLUSION

Obesity is associated with a number of complications following surgery for diverticulitis. Elevated body mass index adds significant risk to procedures for diverticulitis and should be accounted for in risk stratification models. Patients should be counseled on weight reduction before undergoing elective surgery for diverticular disease.

Weight loss and body mass index in advanced gastric cancer patients treated with second-line ramucirumab: a real-life multicentre study

AIMS AND METHODS

This multicenter retrospective study aims to evaluate the correlations between Body Weight Loss (BWL), Body Mass Index (BMI) and clinical outcomes (ORR, PFS, and OS) of advanced gastric cancer (aGC) patients treated with second-line ramucirumab-based therapy in a "real-life" setting.

RESULTS

From December 2014 to October 2018, 101 consecutive aGC patients progressed to a first-line chemotherapy were treated with ramucirumab alone (10.9%) or in combination with paclitaxel (89.1%). Median BMI was 21.2 kg/m2 and mBWL since first-line treatment commencement was 4.5%. Among 53 patients who underwent primary tumor resection (PTR), 73.6% experienced BWL, while 26.4% did not experience BWL (p = 0.0429). Patients who underwent PTR had a significantly higher probability of experiencing BWL (yes vs no) [OR = 2.35 (95% CI 1.02-5.42), p = 0.0439]. Among the 89 evaluable patients, ORR was 26.9% (95% CI 17.2-40.1). At a median follow-up of 17.3 months, mPFS was 5.4 months (95% CI 3.6-6.8) and mOS was 8.7 months (95% CI 7.3-11.9). In the multivariate analysis, only ECOG-PS and BMI were confirmed independent predictors for shorter PFS [HR = 1.69 (95% CI 1.01-2.82), p = 0.04] [HR = 1.97 (95% CI 1.12-3.46), p = 0.01] and OS [HR = 1.69 (95% CI 1.01-2.83), p = 0.04] [HR = 2.08 (95% CI 1.17-3.70), p = 0.01].

CONCLUSION

Efficacy of ramucirumab is confirmed in this "real-life" analysis. BWL seems not to have correlations with clinical outcomes in these patients, while BMI and ECOG-PS remain major prognostic factors. A possible explanation for the lack of prognostic effect of BWL might be the proportion of patients subjected to PTR in this series (52.5%).

Changes in body weight, skeletal muscle and adipose tissue after gastrectomy: a comparison between proximal gastrectomy and total gastrectomy

BACKGROUND

Proximal gastrectomy (PG) offers a well-preserved digestive function after surgery, which may result in a better nutritional outcome in comparison to total gastrectomy (TG). The aim of this study was to clarify the advantage of PG over TG by evaluating the longitudinal changes in body weight (BW) and body composition after surgery.

METHODS

A total of 112 patients undergoing PG with a reconstruction preserving food passage through the duodenum (n = 39) or TG with a reconstruction bypassing the duodenum (n = 73) for clinical stage IA gastric cancer were included. Changes in BW, psoas muscle and subcutaneous (SAT) and visceral adipose tissue were assessed before surgery, and at 1 and 3 years after surgery and were compared between the two groups.

RESULTS

BW and SAT decreased significantly in both groups, but the rate of reduction was significantly lower in the PG group (P < 0.001 and P < 0.001, respectively). There were no significant differences between the groups with regard to skeletal muscle or visceral adipose tissue (P = 0.110 and 0.710, respectively), although they both significantly decreased throughout the course of the study.

CONCLUSIONS

The losses of BW and SAT were significantly smaller in the PG group. PG may be superior to TG in preserving BW and SAT in patients with clinical stage IA gastric cancer.

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Does high body mass index negatively affect the surgical outcome and long-term survival of gastric cancer patients who underwent gastrectomy: A systematic review and meta-analysis

BACKGROUND

Whether high body mass index (BMI) was associated with increased postoperative complications and unfavorable prognosis of gastric cancer (GC) patients remain controversial. In the present study, we performed a systematic review and meta-analysis to evaluate the impact of high BMI on surgical outcome, postoperative complications and long-term survival of GC patients.

METHODS

The related studies were identified by searching PubMed and Embase databases. According to the BMI, all GC patients were classified into BMI ≥25 kg/m² group and BMI <25 kg/m² group. The relevant data was extracted and pooled effect size was assessed using a fixed effect model or random effect model.

RESULTS

A total of 36 relevant studies involving 30,642 GC patients were included in this meta-analysis. The results indicated that high BMI patients had longer operation time, fewer number of retrieved lymph nodes and larger amount of intraoperative blood loss than other patients, regardless of open gastrectomy or laparoscopic gastrectomy. In addition, the risk of postoperative complications was significantly higher in the patients with BMI ≥25 kg/m² than in those with BMI <25 kg/m², especially for infectious complications. However, high BMI had no negative impact on postoperative mortality and long-term survival of GC patients.

CONCLUSION

Despite the increased surgical difficulty and postoperative complications, high BMI was not associated with the prognosis of GC patients. To reduce the risk of postoperative complications, more meticulous operation technique and improved perioperative management should be necessary for high BMI patients.

The Impact of Preoperative Low Body Mass Index on Postoperative Complications and Long-term Survival Outcomes in Gastric Cancer Patients

PURPOSE

The aim of this study was to investigate the impact of preoperative low body mass index (BMI) on both the short- and long-term outcomes in patients with gastric cancer.

MATERIALS AND METHODS

A total of 510 patients with gastric cancer were divided into the following 3 groups: low BMI group (≤18.5 kg/m2, n=51), normal BMI group (18.6-24.9 kg/m2, n=308), and high BMI group (≥25.0 kg/m2, n=151).

RESULTS

There were significantly more stage III/IV patients in the low BMI group than in the other groups (P=0.001). Severe postoperative complications were more frequent (P=0.010) and the survival was worse (P<0.001) in the low BMI group. The subgroup analysis indicated that survival was worse in the low BMI group of the stage I/II subgroup (P=0.008). The severe postoperative complication rate was higher in the low BMI group of the stage III/IV subgroup (P=0.001), although the recurrence rate and survival did not differ in the stage III/IV subgroup among all the BMI groups. Low BMI was an independent poor prognostic factor in the stage I/II subgroup (disease-free survival: hazard ratio [HR], 13.521; 95% confidence interval [CI], 1.186-154.197; P=0.036 and overall survival: HR, 5.130; 95% CI, 1.644-16.010; P=0.005), whereas low BMI was an independent risk factor for severe postoperative complications in the stage III/IV subgroup (HR, 17.158; 95% CI, 1.383-212.940; P=0.027).

CONCLUSIONS

Preoperative low BMI in patients with gastric cancer adversely affects survival among those with stage I/II disease and increases the severe postoperative complication rate among those with stage III/IV disease.

Beyond the Beyond: A Case of an Extraordinary Response to Multiple Lines of Therapy in a de novo Metastatic HER2-Negative Gastric Cancer Patient

Background

Gastric cancer is the fourth cause of cancer-related death in Europe and the prognosis of these patients remains dismal. It has been demonstrated that chemotherapy improved survival compared with best supportive care and recently, subsequent lines of therapy, also with new drugs, obtained positive results.

Summary

We present the case of a patient diagnosed with a de novo metastatic gastric cancer who experienced an extraordinary long response to multiple lines of chemotherapy (FOLFOX6, paclitaxel plus ramucirumab, FOLFIRI, rechallenge with FOLFOX6).

Key Message

Gastric cancer therapy should be considered as the result of a strategy based on the patient's condition, and tolerance and response to various therapies. The emerging evidence of the role of subsequent lines of therapy, along with the recognition of the pivotal role of nutritional support and the availability of new drugs, should help clinicians in the management of patients with gastric cancer.

Practical Implications

We propose a practical therapeutic algorithm in order to help clinicians who deal with patients with gastric cancer.

Prognostic Roles of Perioperative Body Mass Index and Weight Loss in the Long-Term Survival of Gastric Cancer Patients

Background: Most patients with gastric cancer rapidly lose weight after gastrectomy. Therefore, analysis of the effect of body mass index (BMI) on patients with gastric cancer survival should include postoperative BMI and BMI loss and preoperative BMI. This retrospective cohort study analyzed the effect of three BMI variables and their interaction on long-term outcomes.Methods: Preoperative BMI analysis included 2,063 patients with gastric cancer who underwent curative gastrectomy between January 2009 and December 2013 at Seoul National University Bundang Hospital. BMI at postoperative 6 to 12 months was available in 1,845 of these cases.Results: Patients with preoperative BMI 23.0 to <27.5 [HR, 0.63; 95% confidence interval (CI), 0.48-0.82 for BMI 23.0 to <25.0 and HR, 0.57; 95% CI, 0.42-0.78 for BMI 25.0 to <27.5] and postoperative BMI 23.0 to <25.0 (HR, 0.67; 95% CI, 0.46-0.98) showed significantly better overall survival (OS) than pre- and postoperative patients with BMI 18.5 to <23.0, respectively. Postoperative underweight (BMI <18.5; HR, 1.74; 95% CI, 1.27-2.37) and postoperative severe BMI loss (>4.5; HR, 1.79; 95% CI, 1.29-2.50) were associated with higher mortality. Severe BMI loss and preoperative BMI <23.0 had an adverse synergistic effect; patients with BMI <23.0 were more vulnerable to severe BMI loss than those with BMI ≥23.0. Associations with cancer-specific survival were similar.Conclusions: All three BMI variables were prognostic factors for survival of patients with gastric cancer. Preoperative BMI and severe BMI loss had an interaction.Impact: Perioperative BMI and weight loss should be analyzed collectively in patients with gastric cancer undergoing gastrectomy. Cancer Epidemiol Biomarkers Prev; 27(8); 955-62. ©2018 AACR.

Loss of skeletal muscle mass after curative gastrectomy is a poor prognostic factor

Sarcopenia has been reported to relate to poor prognosis in various malignant cancer types. The present study aimed to clarify the prognostic impact of skeletal muscle mass (SMM) loss after curative gastrectomy in patients with gastric cancer. A total of 119 patients who underwent curative gastrectomy for gastric cancer between 2009 and 2016 were analyzed. The SMM loss at 6 months postoperatively compared with the SMM prior to surgery was calculated using the hospital records. The median loss of SMM was 3.8%. Multivariate logistic regression analysis demonstrated that total gastrectomy was a significant and independent risk factor for SMM loss of ≥5% (odds ratio=2.58; P=0.02). Results from multivariate analysis using stepwise Cox proportional hazards regression indicated that the following factors were significantly associated with shorter overall survival after curative gastrectomy: Age [>70 years; hazard ratio (HR)=2.46, P=0.04], TNM stage (≥2; HR=2.65, P=0.04) and loss of SMM (≥5%; HR=2.57, P=0.03). The present findings suggested that loss of SMM after curative gastrectomy for gastric cancer is an independent predictive factor for poor prognosis.

Impact of body mass index on survival outcome in patients with differentiated thyroid cancer

Introduction

Objective

Methods

Results

Conclusion

Prognostic significance of perioperative nutritional parameters in patients with gastric cancer

BACKGROUND & AIMS

It has been suggested that nutritional status is related to the survival outcomes of cancer patients. The purpose of the current research is to evaluate the importance of the prognosis of various nutritional parameters during the perioperative period in patients with gastric cancer.

METHODS

This study enrolled patients with gastric cancer who underwent D2 gastrectomy at the Department of Surgery, Samsung Medical Center, in 2008. The prognostic significance of nutritional parameters was analyzed, along with other clinical and pathological variables, preoperatively and postoperatively at 3, 6, and 12 months.

RESULTS

The total number of patients was 1415. The mean values of nutritional parameters, weight, body mass index (BMI), hemoglobin, total cholesterol, and total lymphocyte count (TLC) decreased significantly over time after surgery. On the contrary, albumin and prognostic nutritional index (PNI) score increased significantly during the postoperative follow-up period. Preoperatively, low BMI (<18.5 kg/m²) and low TLC level (<1000 per mm³) were revealed as independent prognostic factors in multivariate analysis. Low preoperative TLC level and decline in PNI (ΔPNI < -2.2) at postoperative 3 months; low preoperative TLC level and decline in TLC (ΔTLC < -279.9 per mm³) at postoperative 6 months; and low preoperative BMI, albumin, and TLC levels at postoperative 12 months were independent nutritional prognostic indicators.

CONCLUSION

Various perioperative nutritional parameters were confirmed as independent prognostic factors in patients with gastric cancer. Our results imply prognostic benefit from careful nutritional support for patients with poor nutritional parameters.

Impact of Malnutrition After Gastrectomy for Gastric Cancer on Long-Term Survival

BACKGROUND

Preoperative malnutrition can worsen morbidity and mortality; however, the role of postgastrectomy nutritional status remains unclear. Our purpose was to clarify whether malnutrition after gastrectomy could predict long-term survival.

METHODS

Patients with pathological stage I, II, and III gastric cancer who underwent gastrectomy between 2002 and 2013 were included. The nutrition risk index (NRI) was evaluated before and at 1, 3, 6 and 12 months after gastrectomy. The patients were divided into normal (NRI > 97.5) or malnutrition (NRI ≤ 97.5) groups, and we compared the correlations of clinicopathological characteristics, surgical treatment, and overall survival between the two groups.

RESULTS

Among the 760 participants, patients in the malnutrition group were significantly older and had higher incidences of comorbidity and advanced cancer than the patients in the normal group. Multivariate analysis showed that overall survival was poorer in the malnutrition group before gastrectomy [hazard ratio (HR) 1.68] and at 1 month (HR 1.77), 3 months (HR 2.18), 6 months (HR 1.81) and 12 months (HR 2.17) after gastrectomy (all p < 0.01). Malnutrition at 1 and 3 months after gastrectomy was significantly associated with poor cause-specific survival. Total gastrectomy, preoperative malnutrition, older age, and adjuvant chemotherapy were independent risk factors of postoperative malnutrition at 12 months postgastrectomy.

CONCLUSIONS

Malnutrition before gastrectomy and at 1, 3, 6 and 12 months after gastrectomy significantly and adversely affects overall survival. Nutritional interventions to lessen the impact of postoperative malnutrition offer hope for prolonged survival.

Positive Effect of Higher Adult Body Mass Index on Overall Survival of Digestive System Cancers Except Pancreatic Cancer: A Systematic Review and Meta-Analysis

High body mass index (BMI) has been inconsistently associated with overall survival (OS) of digestive system cancers (DSCs). This meta-analysis was conducted to investigate whether high BMI was associated with DSCs prognosis. 34 studies were accepted, with a total of 23,946 DSC cases. Hazard ratios (HRs) with 95% confidence intervals (95% CIs) for OS in BMI categories from individual studies were extracted and pooled by random-effect model. The overall HR of DSCs except pancreatic cancer for OS of adult overweight cases was 0.76 (95% CI = 0.67–0.85). DSC individuals except pancreatic cancer with adult obesity were at decreased risk for OS (HR = 0.85, 95% CI = 0.72–0.98). Among DSC patients except pancreatic cancer, the overall HR for the highest versus the lowest BMI category was 0.82 (95% CI = 0.71–0.92). Additionally, comparing the highest and lowest BMI categories, the combined HR of pancreatic cancer was 1.22 (95% CI = 1.01–1.43). Our meta-analysis suggested an increased OS among adult overweight and obese DSC survivors except pancreatic cancer. Overweight and obesity in adulthood may be important prognostic factors that indicate an increased survival from DSC patients except pancreatic cancer.

A prospective appraisal of preoperative body mass index in D2-resected patients with non-metastatic gastric carcinoma and Siewert type II/III adenocarcinoma of esophagogastric junction: results from a large-scale cohort

Objective

To prospectively investigate associations of presurgical body mass index (BMI) with clinicopathological factors and its prognostic significance in radically D2-resected patients with non-metastasized gastric cancer (GC) and Siewert type II/III adenocarcinoma of esophagogastric junction (AEG).

Methods

A large prospective cohort consisting of radically-resected GC and AEG patients was analyzed. Follow-up was successful in 671 out of 700 patients, who were categorized into underweight (BMI<18.5), normal-weight (BMI=18.5-22.9), overweight (BMI=23-24.9), and obese (BMI≥25) groups according to Asian standards. BMI-associated factors were explored using multivariable logistic regression with adjustment. Cancer-specific survival analyses were conducted applying both univariable and multivariable Cox regression methods.

Results

Pre-operation, higher hemoglobin levels and smaller anemia proportions were observed in larger BMI groups. Higher BMI tended to be associated with higher neutrophil-lymphocyte ratios (NLRs). Patients with higher BMI had smaller tumors and more often stage I tumors, but longer surgical time and postsurgical stay. In multivariable analyses, higher hemoglobin levels, upper tumor location, poorer differentiation, and higher NLR were significantly associated with higher BMI. Overall, survival analyses revealed no significant role of BMI. However, in further stratifications after adjustment, compared to patients with normal BMI, obese patients had better survival in women, but worse in those with AEG; underweight was associated with reduced mortality risk in tumors differentiated well to moderately; overweight patients had increased death hazard when having thrombocytopenia.

Conclusion

Overall, preoperative BMI had limited prognostic significance in operated GC patients. However, under specific conditions (e.g., female, AEG, good differentiation, and thrombocytopenia), BMI might indicate postoperative survival.