Total versus subtotal gastrectomy: surgical morbidity and mortality rates in a multicenter Italian randomized trial. The Italian Gastrointestinal Tumor Study Group

Long-term outcomes of endoscopic submucosal dissection for gastric dysplasia and early neoplasia in a United Kingdom Caucasian population

BACKGROUND

Endoscopic submucosal dissection (ESD) is increasingly used to treat gastric dysplasia and early neoplasia in the West. Unlike Eastern countries, data for Caucasian patients in the United Kingdom is limited due to its limited implementation in a few tertiary centres.

AIM

To evaluate the outcomes of ESD on gastric dysplasia and neoplasia in Caucasian patients.

METHODS

Our ten-year retrospective study at a single tertiary centre included data spanning from May 2012 to July 2023. The efficacy of ESD on gastric dysplasia and early neoplasia was measured using parameters set out by the National Institute for Health and Care Excellence, which include en-bloc and curative resection (CR) rates, local recurrence and survival rates.

RESULTS

ESD was attempted on 111 lesions in 93 patients. 95.0% of completed procedures achieved endoscopic clearance. 74.3% were en-bloc resections and the rest were hybrid ESD with piecemeal resections. In all, 34.7% achieved histological CR. Overall, disease recurrence was 10.9% at latest follow-up (63 months, median follow-up). Importantly 100% of lesions in the CR group showed no disease recurrence at subsequent and latest follow-up. In the Indeterminate and Non-CR group, 18.8% of lesions showed disease recurrence at subsequent endoscopic follow-ups. ESD changed the histological staging of 44.5% of lesions. Immediate complications were observed in 9.9% of all ESD procedures. The median survival time was 69 months post-ESD. The mean age at death is 82.2 years old.

CONCLUSION

The study affirms the long-term efficacy and safety of ESD for gastric dysplasia and early neoplasia in Caucasian patients.

Advances in Gastric Cancer Surgical Management

The goal of a gastric cancer operation is a microscopically negative resection margin and D2 lymphadenectomy. Minimally invasive techniques (laparoscopic and robotic) have been proven to be equivalent for oncologic care, yet with faster recovery. Endoscopic mucosal resection can be used for T1a N0 tumor resection. Better understanding of hereditary gastric cancer and molecular subtypes has led to specialized recommendations for MSI-high tumors and patients with pathogenic CDH1 mutations. In the future, surgical management will support minimally invasive approaches and personalized cancer care based on subtype.

Laparoscopic compared to open approach for distal gastrectomy may reduce pneumonia risk for patients with gastric cancer

Background

Whether laparoscopic approach to gastrectomy for gastric cancer (GC) reduces the risk of pneumonia remains unknown. In this study, we compared pneumonia outcomes for patients with GC who underwent either laparoscopic gastrectomy (LG) or open gastrectomy (OG).

Methods

The ACS NSQIP database was queried to identify patients with GC who underwent LG or OG between Jan 2012 - Dec 2018. Outcomes were compared using regression models. A post-hoc analysis was performed for elderly patients.

Results

The study cohort included 2661 patients, 23.4 % undergoing LG. Laparoscopic approach lowered pneumonia risk (OR 0.47, p = .028) and reduced hospital length of stay, (5.3 vs 7.1 days, p < .001). Elderly patients undergoing LG demonstrated similar benefits. Risk factors for pneumonia included advanced age, dyspnea and weight-loss, whereas laparoscopic approach reduced this risk.

Conclusions

LG in patients with GC has both statistically and clinically significant advantages over OG with respect to pneumonia. Further studies are needed to validate the relationship between postoperative pneumonia and surgical approach for gastrectomy.

Prognostic impacts of categorized postoperative complications in surgery for gastric cancer

BACKGROUND

Postoperative complications generally aggravate postoperative prognosis and are correlated with both cancer-specific death and death from other causes.

METHODS

Subjects were 197 patients who underwent gastrectomy at Kyoto Chubu Medical Center. Cancer-specific survival (CSS) and non-CSS (NCSS) were compared between cases with and without complications. Major complications were classified into C-com and N-com groups based on their prognostic impact on CSS and NCSS, respectively. Uni- and multivariate analyses were conducted using clinicopathological factors.

RESULTS

During the study period, 30 patients (15.2%) died from gastric cancer and 34 (17.3%) died from other causes. The incidence of postoperative complications was 16.8%. Sixteen patients with anastomosis leakage, pancreatic fistula, or organ/space surgical site infection had significantly poorer CSS, whereas 30 patients with pneumonia or passage obstruction had significantly poorer NCSS. These were defined as C-com and N-com cases, respectively. In the uni- and multivariate analyses, C-com was a significant prognostic factor for CSS (p = 0.002, p = 0.039) and N-com was a significant prognostic factor for NCSS (p < 0.0001, p = 0.004). C-reactive protein levels indicated intermediate and severe inflammation in N-com and C-com cases, respectively.

CONCLUSION

In N-com cases, surgical stress caused disruption of essential organ function, whereas damage in C-com cases occurred mostly in the abdominal cavity but was a risk for cancer regrowth. Thus, different postoperative complications worsen patient prognosis after gastrectomy in different ways. To optimize surgical outcomes, improved selection of treatment strategies for different complication types may be important.

The Role of Surgery in the Management of Gastric Cancer: State of the Art

Surgery still represents the mainstay of treatment of all stages of gastric cancer (GC). Surgical resections represent potentially curative options in the case of early GC with a low risk of node metastasis. Sentinel lymph node biopsy and indocyanine green fluorescence are novel techniques which may improve the employment of stomach-sparing procedures, ameliorating quality of life without compromising oncological radicality. Nonetheless, the diffusion of these techniques is limited in Western countries. Conversely, radical gastrectomy with extensive lymphadenectomy and multimodal treatment represents a valid option in the case of advanced GC. Differences between Eastern and Western recommendations still exist, and the optimal multimodal strategy is still a matter of investigation. Recent chemotherapy protocols have made surgery available for patients with oligometastatic disease. In this context, intraperitoneal administration of chemotherapy via HIPEC or PIPAC has emerged as an alternative weapon for patients with peritoneal carcinomatosis. In conclusion, the surgical management of GC is still evolving together with the multimodal strategy. It is mandatory for surgeons to be conscious of the current evolution of the surgical management of GC in the era of multidisciplinary and tailored medicine.

Procedure-specific outcomes following gastrectomy for cancer compared by hospital volume and service capability

BACKGROUND

International literature recommends centralising gastric cancer surgery, however, with volumes that define 'high-volume resection' being higher than those in most major centres in Australia and New Zealand. These reports rarely focus on the difference between total (TG) and partial gastrectomy (PG). We assessed the impact of resection volume and service capability on operative mortality, morbidity and surgical quality in patients who had a PG and TG.

METHODS

Patients who had gastrectomy for adenocarcinoma, between 2001 and 2015, were collected from the Queensland Oncology Repository. Hospitals were characterised by cases-per-annum (high-volume [HV] ≥ 5 and low-volume [LV] < 5) and hospital service capability as (high-service [HS] and low-service [LS]), giving three hospital groups: HVHS, LVHS and LVLS. Chi-squared tests were used to compare post-operative mortality, morbidity, failure to rescue (FTR) from complications and surgical quality between these three groups.

RESULTS

There were 426 patients who had a TG and 827 having PG. HVHS centres performed 59% of PG with high surgical quality rates of: HVHS = 53%, LVHS = 34% and LVLS = 46% (p < 0.01). Surgical complications were highest in LVLS (LVLS = 19%, LVHS = 11%, HVHS = 11%; p = 0.02). There was no difference in 30-day mortality nor in FTR. For TG, HVHS performed 67% of these procedures, with lower 30-day mortality (2%) and FTR rates (5%) compared with LVHS (7%, 22%) and LVLS (12%, 28%; p < 0.01). There was no difference in operative morbidity and surgical quality between hospital groups.

CONCLUSION

Despite the 'high-volume' threshold for gastrectomy being the lowest described in the literature, we have shown that centralisation to HVHS centres was associated with lower operative mortality for TG and improved quality of surgery for PG.

Predictive Factors for Short-Term Survival after Non-Curative Endoscopic Submucosal Dissection for Early Gastric Cancer

BACKGROUND/AIMS

For early gastric cancer (EGC) treated using endoscopic submucosal dissection (ESD) with poor curability defined by the Japanese Guidelines (non-curative EGC, N-EGC), additional gastrectomy has been recommended. However, N-EGC patients without additional gastrectomy often die of other diseases within a relatively short interval after ESD. It has been unclear whether additional gastrectomy is beneficial or not for such patients. The aim of this study was to clarify predictors for short-term survival of N-EGC patients without additional gastrectomy after ESD.

METHODS

One hundred six N-EGC patients without additional gastrectomy were included in this study. Factors related to short-term survival, defined as death within 3 years after ESD, were evaluated using uni- and multivariate analyses by comparing patients with and without short-term survival (Groups S and C, respectively).

RESULTS

During the mean follow-up period of 89 months, 39 patients died (14 patients died within 3 years, being Group S). The cause of death was gastric cancer for only 1 patient in the Group C. The 3- and 5-year overall survival rates were 86.8 and 81.8%, respectively, and the 3- and 5-years disease-specific survival rates were 100 and 98.9%, respectively. Univariate analyses showed that short-term survival was statistically associated with elevated morphology, high-risk status for lymph node metastases as defined by the eCura system, severe comorbidity (Charlson Comorbidity Index [CCI] ≥3), low level of activity in daily living (being unable to go out by oneself), habitation (a nursing home), and several poor nutritional prognostic indices (neutrophil to lymphocyte ratio ≥2.5, geriatric nutritional risk index <92, C-reactive protein ≥1.0). In the multivariate analysis, a high CCI (≥3) was the independent predictor for short-term survival after ESD (odds ratio, 8.1; 95% confidence interval, 1.53-43.0; p = 0.014).

CONCLUSIONS

Severe comorbidity indicated by a high CCI score (≥3) was the independent predictor for short-term survival for EGC patients without additional gastrectomy after non-curative ESD. Since the cause of death for most patients was not gastric cancer, observational follow-ups without additional gastrectomy might be a reasonable option for patients with a poor general status indicated by a CCI ≥3.

Surgical Management of Gastric Cancer: A Systematic Review

Gastric cancer is the fifth most common cancer worldwide, and it is responsible for 7.7% of all cancer deaths. Despite advances in the field of oncology, where radiotherapy, neo and adjuvant chemotherapy may improve the outcome, the only treatment with curative intent is represented by surgery as part of a multimodal therapy. Two concepts may be adopted in appropriate cases, neoadjuvant treatment before gastrectomy (G) or primary surgical resection followed by chemotherapy. Such an approach, combined with early detection and better screening, has led to a decrease in the overall incidence of gastric cancer. Unfortunately, malignant tumors of the stomach are often diagnosed in locally advanced or metastatic stages when the median overall survival remains poor. Surgical care in these cases must be provided by a multidisciplinary team in a high-volume center. Important surgical aspects such as optimum resection margins, surgical technique, and number of harvested lymph nodes are important factors for patient outcomes. The standardization of surgical treatment of gastric cancer in accordance with the patient’s profile is of decisive importance for a better outcome. This review aims to summarize the current standards in the surgical treatment of gastric cancer.

Partial Gastrectomy is Associated with Improved Overall Survival in Signet-Ring Cell Gastric Cancer

BACKGROUND

Signet-ring cell gastric cancer (SRGC) is a histological variant of gastric adenocarcinoma (GAC) with a worse prognosis compared to non-signet-ring cell gastric cancer (NSRGC). To our knowledge, the overall survival (OS) among patients with SRGC undergoing total/near-total (TG) versus partial gastrectomy (PG) has never been reported from a large-scale Western database.

METHODS

We performed a retrospective analysis of patients with both SRGC and NSRGC using The National Cancer Database.

RESULTS

In total, 17,086 patients were included. Patients who underwent TG versus PG were 25.5% (n = 770) versus 74.5% (n = 2246) for SRGC, and 20.9% (n = 2943) versus 79.1% (n = 11,127) for NSRGC, respectively. Patients who had SRGC were more likely to undergo TG (25.5% versus 20.9% P< 0.0001). Patients with distal gastric tumors were less likely to undergo TG (16.5% versus 25.4% P < 0.0001). Patients undergoing PG for the SRGC histological variant had better OS (HR = 0.68, CI=0.61-0.76; P < 0.0001) versus those who underwent TG. Similarly, NSRGC patients undergoing PG also had improved OS, but to a lesser extent (HR = 0.91, CI = 0.85-0.96; P= 0.002). Overall, PG for GAC was associated with improved OS compared to TG, although the OS benefit is more profound in the SRGC histological variant (P < 0.0001).

CONCLUSIONS

Our results show that TG is not associated with improved OS in patients who undergo gastrectomy for GAC, even when adjusted for tumor location. The survival differences are more pronounced in the SRGC histology variant. The worst survival is observed in patients with SRGC who undergo TG after adjusting for different covariates.

[Distal subtotal gastrectomy and gastreectomy in surgical treatment of patients with gastric cancer: a systematic review and meta-analysis]

OBJECTIVE

To analyze the randomized controlled trials (RCTs) devoted to distal subtotal gastrectomy and gastrectomy with D2 lymphadenectomy in patients with distal gastric cancer.

MATERIAL AND METHODS

RCTs were searched in the electronic library, the Cochrane Community database, and PubMed database. A systematic review and meta-analysis were carried out in accordance with the recommendations of the Cochrane Community experts (Higgins et al. 2019). Mathematical calculations of a meta-analysis were made using RevMan 5.3 software package. Statistical criteria were calculated for relative risk (RR), hazard ratio (HR), 95% confidence interval (95% CI) and significance level (p).

RESULTS

Seven primary RCTs were selected. A total number of 1463 surgical interventions with D2 lymphadenectomy were observed (805 patients underwent distal subtotal gastrectomy, 658 - gastrectomy). Postoperative mortality is significantly higher (6.5% and 2.6%) after gastrectomy compared to subtotal distal gastrectomy (RR 2.2, 95% CI 1.34-3.64, I² 0%, fixed effect model). Postoperative complications are also significantly more common (28% and 14%) after gastrectomy (RR 1.72, 95% CI 1.16-2.55, I² heterogeneity 49%, random effect model). Differences in overall five-year survival after gastrectomy and subtotal distal resection (51.6% and 60.8%) are insignificant (HR 0.74, 95% CI 0.45-1.22, I² 90%, random effect model, general reverse inversion).

CONCLUSION

The choice of distal subtotal gastrectomy and gastrectomy with D2 lymphadenectomy in patients with distal gastric cancer is not regulated by evidence-based medicine. The boundaries of minimal surgical clearance from the tumor edge vary from 2.5 cm to 6 cm. An updated meta-analysis shows that postoperative mortality and morbidity are significantly higher after gastrectomy compared to distal subtotal gastrectomy while overall 5-year survival is similar.

Types and implications of abdominal fluid collections following gastric cancer surgery

Background: Little data are available for abscess and non-abscess abdominal fluid collections (AFCs) after gastric cancer surgery and their clinical implications. We sought to analyse the natural history of such collections in a population of patients subject to routine postoperative imaging.Methods: From 1996 to 2012, 1381 patients underwent gastric resections and routine postoperative monitoring with abdominal ultrasound. As a unit protocol, examinations were carried out in all patients prior to drain removal, immediately before discharge, and at follow-up visits.Results: AFCs were diagnosed in 134 (9.7%) patients after a median time from surgery of seven days (interquartile range (IQR) 5-11 days). Sixty-four of the 134 AFCs (48%) were asymptomatic and resolved spontaneously after a median follow-up of 26.5 days (IQR 14-91 days). Seventy (52%) AFCs required interventional drainage. A stepwise logistic regression model demonstrated that interventional treatment was much more likely among patients with enteric fistula (odds ratio (OR) 9.542, 95% CI 1.418-46.224, p=.003) and pancreatic fistula (OR 7.157, 95% CI 1.340-39.992, p=.012).Conclusions: About one half of AFCs after gastric surgery were asymptomatic and eventually resolved spontaneously without any intervention. However, the need for interventional drainage was significantly increased by coexisting pancreatic or enteric fistula.

Prognostic value and nomograms of proximal margin distance in gastric cancer with radical distal gastrectomy

Objective

The proximal margin (PM) distance for distal gastrectomy (DG) of gastric cancer (GC) remains controversial. This study investigated the prognostic value of PM distance for survival outcomes, and aimed to combine clinicopathologic variables associated with survival outcomes after DG with different PM distance for GC into a prediction nomogram.

Methods

Patients who underwent radical DG from June 2004 to June 2014 at Department of General Surgery, Nanfang Hospital, Southern Medical University were included. The first endpoints of the prognostic value of PM distance (assessed in 0.5 cm increments) for disease-free survival (DFS) and overall survival (OS) were assessed. Multivariate analysis by Cox proportional hazards regression was performed using the training set, and the nomogram was constructed, patients were chronologically assigned to the training set for dates from June 1, 2004 to January 30, 2012 (n=493) and to the validation set from February 1, 2012 to June 30, 2014 (n=211).

Results

Among 704 patients with pTNM stage I, pTNM stage II, T1−2, T3−4, N0, differentiated type, tumor size ≤5.0 cm, a PM of (2.1−5.0) cmvs. PM≤2.0 cm showed a statistically significant difference in DFS and OS, while a PM>5.0 cm was not associated with any further improvement in DFS and OSvs. a PM of 2.1−5.0 cm. In patients with pTNM stage III, N1, N2−3, undifferentiated type, tumor size >5.0 cm, the PM distance was not significantly correlated with DFS and OS between patients with a PM of (2.1−5.0) cm and a PM≤2 cm, or between patients with a PM >5.0 cm and a PM of (2.1−5.0) cm, so there were no significant differences across the three PM groups. In the training set, the C-indexes of DFS and OS, were 0.721 and 0.735, respectively, and in the validation set, the C-indexes of DFS and OS, were 0.752 and 0.751, respectively.

Conclusions

It is necessary to obtain not less than 2.0 cm of PM distance in early-stage disease, while PM distance was not associated with long-term survival in later and more aggressive stages of disease because more advanced GC is a systemic disease. Different types of patients should be considered for removal of an individualized PM distance intra-operatively. We developed a universally applicable prediction model for accurately determining the 1-year, 3-year and 5-year DFS and OS of GC patients according to their preoperative clinicopathologic characteristics and PM distance.

Influence of age on postoperative complications especially pneumonia after gastrectomy for gastric cancer

Background

The aim of this study was to investigate the influence of patients’ age on postoperative morbidities including pneumonia.

Methods

We reviewed the clinical records of 211 patients with stages I – III gastric cancer undergoing curative distal gastrectomy (DG) or total gastrectomy (TG). Patients were classified into an elderly (≧80 y.o.) or a control (< 80 y.o.) group. We compared patient characteristics (sex ratio, disease stage, degree of lymph node dissection, number of retrieved lymph nodes, and type of reconstruction) and early postoperative outcomes (operation time, intra-operative blood loss, and postoperative morbidity including pneumonia, and mortality) between the two groups separately in DG and TG.

Results

There were 134 and 77 patients who underwent DG and TG, respectively. The numbers of patients in the elderly and control groups were 25 and 109 in DG and 12 and 65 in TG. The percentage of female patients in the elderly group was greater than that in the control group in both DG and TG. The extent of lymph node dissection did not differ between two groups in TG; in contrast in DG, the rate of a D1 dissection was greater in the elderly group than in the control group. There were no differences between the two groups in distribution of disease stage, number of retrieved lymph nodes, operation time, and blood loss in DG and in TG. Overall postoperative morbidity did not differ between two groups after DG and after TG. The rate of infectious complications in the elderly group was not different from that in the control group after DG and after TG. The incidence of pneumonia was more frequent in the elderly group compared to the control group after DG (8% vs. 1%, P < 0.05) but not after TG (17% vs. 5%). When patients were compared between the elderly and the control groups regardless of type of gastrectomy, the incidence of pneumonia in the elderly group (4/37 (11%)) was greater than that in the control group (4/174 (2%), P < 0.05).

Conclusions

These results suggest that pneumonia is increased in patients older than 80 years after DG.

Laparoscopic versus open gastrectomy for advanced gastric cancer: A meta-analysis based on high-quality retrospective studies and clinical randomized trials

BACKGROUND

Additional studies comparing laparoscopic gastrectomy (LG) with open gastrectomy (OG) have been published, and the meta-analysis of this subject should be improved.

METHODS

Randomized controlled trials and high-quality retrospective studies, which compared LG and OG for advanced gastric cancer (AGC) treatment and were published in English and Chinese between January 2000 and February 2017, were selected through PubMed, EMBASE, and the Cochrane Library database by two reviewers independently. The Jadad Composite Scale and the Newcastle-Ottawa scale were used to evaluate the quality and risk of bias for all included studies. Operative outcomes, postoperative outcomes, postoperative morbidity, harvested lymph nodes and 5-year overall survival (OS) were considered as primary endpoints and were compared.

RESULTS

Fifteen studies including a total of 9337 cases (5000 in LG and 4337 in OG) were enrolled. LG showed longer operative time, less intraoperative blood loss, and quicker recovery after operations. Based on the subgroup analysis of the sample size, however, there was no difference in operative time between LG and OG. The number of harvested lymph nodes, 5-year OS, and postoperative morbidity were similar.

CONCLUSION

LG can be performed as an alternative to OG for AGC, with quicker postoperative recovery and comparable safety and efficacy.

A comparison of the operative outcomes of D1 and D2 gastrectomy performed at a single Western center with multiple surgeons: a retrospective analysis with propensity score matching

BACKGROUND

There has been worldwide debate on lymphadenectomy for gastric cancer, with increasing consensus on performing an extended (D2) resection. There is a paucity of data in Australia. Our aim is to compare overall outcomes between a D1 and D2 lymphadenectomy for gastric cancer in a single specialist unit.

METHODS

We performed a retrospective analysis on patients who underwent a curative primary gastric resection for gastric adenocarcinoma between January 1996 and April 2016, primary outcomes included overall survival (OS) and disease-free survival (DFS). Propensity score matching (PSM) analysis was used to balance covariates between D1/D1+ and D2 groups. Kaplan-Meier survival curves of D1/D1+ versus D2 were constructed and evaluated using the log-rank test with subgroup analyses for pathological node (pN) status. Multiple Cox proportional hazards model was used to determine predictors of overall survival.

RESULTS

Two hundred four patients underwent a gastrectomy, 54 had D1/D1+, and 150 had a D2 lymphadenectomy. After PSM, there were 39 patients in each group, the 10-year OS for D1/D1+ was 52.1 and 76.2% for D2 (p = 0.008), and 10-year DFS was 35% for D1 and 58.1% for D2 (p = 0.058). Subgroup analysis showed that node-negative (N0) patients had improved 5-year OS for D2 (90.9%), compared to D1/D1+ (76.4%) (p = 0.028). There was no difference in operative mortality between the groups (D1 vs D2: 2 vs 0%, p = 0.314), nor in post-operative complications (p = 0.227). Multiple Cox analysis showed advanced tumor stage (stages III and IV), and lymphadenectomy type (D1) and the presence of postoperative complications were independent predictors of poor overall survival.

CONCLUSIONS

D2 lymphadenectomy with spleen and pancreas preservation can be performed safely on patients with gastric adenocarcinoma. Significant improvement in overall survival is observed in patients with N0 disease who underwent D2 lymphadenectomy without increasing operative morbidity or mortality. This paper supports the notion of a global consensus for a D2 lymphadenectomy, particularly in the Western context.

Curative Surgery for Gastric Cancer in the Elderly: Treatment Decisions, Surgical Morbidity, Mortality, Prognosis and Quality of Life

Aims and Background

Surgical risk is deemed to be higher in the aged population because there are often comorbidities that may affect the postoperative result. This consideration is important for the treatment decision-making for gastric cancer in the elderly. The aim of this study was to identify factors influencing mortality, morbidity, survival and quality of life after curative surgery for gastric cancer in patients aged 75 years and older, and to plan their appropriate management.

Methods and Study Design

From January 1993 to December 2004, 135 patients underwent surgery at our department because of gastric cancer. Ninety-four of these patients (69.6%) underwent potentially curative gastrectomy. A cross-sectional study of 23 patients aged 75 years and older and 71 younger patients who underwent curative gastrectomy was carried out: patient characteristics, tumor characteristics, management, morbidity, mortality, survival, and quality of life were evaluated.

Results

Elderly patients had significantly more comorbidities and a poorer nutritional status than younger patients. The surgical procedures were similar in both groups and the overall morbidity rate was 27.9% and the overall mortality rate 8.5%. Medical mortality was significantly higher in elderly patients, and the presence of comorbidities was the only independent factor affecting mortality. The 5-year survival rate was 56.2% in the older group versus 62.1% in the younger group and tumor stage was the only prognostic factor influencing survival. Quality of life after surgery was similar in both groups. The significantly better postoperative functional outcome after subtotal gastrectomy suggested a better compliance of elderly patients with subtotal than total gastrectomy.

Conclusions

In the elderly, surgical strategies must be modulated on the basis of comorbidities, tumor stage and future quality of life. Since elderly patients have no worse prognosis than younger patients, age is not a contraindication to curative resection for gastric cancer. Subtotal gastrectomy should be the procedure of choice mainly in elderly patients as it offers better quality of life.

Gastric cancer treatment in the world: Germany

Epidemiologically, around 15,500 persons per year contract gastric cancer with continuously decreasing incidence and a 5-year survival rate of only 30% to 35%. Contrary to the Asian countries, there are no prevention programs for gastric cancer in Germany, which leads to the disease frequently being diagnosed in locally advanced stages and predominantly being treated with multimodal therapy concepts. Complete (R0) resection is the therapy of choice for resectable gastric cancer. Special forms of gastric cancer that are limited to the mucosa can be endoscopically resected with a curative intent. Systematic D2 lymphadenectomy (LAD) plays a decisive role in the management of local advanced tumors because it significantly contributes to the reduction of tumor-related death and both local and regional relapse rates. Perioperative chemotherapy improves prognosis in the advanced stages, whereas palliative chemotherapy is normally indicated for metastatic diseases. Standardized resection procedures and the use of individualized multimodal therapy concepts have led to improvement in the 5-year survival rate.

The optimal extent of gastrectomy for middle-third gastric cancer: distal subtotal gastrectomy is superior to total gastrectomy in short-term effect without sacrificing long-term survival

BACKGROUND

The optimal extent of gastrectomy for middle-third gastric cancer remains controversial. In our study, the short-term effects and longer-term survival outcomes of distal subtotal gastrectomy and total gastrectomy are analysed to determine the optimal extent of gastrectomy for middle-third gastric cancer.

METHODS

We retrospectively collect and analyse clinicopathologic data and follow-up outcomes from a prospectively collected database at the Peking University Cancer Hospital. Patients with middle-third gastric adenocarcinoma who underwent curative resection are enrolled in our study.

RESULTS

We collect data of 339 patients between January 2005 and October 2011. A total of 144 patients underwent distal subtotal gastrectomy, and 195 patients underwent total gastrectomy. Patients in the total gastrectomy group have longer operative duration (P < 0.001) and postoperative hospital stay (P = 0.001) than those in the distal subtotal gastrectomy group. In the total gastrectomy group, more lymph nodes are harvested (P < 0.001). Meanwhile, the rate of postoperative complications is lower in the distal subtotal gastrectomy group than in the total gastrectomy group (8% vs 15%, P = 0.047). Further analysis demonstrates that the rate of anastomosis leakage is lower in the distal subtotal gastrectomy group than in the total gastrectomy group (0% vs 4%, P = 0.023). Kaplan-Meier (log rank test) analysis shows a significant difference in overall survival between the two groups. The 5-year overall survival rates in the distal subtotal gastrectomy and total gastrectomy groups are 65% and 47%, respectively (P < 0.001). Further stage-stratified analysis reveals that no statistical significance exists in 5-year survival rate between the distal subtotal gastrectomy and total gastrectomy groups at the same stage. Multivariate analysis shows that age (P = 0.046), operation duration (P < 0.001), complications (P = 0.037), usage of neoadjuvant chemotherapy (P < 0.001), tumor size (P = 0.012), presence of lymphovascular invasion (P = 0.043) and N stage (P < 0.001) are independent prognostic factors for survival.

CONCLUSIONS

For patients with middle-third gastric cancer, distal subtotal gastrectomy shortens the operation duration and postoperative hospital stay and reduces postoperative complications. Meanwhile, the long-term survival of patients with distal subtotal gastrectomy is similar to that of those with total gastrectomy at the same stage. The extent of gastrectomy for middle-third gastric cancer is not an independent prognostic factor for survival.

Randomized clinical trial of 24 versus 72 h antimicrobial prophylaxis in patients undergoing open total gastrectomy for gastric cancer

BACKGROUND

Open total gastrectomy carries a high risk of surgical-site infection (SSI). This study evaluated the non-inferiority of antimicrobial prophylaxis for 24 compared with 72 h after open total gastrectomy.

METHODS

An open-label, randomized, non-inferiority study was conducted at 57 institutions in Japan. Eligible patients were those who underwent open total gastrectomy for gastric cancer. Patients were assigned randomly to continued use of β-lactamase inhibitor for either 24 or 72 h after surgery. The primary endpoint was the incidence of SSI, with non-inferiority based on a margin of 9 percentage points and a 90 per cent c.i. The secondary endpoint was the incidence of remote infection.

RESULTS

A total of 464 patients (24 h prophylaxis, 228; 72 h prophylaxis, 236) were analysed. SSI occurred in 20 patients (8·8 per cent) in the 24-h prophylaxis group and 26 (11·0 per cent) in the 72-h group (absolute difference -2·2 (90 per cent c.i. -6·8 to 2·4) per cent; P < 0·001 for non-inferiority). However, the incidence of remote infection was significantly higher in the 24-h prophylaxis group.

CONCLUSION

Antimicrobial prophylaxis for 24 h after total gastrectomy is not inferior to 72 h prophylaxis for prevention of SSI. Shortened antimicrobial prophylaxis might increase the incidence of remote infection. Registration number: UMIN000001062 ( http://www.umin.ac.jp).

Distal gastrectomy versus total gastrectomy for distal gastric cancer

Even though more than a century later, after the first case of gastrectomy has been successfully performed, the best surgical treatment for distal gastric cancer still remains controversial. Thus, the present study was designed to compare the survival impact of distal (DG) or total gastrectomy (TG) for distal gastric cancer. A total of 1262 distal gastric cancer patients were enrolled in current study including 1157 patients who underwent DG and 157 patients who underwent TG. The postoperative complications and 5-year overall survival were compared between the 2 groups. TG group presented a longer surgical time, a higher volume of intraoperative bleeding, and a larger number of excised lymph nodes (all P < 0.05) compared with the DG group. The postoperative complications were comparable (all P >0.05). The 5-year overall survival rate of DG group was significantly higher than that of TG group (67.6% vs 44.3%, P < 0.001). However, multivariate analysis showed that type of resection was not an independent prognostic factor for distal gastric cancer (P > 0.05). The factor-stratified multivariate analysis showed that only in the subgroup of Tumor-node-metastasis staging system (TNM) stage III (P = 0.049), TG was the independent prognostic factor for poor survival. In conclusion, DG was as feasible as TG; however, TG did not increase the survival rate. DG brought better long-term survival than TG in patients with TNM stage III tumor. We recommended that DG should be the optimal surgical procedure for distal gastric cancer under the premise of negative resection margin.

Development and external validation of preoperative risk models for operative morbidities after total gastrectomy using a Japanese web-based nationwide registry

BACKGROUND

Total gastrectomy is a relatively difficult and invasive procedure among gastrointestinal surgeries, and major morbidities following total gastrectomy can be serious and fatal. This study aimed to develop and validate preoperative risk models of morbidities associated with total gastrectomy using a Japanese web-based nationwide registry.

METHODS

The national clinical database was used to retrieve the records of 39,253 patients who underwent total gastrectomy in 1,841 hospitals between January 1, 2011 and December 31, 2012.

RESULTS

Mean patient age was 69.1 years, and 73.8% of the patients were male. The overall morbidity rate was 21.5%, which included 8.1% with surgical site infection (SSI), 4.5% with anastomotic leak, 5.0% with pancreatic fistula, 3.7% with pneumonia, 1.9% with prolonged ventilation, and 1.2% with renal failure. Sex, splenectomy, and Brinkman index were selected as common risk factors for SSI, anastomotic leak, and pancreatic fistula. Pancreatectomy was the most significant preoperative risk factor in the risk model of SSI and pancreatic fistula. Need of assistance with activities of daily living, chronic obstructive pulmonary disease, previous cerebrovascular disease, American Society of Anesthesiologists score class 3 and over, presence of esophageal cancer, and body mass index more than 25 were selected as common risk factors for pneumonia, prolonged ventilation over 48 h, and renal failure.

CONCLUSIONS

We have created the first reported risk models of morbidities associated with total gastrectomy, using a Japanese nationwide database. The risk models developed in this study may be useful to preoperatively predict operative morbidities in patients undergoing total gastrectomy.

Total versus subtotal gastrectomy for distal gastric cancer: meta-analysis of randomized clinical trials

Objectives

This meta-analysis of randomized controlled trials was conducted to give a more precise estimation of the efficacy and drawbacks of total gastrectomy (TG) versus subtotal gastrectomy (SG) for proven distal gastric cancer.

Methods

The electronic databases Cochrane and PubMed (updated on April 10, 2016) were searched for randomized controlled trials comparing TG with SG as surgical procedures for distal gastric cancer. Five outcome variables were analyzed, including postoperative complications, anastomotic fistula rate, hospital mortality rate, mortality rate of recurrence (the patient’s death is caused by the recurrence of gastric cancer, rather than caused by other diseases), and 5-year survival rate. Random or fixed effect model was used to perform this meta-analysis.

Results

Six trials, including 573 cases treated with TG and 791 cases treated with SG, were included. Compared with patients in the SG group, patients in the TG group did not show a higher rate of postoperative complications (odds ratio [OR]: 1.46, 95% confidence interval [CI]: 0.71–3.03, P=0.30). However, patients in the TG group showed a significantly higher rate of anastomotic fistula than patients in the SG group (OR: 3.78, 95% CI: 1.97–7.27, P<0.0001). Hospital mortality rate, which was analyzed in four trials, including 510 TG versus 729 SG patients, showed no significant difference between the two groups (OR: 1.80, 95% CI: 0.85–3.78, P=0.12). Importantly, there was no significant difference in the 5-year survival between the two groups (OR: 0.68, 95% CI: 0.39–1.19, P=0.18). Mortality rate of recurrence, which was also analyzed in three trials, including 396 TG versus 407 SG patients, showed a significantly higher rate in the TG group (OR: 0.07, 95% CI: 0.01–0.13, P=0.03).

Conclusion

This meta-analysis demonstrated that postoperative complications, hospital mortality rate, and 5-year survival rate in TG patients was similar to the SG group. Furthermore, SG was associated with significantly fewer anastomotic fistula and lower mortality rate of recurrence compared with TG. However, lower mortality rate of recurrence was probably related to the criteria of these two procedures.

Does Total Gastrectomy Provide Better Outcomes than Distal Subtotal Gastrectomy for Distal Gastric Cancer? A Systematic Review and Meta-Analysis

Background/Aims

Total gastrectomy (TG) has shown to be superior regarding low risk of recurrence and readmission to distal subtotal gastrectomy (DG) for treatment of distal stomach cancer, but the incidence of postoperative morbidity and mortality in TG cannot be ignored. Therefore, we performed a meta-analysis to compare the effectiveness between TG and DG for distal stomach cancer.

Methodology

A search in PubMed, EMBASE, the Cochrane Library, Web of Science, Chinese Biomedical Database through January 2016 was performed. Eligible studies in comparing of TG and DG for distal gastric cancer were included in this meta-analysis. Review Manager 5.2 software from the Cochrane Collaboration was used for the performance of meta-analysis and STATA 12.0 software for meta-regression analysis.

Results

Ten retrospective cohort studies and one randomized control trial involving 5447 patients were included. The meta-analysis showed no significant difference of postoperative mortality (RR = 1.48, 95%CI = 0. 90–2.44,p = 0.12), intraoperative blood loss (MD = 24.34, 95%CI = -3.31–51.99, p = 0.08) and length of hospital stay(MD = 0.76, 95%CI:-0.26–1.79, p = 0.15). TG procedure could retrieve more lymph nodes than DG(MD = 4.33, 95% CI = 2.34–6.31, p<0.0001). According to different postoperative complications, we performed subgroup analysis, subgroup analysis revealed that patients in TG group tended to have a higher rate of postoperative intra-abdominal abscess than DG procedure (RR = 3.41, 95% CI = 1.21–9.63,p<0.05). No statistical differences were found in leakage, intestinal obstruction, postoperative bleeding, anastomotic stricture and wound infection between the two groups (p>0.05). We pooled the data together, the accumulated 5-year Overall Survival rates of TG and DG groups were 49.6% (919/1852) vs.55.9%(721/1290) respectively. Meta-analysis revealed a favoring trend to DG procedure and there was a statistical difference between the two groups (RR = 0.91,95% CI = 0.85–0.97,p = 0.006).

Conclusion

Based on current retrospective evidences, we found that in spite of similar postoperative mortality, TG for distal gastric cancer provided a high risk of five-year Overall Survival rate. DG procedure can be a recommendation for distal gastric cancer, whereas due to lack of high quality RCTs in multicenter and the relatively small sample size of long-term outcomes, further comparative studies are still needed.

Role of omentectomy as part of radical surgery for gastric cancer

Background

A complete omentectomy is recommended as part of radical (sub)total gastrectomy for gastric cancer, but there is little evidence to suggest any survival benefit. The aim of this study was to evaluate the incidence of, and risk factors for, metastases in the greater omentum in patients undergoing gastrectomy for gastric cancer.

Methods

This was a multicentre prospective cohort study (OMEGA trial) of consecutive patients with gastric cancer undergoing (sub)total gastrectomy with complete en bloc omentectomy and modified D2 lymphadenectomy. After resection, the omentum was separated from the gastrectomy specimen distal to the gastroepiploic vessels and sent separately for pathological examination. The primary endpoint was the presence of metastases in the greater omentum.

Results

Of 100 included patients, five (5·0 per cent) had metastases in the greater omentum. Pathology results showed advanced tumours in all five (pT4b N1 M1, pT4b N2 M1, ypT4a N1 M1, ypT3 N2 M0, ypT3 N3 M0). The resection was microscopically non-radical at the proximal (3) or distal (2) resection margin in all of these patients. Metastases in the greater omentum correlated significantly with a microscopically non-radical resection, tumour expansion in the oesophagus or duodenum, linitis plastica or a proximal gastric tumour with diameter of at least 5 cm, stage III–IV disease and (y)pM1 category.

Conclusion

In resectable gastric cancer, the incidence of metastases in the greater omentum is low, and when present associated with advanced disease and non-radical features. Thus, omentectomy as part of a radical gastrectomy may be omitted. Registration number: NCT02050659 (http://www.clinicaltrials.gov).

Role of frailty and nutritional status in predicting complications following total gastrectomy with D2 lymphadenectomy in patients with gastric cancer: a prospective study

PURPOSE

This study was performed to determine the association of frailty and nutritional status with postoperative complications after total gastrectomy (TG) with D2 lymphadenectomy in patients with gastric cancer.

METHODS

Patients undergoing TG with D2 lymphadenectomy for gastric cancer between August 2014 and February 2016 were enrolled. Frailty was evaluated by sarcopenia which was diagnosed by a combination of third lumbar vertebra muscle index (L3 MI), handgrip strength, and 6-m usual gait speed. Nutritional status was evaluated by the nutritional risk screening 2002 (NRS 2002) score. Univariate and multivariate analyses evaluating the risk factors for postoperative complications were performed.

RESULTS

A total of 158 patients were analyzed, and 27.2 % developed complications within 30 days of surgery. One patient died within 30 days of the operation. In the univariate analyses, NRS 2002 score ≥3 (OR = 2.468, P = 0.012), sarcopenia (OR = 2.764, P = 0.008), and tumor located at the cardia (OR = 2.072, P = 0.046) were associated with the postoperative complications. Multivariable analysis revealed that sarcopenia (OR = 3.084, P = 0.005) and tumor located at the cardia (OR = 2.347, P = 0.026) were independent predictors of postoperative complications.

CONCLUSIONS

This study showed a significant relationship between postoperative complications and geriatric frailty using sarcopenia in patients with gastric cancer after TG with D2 lymphadenectomy. Frailty should be integrated into preoperative risk assessment and may have implications in preoperative decisionmaking.

Vascularizing lymph node dissection for advanced gastric cancer: A single-institution experience

AIM: To compare the short- and long-term outcomes of vascularizing lymph node dissection (VLND) and non-vascularizing lymph node dissection (NVLND) from a single institution.

METHODS: Data of 315 patients with advanced gastric cancer who underwent standard D2 lymphadenectomy with curative intent was collected between January 1994 and December 2006. One hundred and fifty-two patients received VLND while 163 patients received NVLND. Short- and long-term clinical outcomes were compared between the two groups.

RESULTS: The median followed-up time was 82 mo. The rate of postoperative complications in the VLND group was 13.2%, while that in the NVLND group was 11.7% (P = 0.686). The overall 5-year survival rate was 64% in the VLND group and 59% in the NVLND group (P = 0.047). When subgroup analyses were performed according to Bormann type, type of differentiation and lymph node status, survival benefit was demonstrated in patients with Bormann type III or IV (59% vs 50%, P = 0.032), undifferentiated type (63% vs 49%, P = 0.021) or presence of lymph node metastasis (53% vs 38%, P = 0.010) in the VLND group.

CONCLUSION: D2 VLND in advanced gastric cancer treatment allows survival benefit with acceptable morbidity and mortality. VLND for patients with potentially curable advanced gastric cancer is feasible and safe when performed by a well-trained surgical team.

Postoperative Morbidity and Mortality Following D2 Gastrectomy-an Audit of 456 Cases

BACKGROUND

D2 gastrectomy is routinely performed in Japanese centres for carcinoma stomach with low morbidity and mortality. There were concerns in Western centres with regard to D2 gastrectomy in view of high morbidity and mortality rates. This study was aimed to study the postoperative morbidity and mortality following D2 gastrectomy for carcinoma stomach in a high volume centre in India.

METHODS

It was a retrospective analysis of all the patients who underwent D2 gastrectomy from 1991 to 2010.

RESULTS

D2 gastrectomy was performed in 456 patients during this period. Respiratory events were the most common cause of morbidity in the study group (2.4 %). Male gender (p = 0.007), presence of gastric outlet obstruction (p = 0.01) and pathological T4 (p = 0.05) independently predicted increased post operative morbidity in multivariate analysis. The morbidity and mortality rates declined with increase in hospital volume and experience of the surgeon.

CONCLUSION

D2 gastrectomy for carcinoma stomach can be performed safely in specialized centres with low morbidity and mortality rates.

Feasibility of Total Gastrectomy with D2 Lymphadenectomy for Gastric Cancer and Predictive Factors for Its Short- and Long-Term Outcomes

BACKGROUND

The aim of this study was to evaluate the short- and long-term outcomes after total gastrectomy (TG) with D2 lymphadenectomy.

METHODS

Patients undergoing TG with D2 lymphadenectomy for gastric cancer between December 2008 and December 2011 were enrolled. Univariate and multivariate analyses were performed to evaluate the risk factors for the short- and long-term outcomes.

RESULTS

A total of 229 patients were analyzed, and 22.3 % developed complications within 30 days of surgery. No patient died within 30 days, while 2.6 % died within 90 days of the operation. In the multivariate analysis, age ≥65 years and cardiopulmonary comorbidities were associated with morbidity, whereas hypoproteinemia and tumor-node-metastasis (TNM) stage III were associated with the disease-free survival (DFS) and overall survival (OS). The number of preoperative risk factors stratified the morbidity from 10.3 % in those without any risk factors to 40.5 % in patients with both risk factors. Similarly, 5-year survival rates decreased from 68.9 % (DFS) and 71.1 % (OS) in those without risk factors to 20.2 % (DFS) and 22.9 % (OS) in patients with both risk factors.

CONCLUSION

TG with D2 lymphadenectomy has acceptable short- and long-term outcomes. Patient risk stratification may allow for more rational selection of patients and therapeutic strategies for gastric resection.

Nomogram Estimating the Probability of Intraabdominal Abscesses after Gastrectomy in Patients with Gastric Cancer

PURPOSE

Intraabdominal abscess is one of the most common reasons for re-hospitalization after gastrectomy. This study aimed to develop a model for estimating the probability of intraabdominal abscesses that can be used during the postoperative period.

MATERIALS AND METHODS

We retrospectively reviewed the clinicopathological data of 1,564 patients who underwent gastrectomy for gastric cancer between 2010 and 2012. Twenty-six related markers were analyzed, and multivariate logistic regression analysis was used to develop the probability estimation model for intraabdominal abscess. Internal validation using a bootstrap approach was employed to correct for bias, and the model was then validated using an independent dataset comprising of patients who underwent gastrectomy between January 2008 and March 2010. Discrimination and calibration abilities were checked in both datasets.

RESULTS

The incidence of intraabdominal abscess in the development set was 7.80% (122/1,564). The surgical approach, operating time, pathologic N classification, body temperature, white blood cell count, C-reactive protein level, glucose level, and change in the hemoglobin level were significant predictors of intraabdominal abscess in the multivariate analysis. The probability estimation model that was developed on the basis of these results showed good discrimination and calibration abilities (concordance index=0.828, Hosmer-Lemeshow chi-statistic P=0.274). Finally, we combined both datasets to produce a nomogram that estimates the probability of intraabdominal abscess.

CONCLUSIONS

This nomogram can be useful for identifying patients at a high risk of intraabdominal abscess. Patients at a high risk may benefit from further evaluation or treatment before discharge.

Robot-assisted surgery for gastric carcinoma: Five years follow-up and beyond: A single western center experience and long-term oncological outcomes

INTRODUCTION

Robot-assisted surgery for the treatment of gastric cancer is considered to be safe and feasible with early post-operative outcomes comparable to open and laparoscopic series. However, data regarding long-term oncological outcomes are lacking. Aim of this study is to evaluate long-term oncological outcomes of a cohort of gastric cancer patients treated surgically with the robot-assisted approach.

MATERIALS AND METHODS

A prospectively collected database of robot-assisted gastrectomies performed for gastric cancer at the 'Misericordia Hospital' between September 2001 and October 2011 was retrospectively analysed. Data regarding surgical procedures, early postoperative course, and long-term follow-up were analysed.

RESULTS

The study included 98 consecutive robot-assisted gastrectomies. Fifty-nine distal gastrectomies, 38 total gastrectomies, and 1 proximal gastrectomy. Open conversion occurred in seven patients (7.1%) due to locally advanced disease. Postoperative morbidity and mortality were 12.2% and 4.1% respectively. Post-operative staging showed 46 patients (46.9%) with stage I disease, 25 patients (25.5%) with stage II, 26 (26.5%) with stage III and 1 (1.02%) with stage IV. The mean follow-up was 46.9 months. Cumulative 5-year overall survival (OS) was 73.3% (95% CI: 62.2-84.4). Five-year survival by stage subgroups was 100% for patients with stage IA, 84.6% for stage IB, 76.9% for stage II, and 21.5% for stage III. The only patient in stage IV of this series died eight months after surgery.

CONCLUSIONS

Robot-assisted gastrectomy for the treatment of gastric cancer is safe and feasible. It provides long-term outcomes comparable to most open and laparoscopic series. Further studies are necessary to better define its indication.

Clinical outcomes of laparoscopic partial gastrectomy for gastric submucosal tumors

INTRODUCTION

Laparoscopic partial gastrectomy has become a common procedure for gastric submucosal tumors because of its accepted feasibility, safety, and oncologic outcomes. However, long-term postoperative outcomes have not been determined, especially based on the location of submucosal tumors.

METHODS

We reviewed 52 consecutive gastric submucosal tumor patients who underwent laparoscopic partial gastrectomy between 1999 and 2009. They were divided into a lesser curvature group (LC group, n = 23) and a greater curvature group (GC group, n = 26) according to tumor location. We compared the following postoperative data about gastric function between the two groups: (i) body weight change during the first postoperative year; (ii) gastrointestinal symptoms (e.g. abdominal pain/discomfort, bloating, heartburn, and dyspepsia); (iii) the amount of food residue at endoscopy; and (iv) the need for medications such as histamine H2 -receptor antagonists, proton pump inhibitors, and prokinetic drugs.

RESULTS

Only a few patients - one in the LC group and two in the GC group - showed body weight loss (over 10%). Compared to the GC group (n = 0 in all three categories), the LC group showed significantly higher frequency of prolonged postoperative abdominal symptoms (n = 4, P = 0.042), food residue at endoscopic follow-up (n = 4, P = 0.036), and postoperative medication use (n = 5, P = 0.016).

CONCLUSION

Patients who received laparoscopic partial gastrectomy did not have severe body weight loss, which suggests dysfunction of the gastric remnant. However, patients in the LC group should receive special attention, as they have a higher risk of developing postoperative gastrointestinal symptoms.

Comparison of the major postoperative complications between laparoscopic distal and total gastrectomies for gastric cancer using Clavien-Dindo classification

BACKGROUND

Laparoscopy-assisted total gastrectomy (LATG) has not been as popular as laparoscopy-assisted distal gastrectomy (LADG) because of its undetermined safety and postoperative complications compared with LADG. Therefore, LATG requires further study.

PATIENTS AND METHODS

A total of 663 patients who underwent LADG or LATG for gastric cancer in a single institution from April 2004 to April 2014 were included. The clinicopathologic characteristics and risk factors related to major complications (Clavien-Dindo grade ≥ IIIa) were analyzed between the LADG (n = 569) and LATG groups (n = 94).

RESULTS

The incidence of major postoperative complications was significantly higher for LATG (LADG vs. LATG: 8.1 vs. 18.1 %, P = 0.002). Although postoperative bleeding was not different between the groups (3.2 vs. 3.2 %, P = 0.991), the incidence of bowel leakage was significantly higher for LATG (2.6 vs. 6.8 %, P = 0.028). Leakage from the anastomosis site was more frequent following LATG (5.3 %) compared with LADG (0.5 %) (P < 0.001). Leakage from the duodenal stump tended to be more frequent, though not significant, for LADG (2.0 vs. 1.1 %, P = 0.602). Advanced gastric cancer, LATG, and longer operation time were significant factors that affected the incidence of postoperative complications in a univariate analysis. In multivariate analysis, there were no independent risk factors, but LATG was nearly a significant, independent risk factor (odds ratio 1.89; 95 % CI 0.965-3.71, P = 0.063).

CONCLUSION

More major complications were observed for LATG, particularly with esophagojejunostomy. These results show that LATG is more invasive than LADG in terms of the postoperative morbidity. More caution and experience are needed when performing LATG.

Total gastrectomy risk model: data from 20,011 Japanese patients in a nationwide internet-based database

OBJECTIVE

To construct a risk model for total gastrectomy outcomes using a nationwide Internet-based database.

BACKGROUND

Total gastrectomy is a very common procedure in Japan. This procedure is among the most invasive gastrointestinal procedures and is known to carry substantial surgical risks.

METHODS

The National Clinical Database was used to retrieve records on more than 1,200,000 surgical cases from 3500 hospitals in 2011. After data cleanup, 20,011 records from 1623 hospitals were analyzed for procedures performed between January 1, 2011, and December 31, 2011.

RESULTS

The average patient age was 68.9 years; 73.7% were male. The overall morbidity was 26.2%, with a 30-day mortality rate of 0.9%, in-hospital mortality rate of 2.2%, and overall operative mortality rate of 2.3%. The odds ratios for 30-day mortality were as follows: ASA (American Society of Anesthesiologists) grade 4 or 5, 9.4; preoperative dialysis requirement, 3.9; and platelet count less than 50,000 per microliter, 3.1. The odds ratios for operative mortality were as follows: ASA grade 4 or 5, 5.2; disseminated cancer, 3.5; and alkaline phosphatase level of more than 600 IU/L, 3.1. The C-index of 30-day mortality and operative mortality was 0.811 (95% confidence interval [CI], 0.744-0.879) and 0.824 (95% CI, 0.781-0.866), respectively.

CONCLUSIONS

We have performed the first reported risk stratification study for total gastrectomy, using a nationwide Internet-based database. The total gastrectomy outcomes in the nationwide population were satisfactory. The risk models that we have created will help improve the quality of surgical practice.

Quality of life after total and subtotal gastrectomy for gastric carcinoma

BACKGROUND

There remains debate as to whether quality of life (QoL) is better for patients following sub-total gastrectomy (SG) or total gastrectomy (TG) for cancer. Both have similar survival rates provided an R0 resection is performed and in many series the morbidity and mortality after TG is higher than SG. The aim of this study was to evaluate the QoL in patients after TG and SG for cancer.

METHOD

All surviving patients who had undergone TG or SG between 1994 and 2009 were identified from a prospectively collected database and sent the European Organisation for Research and Treatment of Cancer (EORTC) core questionnaire (QLQ-C30 v.3) and the gastric module (QLQ-STO22).

RESULTS

From a total of 261 patients who had undergone TG or SG in the study period, 91 were still alive and 53 responded. There was no significant difference between the QoL between TG and SG based on functional scales and global health status. However dysphagia and eating restrictions were significantly worse in the TG group.

CONCLUSION

This study has demonstrated that there is no difference in overall QoL in patients with TG or SG although eating restrictions and dysphagia are worse after TG.

Risk factors associated with complication following gastrectomy for gastric cancer: retrospective analysis of prospectively collected data based on the Clavien-Dindo system

BACKGROUND

Most studies about complication after gastric cancer surgery have been performed without consideration of the severity of each complication. The purposes of this study were to prospectively analyze all postgastrectomy complications according to severity using Clavien-Dindo classification and to identify risk factors related to postoperative complications.

METHODS

Complication data were collected prospectively through weekly conferences with all gastric adenocarcinoma patients who underwent gastrectomy between March 2011 and February 2012 at Seoul National University Hospital. Complications were categorized according to the Clavien-Dindo classification.

RESULTS

Out of the 881 patients who underwent gastrectomy, there were 254 events in 197 patients (22.4%). The numbers of grade I, II, IIIa, IIIb, IVa, and V complications according to the Clavien-Dindo classification were 71 (8.1%), 58 (6.6%), 108 (12.3%), 8 (0.9%), 5 (0.6%), and 4 (0.5%), respectively. Extended gastrectomy (odds ratio [OR], 3.92; 95% confidence interval [CI], 1.96-7.82, p < 0.001), total gastrectomy (OR, 1.97; 95% CI, 1.24-3.14, p = 0.004), and age of 60 years or more (OR, 1.66; 95% CI, 1.15-2.38, p = 0.007) were found to be significant independent risk factors for overall complications of gastrectomy. These three factors were also risk factors for the complications of grade IIIa or over and local and systemic complications. In addition, ASA 3 or 4 and moderate or severe malnutrition as well as those three factors were risk factors for systemic complications.

CONCLUSION

Age and the extent of gastrectomy were revealed as the prognostic factors for overall complications and the complications of grade IIIa or over according to the Clavien-Dindo classification following gastrectomy for gastric cancer.

Morbidity and mortality after total gastrectomy for gastric malignancy using the American College of Surgeons National Surgical Quality Improvement Program database

BACKGROUND

Frequent perioperative morbidity and mortality have been observed in randomized surgical studies for gastric cancer, but specific patient factors associated with morbidity and mortality after total gastrectomy have not been well characterized.

METHODS

We queried the American College of Surgeons National Surgical Quality Improvement Program database (2005-2011) for all patients with a gastric neoplasm undergoing total gastrectomy. Univariate and multivariate logistic regression analyses were performed to identify factors associated with an increased risk of morbidity or mortality.

RESULTS

In 1,165 patients undergoing total gastrectomy, 416 patients (36%) experienced a complication, and 55 died (4.7%) within 30 days of operation. In a reduced multivariate model, age >70 years, preoperative weight loss, splenectomy, and pancreatectomy were associated with morbidity, whereas age >70 years, weight loss, albumin <3 g/dL, and pancreatectomy were associated with mortality (P < .05 each). The number of present preoperative risk factors stratified morbidity from 26 to 46%, with an adjacent organ resection (splenectomy, pancreatectomy) associated with 56% morbidity. Similarly, mortality rates ranged from 0.4% in those without risk factors to 5 of 9 patients with all three preoperative factors present. Patients undergoing pancreatectomy had a 13% mortality rate.

CONCLUSION

Total gastrectomy for malignancy is associated with substantial morbidity and mortality. Identification of high-risk factors may allow more rational patient selection or sequencing of therapy.

Readmissions following elective radical total gastrectomy for early gastric cancer: a case-controlled study

BACKGROUND

Readmission after gastrectomy is one of the factors that reflect quality of life. Therefore, we analyzed the several factors related to readmissions after total gastrectomy for early gastric cancer.

METHODS

From January 2002 through December 2009, 102 consecutive patients who underwent radical total gastrectomy for early gastric cancer were enrolled in this study. We evaluated the incidence, cause, time point, and type of treatment for readmission after discharge; we compared the readmission and non-readmission groups in regard to clinicopathologic features and postoperative outcomes.

RESULTS

The readmission rate during the five years after total gastrectomy was 22 of 102 (21.6%). The most common cause for readmission was esophagojejunostomy stricture (5 cases). The treatment given for 31 readmissions included 23 conservative therapies, 3 radiologic or endoscopic interventions, and 5 re-operations. No significant differences were detected in the clinicopathologic feature, postoperative outcomes, or 5-year survival rates between the readmission and non-readmission group. No specific risk factor was found to be associated with readmission.

CONCLUSION

Although we could not determine a specific risk factor associated with readmission after radical total gastrectomy, prevention of readmission by evaluating the causes and treatments after radical total gastrectomy can improve the patient's quality of life.

Feasibility of laparoscopy-assisted total gastrectomy in patients with clinical stage I gastric cancer

BACKGROUND

Laparoscopy-assisted total gastrectomy (LATG) for gastric cancer is not yet widespread because of the technical difficulty of reconstruction. We have performed LATG on 100 patients with clinical stage I gastric cancer. This study investigated the short-term outcomes of LATG.

METHODS

Between September 2001 and September 2012, 100 patients with clinical stage I gastric cancer underwent LATG with D1 plus beta or D2 lymphadenectomy. Roux-en-Y esophagojejunostomy was performed intracorporeally using end-to-side anastomosis with a circular stapler (the purse-string suture method). The primary endpoint was the proportion of postoperative complications during hospitalization.

RESULTS

Mean operation time was 249 min; mean blood loss was 182 ml. There were no conversions to open surgery. According to the Clavien-Dindo classification, there were 8 grade II (8 %) and 10 grade IIIa/b (10 %) complications. There were no treatment-related deaths or grade IV complications. The most frequent complication was anastomotic or stump leakage (6 %), followed by pancreatic fistula (5 %). Reoperations were required in two patients with leakage.

CONCLUSIONS

The short-term outcomes of LATG in our study involving 100 patients were outlined. LATG for gastric cancer patients should be attempted preferably in a clinical trial setting by surgeons with sufficient experience in laparoscopic gastrectomy.

Is laparoscopy-assisted total gastrectomy feasible for the treatment of gastric cancer? A case-matched study

BACKGROUND

The aim of this study was to clarify the short- and long-term outcomes of laparoscopy-assisted total gastrectomy (LATG) for gastric cancer compared to conventional open total gastrectomy (COTG) with a case-control study.

METHODS

Between January 2002 and December 2010, a series of 264 patients with gastric cancer underwent R0 total gastrectomy (61 LATG patients and 203 COTG patients). Age, gender, and pathological stage were matched by propensity scoring, and 120 patients (60 LATG and 60 COTG) were selected for analysis.

RESULTS

There were no significant differences in the clinicopathological features between the two groups. Regarding postoperative outcomes, first flatus time was significantly shorter in the LATG group than in the COTG group (p < 0.001), while operation time was significantly longer in the LATG group than in the COTG group (p < 0.001). Postoperative complications occurred in 5 cases (8.3%) of the LATG group and in 11 cases (18.3%) of the COTG group (p = 0.178). There were two recurrences in the LATG group and three recurrences in the COTG group. There was no significant difference in the 5-year survival rate between the two groups (p = 0.667).

CONCLUSIONS

LATG for gastric cancer may be both feasible and efficient compared to COTG for experienced laparoscopic surgeons. This study is valuable for a prospective randomized controlled trial of LATG for gastric cancer in a larger number of patients.

Outcomes of Critical Pathway in Laparoscopic and Open Surgical Treatments for Gastric Cancer Patients: Patients Selection for Fast-Track Program through Retrospective Analysis

Purpose

The aim of this study is to investigate the clinical factors affecting on the cure rate by invasive and open surgery for gastric cancer and to establish a subgroup of patients who can be applied by the early recovery after surgery program through this retrospective analysis.

Materials and Methods

In this retrospective study, we analyzed 425 patients who underwent gastric cancer surgery between January 2011 and December 2011 and were managed with conventional clinical therapies. This clinical algorithm was made when the patient was in minimally invasive surgery group and discharged from hospital one day faster than them in open surgery group.

Results

The completion rate of the clinical pathway was 62.4%. Despite the different applications of clinical pathway, completion rate in minimally invasive surgery group was significantly higher than that of open group (P<0.001). In multivariate analysis, the surgical procedure of minimally invasive surgery (odds ratio=4.281) was the most predictable factor to complete clinical pathway. Additionally, younger patients (odds ratio=1.933) who underwent distal gastrectomy (odds ratio=1.999) without combined resection (odds ratio=3.069) were predicted to accomplish the clinical pathway without any modifications.

Conclusions

We concluded that high efficacy of the clinical pathway for gastric cancer surgery was expected to selected patients through retrospective analysis (expected completion rate=85.4%). In addition, these patients would become enrolled criteria for early recovery program in gastric cancer surgery.

Surgical considerations in the treatment of gastric cancer

Gastric cancer is one of the most common malignancies in the world and is a leading cause of cancer death. Surgical treatment remains the best treatment option for potential cure and can be beneficial in the palliation of advanced disease. Several neoadjuvant chemotherapy regimens have been recently evaluated as potential adjuncts to surgery. This review describes the current role of surgical therapy in staging, resection, and palliation of gastric cancer.

Surgical considerations in the treatment of gastric cancer

Gastric cancer is one of the most common malignancies in the world and is a leading cause of cancer death. Surgical treatment remains the best treatment option for potential cure and can be beneficial in the palliation of advanced disease. Several neoadjuvant chemotherapy regimens have been recently evaluated as potential adjuncts to surgery. This review describes the current role of surgical therapy in staging, resection, and palliation of gastric cancer.

Comparison of short- and long-term outcomes of laparoscopic-assisted total gastrectomy and open total gastrectomy in gastric cancer patients

BACKGROUND

Laparoscopy-assisted total gastrectomy (LATG) has been used more frequently despite the associated technical difficulty and concerns over oncological safety. This study was undertaken to compare the short- and long-term surgical outcomes following either LATG or open total gastrectomy (OTG) for gastric cancer.

METHODS

A total of 120 LATG and 228 OTG were retrospectively matched with respect to sex, age (±5 years), and pathological tumor-node-metastasis stage for comparison of the clinical outcomes.

RESULTS

The total complication rate among 120 LATG and 228 OTG was 18.3 % (22/120) and 16.2 % (37/228), respectively. The most common complication after LATG was anastomotic-related complication (6.7 %); five anastomotic leakages (4.2 %) and three anastomotic strictures were reported (2.5 %). That after OTG was wound complication (3.5 %), including seroma or infection. Matched patients analysis: Time to first gas passing and time to the resumption of a soft diet were significantly shorter in the LATG group than in the OTG group. The postoperative hospital stay of LATG was shorter in the LATG group (9.3 ± 4.2 days) than in the OTG group (11.7 ± 7.3 days; p = 0.057). Among matched patients, there was no significant difference between complication rate (24 vs. 32 %; p = 0.504) or leakage rate (6 vs. 4 %). During median follow-up of 50 (range, 10-92) months, there was no significant difference in the disease-free survival rate between the matched groups, respectively (94.5 vs. 87.1 %: p = 0.148). As for patients with TNM stage I gastric cancer, the disease-free survival rate (100 vs. 90.9 %; p = 0.5) and the cumulative survival rate (91.5 vs. 95.2 %; p = 0.618) did not differ significantly between the LATG and OTG groups.

CONCLUSIONS

LATG for gastric cancer has the advantage over an OTG in terms of better short-term outcomes and similar long-term outcome. LATG is an acceptable alternative to OTG for the treatment of gastric cancer.

Quality of care indicators for the surgical treatment of gastric cancer: a systematic review

BACKGROUND

Quality assurance is increasingly acknowledged as a crucial factor for the (surgical) treatment of gastric cancer. The purpose of the current study was to define a minimum set of evidence-based quality of care indicators for the surgical treatment of locally advanced gastric cancer.

METHODS

A systematic review of the literature published between January 1990 and May 2011 was performed, using search terms on gastric cancer, treatment, and quality of care. Studies were selected based on predefined selection criteria. Potential quality of care indicators were assessed based on their level of evidence and were grouped into structure, process, and outcome indicators.

RESULTS

A total of 173 articles were included in the current study. For structural measures, evidence was found for the inverse relationship between hospital volume and postoperative mortality as well as overall survival. Regarding process measures, the most common indicators concerned surgical technique, perioperative care, and multimodality treatment. The only outcome indicator with supporting evidence was a microscopically radical resection.

CONCLUSIONS

Although specific literature on quality of care indicators for the surgical treatment of locally advanced gastric cancer is limited, several quality of care indicators could be identified. These indicators can be used in clinical audits and other quality assurance programs.

Surgical approaches to gastric cancer

While the incidence of gastric cancer has declined substantially, it remains a major cause of morbidity and mortality. Surgical resection offers the best chance for curative treatment. Despite numerous studies, surgical controversies persist including endoscopic resection, extent of gastric resection, degree of lymphadenectomy, and laparoscopic resection. Balancing the benefits with the risks of surgical morbidity and mortality is essential. This review examines these controversies and provides insight into the surgical management of gastric cancer.

Surgery for gastric cancer: what the trials indicate

To optimize the therapeutic value of an operation for cancer, surgeons must weigh survival value against mortality/morbidity risk. As a result of several prospective, randomized trials, many surgeons feel that international opinion has reached a consensus. Reflexively radical surgical hubris has certainly given way to a more nuanced, customized approach to this disease. But issues remain. This article critically reviews existing data and emphasizes areas of continued controversy.