Tube Enteral Feeding-Associated Non-Occlusive Mesenteric Ischemia Following Gastric Cancer Surgery: A Retrospective Case Series Analysis.

Understanding mechanisms of primary resistance to checkpoint inhibitors will lead to precision immunotherapy of advanced gastric cancer

4050 Background: We recently showed that cancer cells, with proliferative and tumorigenic potential, can spill into the peritoneal cavity during curative (R0) gastric cancer (GC) surgery, which is associated with peritoneal recurrence (PM). To elucidate the pathophysiology of PM, the relationship between spilled cancer cells and cancer stem cells was evaluated. Furthermore, to identify a therapeutic strategy for PM, the prognostic impact of hyperthermic intraperitoneal chemotherapy (HIPEC) following GC surgery with spillage of cancer cells was evaluated. Methods: Patients with advanced GC (≥pT2 [MP]) who underwent R0 gastrectomy between 2010 and 2015 were enrolled. Ninety-four consecutive patients with negative results in peritoneal cytology and cancer cell culture (CCC [-]) following peritoneal washing (PW) before GC surgery were included. Spilled cancer cells in PW after GC surgery (PW-Post) were examined to identify any CD44-positive cancer stem-like cells associated with cancer metastasis. Based on the PW-Post CCC results, associations between HIPEC and recurrence-free survival (RFS), or overall survival (OS) were evaluated. HIPEC was performed following GC surgery using CDDP, MMC, and 5-FU in 5 L saline maintained at 42˚C for 30 min. Results: Spilled cancer cells included CD44+ cancer stem-like cells. In 48 patients with PW-Post positive CCC (CCC [+]), the number of patients with pStage I, II, and III were 4, 7, and 15, respectively, in those who received HIPEC (n = 26), and 3, 9, and 10, respectively, in those who did not (n = 22). Among patients with CCC (+), the 5-year peritoneal RFS, hepatic RFS, and lymph node RFS rates were 93.3%, 100%, and 68.5%, respectively, in patients who received HIPEC, and 56.7%, 35.6%, and 66.7%, respectively, in those who did not ( P = 0.008, P = 0.008, and P= 0.24, respectively). Among patients with PW-Post CCC (-), none developed recurrence, regardless of whether they received HIPEC (n = 28) or not (n = 18). Conclusions: The results show that PW-Post CCC is a promising predictive biomarker for recurrence after R0 GC surgery. Adjuvant HIPEC performed with R0 GC surgery showed preventive effects on peritoneal and hepatic recurrence and survival benefits for patients with PW-Post CCC (+).

7. Multivisceral resection for advanced gastric cancer: Distal subtotal gastrectomy with pancreatoduodenectomy (D3 aortocaval lymphatic dissection)

8. Multivisceral resection for advanced gastric cancer: Total gastrectomy with radical antegrade modular pancreatosplenectomy (D3 lymphatic dissection)

Background and Aim Carcinoma of the stomach is one of the leading causes of mortality worldwide. Surgery for gastric cancer in the form of total or distal gastrectomy is definitive treatment. Feeding jejunostomy (FJ) though improves postoperative nutritional status and outcome, it is not devoid of its complications. In this study, we present the outcomes of nasojejunal (NJ) feeding and FJ and complications associated with them. Materials and Methods It is both retrospective and prospective observational study in patients with gastric cancer undergoing surgery. Patients were divided into two groups: those who underwent FJ and those who underwent NJ route of feeding placed intraoperatively. Results A total of 279 patients of gastric cancer who underwent surgery were taken into study, of which, 165 were male and 114 females. FJ was done in 42 and NJ in 237 patients, respectively. Gastrectomy + NJ was done in 128 patients, gastrectomy + FJ in 27 patients, gastrojejunostomy + NJ in 109 patients, and FJ in 15 patients. We had three patients of bile leaks in FJ group, of which one patient had intraperitoneal leak who needed re-exploration; rest of the two had peri-FJ external leaks, who were managed conservatively. Most of the complications of NJ group were minor. Conclusion Our study of 279 patients in gastric cancer has shown that FJ is sometimes associated with major complications with increased hospital stay and morbidity when compared with NJ tube feeding without any difference in nutritional outcomes. Hence, NJ route of postoperative enteral nutrition can be considered as an alternative to FJ wherever feasible in view of its technical safety and minor complications and morbidity.

PurposeThere has been little information about the impact of coronavirus disease 2019 (COVID-19) pandemic on esophagogastroduodenoscopy (EGD) and gastric cancer claims. This study aimed to measure the impact of COVID-19 pandemic on EGD and gastric cancer claims in South Korea.Materials and MethodsThis nationwide, population-based study compared the claims data of EGD, gastric cancer, early gastric cancer (EGC), advanced gastric cancer (AGC) and gastric cancer operation in 2020 and 2021 (COVID-19 era) to those in 2019 (before COVID-19 pandemic).ResultsThe annual claims of EGD, gastric cancer, EGC, and AGC were reduced by 6.3%, 5.0%, 4.7%, and 3.6% in 2020 and by 2.2%, 1.0%, 0.6%, and 1.9% in 2021, respectively, compared to 2019. The amount of annual claims of gastric cancer operation was reduced by 8.8% in 2020, but increased by 0.9% in 2021, compared to those in 2019. The monthly claims of EGD, gastric cancer, EGC, AGC, and gastric cancer operation were mainly reduced in the first epidemic wave of COVID-19, but decreased in the 2nd to 4th epidemic wave. Compared to 2019, the monthly claim of EGD, gastric cancer, EGC, AGC, and gastric cancer operation were reduced by 28.8%, 14.3%, 18.1%, 9.2%, and 5.8% in March 2020 and by 17.2%, 10.8%, 10.3%, 7.2%, and 35.4% in April 2020, respectively.ConclusionNegative impact of the COVID-19 pandemic on EGD, gastric cancer, EGC, AGC, and gastric cancer operation was worst during the first surge of COVID-19, but decreased in the 2nd to 4th epidemic wave of the disease in 2020 and 2021.

To determine the significance of gastric outlet obstruction (GOO) on the outcomes of radical surgery for distal gastric cancer. Three hundred seventy-one patients who underwent radical surgery for advanced gastric cancer arising at the distal stomach were categorized into two groups according to the presence of GOO, that is, 59 patients with GOO and 312 patients without. Clinicopathologic variables, postoperative morbidity and mortality, recurrence pattern, and survival outcomes of the two groups were compared. Distal gastric carcinoma with GOO was usually diagnosed at a more advanced stage with aggressive pathologic features. GOO adversely affected overall survival after radical surgery with an odds ratio of 2.068 (P < 0.001). In patients with recurrent diseases, patients with GOO had higher rate of locoregional recurrence after radical surgery (P = 0.021). High-grade postoperative complications occurred at similar rates in both groups (P = 0.539). The presence of GOO is an independent prognostic factor after radical surgery for advanced distal gastric cancer and provide additional information for identifying patients at higher risk of recurrence and pattern of recurrence during follow-up. Radical surgery in patients with GOO can be performed with acceptable morbidity and mortality.

As defined by the Global Leaders Malnutrition Initiative (GLIM), malnutrition is strongly associated with a lower quality of life and poor prognosis in gastric cancer patients. However, few studies have precisely explored the predictors of malnutrition, as defined by the GLIM, for overall survival (OS) after gastric cancer surgery in subgroups of patients stratified according to population characteristics. Our research aimed to analyze whether the predictors of malnutrition defined by the GLIM for postoperative OS in gastric cancer patients differ across subgroups. Patients who underwent radical gastric cancer surgery at our center between July 2014 and February 2019 were included in the study. Propensity score matching (PSM) was used to minimize bias. The study population was divided into malnourished and normal groups based on whether they were malnourished as defined by the GLIM. Univariate and multivariate analyses were performed to identify the risk factors affecting OS. The Kaplan–Meier curve and log-rank test were performed to determine the survival rate difference between subgroups. Overall, 1,007 patients were enrolled in the research. Multivariate analysis showed that malnutrition among the patients was 33.47%. Additionally, GLIM-defined malnutrition was an independent risk factor [hazard ratio (HR): 1.429, P = 0.001] for a shorter OS in gastric cancer patients. Furthermore, subgroup analysis showed that the GLIM was more appropriate for predicting OS in older aged patients (≥65 years), females, those with comorbidities (Charlson comorbidity index ≥ 2), and those with advanced gastric cancer (TNM stage = 3). GLIM-defined malnutrition affects the long-term survival of gastric cancer patients, especially older patients, females, patients with comorbidities, and patients with advanced gastric cancer.

Review of the experience of a tertiary care centre for almost 10 years in the CT diagnosis of non-occlusive mesenteric ischaemia (NOMI). Analysis of CT findings, correlation with clinical outcomes and evaluation of the usefulness of measuring the superior mesenteric artery (SMA) diameter for the diagnosis of NOMI. 106 patients were diagnosed with NOMI in a biphasic CT examination from 2008 to 2017 in our hospital. Clinical outcomes and CT findings were reviewed. In 55 patients, the diameter of the SMA was compared with a previous CT scan where NOMI was not the diagnosis, and statistical analysis using paired t-test was performed. 81 patients (76%) had findings consistent with small bowel ischaemia and the ileum was the segment most commonly involved (47%). Lack of wall enhancement, pneumoperitoneum, pneumatosis intestinalis and portal venous gas were all considered signs of bowel necrosis and surgery was performed promptly. 70 patients had signs of vascular narrowing of the SMA branches and in the 55 cases with a previous CT scan, there were statistically significant differences regarding the SMA diameter with a mean reduction of the artery calibre and standard deviation of 1.93 ± 1.1 mm between the NOMI and non-NOMI scans (p < 0.001). Acknowledgment of characteristic bowel necrosis CT findings is crucial for determining the therapeutic attitude and the use of previous CT scans to compare the SMA diameter may help the radiologist to achieve an early diagnosis of NOMI in an often critically ill patient population. Advances in knowledge: Diagnosis of NOMI can be difficult in cases of partial mural ischaemia, thus objective data (diameter of the SMA) should be useful for the radiologist to include NOMI as the first diagnostic option in the differential diagnosis.

Case presentation: A 32-year-old male patient, with moderate intellectual disability, was admitted to the emergency department in a comatose state for approximately 20 minutes (Hunt-Hess V), with third-party reports of severe headache for 3 days. Non-contrast computed tomography of the skull performed on admission showed hyperdense collections in brain grooves and cisterns, characterizing Subarachnoid Hemorrhage (Fisher IV). After diagnosis, the patient was treated according to SAH management protocols. Cerebral arteriography was performed showing the presence of saccular aneurysmal formation in the topography of the anterior communicating artery, and the aneurysm was embolized. Seven days after the ictus, there was a worsening of the hemodynamic state and shock, accompanied by abdominal distension and gastrointestinal tract failure demonstrated by an increase in gastric residue. Abdominal computed tomography was performed showing the dilated small intestine, with signs of intestinal pneumatosis, intestinal dilation, portal venous gas and aerobilia. Abdominal CT angiography was performed, showing the superior mesenteric artery with preserved caliber, contours and flows, without signs of thrombus that would justify occlusion. The diagnosis of Non-Occlusive Mesenteric Ischemia (NOMI) is then concluded. Over the next few days of hospitalization, the patient continued to show increasing clinical and radiological severity, associated with severe acidosis, shock refractory to treatment with vasoactive amines and volume replacement. He died on the 7th day of hospitalization. Discussion: Non-Occlusive Mesenteric Ischemia is associated with vasoconstriction of the mesenteric arteries, without evident occlusion, which causes intestinal hypoperfusion. NOMI as a complication of SAH is secondary to vasospasm, which generally occurs 3 to 14 days after aneurysm rupture. NOMI does not present characteristic symptoms, therefore the diagnosis usually occurs during the progression to a severe stage of the disease, the disease is associated with high mortality rates. The correlation of the diseases in question are barely described in the literature due to the rarity in which they present themselves, however, it has been concluded in previous research that one of the main preponderant factors for their prognostic establishment is how late their diagnostic finding and subsequent installation occur. therapy, with the speed of its execution being essential to minimize the deleterious effects of the disease. Final comments: Therefore, it is described how important the need for timely diagnosis of Non-occlusive Mesenteric Ischemia as a complication resulting from Subarachnoid Hemorrhage, not only for Neurosurgeons, but also for Intensive Care physicians, aiming for its identification and subsequent management quickly and effectively, expanding the patient’s chances of recovery, as this complication is defined as atypical in current medical-scientific circles.

Since the first laparoscopic radical surgery for early gastric cancer 30 years ago, there has been a gradual shift from "open" to "minimally invasive" surgery for gastric cancer. This transition is due to advancements in refined anatomy, enlarged field of view, faster recovery, and comparable oncological outcomes. Several high-quality clinical studies have demonstrated the safety and effectiveness of laparoscopy in the treatment of both early and locally advanced gastric cancer. The role of perioperative chemotherapy in managing locally advanced gastric cancer has been widely recognized, and there have been continuous breakthroughs in the exploration of targeted therapy and immunotherapy for perioperative treatment. Additionally, the application of indocyanine green near-infrared imaging technology, 3D laparoscopic technology, and robotic surgery systems has further improved the accuracy and minimally invasive nature of gastric cancer surgeries. Looking ahead, the field of minimally invasive surgery for gastric cancer is expected to become more standardized, resulting in a significant enhancement in the quality of life for gastric cancer patients.

although the role of surgery is changing for gastric cancer due to increased role of non-surgical treatment, surgery continues to be the most important curative treatment of this disease (1). any patient with curable gastric cancer, from stage I to Iv, inclusive, were treated by D2 dissection in Japan, in the 1970’s and 80’s, until a large data base of T1 tumors revealed that some subgroups of these tumors seldom have any metastases, allowing local excision as a curative treatment. with the development of endoscopic instruments, T1 gastric cancer or “dysplasia” of 5 cm or even larger can be treated by endoscopic submucosal dissection (eSD) (2, 3, 4). For advanced gastric cancer, D2 dissection is the gold standard in the east asian countries in spite of the negative results of the two european trials (5, 6). In Japan, there is a high incidence of gastric cancer which results in high hospital volume; surgical mortality is very low since patients are generally in better condition for this procedure (7). Survival after D2 surgery has never been surpassed by any other treatment, including multimodal ones with more limited surgery for advanced gastric cancer. More extensive surgery than D2 dissection was often carried out in Japan in the 1980’s and early 1990’s, without any solid evidence of benefit of this procedure over D2 dissection (8). This issue was solved by a large clinical trial, which showed no survival benefit for patients who underwent super-extended surgery (9). For locally advanced gastric cancer, which is often incurable, wide regional resection, such as left upper abdominal evisceration with or without appleby’s procedure, was sometimes attempted. However, many of these tumors were eventually incurable, and some curable tumors carried a very poor prognosis even after such surgery. recently, neoadjuvant chemotherapy or chemoradiotherapy has been tried and seems to produce interesting results for these tumors. what kind of surgery should be performed after neoadjuvant treatment is not yet well studied.

Background Gastric cancer is one of the most common diseases in Japan, and surgery for gastric cancer is conducted in many general hospitals. However, there has been little investigation of the differences between institutions in terms of postoperative results in gastric cancer patients. This study aimed to compare the quality of treatment for gastric cancer between university hospital and general hospital.

Neoadjuvant chemotherapy combined with radical gastrectomy is one of the most important parts of the multimodality therapy strategies for locally advanced gastric cancer. With the development of laparoscopic technique in recent decades, laparoscopic technique plays a more and more important role in the surgical treatment of gastric cancer. Neoadjuvant chemotherapy, as a part of comprehensive treatment of gastric cancer, has gained more and more clinical supports and been recommended for guidelines. With the development of laparoscopic technique and clinical evidence, laparoscopic operation for advanced gastric cancer has been applied more and more widely. However, the safety and efficacy of laparoscopic resection following neoadjuvant chemotherapy, as a new treatment modality, still needs prospectively high-level researches to verify. Therefore, we will discuss some key points of laparoscopic gastrectomy after neoadjuvant chemotherapy based on the CLASS 03a trial, which is led by the Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, the Department of Gastrointestinal Surgery, Peking University Cancer Hospital and Institute, and Chinese Laparoscopic Gastric Surgery Study Group. The CLASS 03a trial aims to confirm surgical and oncological safety of laparoscopy distal D2 radical gastrectomy for locally advanced stage gastric cancer patients (cT3~4a, N-/+, M0) who completed neoadjuvant chemotherapy. On the base of CLASS 03a trial, this article elucidates the choice of neoadjuvant chemotherapy for gastric cancer and proposes some associated problems about neoadjuvant chemotherapy combined with laparoscopic gastric cancer operation.

215 Background: The purpose of this study is to evaluate significant prognostic factor and compare the cause of death in patients with advanced or recurrent gastric cancer. Methods: We reviewed the medical records of 170 patients who had been diagnosed as advanced or recurrent gastric cancer between January 2006 and September 2013. The patients were divided into two groups. One group (advanced gastric cancer: AC) included 104 patients had undergone chemotherapy for advanced gastric cancer, and the other group (recurrent gastric cancer: RC) 66 for recurrence after surgical treatment. The causes of death and overall survival were compared between two groups, and the significant prognostic factors were investigated by multivariate analysis. Also, subgroup analysis was performed for 18 patients with gastrectomy for curative intent, and they were proved to have unresectable gastric cancer after surgery (non-palliative surgery for advanced gastric cancer: NS). Results: In the comparison for the causes of death, two groups showed no statistical difference, but AC group had more tendency to die because of bleeding ( p = 0.054) and infection ( p = 0.075). Overall survival of AC group did not differ from that of RC ( p = 0.901). In multivariate analysis, bone metastasis ( p = 0.013, HR = 1.923), peritoneal seeding ( p = 0.001, HR = 2.182) and the frequency of chemotherapy ( p &lt; 0.001, HR = 0.887) were significantly associated with the overall survival. In a subgroup analysis, the overall survival of NS was significantly higher than AC ( p = 0.032). Conclusions: In the patients with advanced or recurrent gastric cancer, AC might have more possibility to die because of bleeding and infection than RC. Additionally, the prognosis of patients with advanced or recurrent gastric cancer was affected by the presence of bone metastasis, peritoneal seeding and frequency of chemotherapy. Non-palliative surgery for gastric cancer might show the better prognosis than AC in the specific conditions.