Robotic-assisted gastrectomy for 700 gastric cancer patients: A comparative analysis between specialized centers in Italy and Korea.

Artificial intelligence (AI)-based anatomical recognition has emerged to support intraoperative cognition; however, its clinical utility beyond education remains limited. This study aimed to develop an AI model for suprapancreatic lymph node dissection during robotic distal gastrectomy (RDG) and evaluate its utility for intraoperative decision-making by surgeons. We developed a deep learning model using 67 RDG videos (54 for training and 13 for testing) to recognize the pancreas, common hepatic artery (CHA), left gastric artery (LGA), and left gastric vein (LGV). Model performance was evaluated using Intersection over Union (IoU). Twenty surgeons participated in two experiments: experiment 1 assessed peritoneal incision line selection, rated by three experts on a 5-point scale, and experiment 2 assessed the time to CHA identification in a crossover design. The IoU values for the pancreas, CHA, LGA, and LGV were 0.66, 0.28, 0.216, and 0.232, respectively. In mixed-effects models, experiment 1 showed that AI assistance reduced the proportion of unsafe peritoneal incision lines (scores 1-2) compared with no assistance (odds ratio, 0.25; 95% confidence interval [CI], 0.15 to 0.41; P < 0.001) and improved the mean expert score by 0.64 points (95% CI, 0.39 to 0.89; P < 0.001). In experiment 2, AI assistance reduced the time to CHA identification by 9.5s (95% CI, 2.20 to 16.81; P = 0.0124). Our AI system successfully supported surgeons' intraoperative decision-making by improving anatomical recognition and thus can potentially enhance surgical safety.

Gastrectomy for gastric cancer (GC) can impair gastrointestinal function, leading to malabsorption, bone loss, and vertebral fractures (VFs), especially in older adults. Pylorus-preserving gastrectomy (PPG) may attenuate these metabolic complications. This study compared long-term bone outcomes after laparoscopic distal gastrectomy with Billroth-I reconstruction (LDGBI) versus laparoscopic PPG (LPPG). We retrospectively analyzed 75 patients aged ≥75 years with clinical T1N0M0 GC who underwent LDGBI (n = 50) or LPPG (n = 25) between 2005 and 2019. Bone mineral density (BMD) was measured using CT-based Hounsfield units at L1, and VFs were evaluated 1, 3, and 5 years postoperatively. Analysis of covariance and logistic regression were performed. BMD loss was significantly greater after LDGBI at 3 years (10 vs. 5 HU, P = 0.038) and 5 years (16 vs. 6 HU, P = 0.036). VF incidence was higher in the LDGBI group at 3 years (14.0% vs. 0%, P = 0.014) and 5 years (28.0% vs. 8.0%, P = 0.034). LDGBI was independently associated with greater 5-year BMD reduction (coefficient 7.83, 95% CI 0.22-15.44, P = 0.044). Logistic regression showed no significant association with VFs (OR 3.57, 95% CI 0.71-17.88, P = 0.12). LPPG was associated with reduced long-term BMD loss in older GC patients and may better preserve postoperative bone health.

Intravenous patient-controlled analgesia (IV-PCA) is widely used for postoperative pain management. However, its temporal usage pattern remains poorly characterized. This secondary analysis included 332 patients from three randomized controlled trials investigating postoperative analgesia following robot-assisted laparoscopic prostatectomy, video-assisted thoracoscopic surgery, and minimally invasive distal gastrectomy (MIDG). Each trial compared two analgesic strategies, yielding six groups. Only the conventional MIDG group received IV-PCA alone without multimodal analgesia. Hourly fentanyl-based IV-PCA consumption and bolus attempts were obtained from electronic device logs. The primary outcome was the first time when 75% of patients reached an hourly IV-PCA consumption of ≤ 20 μg fentanyl/hr, predefined as the low-utilization threshold. The secondary outcomes included the first time when 75% of patients reached a bolus attempt rate ≤ 1/hr, temporal trajectories of PCA use, delivery-to-demand ratio, and correlations between pain scores and cumulative opioid consumption. The low-utilization threshold was reached within 6-8 hours by 75% of patients in all groups, except for the conventional MIDG group. Similarly, bolus attempts declined to ≤ 1/hr after 7-9 hours postoperatively, again excluding the opioid-only group. Delivery-to-demand ratio was the lowest immediately after surgery and increased over time, showing higher values with multimodal analgesia. Pain intensity correlated significantly, but only weakly, with PCA consumption (r = 0.16-0.24, P < 0.05 for all comparisons). Fentanyl-based IV-PCA use declined rapidly, indicating that its benefit is largely confined to the early postoperative phase and that its duration can be shortened when multimodal analgesia is well established.

To evaluate the clinical validity of the critical view of quality (CVQ) as a measure of lymphadenectomy quality in minimally invasive distal gastrectomy and to develop a computer vision model for automated CVQ assessment. Objective intraoperative assessment of lymphadenectomy quality in gastric cancer surgery remains limited, relying largely on postoperative surrogate markers such as lymph node yield. This retrospective study included 260 patients who underwent laparoscopic or robotic distal gastrectomy with complete intraoperative video recordings. CVQ was defined as an anatomy-based scoring system reflecting the completeness of lymph node dissection across five stations. Associations between CVQ and lymph node yield were evaluated using correlation and multivariable linear regression analyses. A computer vision model was developed to classify CVQ components as complete or incomplete using temporally contextualized video segments. CVQ demonstrated a moderate positive correlation with lymph node yield (Pearson r=0.485, P<0.001; Spearman ρ=0.484, P<0.001) and remained independently associated after adjustment for clinical covariates (β=4.79, 95% CI 3.83-5.74, P<0.001). Lymph node retrieval increased across CVQ quartiles (28.9 vs. 47.6 nodes, P<0.001). Lower CVQ scores were associated with older age, higher BMI, higher ASA classification, male sex, and surgeon-related variability (all P<0.05). CVQ was not associated with short-term postoperative outcomes. Automated CVQ classification achieved average precision up to 91.5%. CVQ is a clinically meaningful measure of lymphadenectomy quality that correlates with lymph node yield while capturing operative difficulty and surgeon-related variability. Automated assessment using surgical video is feasible and may enable scalable evaluation of intraoperative performance.

Accurate tumor localization and thorough lymphadenectomy remain challenges in laparoscopic distal gastrectomy for gastric cancer. While indocyanine green (ICG) fluorescence imaging is effective, it requires near-infrared equipment, limiting its use in primary medical institutions. This study aimed to evaluate the application of a carbon nanoparticle suspension (CNS) as an alternative tracer for margin identification and lymphadenectomy. In this retrospective study, 545 patients undergoing laparoscopic distal gastrectomy were categorized into CNS, ICG, or control groups. Propensity score matching (PSM) at a 1:1 ratio was performed. The primary endpoint was the positive rate of the initial proximal margin (PM). Secondary endpoints included the length of margins, the number of harvested lymph nodes, surgical outcomes, and prognosis. After PSM, 133 pairs (CNS vs. control) and 127 pairs (CNS vs. ICG) were analyzed. Compared to the control group, the CNS group had a significantly lower initial positive proximal margin rate (0.8% vs. 6.0%; P = 0.039), more harvested lymph nodes (38 vs. 32; P < 0.001), less variability in PM length (P = 0.048) and shorter operation time (P = 0.008). The CNS group exhibited a smaller gastric wall diffusion range (3.3cm vs. 5.0cm; P < 0.001) than the ICG group. Three-year overall survival and disease-free survival were comparable between the CNS and control groups. CNS serves as a practical auxiliary tool for margin identification and lymphadenectomy in conventional laparoscopic distal gastrectomy. Although CNS provides less precise boundary guidance than ICG, it remains a viable alternative in hospitals lacking fluorescence imaging equipment.

In laparoscopic distal gastrectomy (LDG), intraoperative bleeding directly reflects surgical proficiency, including tissue handling and hemostasis. Conventional assessments of surgical skills, such as global operative assessment of laparoscopic skills, are subjective and time-consuming. Bleeding events can serve as an objective indicator for automated skill evaluation in this procedure. This study aimed to assess the feasibility of using an automated machine learning approach to objectively evaluate surgical skills during LDG by quantifying blood pixels in intraoperative videos. A logistic regression-based machine learning model was developed to classify pixels as blood or non-blood based on RGB values. A total of 1008 images extracted from 28 LDG videos, comprising 234,699 blood pixels and 376,579 non-blood pixels, were used for training, validation, and testing. Additionally, LDG videos submitted for the endoscopic surgery skills qualification system between 2016 and 2021 were analyzed. Blood pixel counts per frame were calculated for both overall and specific lymphadenectomy phases and were then compared among the high-score (n = 42), low-score (n = 24), and novice groups (n = 22). The model achieved an overall accuracy of 94.0%, with a sensitivity of 99.8% and specificity of 90.4%. Analysis of the endoscopic surgery skills qualification system videos revealed significantly lower blood pixel counts per frame in the high-score group compared with the novice group (high-score group 561.8 [279.8-937.5] vs. novice group 1662.9 [660-3076], p = 0.003), particularly during lymphadenectomy on the right greater curvature (high-score group 761 [244.9-1058.3] vs. novice group 2140.1 [650.4-2986.4], p = 0.006) and suprapancreatic lymphadenectomy (high-score group 634.4 [205-948.2] vs. novice group 1867.4 [1011.9-3925.3], p < 0.001). This study demonstrates the feasibility of an automated machine learning-based approach to quantify blood pixels during LDG as an objective indicator of surgical skill. This method may provide a foundation for a more objective and efficient assessment of surgical performance.

Artificial intelligence (AI) has rapidly advanced in surgical applications. However, existing single-modality AI models relying solely on image input lack the ability to integrate anatomical understanding with clinical reasoning, which is essential for safe and actual surgical decision-making. We constructed an AI model with multimodal training combining visual and linguistic data and named Surgical Vision-Language Model (Surgical-VLM) for real-time surgical support. We analyzed surgical videos from 50 cases of robotic distal gastrectomy and extracted 50 still images per case, generating 10,000 vision-question-answer (VQA) pairs. The model was fine-tuned using the Large Language and Vision Assistant (LLaVA) framework. Model performance was assessed using the newly developed Surgical-VLM Bench, which evaluates appropriateness of expression, anatomical accuracy, and clinical usefulness on a 5-point scale, and the Bidirectional Encoder Representations from Transformers (BERT) score. The results were compared with those of ChatGPT-5. Surgical-VLM achieved a mean total benchmark score of 11.33 ± 0.697 versus 10.72 ± 0.536 for ChatGPT-5. Surgical-VLM showed numerically higher mean scores in anatomical accuracy and clinical usefulness. The BERTScore was 0.768 ± 0.008 for Surgical-VLM and 0.804 ± 0.013 for ChatGPT-5. This proof-of-concept study demonstrates the feasibility of domain adaptation for a Surgical-VLM and proposes a clinically grounded benchmark for structured evaluation. In this pilot setting, the prototype generated context-aware responses and showed domain-dependent differences compared with a general-purpose multimodal model. Further validation with larger independent test sets, expanded VQA items, and external evaluators is required before any clinical use.

The optimal surgical approach for upper gastric cancer remains controversial, particularly regarding the postoperative quality of life (QOL) and nutritional outcomes. This study compared the outcomes of subtotal gastrectomy (STG), proximal gastrectomy (PG), and distal gastrectomy (DG). We retrospectively analyzed 94 patients who underwent gastrectomy for upper gastric cancer (DG: n = 39, PG: n = 33, STG: n = 22). The quality of life (QOL) was assessed using the Postgastrectomy Syndrome Assessment Scale (PGSAS-45) 12 months postoperatively. The nutritional status was evaluated based on changes in body weight. The baseline clinicopathological factors and TNM stages were comparable among the three cohorts. PG was associated with significantly worse reflux, dyspepsia, and meal-related complaints than STG and DG. The STG showed fewer dumping-related symptoms than the PG. No significant differences in overall nutritional status were observed between the STG and DG groups, whereas the PG group tended to be associated with less favorable nutritional outcomes. These findings were consistent with the responder analyses. In this retrospective cohort study, STG was associated with a more favorable postoperative symptom profile than PG and showed postoperative outcomes comparable to those of DG.

Postoperative anastomotic luminal obstruction is a rare but clinically significant complication after distal gastrectomy. Endoscopic balloon dilatation (EBD) is a minimally invasive treatment; however, some patients require additional interventions. This study aimed to evaluate the clinical outcomes of EBD for postoperative anastomotic luminal narrowing and to identify predictors associated with treatment failure. We retrospectively reviewed 56 patients who developed anastomotic strictures after distal gastrectomy, and treated with EBD between January 2010 and December 2022 at Asan Medical Center, Seoul, Korea. Clinical data, including patient characteristics, surgical factors, and endoscopic findings, were analyzed. Patients were classified into an EBD-only group and an additional-intervention group (stent insertion or surgery). Univariate and multivariable logistic regression analyses were performed to identify predictors of EBD refractoriness. Of the 56 patients, 45 (80.3%) achieved symptom improvement with EBD alone, whereas 11 (19.6%) required additional interventions. Diabetes mellitus and failure of scope passage were more frequent in patients who required additional interventions compared with those treated with EBD alone. Multivariable analysis indicated that only failure of scope passage remained an independent predictor (odds ratio, 16.81; 95% confidence interval, 1.61-411.44; p = 0.030). There was one procedure-related complication, aspiration pneumonia, which improved with conservative treatment. EBD is an effective and safe first-line treatment for anastomotic strictures after distal gastrectomy. Failure of scope passage through the anastomosis is a simple yet reliable predictor of EBD refractoriness.

Remnant gastric cancer (RGC) after distal gastrectomy (DG) is a rare entity, and its prognostic determinants have not been fully clarified. Although current staging systems and treatment strategies for gastric cancer are well established, they are largely based on the primary disease, and their applicability to RGC remains uncertain. This study aimed to evaluate the clinicopathological characteristics and survival outcomes of patients with RGC after DG, focusing on tumor depth and lymph node status. This multicenter retrospective study evaluated patients who underwent curative resection for RGC arising in the upper stomach after DG at 10 institutions in Japan between January 2000 and December 2016. Clinicopathological factors, such as tumor depth and lymph node status, recurrence patterns, and overall survival (OS) were analyzed. A total of 119 patients were included in the analysis. The 5-year OS rates for pathological stages I, II, and III were 77.5%, 52.9%, and 26.7%, respectively. On multivariate analysis, tumor invasion depth of T3 or deeper was an independent predictor of poor OS, while lymph node metastasis was not. Regarding T3 disease, patients with T3N0 tumors tended to have poorer survival than those with nodal metastasis. Hematogenous recurrence was more frequent in the T3N0 group, and none of the patients in that group received adjuvant chemotherapy. Tumor invasion depth was the most significant prognostic factor for RGC after DG. Patients with T3N0 RGC may represent a distinct subgroup with unfavorable outcomes, warranting further investigation into postoperative treatment strategies.

Objective: To compare the short-term outcomes of distal radical gastrectomy for gastric cancer using domestically produced single-port and multi-port robotic systems. Methods: This retrospective cohort study included 168 patients with gastric cancer who underwent robot-assisted radical gastrectomy at the Third Department of Surgery, the Fourth Hospital of Hebei Medical University, between September 2023 and July 2025. The initial cohort included 115 males and 53 females, with an age of (60.1±10.5) years (range: 36 to 78 years). Among them, 127 patients underwent multi-port robotic surgery (MP group) and 41 underwent single-port robotic surgery (SP group). To minimize baseline differences, 1∶1 nearest-neighbor propensity score matching was performed (the caliper value was set to 0.2), yielding 41 matched patients in each group. Intraoperative variables and early postoperative outcomes were compared using the independent-samples t test, Mann-Whitney U test, chi-square test, or Fisher's exact test, as appropriate. Results: After matching, baseline characteristics were well-balanced. All procedures were successfully completed as R0 resections without conversion to open surgery. Compared with the MP group, the SP group had a longer total operative time (M(IQR) (246.0 (52.0) min vs. 198.0 (40.0) min, Z=-5.862, P<0.01), longer instrument setup time (19.0 (3.0) min vs. 15.0 (3.0) min, Z=-6.986, P<0.01), and longer lymph node dissection time (158.0 (42.0) min vs. 112.0 (24.0) min, Z=-6.271, P<0.01). Gastrointestinal reconstruction time, intraoperative blood loss, and the number of retrieved lymph nodes did not differ significantly between the two groups (all P>0.05). The SP group showed earlier postoperative ambulation (1.0 (0) d vs. 2.0 (1.0) d, Z=-3.661, P<0.01) and earlier recovery of bowel function (2.0 (1.0) d vs. 3.0 (1.0) d, Z=-2.499, P=0.012). No significant between-group differences were observed in time to first postoperative fluid intake (3.0 (1.0) d vs. 3.0 (1.0) d, Z=-1.278, P=0.201), time to first liquid diet (5.0 (1.0) d vs. 5.0 (1.0) d, Z=-1.012, P=0.312), or postoperative hospital stay (7.0 (2.0) d vs. 7.0 (3.0) d, Z=-0.442, P=0.842). The SP group reported lower Scar Assessment Scale scores ((7.8±1.6) points vs. (9.4±2.0) points, t=-3.893, P<0.01) and lower pain scores on postoperative days 1 to 3 (all P<0.05). Additionally, inflammatory markers (neutrophil-to-lymphocyte ratio and systemic immune-inflammation index) were significantly lower in the SP group on postoperative days 1 and 3 (all P<0.05). Postoperative complication rates were similar between the SP and MP groups (9.8% (4/41) vs. 12.2% (5/41), P=1). No Clavien-Dindo classification of surgical complications grade Ⅲ or higher complications occurred in either group. Conclusions: This study provides preliminary evidence that single-port robotic distal radical gastrectomy for gastric cancer is a safe and feasible approach. Short-term outcomes were generally comparable to those of multi-port robotic surgery,with potential advantages in early postoperative pain,recovery of gastrointestinal function,and cosmetic results.

Long-term outcomes of total versus distal gastrectomy in the older population with early gastric cancer: A propensity score-matched analysis.

To evaluate contemporary short-term outcomes of robotic gastrectomy (RG) approximately 5years after its widespread implementation, compared with laparoscopic gastrectomy (LG) using a nationwide Japanese database. RG has been introduced to overcome the technical limitations of LG; however, its real-world clinical advantages remain to be fully defined. This retrospective study used the Japanese National Clinical Database to identify patients with gastric cancer who underwent minimally invasive distal gastrectomy (DG) or total gastrectomy (TG) between January 2023 and December 2024. Patients were classified as undergoing robotic (RDG or RTG) or laparoscopic (LDG or LTG) procedures. Propensity score matching was performed separately for the DG and TG cohorts to adjust for patient-, tumor-, and hospital-related confounders. The primary outcome was postoperative morbidity within 30days (Clavien-Dindo grade ≥ IIIa). After propensity score matching, 9743 RDG-LDG pairs and 1617 RTG-LTG pairs were analyzed. RDG was associated with a significantly lower morbidity rate than LDG (4.3 vs. 4.9%, P = 0.049). Despite longer operative time, RDG was associated with lower blood loss, lower conversion rates, fewer intra-abdominal infectious complications, and shorter postoperative hospital stay than LDG. Overall morbidity did not differ significantly between RTG and LTG (8.7 vs. 8.3%, P = 0.66); however, RTG was associated with lower blood loss, lower conversion rates, and shorter hospital stay. RDG was associated with improvements in multiple short-term outcomes, whereas RTG still did not improve the primary outcome measure.

Palliative surgery is often considered for advanced stages of gastric cancer to reduce symptoms and improve quality of life; however, it is associated with considerable risks of postoperative complications and mortality. The aim of this study is to analyze the differences in severe complication rates and mortality between palliative and curative gastric cancer surgeries using data from a nationwide survey conducted by the Korean Gastric Cancer Association. Data from 12,420 patients who underwent gastric cancer surgery in 2019 were analyzed. Surgical procedures were categorized as total gastrectomies (TGs), distal gastrectomies (DGs), or bypass operations. Patients were divided into curative gastrectomy (CG, n = 12,114) and palliative surgery (PS, n = 306) groups. Postoperative complications were classified using the Clavien-Dindo (C-D) classification. Severe complications were defined as C-D grade IIIa or higher. Compared with the CG group, the PS group had significantly higher rates of severe complications (10.2% vs. 4.8%, p < 0.001) and mortality (1.6% vs. 0.2%, p = 0.001). Leakage (3.9% vs. 1.3%, p = 0.001) and pancreatic fistula (1% vs. 0.2%, p = 0.036) were significantly more common in the PS group. When compared by resection extent, the PS group had higher severe complication rates than the CG group for DGs (13% vs. 3.8%, p < 0.001) and a higher mortality rate for TGs (3.3% vs. 0.3%, p = 0.006). Palliative gastric cancer surgeries are associated with significantly higher rates of severe complications and mortality than are curative surgeries. These findings emphasize the need for careful patient selection and thorough preoperative counseling when considering palliative gastric cancer surgery.

Quality of life (QoL) assessments in surgical practice have traditionally focused on postoperative recovery and long-term outcomes. This study evaluated the predictive value of preoperative QoL for postoperative complications. We retrospectively analyzed the prospectively collected data from 908 patients who underwent gastrectomy for gastric carcinoma. Preoperative QoL was measured using the EORTC QLQ-C30 and STO22 questionnaires. A multivariate logistic regression was used to develop a predictive model, and model performance was assessed with a receiver operating characteristic (ROC) curve. Distal gastrectomy was performed in 763 patients (84.0%) and total gastrectomy in 145 patients (16.0%). Postoperative complications occurred in 189 patients (20.8%); local and systemic complications were observed in 160 (17.6%) and 48 (5.3%) patients, respectively, with some overlap. Patients with complications had significantly lower preoperative QoL scores across multiple functional and symptom domains. The predictive model identified global health status, stomach pain, anxiety, and body image as key indicators for complications, with an area under the ROC curve of 0.630 (95% CI 0.583-0.676). High-risk QoL classification by the model was an independent predictor of complications after adjusting for clinical risk factors. Preoperative QoL, reflected in multiple functional and symptom domains, is associated with increased postoperative complications. Early identification of high-risk patients may facilitate targeted interventions to improve surgical outcomes.

Various nutritional and inflammatory biomarkers have been proposed to predict prognosis in cancer patients. This study aimed to identify the most significant of these, along with clinical features, in gastric cancer patients who underwent gastrectomy. We retrospectively analyzed gastric cancer patients who underwent gastrectomy. Preoperative markers included mGPS(Modified Glasgow Prognostic Score), NLR(Neutrophil-to-Lymphocyte Ratio), CAR(CRP to Albumin ratio), PNI( Prognostic Nutritional Index), and CONUT (Controlling Nutrition Status)score. Postoperative markers were CRPmax, postoperative complications, and operative procedures. The primary endpoints were overall survival (OS) and recurrence-free survival (RFS). Survival was analyzed with the Kaplan-Meier method. Key prognostic factors were identified using stepwise univariate and multivariable Cox regression. 360 patients were analyzed. Stepwise Cox analysis showed mGPS as the strongest preoperative predictor of OS and RFS. When including both pre- and postoperative variables, age, pathological stage, and surgical procedure were independent prognostic factors. In a model limited to modifiable factors, mGPS and postoperative complications independently predicted both OS and RFS, while surgical procedure independently predicted RFS only. Improving preoperative mGPS and minimizing postoperative complications may enhance survival after gastrectomy. When appropriate, stomach-preserving procedures (e.g., subtotal distal gastrectomy) should be favored over total gastrectomy.

Background/Objectives: Although Billroth I (BI) and Billroth II (BII) are standard reconstructions after distal gastrectomy, evidence on their longitudinal quality-of-life (QoL) trajectories remains inconclusive. This study compared postoperative QoL patterns between BI and BII groups using a validated gastric cancer-specific instrument. Methods: We analyzed 234 patients (BI n = 51, BII n = 183) who underwent laparoscopic distal gastrectomy. QoL was assessed using the KOQUSS-40 questionnaire at 1, 3, 6, 9, and 12 months postoperatively. To address selection bias, inverse probability of treatment weighting (IPTW) was applied alongside linear mixed-effects models to evaluate group effects and group × time interactions. Results: A significant main effect of group was observed (p = 0.032), with the BII group maintaining higher total scores. These findings remained consistent after IPTW adjustment. While the overall group × time interaction was not significant (p = 0.846), indicating parallel recovery trajectories, significant interactions were identified in specific domains, including dumping syndrome and constipation. In these domains, the BI group showed gradual improvement, whereas the BII group exhibited relatively stable scores. Conclusions: While both reconstruction methods demonstrated comparable overall QoL trajectories with no significant group × time interaction, the KOQUSS-40 revealed exploratory differences in specific symptom domains, notably dumping-related symptoms and constipation. These findings provide clinically meaningful insights for postoperative patient counseling, enabling tailored expectations during the first year after distal gastrectomy. However, these domain-specific results should be regarded as hypothesis generating and interpreted with caution.

Gastric signet‐ring cell carcinoma (GSRCC) represents 10%–14% of all gastric malignancies. The overall prognosis for GSRCC is poorer compared to other types of gastric cancer, as it is characterized by a high degree of malignancy, rapid progression, and early metastasis (particularly peritoneal metastasis). Current therapies combining surgery and chemotherapy are challenged by tumor invasiveness, drug resistance, and limited targeted options. Herein, we present the case of a 60‐year‐old male diagnosed with GSRCC who underwent laparoscopic distal radical gastrectomy with D2 lymphadenectomy. Postoperative histopathological analysis confirmed a mixed tumor composition comprising 60% GSRCC and 40% moderately differentiated adenocarcinoma. Following surgery, the patient was administered adjuvant therapy with oxaliplatin and S‐1 and metformin enteric‐coated tablets for 6 months, followed by 42‐month maintenance therapy regimen combining oral S‐1 and apatinib and metformin enteric‐coated tablets. Over 9 years of follow‐up, the patient demonstrated sustained recurrence‐free survival (RFS) and achieved clinical recovery. This case underscores the potential of individualized adjuvant therapy in addressing the aggressive biological characteristics of GSRCC and offers a valuable reference for strategies to minimize recurrence in GSRCC patients. Trial Registration: ClinicalTrials.gov identifier NCT01101438

The study aimed to investigate the influence of Billroth II combined with Braun anastomosis on perioperative stress indicators and pepsinogens in patients undergoing laparoscopic gastric cancer surgery. This study is a single-center retrospective research design. This study included 148 patients who underwent laparoscopic radical distal gastrectomy for gastric cancer between March 2021 and June 2024, with all surgical procedures performed by the same surgical team. According to the digestive tract reconstruction methods, participants were divided into a Billroth II group (n = 63) and a Billroth II+Braun group (n = 85). The short-term efficacy outcomes included perioperative stress indicators, pepsinogen I to pepsinogen II ratio (PGR), Gastrin-17 (G-17), and postoperative complications. Moreover, the long-term efficacy outcomes comprised bile reflux rate, incidence rate of reflux residual gastritis and 1-year survival rate. The C-reactive protein (CRP) showed a gradual increase preoperatively (T0) and at postoperative day 1 (T1) and day 2 (T2) (F interaction = 2.74, p = 0.064; F time-point = 757.8, p < 0.001; F between-group = 2.50, p = 0.114). However, norepinephrine (NE) and cortisol (COR) initially increased and then declined at these time points (F interaction = 0.90, 0.58, p = 0.407, 0.559; F time-point = 1628, 466.4, both p < 0.001; F between-group = 0.83, 0.70, p = 0.36, 0.40). Furthermore, no statistical differences in CRP, NE and COR were observed between the Billroth II+Braun group and the Billroth II group at the three time points (p > 0.05). Compared with preoperative levels (T0), PGR increased in both groups, whereas G-17 decreased at postoperative day 30 (T3) (p < 0.01). Additionally, PGR was significantly higher in Billroth II+Braun group (p < 0.001) while there was no statistical difference in G-17 between the two groups at T3 (p = 0.943). Similarly, the anastomotic leakage (Fisher's exact test, p = 0.312), anastomotic stenosis (Fisher's exact test, p = 1.000), duodenal stump bleeding (Fisher's exact test, p = 0.426), duodenal stump leakage (Fisher's exact test, p = 0.180), and intestinal obstruction rate (Fisher's exact test, p = 0.402) also showed no statistical differences between the two groups. The bile reflux rate was substantially lower in the Billroth II+Braun group (p = 0.005), while no statistical differences were observed in residual food (p = 0.097), reflux residual gastritis (Fisher's exact test, p = 0.312) and survival rate (Fisher's exact test, p = 0.700) between groups. This study demonstrates that Billroth II+Braun anastomosis and Billroth II anastomosis are equally safe and effective during radical distal gastrectomy for gastric cancer. There is no significant difference in the influence of two digestive tract reconstruction methods on perioperative stress indicators in this cohort. Additionally, Billroth II+Braun anastomosis can improve PGR level and reduce bile reflux rate.