Radical Total Gastrectomy Research Articles

Extent of lymphadenectomy for Barrett's cancer.

Adenocarcinoma of the esophagus and esophagogastric junction (EGJ) has become the predominant histological cell type in western countries due to the prevalence of obesity, gastroesophageal reflux disease and Barrett's esophagus. There is some evidence that this is increasing in the East as well. Surgery aims at achieving an R0 resection with clear margins, together with adequate and appropriate lymphadenectomy. Siewert type I and II cancers are more likely to be associated with Barrett's esophagus (especially in western countries), while type III cancers are mostly proximal gastric cancers that have grown upwards to involve the EGJ. For type I cancers, most surgeons would perform an esophagectomy, with at least an infra-carinal lymphadenectomy. It is more controversial for type II tumors, with some surgeons preferring an esophagectomy, while others may opt for a proximal or total radical gastrectomy via an abdominal approach. All procedures can be performed using open or minimally invasive methods. In addition to oncologic reasons, the chosen surgical approach also depends on expertise available, safety issues, and postoperative quality-of-life considerations. More data are needed in this area. How to integrate knowledge and also multimodality treatment strategies is an active area of research.

Comparison of short-term effect of totally laparoscopy versus open radical total gastrectomy with D2 lymph node dissection on local advanced upper gastric cancer

Objective To explore the short-term effect of totally laparoscopic radical total gastrectomy with D2 lymph node dissection for treatment of local advanced upper gastric cancer. Methods Clinical data of 112 patients with local advanced upper gastric cancer who underwent totally laparoscopic or open radical total gastrectomy with D2 lymph node dissection in Affiliated Cancer Hospital of Shanxi Medical University from June 2016 to June 2018 were analyzed. The patients were divided into totally laparoscopic radical total gastrectomy with D2 lymph node dissection group (totally laparoscopic gastrectomy group, 54 cases) and open surgery radical total gastrectomy with D2 lymph node dissection group (opening gastrectomy group, 58 cases). The perioperative conditions and postoperative pathological conditions between the two groups were compared. Results All the 112 operations were technically successful. Compared with the opening gastrectomy group, the operating time of the totally laparoscopic gastrectomy group was longer [(240±47) min vs. (203±30) min], and the estimated blood loss was reduced [(103±21) ml vs. (260±34) ml], and the length of operative incision on body surface was shorter [(4.3±0.8) cm vs. (17.0±1.3) cm], and the differences between the two groups were statistically significant (all P 0.05). Compared with the opening gastrectomy group, the pain degree in 3-5 d after operation was slighter in the totally laparoscopic gastrectomy group, and the ratio of postoperative complications was lower, and the time of intestinal recovery and postoperative hospital stay was shorter, and the differences between the two groups were statistically significant (all P < 0.05). Conclusion Totally laparoscopic radical total gastrectomy with D2 lymph node dissection for local advanced upper gastric cancer has advantages in operation safety, the time of postoperative recovery and the number of postoperative complications, and the effect of lymph node dissection can reach the level of open surgery. Key words: Gastric neoplasms; Laparoscopy; D2 lymphnode dissection; Upper gastric cancer; Advanced

Can Proximal Gastrectomy with Double-Tract Reconstruction Replace Total Gastrectomy? A Propensity Score Matching Analysis

BackgroundThis retrospective cohort study compared proximal gastrectomy (PG) with double-tract reconstruction (DTR) versus total gastrectomy (TG) with Roux-en-Y reconstruction in terms of clinical outcomes. MethodsAll consecutive patients with upper early gastric cancer (EGC) who underwent PG-DTR or TG in 2008–2016 were selected. TG patients who matched PG-DTR patients in age, sex, body mass index, clinical stage, and ASA score were selected by propensity score matching. Groups were compared in terms of clinicopathological characteristics, clinical outcomes, early (≤ 30 days), late (> 30 days), and severe (Clavien-Dindo grade ≥ III) postoperative complications, 1-year reflux morbidity, recurrence, and mortality. ResultsOf 322 patients, 52 underwent PG-DTR. A matching TG group of 52 patients was selected. The PG-DTR group had smaller tumors (p = 0.02), smaller proximal and distal resection margins (p = 0.01, p < 0.01), and fewer retrieved lymph nodes (p < 0.01). PG-DTR associated with shorter times to diet and hospital stay (both p = 0.02). Groups did not differ in early (11.3 vs. 19.2%, p = 0.19), late (1.9 vs. 5.7%, p = 0.31), or severe complication rates (7.7 vs. 13.5%, p = 0.34). At 1 year, the groups did not differ in reflux symptoms (Visick score) or endoscopic esophagitis (Los Angeles Classification). There were no recurrences. Five-year overall survival rates were 100 and 81.6% (p = 0.02), respectively. ConclusionPG-DTR associated with better clinical outcomes and survival. Complication and reflux rates were similar. PG-DTR may be suitable for upper EGC.

Effects of robotic and laparoscopic-assisted surgery on lymph node dissection and short-term outcomes in patients with Siewert II adenocarcinoma of esophagogastric junction

To compare the effects of robotic and laparoscopic-assisted radical total gastrectomy on lymph node dissection and short-term outcomes in patients with Siewert type II adenocarcinoma of esophagogastric junction (AEG). Inclusion criteria: the tumor center was located between 2 cm above and below the esophagogastric junction and was confirmed as adenocarcinoma by endoscopic biopsy. tumor with local invasion of the liver,spleen, pancreas or other organs; intraoperative finding of tumor dissemination or distant metastasis; patients undergoing palliative surgical treatment or preoperative neoadjuvant chemotherapy; patients with serious heart diseases, lung diseases, liver diseases, kidney diseases and other comorbidities; patients with multiple primary cancers;patients receiving emergency surgery. According to the above criteria, 82 patients with Siewert type II AEG who underwent gastrointestinal surgery at the Affiliated Hospital of Qingdao University from October 2014 to October 2018 were enrolled in the study. They were randomly divided into robotic surgery groups (41 cases) and laparoscopic group (41 cases) according to a computer-generated randomized allocation table. Both groups underwent radical total gastrectomy plus D2 lymph node dissection through the transabdominal esophageal hiatus approach. The intraoperative conditions and postoperative short-term outcomes were compared between two groups, including surgery time, intraoperative blood loss, length of esophagectomy, postoperative complications, postoperative gastrointestinal recovery time, length of hospital stay, postoperative unplanned reoperation rate and rehospitalization rate. Mean±SD is used for the measurement data that conforms to the normal distribution, and two independent sample t-tests are used to compare the two groups; the comparison of the count data is performed by the χ² test. There were 35 males (85.4%) with age of (62.3±10.0) years and body mass index of (24.4±3.2) kg/m² in the robotic surgery group. There were 37 males (90.2%) with age of (62.5±10.0) years and body mass index of (23.8±2.6) kg/m² in the laparoscopic group. No significant differences in the baseline data between two groups were found (all P>0.05). All the patients of both groups completed R0 resection successfully without conversion to laparotomy or perioperative death. Compared with the laparoscopic group, the robotic group had less intraoperative blood loss [(70.7±39.9) ml vs. (110.2±70.6) ml, t=3.118, P=0.003], longer resected esophagus [(3.0±0.7) cm vs. (1.9±0.5) cm, t=8.759, P<0.001], but longer setup time [(56.5±7.4) minutes vs. (36.0±6.6) minutes, t=4.241, P<0.001], and higher hospitalization costs [(122 317.31±57 789.33) yuan vs. (99 401.56±39 349.53) yuan, t=2.099, P=0.039], whose differences were statistically significant (all P<0.05). The total number of harvested lymph node in the robotic surgery group was 39.2±15.3,which was significantly higher than that in the laparoscopic group (33.0±12.1) (t=0.733, P=0.047). In the robotic group and the laparoscopic group, the mediastinal lymph node No.110 and No.111 were 3.6±1.2 vs. 1.5±1.0 and 3.7±2.0 vs. 1.8±1.1, respectively, with significant difference (t=10.138, P<0.001, t=8.227, P<0.001); axillary lymph node No.19 and No.20 were 2.3±1.2 vs. 1.1±0.9 and 2.0±1.0 vs. 1.0±0.1, respectively, with significant difference (t=7.082, P<0.001,t=8.672,P<0.001). There were no significant differences in the total number of abdominal lymph node and the number of lymph node in abdominal stations between two group (all P>0.05). The highest lymph node metastasis rate was approximately 20% and observed in No.1, No.2, No.3, and No.7, followed by No.8a, No.9, No.11p, and No.110 with around 5%. The lymph node metastasis rate in other stations (No.4sa, No.4sb, No.4d, No.5, No.6, No.11d, No.12a, No.19, No.20 and No.111) was less than 5%.There were no significant differences in postoperative complication rate, postoperative fever time, postoperative exhaust and defecation time, fluid diet time, and postoperative hospital stay (all P>0.05). There were 2 patients(4.9%) with unplanned reoperation and 1 patient (2.4%) with unplanned re-admission in the laparoscopic group,while 3 patients (7.3%)with unplanned reoperation and 2 patients (4.9%)with unplanned re-admission in the robotic surgery group, whose differences were also not statistically significant (χ²=0.240,P=0.675;χ²=0.346,P=1.000). Robot-assisted radical total gastrectomy for Siewert II AEG is safe and feasible, which is characterized by more sophisticated operation, less blood loss and higher quality of lymph node dissection, especially for subphrenic and inferior mediastinal lymph nodes.

Efficacy of continuous irrigation combined with closed thoracic drainage for esophagojejunal anastomotic fistula complicated with mediastinal, thoracic and abdominal infections

To investigate the clinical efficacy of continuous irrigation combined with closed thoracic drainage for esophagojejunal anastomotic fistula (EJAF) complicated with mediastinal, thoracic and abdominal infection after total gastrectomy. Clinical data of 22 EJAF patients complicated with mediastinal, thoracic and abdominal infection after radical gastrectomy at Department of General Surgery of the 901th Hospital of PLA from June 2012 to May 2018 were retrospectively analyzed. Case inclusion criteria:(1) gastric adenocarcinoma confirmed by preoperative endoscopic pathology undergoing radical total gastrectomy without severe organ dysfunction;(2)EJAF complicated with mediastinal, thoracic and abdominal infections diagnosed by postoperative radiography, the presence of pleural effusion confirmed by CT and ultrasound. Among them, 10 cases were treated with simple thoracic closed drainage (single drainage group); 12 cases received same closed thoracic drainage, and a rubber catheter was placed next to the closed thoracic drainage tube in the same sinus. A 0.9% sodium chloride solution was applied in continuous drip irrigation with drip velocity at 50 to 100 ml/h(continuous flushing plus drainage group). Infection indicators, anastomotic fistula healing time and related clinical indicators were compared between the two groups. In the simple drainage group, 5 cases were males, age was (61.9±10.7) years old, 4 cases received laparoscopic surgery, 6 cases received open surgery, 6 cases were EJAF grade III, 4 cases were EJAF IV. In continuous flushing and drainage group, 6 cases were males, age was (61.7±11.0) years old, 7 cases received laparoscopic surgery, 5 cases received open surgery, 6 cases were EJAF grade III, and 6 cases were EJAF grade IV. Baseline data including gender, age, underlying diseases, preoperative hematological examination indexes, surgical methods, tumor TNM stage and EJAF grade were not significantly different between the two groups (all P>0.05). When postoperative EJAF was complicated with mediastinal, thoracic and abdominal infection, biochemical parameters including white blood cell, procalcitonin, C-reactive protein were not significantly different between two groups (all P>0.05). All patients of both groups achieved clinical cure without death. Compared with the simple drainage group after closed thoracic drainage, the continuous irrigation plus drainage group had significantly shorter duration of infection parameters returning to normal levels [white blood cell count: (6.8 ± 2.0) days vs.(10.5±3.0) days, t=4.062, P<0.001; procalcitonin: (7.5±1.0) days vs. (9.2±1.9) days, t=3.236, P=0.040; C-reactive protein: (8.8±1.0) days vs. (11.2±1.5) days, t=5.177, P<0.001], meanwhile time in surgical ICU [(4.9±2.5) days vs. (9.9±6.7) days, t=2.935, P=0.006], healing time of fistula [(42.9±12.5) days vs. (101.8±53.2) days, t=4.187, P=0.001] and total postoperative hospital stay [(62.3±15.8) days vs. (119.7 ±59.4) days, t=3.634, P=0.002] were significantly shorter, and total hospitalization cost was significantly lower (median 86 000 yuan vs. 124 000 yuan, Z=2.063, P=0.040) in the continuous irrigation plus drainage group. The continuous closed thoracic drainage with 0.9% sodium chloride solution can accelerate infection control and remission of EJAF patients complicated with mediastinal, thoracic and abdominal infections, and shorten the healing time of anastomotic fistula.

Feasibility of No.8p lymphadenectomy for the patients with advanced gastric cancer

To analyze the feasibility of No.8p lymphadenectomy for the patients with advanced gastric cancer and to preliminaryly explore its value in improving prognosis. Clinical data of 1158 patients with advanced gastric cancer undergoing radical gastrectomy plus D2 or above D2 lymphadenectomy (No.8 lymphadenectomy) from July 2003 to July 2013 at Department of Gastrointestinal Surgery, Fujian Cancer Hospital were collected. A retrospective cohort study was carried out. Among 1158 patients, 343 patients from July 2003 to June 2008 only received No.8a lymph node dissection (No.8a group), and 815 patients from July 2008 to July 2013 received No.8a+No.8p lymph node dissection (No.8a+No.8p group). Patients in No.8a group received the dissection of the lymph nodes in the upper margin of the pancreas and the front of total hepatic artery, and those in No.8a+No.8p group, on the basis of No.8a group, received the dissection of lymph nodes in the common hepatic artery and the left lymph nodes behind the hepatic artery and the portal vein. The metastasis degree and metastasis rate of lymph node(No.8a and No.8p), as well as intraoperative and postoperative presentations in both groups were investigated. The prognosis of two groups were analyzed with Kaplan-Meier method and Log-rank test. Among 1158 patients with advanced gastric cancer, 849 were males and 309 were females with aged 17 to 83(58.5 ±11.7) years. Radical distal gastrectomy was performed in 325 cases (28.1%) and radical total gastrectomy in 833 cases(71.9%). All the patients completed operations successfully. A total of 2587 No.8a lymph nodes were removed, and the lymph node metastasis rate and metastasis degree of No.8a were 20.6% (239/1158) and 13.0%(336/2587), respectively. A total of 2170 No.8p lymph nodes were removed, and the lymph node metastasis rate and metastasis degree of No.8p were 10.9%(89/815) and 7.2%(156/2170), respectively. The operation time of the No.8a+No.8p group was longer than that of No.8a group [(180.2±40.3) minutes vs. (168.4±41.8) minutes], and the difference was statistically significant (t=-4.627, P=0.000). However, intraoperative blood loss [(222.8±92.8) ml vs. (215.6±91.1) ml], postoperative 1-day peritoneal drainage volume [(257.7±120.0) ml vs. (270.3±121.0) ml], time to withdraw of gastric tube [(2.1±0.9) days vs. (2.2±0.8) days], time to withdraw of peritoneal tube [(6.8±1.1) days vs. (6.9±1.1) days], time to withdraw of nasal feeding tube[(6.5±1.2) days vs. (6.4±1.1) days], the morbidity of complications [19.8%(68/343) vs. 16.0%(130/815)] and postoperative hospital stay [(8.1±3.0) days vs.(8.3±3.1) days] in No.8a group and No.8a+No.8p group were not significantly different(all P>0.05). The average follow-up period was 41(2 to 144) months. The median postoperative survival was 83.0 months, and the 1-, 2-, and 5-year survival rates were 90.9%, 78.8% and 56.9% in No.8a group respectively. The median survival was 94.8 months, 1-, 2-, and 5-survival rates were 94.9%, 82.3% and 63.0% in No.8a+No.8p group respectively. The survival rate of No.8a+No.8p group was significantly higher than that of No.8a group (P=0.016). The stratified analysis showed that in stage II patients, the survival rate of No.8a+No.8p lymph node dissection was significantly higher than that of only No.8a lymph node dissection(P=0.021), but difference of survival between two groups was not significantly different in stage I patients(P=0.469) and stage III patients (P=0.820). For the patients with advanced gastric cancer, the dissection of No.8a+No.8p is safe and feasible, and may improve the prognosis, especially for those with stage II, suggesting that No.8a+No.8p lymphadenectomy should be performed for selected patients with advanced gastric cancer.

Similar hematologic and nutritional outcomes after proximal gastrectomy with double-tract reconstruction in comparison to total gastrectomy for early upper gastric cancer.

Proximal gastrectomy offers theoretical benefits over total gastrectomy in terms of hematologic and nutritional outcomes. However, little evidence confirming these benefits has been reported. The aim of this study was to assess the hematologic and nutritional outcomes of proximal gastrectomy with double-tract reconstruction in comparison to those of total gastrectomy. We retrospectively analyzed data from 80 patients with stage I gastric cancer who underwent proximal gastrectomy with double-tract reconstruction (n = 38) or total gastrectomy (n = 42) from September 2014 to December 2015. We compared hematologic (including hemoglobin, ferritin, vitamin B12, etc.) and nutritional outcomes [including body mass index (BMI), serum total protein, albumin, total cholesterol, and total lymphocyte count] between the two groups. We found no significant differences in changes in hemoglobin (P = 0.250) or cumulative incidence of iron deficiency anemia (P = 0.971) during a median follow-up period of 24months (range 18-30 months) after surgery. Cumulative incidence of vitamin B12 deficiency also did not differ significantly between the proximal and total gastrectomy groups (P = 0.087). BMI changes from baseline were not significantly different between the two groups (P = 0.591). Likewise, there were no statistically significant differences in nutritional outcomes. Proximal gastrectomy with double-tract reconstruction exhibited similar outcomes in terms of hematologic and nutritional features in comparison to total gastrectomy.

PS01.158: WHAT IS THE IDEAL RECONSTRUCTIVE TECHNIQUE FOR TYPE 2 GEJ TUMOURS—ESOPHAGOGASTROSTOMY OR ESOPHAGOJEJUNOSTOMY

Abstract Background In the management of OG junction tumors the border issue arises in type 2 cancers. It can be managed with various options like esophago gastrectomy (Ivor Lewis), transabdominal extended transhiatal gastrectomy or total esophago gastrectomy depends upon the extent strectomy of the tumor above and below. After resection the reconstruction can be either with stomach or jejunum or colon. However the functional result after either of these procedures varies. The aim of this study is to know the functional outcome of different reconstruction methods after esophagogastrectomy for locally advanced Type 2 OG junction tumours. Methods 148 consecutive patients who underwent surgery for OG junction tumors in the last 6 years were evaluated. Of them 62 locally advanced type2 OG junction tumors were included in our study. 26 underwent Ivor Levis procedure with gastric replacement. 36 underwent extended transhiatal gastrectomy with esophago jejunal anastamosis. Intra operative details like pyloroplasty, Operative time, blood loss, the distal margin, nodal clearance was noted. The functional outcome since immediate postoperative period to 1 year of follow up is reviewed retrospectively and prospectively in few cases. Results There is no significant difference in operating time, blood loss. Two patients with Partial gastrectomy had positive distal margin even though it is not statistically significant. The average number of nodes harvested is higher with total gastrectomy group with jejunal anastamosis and it is statistically significant between 2 groups (P &lt; 0.05).The GERD is more with gastric conduit when compared to Jejunal reconstruction but the weight loss is more with jejunal reconstruction when compared with gastric reconstruction. Conclusion The functional outcome and oncological outcome are superior with jejunal reconstruction after total gastrectomy when compared with gastric reconstruction after Ivor Lewis procedure. Disclosure All authors have declared no conflicts of interest.

Laparoscopic perigastric mesogastrium excision technique for radical total gastrectomy.

IntroductionComplete mesogastrium excision (CME) of the perigastric mesogastrium and dissection of lymph nodes (LNs) no. 10 and no. 11 remain technically challenging aspects of laparoscopic radical total gastrectomy (LRTG) plus CME. To address some of these difficulties, we introduced the laparoscopic perigastric mesogastrium excision technique (LPMET) and the concept of the “enjoyable space” to partly modify the procedures of conventional radical surgery and characterize the perigastric space and the surgical plane as well as its boundaries.AimTo introduce the laparoscopic perigastric mesogastrium excision technique (LPMET) and the “enjoyable space” when undergoing laparoscopic radical total gastrectomy.Material and methodsFrom July 2016 to June 2017, 79 cases of upper gastric cancer that were treated by laparoscopic D2 gastrectomy plus CME were investigated. The retrospective database included the patient characteristics, intraoperative and postoperative outcomes, and morbidity and mortality rates depending on the completeness of their medical records.ResultsLaparoscopic D2 gastrectomy plus CME was successfully performed in all 79 cases. The mean surgical time was 232.5 ±46.0 min, and the intraoperative blood loss was 67.6 ±52.3 ml. A total of 2245 LNs were retrieved (mean 28.1 ±10.8 retrieved from each specimen). The mean postoperative hospital stay was 10.3 ±1.6 days. The postoperative morbidity rate was 17.7%. After a median follow-up period of 12 months, one patient experienced liver metastasis; of the other 78 patients, none died or experienced tumor recurrence or metastasis.ConclusionsLaparoscopic perigastric mesogastrium excision technique and the “enjoyable space” could be a novel, minimally invasive approach and space to achieve CME and provide benefit for the dissection of LNs no. 10 and no. 11.

The Effect of Roux-en-Y Reconstruction on Type 2 Diabetes in the Early Postoperative Period.

The aim of this study was to investigate the effect of Roux-en-Y (RY) reconstruction on type 2 diabetes with gastric cancer in the early postoperative period. A total of 44 patients with gastric cancer with type 2 diabetes who underwent total gastrectomy (TG) or distal gastrectomy (DG) with Roux-en-Y reconstruction or DG with Bilroth I were enrolled. All three groups had their fasting glucose and daily insulin dose recorded preoperatively, on day 2 postoperatively (POD2) and at discharge. The TG group showed low fasting glucose and daily insulin dose on POD2 compared to their preoperative state. On discharge, the fasting glucose and daily insulin dose were significantly lower in both TG and DG Roux-en-Y groups than preoperatively. Roux-en-Y reconstruction showed early improvement of type 2 diabetes regardless of any body weight loss. The effect of Roux-en-Y reconstruction in TG on type 2 diabetes was more remarkable than that of DG.

Can the neutrophil-lymphocyte ratio and platelet-lymphocyte ratio be beneficial in predicting lymph node metastasis and promising prognostic markers of gastric cancer patients? Tumor maker retrospective study

BackgroudInflammation can promote tumor growth, invasion, angiogenesis and even metastasis. Inflammatory markers have prognostic value in some malignancies. The aim of the present study was to examine whether neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) served as sensitive serum markers for predicting lymph node metastasis and prognostic factors in gastric cancer (GC) patients. Methods904 consecutive patients who underwent radical total or subtotal gastrectomy between 2010 and 2011, were included in this study. The clinical utility of the NLR and PLR was evaluated by receiver operating characteristic (ROC) curves,Kaplan-Meier curves and Cox regression analyses were used to calculate the overall survival (OS) characteristics. ResultsWe determined the cutoff values of NLR and PLR was 2.0 and 160 respectively according to the ROC curve. Both the NLR and PLR were significantly associated with LN (lymph node) metastasis, and high NLR and PLR groups were significantly associated with poor overall survival. Additionally, NLR and TNM stage were independent prognostic factors for overall survival, however, PLR had limited value. ConclusionsNLR and PLR levels may be valuable indexes for lymph node metastasis. Although both the PLR and NLR may have prognostic value of gastric cancer patients, NLR is better to predict overall survival than PLR.

Laparoscopic total gastrectomy for remnant gastric cancer: A single-institution experience.

The incidence of remnant gastric cancer is increasing because of past use of subtotal gastrectomy to treat peptic ulcer and increased survival rates after radical gastrectomy for gastric cancer. The feasibility and advantages of laparoscopic total gastrectomy (LTG) for remnant gastric cancer remain unclear. Therefore, we aimed to investigate the safety, feasibility, and clinical short-term outcomes of LTG for remnant gastric cancer. Patients who underwent completion total gastrectomy for remnant gastric cancer between April 2007 and October 2017 were divided into two groups: the open total gastrectomy (OTG) group and the LTG group. Clinicopathological data and short-term outcomes were analyzed. A total of 31 remnant gastrectomies (23 OTG, 8 LTG) were performed. Blood loss was significantly lower in the LTG group than in the OTG group (135.5 vs 568.3 mL, P = 0.013). However, there was no significant difference in the operation time, days to food intake, or length of hospital stay between the two groups. Additionally, there was no significant difference in the postoperative complications, number of retrieved lymph nodes, or pathological findings. Two LTG patients (25.0%) required conversion to open surgery. There was no mortality in either group. LTG for remnant gastric cancer can be a safe treatment option and may have an advantage of less blood loss than OTG.

Effect of early oral feeding on length of hospital stay following gastrectomy for gastric cancer: a Japanese multicenter, randomized controlled trial.

This multicenter, randomized controlled study evaluates the safety of early oral feeding following gastrectomy, and its effect on the length of postoperative hospital stay. The subjects of this study were patients who underwent distal gastrectomy (DG) or total gastrectomy (TG) for gastric cancer between January 2014 and December 2015. Patients were randomly assigned to the early oral feeding group (intervention group) or the conventional postoperative management group (control group) for each procedure. We evaluated the length of postoperative hospital stay and the incidence of postoperative complications in each group. No significant differences in length of postoperative stay were found between the intervention and control groups of the patients who underwent DG. The incidence of postoperative complications was significantly greater in the DG intervention group. In contrast, the length of postoperative stay was significantly shorter in the TG intervention group, although the TG group did not attain the established target sample size. Early oral feeding did not shorten the postoperative hospital stay after DG. The higher incidence of postoperative complications precluded the unselected adoption of early oral feeding for DG patients. Further confirmative studies are required to definitively establish the potential benefits of early oral feeding for TG patients.

Status and progress about total gastrectomy for gastric carcinoma

Gastric cancer is a common gastrointestinal cancer. With the incidence of cancer in the middle and proximal stomach is increasing year by year, radical total gastrectomy as a major operative method, is widely used in the treatment of gastric cancer. However, various surgical complications often occur after total gastrectomy, which affect patients’ postoperative recovery and the quality of life. This article discussed the influential factors of surgical complications after total gastrectomy, and discussed the feasibility of applying Clavien-Dindo classification system to evaluate the severity of complications after total gastrectomy. Key words: Stomach neoplasms; Postoperative complications; Review; Total gastrectomy; Clavien-Dindo Classification

Application of robotic and laparoscopic radical total gastrectomy to gastric cancer patients with body mass index ≥24 kg/m2

To compare the short-term outcomes between robotic and laparoscopic radical total gastrectomy in gastric cancer patients with BMI index ≥24 kg/m2. Clinical data of 93 gastric cancer patients who underwent robotic and laparoscopic radical total gastrectomy at PLA General Hospital from April 2016 to April 2017 were retrospectively analyzed. The retrospective cohort study was adopted. preoperatively definite diagnosis of primary gastric cancer by endoscopy and biopsy; preoperative BMI ≥24 kg/m2; no previous abdominal surgery; no previous chemotherapy and radiotherapy; no distant metastasis or invasion into adjacent organs before operation or during operation; receiving radical gastrectomy; Roux-en-Y reconstruction of digestive tract in open procedure. According to approaches of minimally invasive surgery, 24 patients underwent robotic surgery and 69 underwent laparoscopic surgery. The intraoperative parameters (overall operative time, pneumoperitoneal time, open procedure time, intraoperative blood loss, transfusion rate, number of total retrieved lymph nodes and metastatic lymph nodes) and postoperative parameters (drainage in the first postoperative day, the first defecation time, morbidity of postoperative complication and hospital stay) were compared between two groups. Correlation of the above parameters were analyzed. Of 93 patients, 77 were male and 16 female with an average age of (60.0±10.6) years. The average BMI was (26.8±1.3) kg/m2 in whole patients, (26.9±1.6) kg/m2 in robotic group and (26.8±1.7) kg/m2 in laparoscopic group. No significant differences in age, gender, BMI, preoperative ASA class, postoperative pathological findings and clinical classification were observed between two groups, which made short-term parameters between two groups comparable. The robotic group had a significantly longer overall operative time [(301.2±68.9) minutes vs. (247.3±59.6) minutes, P=0.000], longer open procedure time [(141.5±26.3) minutes vs. (92.5±36.7) minutes, P=0.029] and higher cost than laparoscopy group[(17.5×104 ± 9.7×104) yuan vs. (10.0×104 ± 2.3×104) yuan, P=0.001]. Pneumoperitoneal operative time, intraoperative blood loss, transfusion rate, number of total retrieved lymph nodes, number of harvested metastatic lymph nodes and postoperative short-term efficacy were similar between the two groups (all P>0.05). In robotic group, pneumoperitoneal operative time was positively correlated with overall operative time (r=0.708, P=0.010); total cost was positively correlated with postoperative hospital stay (r=0.493, P=0.000) and open procedure time was negatively correlated with the first defecation time (r=-0.962, P=0.038). In laparoscopy group, total cost was positively correlated with overall operative time (r=0.411, P=0.046), drainage volume in the first postoperative day was positively correlated with the number of total dissected lymph node (r=0.540, P=0.006), postoperative hospital stay was positively correlated with intraoperative blood loss (r=0.574, P=0.003), total cost was positively correlated with intraoperative blood loss and hospital stay (r=0.609, P=0.002; r=0.865, P=0.000), drainage volume in the first postoperative day was positively correlated with BMI (r=0.533, P=0.007). For gastric cancer patients with BMI ≥24 kg/m2, robotic radical total gastrectomy is associated with longer operative time and higher cost, but is less vulnerable to the change of BMI and more in favor of the realization of enhanced recovery after surgery (ERAS) than laparoscopic radical total gastectomy.

Total vs proximal gastrectomy for adenocarcinoma of the upper third of the stomach: a propensity-score-matched analysis of a multicenter western experience (On behalf of the Italian Research Group for Gastric Cancer-GIRCG).

The aim of this study is to compare surgical outcomes including postoperative complications and prognosis between total gastrectomy (TG) and proximal gastrectomy (PG) for proximal gastric cancer (GC). Propensity-score-matching analysis was performed to overcome patient selection bias between the two surgical techniques. Among 457 patients who were diagnosed with GC between January 1990 and December 2010 from four Italian institutions, 91 underwent PG and 366 underwent TG. Clinicopathologic features, postoperative complications, and survivals were reviewed and compared between these two groups retrospectively. After propensity-score matching had been done, 150 patients (75 TG patients, 75 PG patients) were included in the analysis. The PG group had smaller tumors, shorter resection margins, and smaller numbers of retrieved lymph nodes than the TG group. N stages and 5-year survival rates were similar after TG and PG. Postoperative complication rates after PG and TG were 25.3 and 28%, respectively, (P=0.084). Rates of reflux esophagitis and anastomotic stricture were 12 and 6.6% after PG and 2.6 and 1.3% after TG, respectively (P<0.001 and P=0.002). 5-year overall survival for PG and TG group was 56.7 and 46.5%, respectively (P=0.07). Survival rates according to the tumor stage were not different between the groups. Multivariate analysis showed that type of resection was not an independent prognostic factor. Although PG for upper third GC showed good results in terms of survival, it is associated with an increased mortality rate and a higher risk of reflux esophagitis and anastomotic stricture.

Clinicopathology and Survival in Patients with Gastroesophageal Reflux After Radical Surgery of Proximal Gastric Cancer.

Gastroesophageal reflux (GR) after radical resection of proximal gastric cancer (PGC) may influence survival; however, few studies have investigated survival in PGC patients who develop GR following radical resection. This study aimed to correlate the occurrence of GR after proximal gastrectomy (PG) and total gastrectomy (TG) with clinicopathological factors and long-term survival. The PGC patient cohort was retrospectively grouped as follows: postoperative patients with and without GR (NGR). Clinicopathological characteristics and survival data were compared between the two groups. A total of 88 patients who underwent PG (53%) experienced postoperative GR; however, only 30 patients who underwent TG (14%) experienced GR (P=0.000). The incidence of GR was significantly associated with surgical procedure (P<0.01), tumor size (P<0.01), infiltration depth (P<0.01), lymph node metastasis (P=0.018), postoperative distant metastasis (P<0.01) and recurrence (P=0.001). The 5-year overall survival of the GR group was significantly worse than that of the NGR group (39.3 vs. 46.5%, respectively; P=0.046). The PG and TG groups had significantly different 5-year overall survival (45.2 vs. 50.9%, respectively; P=0.047), and multivariate analysis revealed GR as an independent risk factor associated with poor overall survival. Patients who experienced GR after radical resection for PGC were more likely to develop recurrence and metastasis, leading to shorter survival. TG for PGC was associated with a more favorable 5-year overall survival than was PG. Thus, TG should be performed for PGC patients with tumors larger than 5cm, T3/T4 disease or lymph node metastasis to improve their long-term survival.

An evaluation of the surgical treatment strategy for the adenocarcinoma of the esophagogastric junction: A retrospective single center study in Japan.

177 Background: The incidence of Siewert type II adenocarcinoma of the esophagogastric junction (AEG II) has been increasing in the East, and total gastrectomy (TG) has been a standard treatment procedure. However, it is reported that the incidence of distal perigastric lymph node (LN) metastasis is low, and thus proximal gastrectomy (PG) could be a treatment option. The aim of this study was to demonstrate the oncological safety of PG for patients with AEG II. Methods: This study included 99 patients with AEG II who underwent gastrectomy with lower esophagectomy from Jan. 2008 to June 2017. Patients with esophageal invasion over 30 mm, and those with positive LN in the upper/middle mediastinum were excluded. PG was selected when more than half of the stomach could be preserved, and no obvious distal perigastric LN metastasis was found. Surgical approach was selected at the patients’ discretion. Short- and long-term outcomes were compared between patients who underwent TG (N = 43) and PG (N = 56). Results: Laparoscopic surgery was the predominant procedure (75.0%) in the PG group while open surgery was most frequently selected (79.1%) in the TG group. Intraoperative and short-term surgical outcomes were not different between the groups except for intraoperative blood loss, which was less in the PG group than in the TG group. Survival outcomes tended to be better in the PG group than in the TG group (3-/5-year OS, 91.1%/ 91.1% vs 67.4%/ 65.1%), presumably due to the predominance of early stage cancers in the PG group. After stratification by pStage, however, survival outcomes were not significantly different between the groups in any pStage. In the PG group, distal perigastric LN reccurence was not found during the follow-up period. In the TG group, 2 patients (4.7%) had distal perigastric LN metastasis, and both died within 2 years of surgery. Conclusions: Therapeutic value of distal perigastric LN dissection is quite limited in patients with AEG II. PG seems to be as oncologically safe as TG, and could be a suitable treatment strategy for patients with AEG II.

Influence of body configuration on the therapeutic effects of totally laparoscopic and laparoscopy-assisted radical total gastrectomies: a multicentre retrospective study (A report of 677 cases)

Influence of body configuration on the therapeutic effects of totally laparoscopic and laparoscopy-assisted radical total gastrectomies: a multicentre retrospective study (A report of 677 cases)

Long-Term Nutritional Outcomes of Near-Total Gastrectomy in Gastric Cancer Treatment: a Comparison with Total Gastrectomy Using Propensity Score Matching Analysis.

PurposeThis study sought to examine whether near total gastrectomy (nTG) confers a long-term nutritional benefit when compared with total gastrectomy (TG) for the treatment of gastric cancer.Materials and MethodsPatients who underwent nTG or TG for gastric cancer were included (n=570). Using the 1:2 matched propensity score, 25 patients from the nTG group and 50 patients from the TG group were compared retrospectively for oncologic outcomes, including long-term survival and nutritional status.ResultsThe length of the proximal resection margin, number of retrieved lymph nodes and tumor nodes, metastasis stage, short-term postoperative outcomes, and long-term survival were not significantly different between the groups. The body mass index values, and serum total protein and hemoglobin levels of the patients decreased significantly until postoperative 6 months, and then recovered slightly over time (P<0.05); however, there was no difference in the levels between the groups. The prognostic nutritional index values and serum albumin levels decreased significantly until postoperative 6 months and then recovered (P<0.05); the levels decreased more in the nTG group than in the TG group (P<0.05). The mean corpuscular volumes and serum transferrin levels increased significantly until postoperative 1 year and then recovered slightly over time (P<0.05); however, there was no difference between the groups. Serum vitamin B12, iron, and ferritin levels of the patients did not change significantly over time, and no difference existed between the groups.ConclusionsA small remnant stomach after nTG conferred no significant nutritional benefits over TG.