Gastric Surgery Research Articles

Plasmatic variability of direct oral anticoagulants in people with atrial fibrillation and previous gastric surgery: a pilot case series.

Data on cardioembolic prevention with direct oral anticoagulants (DOAC) in atrial fibrillation (AF) patients with previous gastric surgery are lacking. We report inter- and intra-individual differences in DOAC concentration in people with gastric surgery, to identify potential treatment options. Patients with previous gastric surgery receiving DOAC for AF as stroke secondary prevention, and undergoing peak-trough DOAC plasmatic testing were selected from the regional EDDIE-AF registry. DOAC levels were tested at least 75-102h after DOAC initiation with Siemens Innovance® assays. Eight patients with previous gastric surgery were included (mean age 75years, 50% women). Overall, only 20/36 tests were within range (55.5%; apixaban 75.0%; dabigatran 0%; edoxaban 64.3%; rivaroxaban 33.3%). Rivaroxaban and dabigatran failed to reach therapeutic peak-trough concentrations. Apixaban and edoxaban reached therapeutic levels in 4/6 and 3/7 cases respectively, with marginal out-of-target concentrations in all remaining cases. Our data support a consistent variability in DOAC absorption after gastric surgery, suggesting that implementation of DOAC plasmatic testing may help in ensuring therapeutic levels are met whenever DOACs are preferred over warfarin.

Evaluation of the safety and effectiveness of easyEndo™ universal stapler compared with easyEndo™ E-lite in patients submitted to gastric surgery: a retrospective/prospective study including a large number of patients

Background: Staple line complications represent the most dangerous complication after gastric surgery. Better-formed staples could potentially reduce complications postoperatively. The newer motorized generation stapling system would lead to fewer intraoperative staple line complications compared to traditional stapling systems. Purpose was to evaluate the safety and efficacy of these two types of stapler models by determining its intraoperative performance and peri-operative complications. Methods: It was an observational cohort study including a total of 3613 patients submitted to gastric surgery for benign or malignant disease. The study was conducted within two periods: stage A using easyEndoTM universal (n=2359 patients, from January 2017 to December 2022) and stage B (n=1254 patients, from January 2023 to June 2024) using easyEndoTM E-lite motorized stapler including obese patients (n=3239), benign diseases with indication of surgical treatment (n=268) and patients with gastric cancer (n=106). Results: Although higher rate of leaks and postoperative complications were observed in patients submitted to sleeve gastrectomy or gastric bypass during stage A compared with stage B (p=0.0025), both type of staplers are safe and effective for performing gastric surgery. In patients submitted to gastric resections, no significates differences were demonstrated in terms of postoperative complications comparing the two groups (p=0.1). Conclusions: Patients operated on using motorized stapler presented less suture line interventions but no differences regarding postoperative complication. The results confirmed data published in previous reports and meta-analysis, but now including a big number of patients and complex procedures.

Implications of compressive loading of the stomach wall: Interplay between mechanical deformation and microstructure.

During gastric surgery, the stomach wall is compressed with clamps and sutures or staple lines. These short- and long-term deformations can severely compromise the integrity of the tissue and make it difficult for the stomach wall to respond and remodel to the new loading conditions. Consequently, serious intra- and postoperative complications such as the formation of leaks during bariatric surgeries, can be associated with these immense tissue deformations. Hence, the study aimed to investigate the effects of compressive loading of the stomach wall in the radial direction. This was done by macroscopic mechanical loading of the stomach wall in each region of the stomach and evaluating the microstructural changes inflicted in the tissue. For this purpose, several imaging techniques were used, i.e., a histological analysis, second-harmonic generation microscopy, and X-ray micro-computed tomography. The combination of these three methods allowed us to investigate the gradual compression of the different stomach layers as well as the local reorientation and deformation of the main microstructural components, e.g., collagen fibers and muscle bundles. Importantly, this study found that the collagen bundles in the stomach wall straighten and reorient toward the circumferential-longitudinal plane and partially fan out with increased radial compressive deformation. The 3D scans of the stomach wall indicated a deterioration of the blood vessels and buckling of the mucosal glands due to compression. Statement of significance Unfortunately, little is known about the load transfer in the stomach wall during gastric surgery and the associated deformations on the macro- and microscale. The present study investigates the structural changes of the stomach wall, its layers and the inherent biological building blocks using histology, multi-photon microscopy, and micro-computed tomography. For the first time, the layer-specific response to stepwise radial compression of the stomach wall was studied, the related collagen fiber parameters were estimated, and a 3D sample structure was visualized. This clinically-oriented study links the structural changes within the wall to the postoperative remodel- ing process and the irreversibly altered gastric motility, thereby underscoring its relevance to the field of biomedical engineering, e.g., the development and improvement of surgical instruments.

A nomogram for predicting nutritional risk before gastric cancer surgery.

Gastric cancer (GC) is the fourth leading cause of cancer death worldwide. Patients with GC have higher nutritional risk. This study aimed to construct a nomogram model for predicting preoperative nutritional risk in patients with GC in order to assess preoperative nutritional risk in patients more precisely. Patients diagnosed with GC and undergoing surgical treatment were included in this study. Data was collected through clinical information, laboratory testing, and radiomics-derived characteristics. Least absolute shrinkage selection operator (LASSO) regression analysis and multi-variable logistic regression were employed to construct a clinical prediction model, which takes the form of a logistic nomogram. The effectiveness of the nomogram model was evaluated using receiver operat-ing characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA). A total of three predictors, namely body mass index (BMI), hemoglobin (Hb) and radiomics characteristic score (Radscore) were identified by LASSO regression analysis from a total of 21 variables studied. The model constructed using these three predictors displayed medium prediction ability. The area under the ROC curve was 0.895 (95% CI 0.844-0.945) in the training set, with a cutoff value of 0.651, precision of 0.957, and sensitivity of 0.718. In the validation set, it was 0.880 (95% CI 0.806-0.954), with a cutoff value of 0.655, precision of 0.930, and sensitivity of 0.698. DCA also confirmed the clinical benefit of the combined model. This simple and dependable nomogram model for clinical prediction can assist physicians in assessing preoperative nutritional risk in GC patients in a time-efficient and accurate manner to facilitate early identification and diagnosis.

Using three-dimensional stomach models to identify anatomical landmarks and estimate the resection site in gastric cancer surgery

Using three-dimensional stomach models to identify anatomical landmarks and estimate the resection site in gastric cancer surgery

ICG lymph node mapping in gastric cancer operations

ICG lymph node mapping in gastric cancer operations

Short-Term Weight Loss Outcomes of 104 Mini-Gastric Bypass or One-Anastomosis Gastric Bypass Operations: Retrospective study.

This study aimed to examine the short-term effects of mini-gastric bypass (MGB) or one-anastomosis gastric bypass (OAGB) procedures on weight loss in individuals with obesity. This retrospective study was conducted in Medicano Hospital, Erbil, Iraq, from January 2019 to May 2020. Preoperative body mass index (BMI), age, height and preoperative weight were recorded as baseline measures. Weight-related changes were evaluated during a follow-up phase of 48 weeks. A total of 104 patients with obesity underwent MGB or OAGB surgery. The mean baseline parameters of the subjects before surgery included 1.64 m for height, 122.9 kg for weight and 45.6 kg/m2 for BMI. During the 48-week follow-up period, there was a substantial reduction in mean weight, which dropped from 122.9 kg at baseline to 75.5 kg at week 48. The weight change (in percentage) gradually increased from -11.8% at week 12 to -37.9% at week 48, without statistically significant association with demographic factors or chronic diseases. From week 12 to week 48, the percentage of excess weight loss (%EWL) increased substantially from 26.8% to 86.1%. The results of the subgroup analysis indicated that the %EWL was considerably higher among those aged 30 or older at week 36 and singles at week 48. This study's results illustrate the efficacy of MGB or OAGB procedures in significantly reducing weight in the short term. The %EWL increased with the follow-up time and was significantly associated with age and marital status.

Variation of Stomach Shapes in Gastric Emptying Scintigraphy: Correlation With Gastric Emptying Results, Body Weight, and Symptoms.

Although different gastric shapes are encountered in gastric emptying scintigraphy (GES), it is not known whether gastric shape is related to gastric emptying (GE) or symptoms. To investigate different stomach shapes observed during GES and examine their associations with GE, body weight, and gastrointestinal (GI) symptoms. This was a retrospective review of GES studies performed at our institution. Patients with prior gastric surgery were excluded. A classification of gastric shapes included: crescentic, J-shaped, reversed-L, cylindrical, and bag-like. Gastric shapes were correlated with GE, BMI, and GI symptoms using PAGI-SYM. 397 GES studies were reviewed (317 females, age 40.0 ± 20.3 years, BMI 27.8 ± 13.8 kg/m2). Gastric shapes were: 41.8% crescentic/comma-shaped, 34.0% J-shaped, 19.9% reversed L-shape, 2.8% cylindrical, and 1.5% bag-like. BMI was highest in crescentic/comma-shaped stomachs (30.1 ± 12.4 kg/m2) and lowest in bag-like stomachs (25.2 ± 9.9 kg/m2; p = 0.022). Delayed GE was most pronounced in bag-like stomachs (34.4 ± 33.1% retention at 4 h) and lowest in reversed-L shape (10.3 ± 15.6% retention at 4 h; p = 0.008). Regurgitation severity was greatest in bag-like stomachs (2.2 ± 1.5) compared to milder symptoms in reversed-L shape (1.3 ± 1.4; p = 0.029). Heartburn severity was increased in bag-like stomachs (2.3 ± 1.6) while patients with cylindrical stomachs reported least heartburn severity (1.1 ± 1.3; p = 0.11). A classification system based on five gastric shapes observed during GES showed that crescent-shaped stomach was the most common shape and correlated with higher BMIs. Delayed GE was most pronounced in bag-like stomachs and lowest in reversed-L stomachs. Regurgitation and heartburn severity were greatest in bag-like stomachs with milder symptoms in reversed-L stomachs. Thus, gastric shape during GES is associated with gastric emptying, BMI, and symptom severity.

An initial exploratory clinical study and outcome assessment of gastrointestinal surgeries using advanced robotic-assisted techniques.

In addition to the Da Vinci surgical robot, domestic surgical robots are being developed rapidly. Chinese Toumai® laparoscopic surgical robot was approved for urological surgery in 2022.This study aims to systematically evaluate the safety and efficacy of the Toumai® robotic surgical system in performing complex gastrointestinal surgeries. This prospective, single-center, single-arm exploratory study was conducted at Gansu Provincial Hospital between June 2022 and October 2023, enrolling 12 patients undergoing gastrectomyand 9 patients undergoing colorectal resection. The primary endpoints are oncological outcomes and surgical success rates, while secondary endpoints encompassed intraoperative blood loss, operative duration, complication rates, system performance metrics, length of hospital stay, and postoperative pain levels. All patients successfully underwent robotic-assisted surgery with adequate oncological resection and favorable postoperative outcomes. There were no conversions to open or laparoscopic surgery, resulting in a 100% procedural success rate. The median docking time for radical gastrectomy was 17.50 (14.25, 21.50) minutes, with a median master-slave control time of 121.50 (105.50, 172.00) minutes, median intraoperative blood loss of 100.00 (50.00, 275.00) mL, and a median postoperative hospital stay of 9.00 (7.25, 10.75) days. For radical colorectal surgery, the median docking time was 22 (17.50, 30.50) minutes, the median master-slave control time was 68 (56.50, 119.00) minutes, with a median blood loss of 50 (50.00, 150.00) mL, and a median postoperative hospital stay of 7 (7.00, 10.00) days. No intraoperative organ injury, mortality, system failure, or severe postoperative complications were reported. These preliminary findings provide compelling evidence supporting the safety and efficacy of the Toumai® laparoscopic surgical robotic system in performing gastric and colorectal surgeries.

Relationship between immune cell traits, circulating inflammatory cytokines, and the risk of incisional hernia after gastric surgery.

The systemic and local inflammatory response in patients after surgical operation is closely related to the quality of the wound healing. Low-quality wound healing and defects in the suture technique lead to the occurrence of incisional hernia (IH). However, the causal relationship between human circulating inflammatory cytokines, immune cell traits, and the risk of IH remains unclear. We used summary data from genome-wide association studies to assess the causal relationship between 91 types of circulating inflammatory factors, 731 types of circulating immune cell traits, and the risk of IH. The outcome dataset was obtained from FinnGen, including 6,336 patients with IH and 232,612 controls. We performed Mendelian Randomization (MR) analysis to identify their causal relationship and immune cell phenotypes upstream of inflammatory factors. Inverse variance weighting is considered to be the main analysis method. Among the identified cytokines, TNF-related activation-induced cytokine levels were associated with a lower risk of IH (OR: 0.89; 95% CI: 0.82-0.96; P = 0.003). In contrast, interleukin-5 levels were associated with an increased risk of IH (OR: 1.18; 95% CI: 1.06-1.31; P = 0.003). Additionally, a significant causal relationship was found between four immune cell traits and the risk of IH (P < 0.01). Through two-step MR analysis, we determined that interleukin-5 levels mediate the causal relationship between the relative count of CD25hi % CD4 + in Treg cells and the higher risk of IH. This study found a causal relationship between specific inflammatory cytokines, immune cell traits, and risk of IH. These results can help surgeons predict the risk of IH and take preventive measures.

Preoperative D‑dimer level and prognosis in patients diagnosed with gastric cancer and undergoing gastric cancer radical surgery: A retrospective cohort study.

Gastric cancer, one of the most aggressive tumors affecting the digestive tract, has seen a rise in both incidence and mortality rates in recent years, with a lack of clear prognostic indicators. D-dimer, a byproduct of fibrin degradation, is a conventional coagulation biomarker that has been investigated as a potential adverse prognostic factor for postoperative cancer patients. However, conflicting results exist, with some studies suggesting that D-dimer is an independent risk factor for the postoperative prognosis of gastric cancer, and others suggesting that there is no significant association between D-dimer level and gastric cancer prognosis. This controversy underscores the need for further research to determine the true influence of D-dimer level on the prognosis of postoperative cancer patients, including exploring the linear and non-linear associations, and identifying optimal critical values before surgery. The present study aimed to assess the association between preoperative D-dimer levels and 5-year overall survival (OS) rate in patients undergoing radical surgery for gastric cancer. Data was analyzed from patients diagnosed with gastric cancer who underwent a radical gastrectomy at Shanxi Cancer Hospital (Taiyuan, China) in 2017 and were followed up for 5 years until December 2022. Preoperative D-dimer levels and tumor-related indicators were collected as covariates from hospital records, with patient follow-up information obtained from the hospital's tracking system. Utilizing multivariate Cox regression, curve fitting and inflection point analysis, the present study sought to investigate the link between preoperative D-dimer levels and 5-year OS rate following radical surgery for gastric cancer. After strict admission and exclusion procedures, a total of 133 patients were included in the study and were then classified based on D-dimer level. Based on the mean value, the D-dimer levels were segregated into two distinct cohorts: The D-dimer_high group (n=66) and the D-dimer_low group (n=67). Cox multiple regression analysis was conducted using both continuous and binary variables. The results showed no effect in terms of the continuous variables, but higher preoperative D-dimer levels were significantly associated with a higher 5-year overall survival compared with lower preoperative D-dimer levels in the categorical variables. Therefore, curve fitting was performed, which indicated that the association between D-dimer level and 5-year survival rate after radical gastrectomy for cancer showed a U-shaped curve, with P<0.001, high and low D-dimer levels both indicated poorer prognosis. A curvilinear correlation was demonstrated between preoperative D-dimer levels and the 5-year survival rate following radical gastrectomy for cancer. Subsequently, an inflection point analysis found that the inflection point was located at 100-200 ng/ml. In conclusion, in patients undergoing radical gastrectomy for gastric cancer, preoperative D-dimer can be used to indicate the current state of the tumor to some extent through blood coagulation status. Notably, a U-shaped association exists between D-dimer levels and 5-year postoperative survival rate in gastric cancer. This association demonstrates varying effects across different intervals. Specifically, D-dimer levels <100 ng/ml are associated with a worse prognosis, whereas levels >200 ng/ml are associated with a better prognosis.

Current clinical trials on gastric cancer surgery in China.

Gastric cancer (GC) is the leading diagnosed malignancy worldwide, especially in China. Radical surgery is the cornerstone of GC treatment. We reviewed previous clinical trials and aimed to provide an update on the factors related to the surgical treatment of GC. The number of registered clinical trials in the field of GC surgery is rapidly increasing. With the development and popularization of endoscopic, laparoscopic, and robotic techniques, GC surgery has gradually entered a new era of precise minimally invasive surgery. Postoperative quality of life has become a major issue in addition to surgical oncological safety. Although great progress has been made in clinical research on GC in China, there are still deficiencies. Many studies enrolled large numbers of patients, but the research data were not of high quality. The characteristics of GC in China include a high incidence, large population, and large proportion of patients with advanced GC, which provides sufficient reason for studying this disease. There is still a need for well-designed, large, randomized clinical trials to improve our knowledge of the surgical treatment of GC.

OGC O01 - Stomach Cancer Elective Surgery Morbidity and Mortality at 90-Days (HOLD Study): A Prospective, International Collaborative Cohort Study

Abstract Background Data on multinational 90-day mortality and morbidity rates after surgery for gastric cancer is limited in the literature. This study aimed to understand the 90-day mortality and morbidity outcomes according to GASTRODATA Registry for elective gastric cancer surgery patients and identify risk factors. Method We conducted an international prospective study on ≥18 years patients undergoing elective surgery for gastric cancer with curative intent from 01 April 2022 to 30 September 2022. Known metastatic disease, concurrent secondary cancers, gastrointestinal stromal tumour (GIST) and Siewert type I/II oesophagogastric junction malignancies were excluded. Univariate and multivariate logistic regression was used to identify variables associated to 90-day outcome. Results 380 collaborators from 47 countries submitted data on 1538 patients. Mean age was 64.2 years and 58.5% were males. 90-day morbidity rate was 38.2% (n=587) and mortality rate was 2.9% (n=45). Pre-operative higher CCI or ASA score, pre-operative weight loss &amp;gt;10%, and surgical determinants such as type of gastric resection, positive specimen margin, number of harvested lymph nodes, longer surgery duration and post operative pathological IV staging (p value&amp;lt;0.05) were identified as predictors of postoperative severe complications and mortality. Conclusion Elective gastric cancer surgery has a 90-day morbidity of 38.2% and 90-day mortality of 2.9%, globally. This study identified several factors associated with higher morbidity and exemplified the importance of a unified language on surgical morbidity, pre-habilitation and ongoing audits to enhance patient outcomes.

BS SO19 - Left Paraduodenal Hernia - Laparoscopic reduction and repair

Abstract Background We present a case of a 39 year old female patient, with a BMI of 37.5 and a background of hypertension scheduled for a bariatric gastric sleeve surgery. During the surgery, incidentally, a left paraduodenal hernia was identified. The incidence of a left paraduodenal hernia is 0.03% of all hernias, which makes it a rare case to present. Method The hernia with all it contents was reduced. The defect was visualised and repaired. Haemostasis achieved. Results The postoperative period was uneventful. The patient was followed up regularly in the bariatric clinic with no further complaints. Conclusion In conclusion, this case highlights the incidental discovery and successful management of a rare left paraduodenal hernia in a 39-year-old female patient undergoing bariatric gastric sleeve surgery. Despite the rarity of this type of hernia, with an incidence of 0.03% of all hernias, prompt intervention led to a favorable outcome. The postoperative course was uneventful, and the patient reported no further complaints during regular follow-ups in the bariatric clinic. This case underscores the importance of vigilance for unexpected findings during surgery and demonstrates the successful resolution of such rare occurrences through careful surgical management.

MS O07 - OGC ‘Textbook Outcome’ for Gastrectomy: Redefining a Valid Composite Measure Assessment Tool for Surgical Performance in a Specialist Unit within the United Kingdom

Abstract Background A ten-item composite measure defining ‘textbook outcome’ (TBO) following oesophagogastric cancer surgery was proposed to benchmark surgical quality. While subsequent studies have demonstrated an association between TBO and improved survival, the reported proportion of patients who meet all the required criteria remained consistently low. Postoperative complications of Clavien-Dindo grade ≥2 (CD≥2) commonly preclude TBO, despite evidence that minor complications are unlikely to influence long-term outcomes. This study aimed to assess whether modification of TBO parameters to Clavien-Dindo grade ≥3 (CD≥3) is associated with improved overall survival in patients undergoing gastric cancer surgery within an UK specialist unit. Method Consecutive patients who underwent a surgical resection for gastric cancer, at a single tertiary centre between January 2016 and December 2019, were identified from a prospectively maintained regional database. Patients were included irrespective of (neo)adjuvant treatments. Data collected included clinicopathological characteristics, treatment modalities and postoperative outcomes. Comparisons were drawn between patients who met all the parameters defining TBO and those who did not, using both CD≥2 and CD≥3 classifications for ‘major’ complications. The primary outcome of interest was overall survival. Results Sixty-seven patients (median 70 years, 61.2% male) underwent resection for gastric cancer during this study. Of these, 27 patients (40.3%) achieved TBO based on a CD≥2 complication grading and 38 patients (56.7%) when CD≥3 was used. Clinicopathological characteristics were all comparable between TBO groups based on both cut-offs. Improved overall survival was evident with a CD≥3 TBO (p=0.026), however not with CD≥2 TBO (p=0.430). Following adjustment for confounding variables, CD≥3 TBO remained associated with improved overall survival (HR: 0.30 (95% CI: 0.10-0.93), p=0.037) while CD≥2 TBO was not (HR: 0.64 (95% CI: 0.21-1.93), p=0.428). Conclusion Textbook outcome is a multi-parameter metric for benchmarking quality in gastric cancer surgery. Modification of the complications parameter required for TBO to CD≥3 in our patient population resulted in a stronger association with overall survival amongst patients undergoing surgical resection for gastric cancer.

Vagus Nerve Preservation for Early Distal Gastric Cancer With Monitoring and Indocyanine Green Labeling

Radical gastric cancer surgery can cause functional and physiological disorders due to the resection of perigastric vagus nerves. Few studies have used intraoperative neurophysiological monitoring and indocyanine green (ICG) labeling to preserve the perigastric vagus nerve and to evaluate the corresponding effects. To assess the feasibility and effects of vagus nerve preservation using neurophysiologic monitoring and ICG labeling during laparoscopic distal gastrectomy in patients with early distal gastric cancer. This open-label, prospective randomized clinical trial initially enrolled 285 patients with clinical stage cT1N0M0 distal gastric cancer from May 2022 to May 2023. This trial was conducted at Qilu Hospital of Shandong University in Jinan, China, and enrolled patients aged 18 to 80 years with histologically proven gastric adenocarcinoma scheduled for distal gastrectomy. The final follow-up examination was performed May 1, 2024. Eligible participants were randomly assigned 1:1 to vagus nerve preservation distal gastrectomy (VPG) or vagus nerve resection distal gastrectomy (VRG). The primary outcome was the incidence of postsurgical gastroparesis. Secondary outcomes included postoperative gallstone formation, quality of life, morbidity, mortality, overall survival, and disease-free survival up to 12 months postoperatively. All analyses were based on both intention-to-treat and per-protocol analyses. Of 264 patients included in the intention-to-treat analysis, the median (IQR) patient age was 58.0 (52.0-67.0) years, and 67 patients (25.4%) were female. Both the VPG and VRG groups included 132 patients. Postoperative gastroparesis occurred in 1 patient (0.8%) in the VPG group and in 10 patients (7.6%) in the VRG group. Gallstones developed in 0 patients in the VPG group and in 9 patients (6.8%) in the VRG group. As assessed by mean (SD) score on the 30-item European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, the VRG group experienced more nausea and vomiting at 6 months postsurgery (19.38 [7.62]) than the VPG group (17.15 [9.21]) (P = .03) and had significantly higher rates of persistent appetite loss, reflux symptoms, and eating difficulties at both 6 months and 12 months than the VPG group. Differences in postoperative complications and metastasis were not significant. Neurophysiologic monitoring and ICG labeling during distal laparoscopic gastrectomy for vagus nerve preservation in patients with early distal gastric cancer are safe and feasible. Preserving the perigastric vagus nerve may retain the function of the remnant stomach and improve quality of life. Chictr.org.cn Identifier: ChiCTR2200059489.

OGC SO44 - Robotic gastric resection is feasible and safe - the first 25 cases at a tertiary UK Oesophago-gastric unit

Abstract Background Robotic approaches to upper GI surgery are being increasingly used due to purported benefits including improved vision and dexterity over conventional laparoscopy, and reduction in surgical trauma and wound-related morbidity over open surgery. Introduction of new technology and its implementation into practice comes with an inevitable learning curve and it is paramount that this does not occur at the expense of patient outcomes. This study looked at the surgical and oncological outcomes from the implementation of a robotic gastric resectional service at a tertiary centre in the UK. Method A prospectively maintained database was used to identify all patients undergoing robotic subtotal and total gastrectomy irrespective of indication. Patients having sleeve gastrectomy or gastric wedge resection were not included. Demographic, operative, pathological and complications data were included. Complications were graded using the Clavien-Dindo classification. Textbook outcomes for gastric cancer surgery were defined as complete resection, pathological R0, &amp;gt;15 lymph nodes resected, no intraoperative complications, no reintervention, no ICU readmission, no prolonged hospital stay (defined as &amp;gt; 21 days), no mortality or readmission at 30 days, and no severe complications (Clavien Dindo ≥ II). Results Twenty-five patients were identified, 13 (52%) were women and the median age was 73 (range: 40 – 88). Twenty-two (92%) had a subtotal gastrectomy and adenocarcinoma was the diagnosis in 15 (62.5%). Median blood loss was 50ml (50 – 310 ml) and operative time 320 minutes (225 – 480 minutes). There were no conversions to open. Complications occurred in 6 (24%) with one leak, 2 theatre returns, one death and no readmissions. Median stay was 6 days (4-14 days). Of the 16 having cancer surgery, median nodal yield was 29.5 (16 – 66), R0 rate 100% and a textbook outcome achieved in 14 (87.5%). Conclusion Robotically-assisted gastric resection can be implemented with a low rate of complication. In those patients having surgery for cancer, pathological outcomes were good and 14/16 patients achieved a textbook outcome which is significantly higher than most published studies.

Prognostic impact of a 3-week multimodal prehabilitation program on frail elderly patients undergoing elective gastric cancer surgery: a randomized trial

BackgroundResearch indicates that prehabilitation is effective in optimizing physical status before surgery, although this method may be considered “aggressive” for frail elderly patients. This study aimed to evaluate whether multimodal prehabilitation decreases postoperative complications and improves functional recovery in frail elderly patients undergoing gastric cancer surgery, in comparison to usual clinical care.MethodsThis study was a single-center, single-blind, randomized controlled trial. Patients over 65 years old with a Fried Frailty Index of 2 or higher, scheduled for gastric cancer surgery, were considered for inclusion. Eligible participants were randomized in a 1:1 ratio to either the intervention or control group. The intervention group underwent a 3-week multimodal prehabilitation program prior to surgery, in addition to perioperative care guided by ERAS protocols. The control group received only the latter. The primary outcome was the comprehensive complications index (CCI) measured at 30 days after surgery. Secondary outcomes included 30-day overall complications, functional walking capacity as assessed by 6-minute walking distance (6MWD) at 4 weeks postoperatively, and 3-month postoperative quality of life. This study was registered at ClinicalTrials.gov (No. NCT06510088).ResultsAmong the 112 eligible patients, the median age was 74 years, with 58 (52.7%) being female. No between-group difference was found in the primary outcome measure, 30-day CCI. The Median (Q1-Q3) CCI for the intervention and control groups was 0 (0-12.2) and 0 (0-22.6) (P = 0.082), while the mean (SD) CCI was 6.1 (15.8) and 9.8 (12.7), respectively (P = 0.291). Notably, the incidence of severe complications (CCI > 20) was significantly lower in the intervention group compared to the control group (11.1% vs. 25.9%, P = 0.046), particularly in terms of medical complications (12.3% vs. 29.3%, P = 0.025). Preoperatively, 27 patients (47.4%) in the intervention group exhibited an increase in the 6MWD of at least 20 m, compared to 16 patients (27.6%) in the control group (P = 0.028). At 4 weeks postoperatively, more patients in the intervention group returned to their baseline 6MWD levels (63.2% vs. 43.1%, P = 0.031). Secondary parameters of functional capacity in the postoperative period generally favored the multimodal prehabilitation approach.ConclusionsIn frail elderly patients undergoing elective gastric cancer surgery, a prehabilitation program did not affect the 30-day postoperative complication rate or CCI but reduced severe complications and improved perioperative functional capacity.Trial registration[ClinicalTrials.gov], [NCT06510088], [07/15/2024], [Retrospectively registered]

Three-year follow-up outcomes of postoperative quality of life from a randomized controlled trial comparing multi-port versus single-port laparoscopic distal gastrectomy.

Laparoscopic surgery for gastric cancer has become widely used; minimally invasive surgery has become the mainstream of treatment. This randomized controlled trial (RCT) aimed to compare long-term quality of life (QoL) and weight loss rates in patients who underwent single-port laparoscopic gastrectomy (SLG) or multi-port laparoscopic gastrectomy (MLG) for gastric cancer. This single-center RCT compared MLG and SLG in patients with clinical stage I gastric cancer, all of which underwent distal gastrectomy between April 2016 and September 2018. A total of 101 patients were evaluated for eligibility; all were randomized into either the SLG group (n = 50) or MLG group (n = 51). Blood tests, weight measurements, and postoperative questionnaires (DAUGS20, EORTC QLQ-C30, PGSAS-45) were performed at 3, 6, 12, and 36months after surgery to compare the QoL. At six months postoperatively, there was a higher trend toward lower weight loss in the SLG group compared with the MLG group. At 1, 3, 6, and 36months postoperatively, the neutrophil-to-lymphocyte ratio was significantly lower in the SLG group than that in the MLG group. The QoL, as measured using the postoperative questionnaires, was generally comparable. However, some favorable results, such as fewer diarrheas, were achieved. SLG was partially superior to MLG in terms of long-term QoL, in addition to assurance of esthetics and reduced pain. In addition, systemic inflammatory markers and weight loss rates were lower, suggesting a potential long-term benefit. SLG may be an option for stage I gastric cancer surgery. Further follow-up and multicenter studies should be considered.

Screening high-risk individuals for primary gastric adenocarcinoma: evaluating progression-free survival probability score in the presence and absence of Rictor expression after gastrectomy.

Developing nomogram-based risk stratification model to determine 3-year and 5-year progression-free survival (PFS) and to identify high-risk patients with gastric adenocarcinoma based on different Rictor statuses. 1366 individuals who underwent radical gastric surgery to treat gastric adenocarcinoma at Shanxi Cancer Hospital from May 2002 to December 2020 were analyzed. Cox regression analysis was employed to create the nomograms. The nomograms' performance was assessed using C-index, time receiver operating characteristic (t-ROC) curves, calibration curves, and decision curve analysis (DCA) curves in training and validation cohorts. Subsequently, patients were categorized into high-risk and low-risk groups based on the nomogram's risk scores. The Rictor (-) nomogram for predicting PFS included variables such as age, number of positive lymph nodes, vascular invasion, maximum diameter of the tumor, omentum metastasis, and expression of MSH2. In the internal validation, the C-index of the Rictor (-) nomogram was 0.760 (95%CI: 0.720-0.799), which was superior to the C-index of the American Joint Committee on Cancer (AJCC) 8th edition TNM staging (0.683, 95%CI: 0.646-0.721). Similarly, the Rictor (+) nomogram for predicting PFS included variables such as gender, age, pT stage, number of positive lymph nodes, neural invasion, maximum diameter of the tumor, omentum metastasis, Clavien-Dindo classification for complications, and CGA expression. The C-index of the Rictor (+) nomogram was 0.795 (95%CI: 0.764-0.825), which outperformed the C-index of the AJCC 8th edition TNM staging (0.693, 95%CI: 0.662-0.723). The calibration curves, t-ROC curves, and decision curve analysis for both nomogram models demonstrated their excellent prediction ability. This study presents the first risk stratification for Rictor status in gastric adenocarcinoma. Our model identifies low-risk patients who may not require additional postoperative treatment, while high-risk patients should consider targeted therapies that specifically target Rictor-positive indicators.