Function-preserving surgery for gastric cancer: current status and future perspectives

Pylorus-preserving gastrectomy for early gastric cancer

Pylorus-preserving gastrectomy (PPG) has been widely accepted as a function-preserving gastrectomy for middle-third early gastric cancer (EGC) with a distal tumor border at least 4 cm proximal to the pylorus. The procedure essentially preserves the function of the pyloric sphincter, which requires to preserve the upper third of the stomach and a pyloric cuff at least 2.5 cm. The suprapyloric and infrapyloric vessels are usually preserved, as are the hepatic and pyloric branches of the vagus nerve. Compared with distal gastrectomy, PPG has significant advantages in preventing dumping syndrome, body weight loss and bile reflux gastritis. The postoperative complications after PPG have reached an acceptable level. PPG can be considered a safe, effective, and superior choice in EGC, and is expected to be extensively performed in the future.

Long-term Results of Totally Laparoscopic Near-total Gastrectomy for Middle-third Gastric Cancer

PURPOSE

In recent years, laparoscopic near-total gastrectomy (LnTG) has emerged as a surgical option for gastric cancer in the middle-third of the stomach. However, its application in locally advanced stages presents technical challenges. This study aims to provide a detailed analysis of the operative outcomes and long-term functional and oncological results of totally LnTG in combination with D2 lymphadenectomy for middle-third gastric cancer.

PATIENTS AND METHOD

A prospective study was conducted on 79 patients who underwent totally LnTG and D2 lymphadenectomy for middle-third gastric cancer between January 2017 and December 2021. Short-term outcomes included operative characteristics, and the evaluation of gastroesophageal reflux and gastric remnant condition using endoscopy based on the Los Angeles (LA) and Residue-Gastritis-Bile classifications. Long-term oncological outcomes included overall survival and disease-free survival.

RESULTS

Totally LnTG was successfully performed in 98.7% of patients without intraoperative complications or conversions to laparotomy. The mean operation time was 202.2±43.0 min, and the median blood loss was 50 (50;100) mL. The overall incidence of postoperative morbidities was 16.5%, with one patient experiencing a narrowing of the gastrojejunostomy, successfully treated by endoscopic balloon dilation. All patients had tumor-free resection margins, and there were no mortalities. The 5-year overall survival and disease-free survival rates were 80% and 55%, respectively.

CONCLUSIONS

Totally LnTG is an effective and feasible approach for gastric cancer in the middle-third of the stomach, yielding favorable short-term outcomes and acceptable long-term results. Routine application of totally LnTG for middle-third gastric cancer is practical and promising.

Cardia function-preserving surgery and anti-reflux anastomotic method after proximal gastrectomy for gastric cancer: Current status and future perspectives

The incidence and mortality of gastric cancer ranked 5th and 3rd worldwide, respectively, in 2018, and the incidence of gastroesophageal junction adenocarcinoma increased over the past 40 years. Radical resection and lymph node dissection is the preferred treatment for gastric cancer. Proximal gastrectomy or total gastrectomy is usually performed for gastroesophageal junction adenocarcinoma and upper gastric cancer. Owing to the resection of the cardia structures, the incidence of reflux esophagitis increases significantly after proximal gastrectomy and total gastrectomy, resulting in poor postoperative quality of life. To reduce the incidence of reflux esophagitis and improve patients' postoperative quality of life, various methods to preserve the function of the cardia or to perform anti-reflux reconstruction have emerged. In this manuscript, we systematically introduced the advantages and problems of various anti-reflux anastomotic method after proximal gastrectomy, and cardia-preserving gastrectomy including endoscopic resection (ER), local gastrectomy by gastroscopy combined with laparoscopy, segmental gastrectomy, subtotal gastrectomy, and cardia-preserving radical gastrectomy. Cardia-preserving radical gastrectomy has the advantage of more thorough lymph node dissection and wider indications than those for subtotal gastrectomy. However, the clinical efficacy of cardia-preserving radical gastrectomy requires verification in prospective and controlled clinical trials. Cardia-preserving radical gastrectomy is a promising approach as one of the more reasonable anti-reflux surgeries.

Systematic review of health-related quality of life (HRQoL) issues associated with gastric cancer: capturing cross-cultural differences

The treatment landscape for gastric cancer (GC) is constantly evolving with therapies affecting all aspects of health-related quality of life (HRQoL) which need careful monitoring. While there are HRQoL measures designed specifically to capture issues relevant to patients with GC, these might be outdated and only relevant to patients in westernised cultures. This review identifies the patient-reported measures used to assess HRQoL of patients with GC and compares the HRQoL measures used across cultures including East Asia, where GC is more prevalent. We conducted a systematic review of publications between January 2001 and January 2021. A total of 267 papers were identified; the majority (66%) of studies involved patients from East Asian countries. Out of the 24 HRQoL questionnaires captured, the European Organisation for Research and Treatment of Cancer Core Cancer measure (QLQ-C30) was the most widely used (60% of all studies and 62% of those involving patients from East Asian countries), followed by its gastric cancer-specific module (QLQ-STO22, 34% of all studies and 41% from East Asia). Eight questionnaires were developed within East Asian countries and, of the 20 studies including bespoke questions, 16 were from East Asia. There were six qualitative studies. HRQoL issues captured include diarrhoea, constipation, reflux, abdominal pain and abdominal fulness or bloating, difficulty swallowing, restricted eating, and weight loss. Psychosocial issues related to these problems were also assessed. Issues relating to the compatibility of some of the westernised measures within East Asian cultures were highlighted.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Proximal gastrectomy with double-tract reconstruction versus total gastrectomy for proximal early gastric cancer: A systematic review and meta-analysis

BACKGROUND

The incidence of proximal gastric cancer in the gastric fundus, cardia, and other parts is increasing rapidly. The purpose of this study was to systematically compare the short-term and long-term clinical effects of proximal gastrectomy with double tract reconstruction (PG-DTR) to total gastrectomy (TG) for proximal early gastric cancer (EGC).

METHODS

A systematic review and meta-analysis was conducted through searching the literature in PubMed, Web of Science, Cochrane Library, EMBASE, CNKI, WAN FANG, and VIP databases. All clinical controlled trials and randomized controlled trials (RCTs) of PG-DTR and PG were included. Simultaneously, the relevant data were extracted, and the software RevMan version 5.1 was used for the meta-analysis.

RESULTS

Eight studies with a total of 753 patients were eligible for the meta-analysis. There were no significant differences in the operation time, intraoperative blood loss, postoperative hospital stay, early complications (anastomotic fistula and anastomotic bleeding), late complications (reflux symptoms and anastomotic stenosis), and 5-year survival rate between PG-DTR and TG. However, the levels of partial nutritional indicators (vitamin B12 supplements and vitamin B12 deficiency) were significantly higher in the PG-DTR group than in the TG group.

CONCLUSION

This study showed ample evidence to suggest that PG-DTR improved the postoperative nutritional status without compromising patient safety while providing the same surgical characteristics and postoperative morbidity as TG.

Proximal gastrectomy with gastric tube reconstruction or jejunal interposition reconstruction in upper-third gastric cancer: which offers better short-term surgical outcomes?

Objective

Proximal gastrectomy acts as a function-preserving operation for upper-third gastric cancer. The aim of this study was to compare the short-term surgical outcomes between proximal gastrectomy with gastric tube reconstruction and proximal gastrectomy with jejunal interposition reconstruction in upper-third gastric cancer.

Methods

A retrospective review of 301 patients who underwent proximal gastrectomy with jejunal interposition (JI) or gastric tube (GT) at Harbin Medical University Cancer Hospital between June 2007 and December 2016 was performed. The Gastrointestinal Symptom Rating Scale (GSRS) and Visick grade were used to evaluate postgastrectomy syndromes. Gastrointestinal fiberoscopy was used to evaluate the prevalence and severity of reflux esophagitis based on the Los Angeles (LA) classification system.

Results

The JI group had a longer operation time than the GT group (220 ± 52 vs 182 ± 50 min), but no significant difference in blood loss was noted. Compared to the GT group, the Visick grade and GSRS score were significantly higher. Reflux esophagitis was significantly increased in the GT group compared with the JI group.

Conclusion

Proximal gastrectomy is well tolerated with excellent short-term outcomes in patients with upper-third gastric cancer. Compared with GT construction, JI construction has clear functional advantages and may provide better quality of life for patients with upper-third gastric cancer.

Comparison of effects of six main gastrectomy procedures on patients’ quality of life assessed by Postgastrectomy Syndrome Assessment Scale-45

BACKGROUND

The effects of various gastrectomy procedures on the patient’s quality of life (QOL) are not well understood. Thus, this nationwide multi-institutional cross-sectional study using the Postgastrectomy Syndrome Assessment Scale-45 (PGSAS-45), a well-established questionnaire designed to clarify the severity and characteristics of the postgastrectomy syndrome, was conducted.

AIM

To compare the effects of six main gastrectomy procedures on the postoperative QOL.

METHODS

Eligible questionnaires retrieved from 2368 patients who underwent either of six gastrectomy procedures [total gastrectomy with Roux-en-Y reconstruction (TGRY; n = 393), proximal gastrectomy (PG; n = 193), distal gastrectomy with Roux-en-Y reconstruction (DGRY; n = 475), distal gastrectomy with Billroth-I reconstruction (DGBI; n = 909), pylorus-preserving gastrectomy (PPG; n = 313), and local resection of the stomach (LR; n = 85)] were analyzed. Among the 19 main outcome measures of PGSAS-45, the severity and characteristics of postgastrectomy syndrome were compared for the aforementioned six gastrectomy procedures using analysis of means.

RESULTS

TGRY and PG significantly impaired the QOL of postoperative patients. Postoperative QOL was excellent in LR (cardia and pylorus were preserved with minimal resection). In procedures removing the distal stomach, diarrhea subscale (SS) and dumping SS were less frequent in PPG than in DGBI and DGRY. However, there was no difference in the postoperative QOL between DGBI and DGRY. The most noticeable adverse effects caused by gastrectomy were meal-related distress SS, dissatisfaction at the meal, and weight loss, with significant differences among the surgical procedures.

CONCLUSION

Postoperative QOL greatly differed among six gastrectomy procedures. The severity and characteristics of postgastrectomy syndrome should be considered to select gastrectomy procedures, overcome surgical shortcomings, and enhance postoperative care.

Comparison of biannual and annual endoscopic gastric cancer surveillance after endoscopic resection

BACKGROUND

Patients who received endoscopic resection (ER) for early gastric cancer (EGC) or high-grade dysplasia (HGD) are at high risk for the subsequent development of metachronous gastric cancer (MGC). This study aims to compare the detection rate and stage of MGC between biannual and annual endoscopic surveillance after ER of EGC or HGD.

METHODS

From September 2009 to August 2019, 859 patients who underwent ER for the treatment of EGC or HGD were analyzed, retrospectively. Patients received endoscopic surveillance twice a year (high-intensity group) or annually (low-intensity group) for 3 years.

RESULTS

A total of 521 patients were enrolled in this study (267 patients in the high-intensity group and 254 patients in the low-intensity group). During a mean follow-up of 5.3 ± 1.6 years, MGCs were found in 27 patients (16.9%) in the high-intensity group and 18 patients (7.1%) in the low-intensity group (P = 0.219). In patients with moderate to severe atrophy (Kimura-Takemoto grade C3 ~ O3), detection rates of MGC during 3 years from were 8.4% (16/191) and 2.2% (4/186), respectively (P = 0.007). Forty-four patients who received treatment for MGC, including endoscopic or surgical resection, were stage IA. Only one patient in the low-intensity group was diagnosed as stage IIIA advanced gastric cancer.

CONCLUSIONS

There was no significant difference in the detection rate of MGC between biannual and annual endoscopic surveillance after ER of EGC or HGD. However, biannual surveillance showed a higher detection rate during the first 3 years, especially for patients with moderate to severe gastric atrophy.

Endoscopy in Patients With Surgically Altered Anatomy

A comprehensive understanding of gastrointestinal anatomy is essential for performance of any endoscopic procedure. Surgical approaches to therapy have become increasingly common in the past decade, which has resulted in a substantial proportion of patients with surgically altered anatomy who require endoscopy. In parallel with the obesity epidemic, bariatric surgery for obesity management has been widely adopted. In response to these trends, gastroenterologists must become familiar with patient anatomy after these surgical interventions and understand the implications of this altered anatomy on the current array of available endoscopic modalities for diagnosis and therapy. This review describes the range of surgically altered anatomy commonly encountered in the upper gastrointestinal tract. For each foregut location-esophagus, stomach, and small bowel-we describe indications for and specific details of the range of common surgical approaches affecting this regional anatomy. We then provide an endoscopic roadmap through the altered anatomy resulting from these surgical interventions. Finally, we address the impact of postsurgical anatomy on performance of endoscopic ultrasound and endoscopic retrograde cholangiopancreatography, with guidance surrounding how to successfully execute these procedures. Evolution of endoscopic approaches over time might be expected to enhance the safety and efficacy of these interventions in patients with surgically altered anatomy.

Assessment of Lymph Node Metastasis in Patients With Gastric Cancer to Identify Those Suitable for Middle Segmental Gastrectomy

IMPORTANCE

Segmental gastrectomy, a type of function-preserving surgery, is not broadly studied but can improve postoperative function and quality of life among patients with gastric cancer (GC).

OBJECTIVE

To establish an indication for middle segmental gastrectomy (MSG) as a treatment for middle-body (MB) and high-body (HB) GC.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study analyzed patients with GC undergoing surgery between January 2000 and December 2015 in the National Cancer Center, Goyang, Korea, a high-volume cancer center with a structured database and accurate long-term follow-up. Inclusion criteria were age 18 to 85 year, histologically proven adenocarcinoma located in the HB or MB, cT1 to cT3 category cancers, curative resection with negative margins performed, and follow-up for at least 3 years. Exclusion criteria were Borrmann type 4 GC, T4 category cancer, neoadjuvant chemotherapy, and a history of other cancers. Data analysis was performed from December 2018 to May 2020.

EXPOSURES

Total or subtotal gastrectomy and LN dissection.

MAIN OUTCOME AND MEASURES

The primary outcome was the rate of metastasis at LN stations 2, 4sa, 5, 6, and 11d, which cannot be dissected during MSG.

RESULTS

Among 9952 patients who underwent surgery for GC, 8219 underwent either laparoscopic or open total or subtotal gastrectomy. Seven hundred seventy-three patients (mean [SD] age, 56.21 [12.16] years; 464 men [60.0%]) had GC in the MB or HB of the stomach. Among the 701 patients included in the final analysis after exclusion of the cN2/N3 carcinomas, the mean (SD) age was 56.35 (12.24) years, and 418 (59.6%) were men. The incidence of LN metastasis was 0% at station 5 for cT1-3N0/1M0 cancers, station 4sa for cT1-2N0/1M0 cancers, station 2 for cT1N0/1M0 cancers, station 6 for cT1N1M0 cancers, station 11d for cT1N1M0-cT2N0/1M0 cancers, and station 12a for cT1N0/1M0-T2N1M0 cancers, regardless of size and differentiation. The rates of LN metastasis for cT1N0M0 cancers were 0.3% (1 of 396 LNs) at station 6 and 0.8% (1 of 129 LNs) at station 11d. Tumors 4 cm or smaller were associated with a lower risk of LN metastasis compared with tumors 4.1 cm or larger (odds ratio, 2.10; 95% CI, 1.20-3.67; P = .009), and well-differentiated tumors were associated with lower risk of LN metastasis compared with poorly differentiated tumors (odds ratio, 2.88; 95% CI, 1.45-5.73; P = .002).

CONCLUSIONS AND RELEVANCE

These findings suggest that MSG with dissection of stations 1, 3, 4sb, 4d, 7, 8a, 9, 11p, and 12a could be done for HB and MB cT1N0/1M0 gastric cancers 4 cm or smaller and well-differentiated cT2N0/1M0 cancers.

A multicenter non-randomized phase III study of sentinel node navigation surgery for early gastric cancer

This prospective multicenter non-randomized phase III study aims to evaluate the long-term outcome of sentinel node navigation surgery for early gastric cancer compared with conventional distal or total gastrectomy. Clinically diagnosed primary T1N0M0 gastric cancer patients with a single lesion (≤40 mm) and without previous endoscopic treatment will be enrolled in this study. Sentinel nodes are identified by dye and radioisotope tracers and are subjected to intraoperative rapid pathology. For patients with negative sentinel node metastasis, individualized surgery consisting of limited stomach resection and sentinel node basin dissection is performed, while standard gastrectomy with D2 lymph node dissection is employed for the positive sentinel node patients. A total of 225 patients will be accrued from 13 hospitals that have experience in sentinel node mapping. The primary endpoint is 5-year relapse-free survival. The secondary endpoints are overall survival, sentinel node detection rate, diagnostic accuracy for sentinel node, distribution of sentinel nodes and metastatic sentinel node/non-sentinel node, and postoperative quality of life.

A "Just Enough" Gross Proximal Margin Length Ensuring Pathologically Complete Resection in Distal Gastrectomy for Gastric Cancer

Introduction

The objective of this study is to determine a "just enough" gross proximal margin (PM) length to ensure a pathologically negative PM in distal gastrectomy for gastric cancer. There is a discrepancy between the gross and pathological proximal boundaries of gastric cancer. We must transect the stomach maintaining some safety margins to obtain a pathologically negative PM. However, we have no standard to indicate where to transect the stomach.

Methods

Patients undergoing distal gastrectomy for gastric cancer were enrolled. A new parameter named ΔPM, which corresponded to the pathological extension proximal to the gross tumor boundary toward the resection stump, was evaluated. The number of patients was counted in each ΔPM range of 1-cm increments. The maximum ΔPM was defined as the first value at which the number of patients became 0, and it was determined as the recommended gross PM length for each disease type.

Results

In cT1, 259 and 330 patients were assigned to differentiated (Dif) and undifferentiated types (Und), respectively. The maximum ΔPM was 20 mm for Dif and 40 mm for Und. In cT2-4, 194 and 490 patients were assigned to the expansive (Exp) and infiltrative (Inf) growth types. The maximum ΔPM was 30 mm for Exp. The maximum ΔPM was 50 mm for Inf of less than 80 mm and 60 mm for Inf of 80 mm or more.

Conclusions

A newly recommended gross PM length to ensure pathologically negative PMs in distal gastrectomy for each gastric cancer type was determined.

Comparison of clinicopathologic profiles and prognosis of gastric cancer in the upper, middle and lower third of the stomach: A retrospective cohort study

Gastric cancer (GC) is the fourth most common cancer in the world and the second most common cancer in China. The aim of this study was to investigate the clinicopathologic profiles and prognosis of GC in the upper third (UT), middle third (MT) and low third (LT) of the stomach.Five hundred and forty-two patients with GC resected between January 2010 and January 2014 were retrospectively studied and divided in 3 groups according to cancer location: upper third gastric cancer (UTGC) (n = 62); MTGC (n = 131) and LTGC (n = 349). Clinical and pathological parameters including gender, age, tumor size, macroscopic types, histological types, depth of invasion, lymph node metastasis, venous infiltration and lymph embolism were compared among groups. Overall survival (OS) was calculated based on the aforementioned parameters. Univariate and multivariate survival was analyzed and Cox regression was conducted for each location. The prognostic accuracy was determined using receiver operating characteristic curve analysis.Patients with UTGC was similar to those with MTGC and both were distinct from those with LTGC based on the tumor size, macroscopic types, depth of invasion and 5-year OS. Patients with MTGC were similar to those with LTGC and distinct from UTGC patients based on gender. 5-year OS were lower for patients with UTGC than those with LTGC (P = .001) and were comparable between MTGC and LTGC. No significant differences in 5-year OS were observed between UTGC and MTGC. Cox regression revealed that macroscopic types, depth of invasion and lymph node metastasis were the independent prognostic factors for GC patients regardless of locations. Receiver operating characteristic curve analysis revealed that macroscopic types, depth of invasion and lymph node metastasis were the significantly effective prognosis for the 5-year OS in GC patients regardless of locations.Our results showed that UTGC is distinct from LTGC whereas MTGC shares some characteristics from both UTGC and LTGC.

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

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

Functional and nutritional outcomes after gastric cancer surgery

Recent improvements in diagnostic techniques and national screening programs have resulted in increasing number of patients diagnosed with early gastric cancer (EGC). The low incidence rate of lymph node metastasis and excellent survival rates after surgical treatment for EGC enabled the reduction in the extent of lymphadenectomy and the range of gastric resection for function-preserving gastrectomy. Thus, the quality of life (QOL) of patients with gastric cancer (GC) in the curative stage can be maintained. Moreover, these function-preserving procedures have been widely performed by less invasive procedures, such as laparoscopic and robotic approaches. Pylorus-preserving gastrectomy (PPG) and proximal gastrectomy (PG) represent the two main function-preserving surgical procedures for GC. PPG is an alternative to distal gastrectomy (DG) for cT1 N0 EGC located in the middle part of the stomach. Preservation of the pyloric function is expected to prevent post-gastrectomy syndromes such as dumping syndrome. PG is an alternative to total gastrectomy (TG) and can thus be performed for cT1 N0 EGC located in the upper part of the stomach. Preservation of the residual stomach is expected to work as a reservoir for ingested food. The optimal reconstruction method after PG among the three most commonly performed procedures (esophagogastrostomy, jejunal interposition, and double-tract reconstruction) remains controversial. In addition to these three reconstruction methods, the novel double-flap technique (DFT) of esophagogastrostomy has gained attention recently because of its potential usefulness to prevent postoperative esophageal reflux. In this review article, we summarize the current evidence of PPG and PG with esophagogastrostomy by the DFT, focusing on postoperative nutrition and QOL.

Double-Tract Reconstruction Designed to Allow More Food Flow to the Remnant Stomach After Laparoscopic Proximal Gastrectomy

PURPOSE

Laparoscopic proximal gastrectomy (LPG) is a function-preserving surgery performed on patients with cancer of the upper third of the stomach. However, if much of the ingested food passes through the jejunum, LPG might function broadly like a total gastrectomy. We devised a jejunogastrostomy with double-tract reconstruction (DTR) to ensure that most food flows easily to the remnant stomach.

METHODS

A side-to-side jejunogastrostomy was created between the remnant stomach's posterior wall and the jejunum 10 cm below the esophagojejunostomy, and the common stab incision was also closed with a linear stapler. The jejunogastrostomy was created as a delta-shaped anastomosis by using only linear staplers. The 15 patients who underwent delta-shaped anastomosis from 2017 to 2018 were retrospectively reviewed to collect and analyze their surgical and postoperative outcomes, including nutritive conditions, in comparison to the reconstruction that was performed before then.

RESULTS

Operative times and postoperative complications were not significantly different compared to the previous reconstruction. We confirmed significant differences in operative bleeding and passage of food through the remnant stomach. The level of nutritional indicators at the end of postoperative year one did not tend to be lower, but total weight loss (TWL) and %TWL were significantly lower. As expected, there was a correlation between differences in jejunogastrostomy type and postoperative malnutrition.

CONCLUSIONS

This method devised for intracorporeal DTR provided patients with improved postoperative nutritional status by directing more food through the remnant stomach after LPG.

Surgical resection of gastric stump cancer following proximal gastrectomy for adenocarcinoma of the esophagogastric junction

BACKGROUND

Proximal gastrectomy (PG) is performed widely as a function-preserving operation for early gastric cancer located in the upper third of the stomach and is an important function-preserving approach for esophagogastric junction (EGJ) adenocarcinoma. The incidence of gastric stump cancer (GSC) after PG is increasing. However, little is known about the GSC following PG because very few studies have been conducted on the disease.

AIM

To clarify clinicopathologic features, perioperative complications, and long-term survival rates after the resection of GSC following PG.

METHODS

Data for patients with GSC following PG for adenocarcinoma of the EGJ diagnosed between January 1998 and December 2016 were retrospectively reviewed. Multivariate analysis was performed to identify factors associated with overall survival (OS). GSC was defined in accordance with the Japanese Gastric Cancer Association.

RESULTS

A total of 35 patients were identified. The median interval between the initial PG and resection of GSC was 4.9 (range 0.7-12) years. In 21 of the 35 patients, the tumor was located in a nonanastomotic site of the gastric stump. Total gastrectomy was performed in 27 patients; the other 8 underwent partial gastrectomy. Postoperative complications occurred in 6 patients (17.1%). The tumor stage according to the depth of tumor invasion was T1 in 6 patients, T2 in 3 patients, T3 in 9 patients, and T4 in 17 patients. Lymph node metastasis was observed in 18 patients. Calculated 1-, 3-, and 5-year OS rates were 86.5%, 62.3%, and 54.2%, respectively. Multivariate analysis showed advanced T stage to be associated with OS.

CONCLUSION

This study reveals the characteristics of GSC following PG for adenocarcinoma of the EGJ and suggests that a surgical approach can lead to a satisfactory outcome.

Potential for local resection with sentinel node basin dissection for early gastric cancer based on the distribution of primary sites

BACKGROUND

Based on the sentinel node (SN) concept, function-preserving surgery with SN basin dissection (SNBD) can be performed for SN-negative early gastric cancers. Particularly, a resection area can be minimized when the SN basin and primary site are closely localized. The aim of this study was to compare probabilities of being candidates for local resection with SNBD based on tumor location among patients with early gastric cancer.

METHODS

We retrospectively analyzed 358 patients who underwent surgery with SN mapping for gastric cancer in our institution from November 1999 to April 2014. The proportion of patients who had a localized single basin and the distributions of the SN basins and primary sites were investigated. Patients with single basin drainage excluding remote sentinel node basin were considered as candidates for local resection with SNBD.

RESULTS

Of the 358 patients, 191 (53%) patients were considered eligible for local resection with SNBD. Patients with tumors located in the upper third of the stomach were more likely candidates for local resection than those with tumors in other locations (upper third, 68%; middle third, 50%; and lower third, 51%), whereas patients with tumors located in the anterior wall were less likely candidates than those with tumors other locations (anterior wall, 31%; posterior wall, 58%; greater curvature, 55%; and lesser curvature, 57%).

CONCLUSION

We found that > 50% of the patients indicated for SN navigation surgery, particularly those with tumors in the upper third of the stomach, potentially could undergo partial resection with SNBD.

Should Pyloric Lymph Nodes Be Dissected for Siewert Type II and III Adenocarcinoma of the Esophagogastric Junctions: Experience from a High-Volume Center in China

BACKGROUND

The optimal extent of lymph node (LN) dissection remains controversial in adenocarcinoma of the esophagogastric junction (AEG), especially in Siewert types II and III. The aim of this study was to analyze clinicopathological characteristics of patients with Siewert type II and III AEGs to clarify whether pyloric (no. 5 and no.6) lymphadenectomy is essential in these patients.

METHODS

A retrospective analysis was performed in the Third Affiliated Hospital of Soochow University from September 2008 to December 2012, and clinicopathological characteristics on all patients with Siewert type II and III AEGs, who underwent curative total gastrectomy with lymphadenectomy were collected. The index of estimated benefit from lymph node dissection (IEBLD) was used to evaluate the efficacy of lymph node dissection of no. 5 and no. 6. Both clinicopathological characteristics and IEBLDs were set as the standards in the assessment of the value of pyloric lymph nodes dissection.

RESULTS

A total of 216 patients with AEG (Siewert type II: 141, Siewert type III: 75) were included into the study. Type III AEG had a larger tumor size and relatively advanced T stage compared to Type II AEG. The 5-year overall survival (OS) rates in type II and type III AEGs were almost similar (type II 50.4% vs. type III 46.7%, p = 0.782). There was a very low incidence of pyloric lymph nodes metastases in type II AEG (no. 5 is 1.4% and no. 6 is 0.7%). Hence, the IEBLDs of no. 5 and no. 6 lymph node were negligible regardless of the T stage and tumor differentiation. In type III AEG, metastasis rates of no. 5 and no. 6 lymph node were 9.3 and 5.3%, respectively. The IEBLDs of no. 5 and no. 6 lymph node were 2.7 and 1.3, respectively.

CONCLUSIONS

Based on the IEBLDs of pyloric lymph nodes, dissection of no. 5 and no. 6 lymph nodes were worthwhile for Siewert type III AEG but not essential for Siewert type II AEG.

Clinicopathologic characteristics in patients with upper third gastric cancer following radical surgical treatment: A retrospective cohort study

The incidences of upper third gastric cancer (UTGC) have been increasing. However, the prognostic factors for UTGC following radical surgical treatment remains largely unknown. This study was to investigate prognostic factors for overall survival (OS), lymph node metastasis and recurrence of UTGC.Clinicopathologic data of 126 UTGC patients who underwent radical surgical treatment were retrospectively analyzed. OS and univariate analysis were determined by Kaplan-Meier analysis and the significance of the difference between curves was calculated with the log-rank test. The Cox proportional hazards regression model was applied to perform multivariate analysis. Receiver operating characteristic (ROC) curve analysis was used to determine the prognostic accuracy.The 1-, 3-, and 5-year OS for patients with UTGC were 81%, 47.6%, and 38.6% respectively. Univariate analysis showed that tumor size (P = .019), tumor invasion depth (P < .001), and lymph node metastasis (P < .001) were the risk factors for 5-year OS. Multivariate analysis identified tumor invasion depth (P < .001) and lymph node metastasis (P < .001) as independent prognostic factors for the 5-year OS in patients with UTGC. In addition, ROC curve analysis showed that tumor invasion depth (P = .017) or lymph node metastasis (P = .001) alone showed significantly effective prognosis for the 5-year OS in patients with UTGC. For UTGC patients with lymph node metastasis, tumor size (P = .023), lym embolism (P = .003), tumor invasion depth (P = .002), and invasion of tunica serosa (P = .004) were the risk factors for the 5-year OS. Multivariate analysis identified tumor size (P = .048), lym embolism (P = .032), tumor invasion depth (P = .004), and invasion of tunica serosa (P = .031) as independent prognostic factors for the 5-year OS. For UTGC patients with distant metastasis or tumor recurrence, univariate and multivariate analyses demonstrated that tumor invasion depth and lymph node metastasis were independent prognostic factors for the 5-year OS.The results suggested that for UPGC patients undergoing the radical surgical treatment, tumor invasion depth and/or lymph node metastasis are the independent prognostic factors for the 5-year OS, lymph node metastasis, distant metastasis and tumor recurrence.

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

CONTEXT

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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