Type Of Gastrectomy Research Articles

Gastric Carcinoma and Role of Proximal Gastrectomy

Objective: Comparative analysis of different surgical methods for the treatment of gastric carcinoma with proximal gastrectomy. Study Design: Retrospective study Place and Duration of Study: Department of Surgery Unit-2, Ghulam Muhammad Mahar Medical College, Teaching Hospital, Sukkur, Department of Surgery, Wah Medical College POF Hospital, Wah Cantt and from Department of Surgery, CMH Kharian Medical College, Kharian from 1st January 2015 to 30th June 2021. Methodology: One hundred patients were retrospectively evaluated for the proximal gastrectomy with the previously conducted procedures of open gastrectomy as well as laparoscopic gastrectomy. The patients were compared for the various types of gastrectomy used with the new established proximal gastrectomy method. The patient distribution was based on available resources and patients’ consent. Patients were identified as into two groups where group 1 patients were placed for open total gastrectomy whereas group 2 patients were defined as laparoscopic proximal gastrectomy. All the patients were compared in terms of operation time, recurrence rate and associated complications. Results: Mean age of the study participants were 54.5±3.3 years. Higher frequency of males participants were observed as compared to the females. Estimated blood loss was considerably different in both study groups. Excess blood loss was seen in total gastrectomy in contrast to laparoscopic procedure. Less complication was observed in open gastrectomy than to laparoscopic proximal gastrectomy. Conclusion: Minimally invasive surgical method could be the standard surgical procedure for gastric oncology treatment in which function of the stomach can be preserved along with safety profiles. Therefore, LPG can be a preferable treatment option for other available treatment options. Keywords: Invasive, Oncology, Laparoscopic, Complications, Gastric

Bariatric Surgery and Psychological Health: A Randomised Clinical Trial in Patients with Obesity and Type 2 Diabetes

PurposeThis study investigated the impact of either Roux-en-Y gastric bypass with silastic ring (SR-RYGB) or sleeve gastrectomy (SG) types of bariatric surgery on psychological health and explored the role of pre-existing depressive symptoms on weight loss.Materials and MethodsA total of 114 participants with obesity and type 2 diabetes were randomized to receive SR-RYGB or SG at a single centre. Data from the Hospital Anxiety and Depression Scale (HADS), RAND 36-item Health Survey and body weight were collected before surgery and annually for 5 years.ResultsSixteen patients were lost to follow-up at 5 years. Of the 98 patients who completed 5-year psychological follow-up assessments, 13 had mild to severe depressive symptoms (SR-RYGB n = 6, SG n = 7). SR-RYGB and SG resulted in similar psychological health improvement but percent weight loss at 5 years was greater for SR-RYGB by 10.6% (95% CI: 7.2 to 14.0, P < 0.0001). Scores for depressive symptoms and most RAND-36 domains improved significantly from baseline to 5 years in both groups. Patients with pre-existing depressive symptoms had similar percent weight loss at 5 years compared to patients without depressive symptoms, irrespective of procedural type.ConclusionPatients receiving either SR-RYGB or SG had comparable psychosocial functioning, which was maintained to 5 years post-surgery. Pre-existing depressive symptoms did not affect weight loss achieved at 5 years. These findings confirm previous longitudinal studies demonstrating that bariatric surgery is generally associated with improved psychosocial functioning.Graphical

Laparoscopic vs. open distal gastrectomy for locally advanced gastric cancer: A systematic review and meta-analysis of randomized controlled trials.

The aim of this systematic review and meta-analysis is to compare the short- and long-term outcomes of laparoscopic distal gastrectomy (LDG) with those of open distal gastrectomy (ODG) for patients with advanced gastric cancer (AGC) who exclusively underwent distal gastrectomy and D2 lymphadenectomy in randomized controlled trials (RCTs). Data in published meta-analyses that included different gastrectomy types and mixed tumor stages prevented an accurate comparison between LDG and ODG. Recently, several RCTs that compared LDG with ODG included AGC patients specifically for distal gastrectomy, with D2 lymphadenectomy being reported and updated with the long-term outcomes. PubMed, Embase, and Cochrane databases were searched to identify RCTs for comparing LDG with ODG for advanced distal gastric cancer. Short-term surgical outcomes and mortality, morbidity, and long-term survival were compared. The Cochrane tool and GRADE approach were used for evaluating the quality of evidence (Prospero registration ID: CRD42022301155). Five RCTs consisting of a total of 2,746 patients were included. Meta-analyses showed no significant differences in terms of intraoperative complications, overall morbidity, severe postoperative complications, R0 resection, D2 lymphadenectomy, recurrence, 3-year disease-free survival, intraoperative blood transfusion, time to first liquid diet, time to first ambulation, distal margin, reoperation, mortality, or readmission between LDG and ODG. Operative times were significantly longer for LDG [weighted mean difference (WMD) 49.2 min, p < 0.05], whereas harvested lymph nodes, intraoperative blood loss, postoperative hospital stay, time to first flatus, and proximal margin were lower for LDG (WMD -1.3, p < 0.05; WMD -33.6 mL, p < 0.05; WMD -0.7 day, p < 0.05; WMD -0.2 day, p < 0.05; WMD -0.4 mm, p < 0.05). Intra-abdominal fluid collection and bleeding were found to be less after LDG. Certainty of evidence ranged from moderate to very low. Data from five RCTs suggest that LDG with D2 lymphadenectomy for AGC has similar short-term surgical outcomes and long-term survival to ODG when performed by experienced surgeons in hospitals contending with high patient volumes. It can be concluded that RCTs should highlight the potential advantages of LDG for AGC. PROSPERO, registration number CRD42022301155.

The definition of “R1” lymph node dissection status in patients undergoing curative-aim gastrectomy for gastric carcinoma: A proof of concept study

IntroductionThe aim of this study was to define and investigate the prognostic impact of “R1-Lymph-node dissection” during gastrectomy. MethodsThis was a retrospective study conducted with 499 patients undergoing curative-aim gastrectomy. We defined R1-Lymph dissection as an involvement of lymph node stations anatomically connected with lymph node stations outside the declared level of dissection (D1 to D2+). The primary outcomes were disease-free and disease-specific survival (DFS and DSS). ResultsAt multivariable analysis, the type of gastrectomy, pT and pN were associated with DFS, and the type of gastrectomy, R1-Margin status, R1-Lymph status, pT, pN and adjuvant therapy were associated with DSS. Moreover, pT and R1-Lymph status were the only factors associated with overall loco-regional recurrence. ConclusionsIn this study, we introduced the concept of R1-Lymph-node dissection, which was significantly associated with DSS and appeared to be a stronger prognostic factor for loco-regional recurrence than the R1 status on the resection margin.

Predictive significance of surgery-induced lymphopenia on the survival after curative resection for locally advanced gastric cancer: a retrospective cohort analysis

BackgroundFollowing the establishment of the anti-cancer effect of immune checkpoint inhibitors, lymphopenia has attracted attention as a parameter of preexisting cancer-related immune tolerance. Although the pretreatment absolute lymphocyte count (ALC) has been reported as a prognostic factor in gastric cancer patients, the impact of perioperative changes in the ALC remains unknown. The aim of the present study was to explore the relationship between surgery-induced lymphopenia and outcome.MethodsDatabase entries for 584 patients who underwent curative resections for pathological Stage IB-III gastric cancer were reviewed. We retrospectively compared clinicopathological factors including pretreatment ALC (pre-ALC) and ALC at first visit after discharge (post-ALC) with the survival. The low ALC was defined as < 1000/μL.ResultsThe ALC decreased significantly at 1 and 3 days after surgery and then recovered to the baseline value. A low pre-ALC (p < 0.001) and a low post-ALC (p < 0.001) were both correlated with a poor relapse-free survival (RFS). A multivariate analysis of RFS identified a low post-ALC (hazard ratio 1.875, 95% CI 1.156–3.402, p = 0.01), age, gender, BMI, T disease, N disease, severe vessel invasion, type of gastrectomy and postoperative morbidity as independent factors. The low post-ALC group had a poor RFS among patients with Stage II (p = 0.04) and Stage III (p = 0.04) disease, but not among patients with Stage IB disease (p = 0.13). Consistently, the overall survival (OS) rate was significantly lower among patients with a low post-ALC for all stage (p < 0.001), stage II (p = 0.02) and stage III (p = 0.01) disease, not for stage IB (p = 0.09). A low post-ALC was identified as an independent factor for predicting OS by multivariate analysis (hazard ratio: 2.275, 95% CI 1.373–3.769, p = 0.01).ConclusionsA decrease in post-ALC was correlated with both of RFS and OS after curative resection in patients with locally advanced gastric cancer.HighlightsPostoperative lymphopenia was a poor prognostic factor for gastric cancer.

Effect of Four Main Gastrectomy Procedures for Proximal Gastric Cancer on Patient Quality of Life: A Nationwide Multi-Institutional Study.

This study aimed to examine the effects of 4 main types of gastrectomy for proximal gastric cancer on postoperative symptoms, living status, and quality of life (QOL) using the Postgastrectomy Syndrome Assessment Scale-45 (PGSAS-45). We surveyed 1,685 patients with upper one-third gastric cancer who underwent total gastrectomy (TG; n=1,020), proximal gastrectomy (PG; n=518), TG with jejunal pouch reconstruction (TGJP; n=93), or small remnant distal gastrectomy (SRDG; n=54). The 19 main outcome measures (MOMs) of the PGSAS-45 were compared using the analysis of means (ANOM), and the general QOL score was calculated for each gastrectomy type. Patients who underwent TG experienced the lowest postoperative QOL. ANOM showed that 10 MOMs were worse in patients with TG. Four MOMs improved in patients with PG, while 1 worsened. One MOM was improved in patients with TGJP versus 8 MOMs in patients with SRDG. The general QOL scores were as follows: SRDG (+39 points), TGJP (+6 points), PG (+3 points), and TG (-1 point). The TG group experienced the greatest decline in postoperative QOL. SRDG and PG, which preserve part of the stomach without compromising curability, and TGJP, which is used when TG is required, enhance the postoperative QOL of patients with proximal gastric cancer. When selecting the optimal gastrectomy method, it is essential to understand the characteristics of each and actively incorporate guidance to improve postoperative QOL.

Impact of gastrectomy on body composition within 1month in patients with gastric cancer.

The present study examined the changes in and risk factors for body composition (BC) during the first postoperative month when dynamic biological reactions occur. We retrospectively assessed 202 patients who underwent gastrectomy. The BC was assessed using a bioelectrical impedance analysis and evaluated within 1month preoperatively, 1week postoperatively, and 1month postoperatively. Multiple regression analyses were performed to identify predictive factors for BC change. The mean reduction rate in BC at 1month postoperatively was - 6.0, - 10.5, - 5.6, - 1.1, - 10.1, and + 1.2% for body weight, body fat, skeletal muscle, bone mineral, extracellular water/total body water, and the whole-body phase angle, respectively. A multiple regression analysis revealed that independent risk factors for weight loss were complications, operative time, and type of gastrectomy (P = 0.004, 0.011, 0.015, respectively), and those for skeletal muscle loss were complications and gastrectomy type (P = 0.002, 0.010, respectively). A segmental lean mass analysis revealed that the lower limbs were markedly reduced at 1week postoperatively (- 8.0%), and these independent risk factors were the female sex and Stage II/III disease (P = 0.008, 0.036, respectively). Detailed analyses of BC might help elucidate the mechanisms underlying postoperative physical changes, which might be useful for perioperative management.

Current status of gastrectomy and reconstruction types for patients with proximal gastric cancer in Japan

BackgroundSurgical procedures for proximal gastric cancer remain a highly debated topic. Total gastrectomy (TG) is widely accepted as a standard radical surgery. However, subtotal esophagectomy, proximal gastrectomy (PG) or even subtotal gastrectomy, when a small upper portion of the stomach can technically be preserved, are alternatives in current clinical practice. MethodsUsing a cohort of the PGSAS NEXT trial, consisting of 1909 patients responding to a questionnaire sent to 70 institutions between July 2018 and December 2019, gastrectomy type, reconstruction method, and furthermore the remnant stomach size and the anti-reflux procedures for PG were evaluated. ResultsTG was the procedure most commonly performed (63.0%), followed by PG (33.4%). Roux-en-Y was preferentially employed following TG irrespective of esophageal tumor invasion, while jejunal pouch was adopted in 8.5% of cases with an abdominal esophageal stump. Esophagogastrostomy was most commonly selected after PG, followed by the double-tract method. The former was preferentially employed for larger remnant stomachs (≧3/4), while being used slightly less often for tumors with as compared to those without esophageal invasion in cases with a remnant stomach 2/3 the size of the original stomach. Application of the double-tract method gradually increased as the remnant stomach size decreased. Anti-reflux procedures following esophagogastrostomy varied markedly. ConclusionsTG is the mainstream and PG remains an alternative in current Japanese clinical practice for proximal gastric cancer. Remnant stomach size and esophageal stump location appear to influence the choice of reconstruction method following PG.

Individualized Choice of Simultaneous Cholecystectomy in Patients with Gastric Cancer: A Systematic Review and Meta-analysis.

Patients undergoing gastrectomy for gastric cancer are more likely to develop gallstones than the general population. Prophylactic cholecystectomy remains controversial. Studies from 2000-2022 were systematically searched in the PubMed, EMBASE, and Cochrane Library databases. The search included simultaneous cholecystectomy or risk factors for gallstone formation with gastrectomy alone. Major prognostic factors included complications and mortality, and risk factor analyses included age, sex, TNM stage, gastrectomy type, lymph node dissection, diabetes, and duodenal exclusion. Random effects regression models were used to analyze risk estimates and data were presented as odds ratios (ORs) with corresponding 95% confidence intervals (CIs). There were no significant differences in postoperative morbidity (OR 1.12, 95% CI 0.90-1.39; p=0.33, I2=11%) and mortality (OR 1.23, 95% CI 0.62-2.43; p=0.56, I2=0%) between gastrectomy alone and simultaneous cholecystectomy. Older age (OR 1.48, 95% CI 1.36-1.59; p<0.001, I2=59%), male sex (OR 1.38, 95% CI 1.10-1.71; p=0.004, I2=77%), total gastrectomy (OR 1.50, 95% CI 1.25-1.81; p<0.001, I2=72%), diabetes mellitus (OR 1.38, 95% CI 1.17-1.63; p<0.001, I2=8%), and duodenal exclusion (OR 1.77, 95% CI 1.47-2.15; p<0.001, I2=30%) were risk factors for cholecystolithiasis. Simultaneous cholecystectomy did not increase the incidence of postoperative complications or mortality. Older age, male sex, total gastrectomy, duodenal exclusion, and diabetes were risk factors for gallstone development after gastrectomy.

Nuclear factor erythroid-2-related factor 2 (Nrf2) is a potential prognostic factor in patients with gastric adenocarcinoma

BackgroundGastric cancer is one of the leading causes of cancer-related death, and many researchers are focused on the discovery and use of different biomarkers in prognosis prediction. The use of Nrf2 as a prognostic marker in patients with gastric cancer remains controversial. In this study, we evaluated the expression of Nrf2 protein in gastric adenocarcinoma. Patients and methodsA total of 86 patients who underwent gastric resection and D2 lymph node dissection due to gastric adenocarcinoma were included. Clinicopathological characteristics, such as age, gender, gastrectomy type, pathologic T (pT) and N (pN) stages, tumor grade, tumor type per Lauren’s classification, presence of lymphovascular invasion, and Nrf2 expression were evaluated. ResultsWhile pT, pN, and Nrf-2 expression were found to be negative prognostic predictors for overall survival in one-way analysis of variance, Nrf-2 expression was the only significant negative prognostic predictor in multivariance analysis. pT, pN, diffuse type, high tumor grade, and Nrf-2 expression significantly affected overall survival in Kaplan-Meier survival analyses (p = 0.02, p = 0.03, p < 0.01, p = 0.027, and p = 0.001, respectively). ConclusionsOur findings support that Nrf2 is a prognostic marker in patients with gastric adenocarcinoma. Anti-Nrf2 therapy options should be investigated to improve prognosis in gastric cancer patients.

Comparison of Short-Term Surgical Outcomes of Two Types of Robotic Gastrectomy for Gastric Cancer: Ultrasonic Shears Method Versus the Maryland Bipolar Forceps Method

BackgroundThis study investigated the impact and short-term surgical outcomes of two different main energy devices for robotic gastrectomy for gastric cancer. The outcomes of robotic gastrectomy with ultrasonic shears and those of robotic gastrectomy with conventional forceps were compared. MethodsWe retrospectively evaluated 171 patients who underwent robotic distal gastrectomy or total gastrectomy for gastric cancer. We classified patients into the ultrasonic shears (US) and Maryland bipolar (MB) forceps groups according to the main energy device used for robotic gastrectomy. ResultsWe extracted 58 patients from the US group and 58 patients from the MB forceps groups using propensity score matching. The total console time (310 min [interquartile range (IQR), 253–369 min] and 332 min, [IQR, 294–429 min]; p = 0.022) and the console time to gastrectomy (222 min [IQR, 177–266 min] and 247 min [IQR, 208–321 min]; p = 0.004) were significantly shorter in the US group than in the MB forceps group. Less blood loss occurred in the US group than in the MB forceps group (20 mL [IQR, 10–40 mL] and 30 mL [IQR, 16–80 mL]; p = 0.014). The postoperative complication rate and postoperative hospital stay length were similar between groups. A multivariate multiple linear regression analysis demonstrated that the use of an ultrasonically activated device was one an independent factor that reduced the operative time of robotic gastrectomy. ConclusionUsing ultrasonic shears as the main energy device may contribute to better surgical outcomes after robotic gastrectomy for gastric cancer.

Chinese expert consensus on prevention and treatment of complications related to digestive tract reconstruction after laparoscopic radical gastrectomy for gastric cancer (2022 edition)

According to the different tumor locations and stages of gastric cancer, distal radical gastrectomy, radical total gastrectomy and proximal radical gastrectomy for gastric cancer are respectively selected in clinical practice. Regardless of the type of radical gastrectomy, digestive tract reconstruction is of great importance to gastrectomy, and it is also susceptible to related surgical complication. The occurrence of surgical complications directly affects the efficacy and postoperative quality of life, and even leads to death, resulting in serious consequences of giving up all previous efforts! Therefore, in the era of laparoscopic surgery, how to safely perform digestive tract reconstruction to reduce the occurrence of related complications, and how to properly and effectively deal with complications will be helpful to improve the overall level of gastric cancer treatment in China. This consensus is mainly aimed at the complications that occur during the process of digestive tract reconstruction and in the recent postoperative period. From the aspects of causes, preventive measures and treatment measures, after extensive review of data and combination with clinical practice, the opinions of domestic authoritative experts have been repeatedly collected and discussed. Finally, an expert consensus was formed, which provided an effective reference for Chinese surgeons to improve the prevention and treatment of complications of gastrointestinal reconstruction after radical resection of gastric cancer.

Benefits of minimally invasive surgery in the treatment of gastric cancer.

We read with great interest the article that retrospectively analyzed 814 patients with primary gastric cancer, who underwent minimally invasive R0 gastrectomy between 2009 and 2014 by grouping them in laparoscopic vs robotic procedures. The results of the study highlighted that age, American Society of Anesthesiologists status, gastrectomy type and pathological T and N status were the main prognostic factors of minimally invasive gastrectomy and showed how the robotic approach may improve long-term outcomes of advanced gastric cancer. According to most of the current literature, robotic surgery is associated with a statistically longer operating time when compared to open and laparoscopic surgery; however, looking at the adequacy of resection, defined by negative surgical margins and number of lymph nodes removed, it seems that robotic surgery gives better results in terms of the 5-year overall survival and recurrence-free survival. The robotic approach to gastric cancer surgery aims to overcome the difficulties and technical limitations of laparoscopy in major surgery. The three-dimensional vision, articulation of the instruments and good ergonomics for the surgeon allow for accurate and precise movements which facilitate the complex steps of surgery such as lymph node dissection, esophagus-jejunal anastomosis packaging and reproducing the technical accuracy of open surgery. If the literature, as well as the analyzed study, offers us countless data regarding the short-term oncological results of robotic surgery in the treatment of gastric cancer, satisfactory data on long-term follow-up are lacking, so future studies are necessary.

Long-term postoperative pneumonia in elderly patients with early gastric cancer

BackgroundPneumonia is a major cause of death in the elderly population. Considering body weight loss, muscle loss, and reflux after gastrectomy, elderly patients are considered to be at very high risk for pneumonia, which could decrease overall survival because early gastric cancer is mostly curable only by surgery. We aimed to clarify the incidence of pneumonia in the long-term period after gastrectomy in elderly patients who were diagnosed with early gastric cancer and its risk factors.MethodsWe retrospectively examined patients of > 75 years of age who underwent R0 gastrectomy for gastric cancer and who were diagnosed with T1 disease at National Cancer Center Hospital between 2005 and 2012. Long-term postoperative pneumonia was diagnosed by chest computed tomography every year until 2 years after surgery. The presence of preoperative sarcopenia was assessed using preoperative L3 skeletal muscle index.Results167 patients were included in this study. Long-term postoperative pneumonia was observed in 44 (26%) patients. Of the 44 people diagnosed with long-term postoperative pneumonia, 33 were diagnosed in the 1st year and 11 in the 2nd year. 117 patients (70%) were diagnosed with sarcopenia which was significantly frequently found in the patients who developed long-term postoperative pneumonia (91%) than those without (63%). Preoperative sarcopenia was the only independent risk factor in multivariate analysis. Type of gastrectomy was not a significant risk factor.ConclusionsLong-term postoperative pneumonia was frequently observed in the elderly patients. Preoperative sarcopenia was associated with long-term postoperative pneumonia in elderly patients who underwent curative surgery for gastric cancer. After gastrectomy, long-term special care would be required for elderly patients, especially with sarcopenia.

Comparison of CEA and CA19-9 as a predictive factor for recurrence after curative gastrectomy in gastric cancer

BackgroundOur aim of was to compare importance of the tumor markers (TMs) serum carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9 in prediction of recurrence after curative gastrectomy for gastric cancer.MethodsWe reviewed retrospectively the clinical records of 149 patients who underwent curative gastrectomy for stage I–III gastric cancer and whose CEA and CA19-9 levels were determined once preoperatively and for more than 3 years postoperatively. We investigated whether the clinicopathological characteristics of patients including age, sex, pathological disease stage, operative approach, type of gastrectomy, and degree of lymph node dissection as well as preoperative positivity of CEA and CA19-9 were risk factors for recurrence in univariate and multivariate analyses. Rate of recurrence was compared between patients positive and negative for postoperative CEA or CA19-9. We also calculated sensitivity, specificity, positive and negative predictable values of postoperative positivity of CEA and CA19-9 for recurrence. The lead time was compared between CEA and CA19-9 that was defined as the time of the first detection of increases in tumor markers and confirmation of recurrence on imaging modalities.ResultsThe number of patients positive for preoperative CEA was 25 (17%) and for CA19-9 was 11 (7%). Recurrence was confirmed in 29 (19%) patients. Stage III disease, preoperative positivity for CA19-9 but not CEA, and total gastrectomy were risk factors for recurrence in univariate analysis, but stage III disease was the only risk factor for recurrence in multivariate analysis. Forty and 15 patients were positive for postoperative CEA and CA19-9, respectively. The recurrence rate of 47% (7/15) in patients positive for postoperative CA19-9 was greater than that in negative patients (22/134 = 16%), but it did not differ between patients who were positive or negative for postoperative CEA. Specificity for CA19-9 was greater than that for CEA (P < 0.05). The lead time of CEA (3.9 ± 4.7 months) was not different from that of CA19-9 (6.1 ± 7.1 months).ConclusionsThese results indicate that CA19-9 rather than CEA is likely to be more useful for the detection of recurrence after curative gastrectomy for gastric cancer.

Pancreaticoduodenectomy for the patients who underwent all types of gastrectomy: Single center experience

Pancreaticoduodenectomy for the patients who underwent all types of gastrectomy: Single center experience

31: UTILITY OF ABDOMINAL DRAIN IN GASTRECTOMY (ADIGE) TRIAL: STUDY PROTOCOL FOR A MULTICENTER NON-INFERIORITY RANDOMIZED TRIAL

Abstract Background and aim Prophylactic use of abdominal drain in gastrectomy has been questioned in the last 15 years and a 2015 Cochrane meta-analysis on four RCTs concluded that there was no convincing evidence to the routine drain placement in gastrectomy. Nevertheless, the Authors evidenced the moderate/low quality of the included studies and highlighted how 3 out of 4 came from Eastern countries. After 2015 only retrospective studies have been published, all with inconsistent results. Methods ADiGe (Abdominal Drin in GastrEctomy) Trial is a multicenter prospective randomized non-inferiority trial with a parallel design. It aimed to verify whether avoiding routine use of abdominal drain is burdened with complications, particularly an increase in postoperative invasive procedures. Patients with gastric cancer, scheduled for subtotal or total gastrectomy with curative intent, are eligible for inclusion, irrespective of previous oncological treatment. The primary composite endpoint is reoperation or percutaneous drainage procedures within 30 postoperative days. The primary analysis will verify whether the incidence of the primary composite endpoint is higher in the experimental arm, avoiding routine drain placement, than control arm, undergoing prophylactic drain placement, in order to falsify or support the null hypothesis of inferiority. Secondary endpoints assessed for superiority are overall morbidity and mortality, Comprehensive Complications Index, incidence and time for diagnosis of anastomotic and duodenal leaks, length of hospital stay, readmission rate. Trial registration Prospectively registered (last updated on October 29, 2020) at Clinicaltrials.gov with the identifier NCT04227951, https://clinicaltrials.gov/ct2/show/NCT04227951. Results Assuming one-sided alpha of 5%, and cumulative incidence of the primary composite endpoint of 6.4% in control arm and 4.2% in the experimental one, 364 patients allow to achieve 80% power to detect a non-inferiority margin difference between the arm proportions of 3.6%. Considering a 10% drop-out rate, 404 patients are needed. In order to have a balanced percentage between total and subtotal gastrectomy, recruitment will end at 202 patients for each type of gastrectomy. The surgeon and the patient are blinded until the end of the operation, while postoperative course is not blinded to patient and caregivers. Conclusion ADiGe Trial could contribute to critically re-evaluate the role of prophylactic drain in gastrectomy, a still widely used procedure.

Prognostic significance of metastatic lymph node ratio in patients with gastric cancer after curative gastrectomy: a single-center retrospective study

Background The objective of this study was to evaluate the prognostic value of Metastatic lymph node ratio (MLNR) after curative gastrectomy in patients with gastric cancer (GC) and the potential for new indicators to strengthen the current guidelines. Methods We retrospectively researched 3864 GC patients with curative gastrectomy between February 2011 and February 2016. The following clinical data were collected from the included patients: gender, type of gastrectomy, tumor location, T stage, N stage, ELN, tumor size, age at surgery, perineural invasion, vascular invasion, TNM stage, survival time and survival status. Patients were divided into low-MLNR (L-MLNR), and high-MLNR (H-MLNR) groups based on adjusted the X-tile cutoff-value of 0.25 for MLNR, the survival rates and clinicopathological characteristics of each group were compared. For the assessment of significant associations between clinicopathological characteristics and patients’ survival, univariate and multivariate analyses were performed using the Kaplan-Meier method and Cox proportional hazards analysis. The log-rank test was used to examine the statistical significance of differences among different survival curves. Clinicopathological features significantly associated with MLNR were assessed by the Chi-square test and multinomial logistic regression. The discriminative ability was measured by calculating the Bayesian Information Criterion (BIC) values for each category. Assessment of the effect of clinicopathological features on MLNR for predicting prognosis of GC patients used stratum analysis through Kaplan-Meier analysis and Cox proportional risk Analysis. Results Survival analysis indicated that MLNR was negatively associated with overall survival (OS) (p < .001) and was an independent prognostic predictor in 3864 GC patients (p < .001). MLNR had significant prognostic significance in various subgroups with clinicopathological characteristics (gender, type of gastrectomy, tumor location, T stage, N stage, ELN, tumor size, age at surgery, perineural invasion, vascular invasion, and TNM stage) (p < .001). Conclusions The MLNR may become a new indicator to assess the prognosis of GC patients who underwent curative gastrectomy. The results may have potential clinical implications that should be considered when developing clinical practice guidelines or the design of the future investigation.

Laparoscopic vs. Open Gastrectomy for Locally Advanced Gastric Cancer: A Propensity Score-Matched Retrospective Case-Control Study.

Introduction: Minimally invasive surgery has been increasingly used in the treatment of gastric cancer. While laparoscopic gastrectomy has become standard therapy for early-stage gastric cancer, especially in Asian countries, the use of minimally invasive techniques has not attained the same widespread acceptance for the treatment of more advanced tumours, principally due to existing concerns about its feasibility and oncological adequacy. We aimed to examine the safety and oncological effectiveness of laparoscopic technique with radical intent for the treatment of patients with locally advanced gastric cancer by comparing short-term surgical and oncologic outcomes of laparoscopic versus open gastrectomy with D2 lymphadenectomy at two Western regional institutions. Methods: The trial was designed as a retrospective comparative matched case-control study for postoperative pathological diagnoses of locally advanced gastric carcinoma. Between January 2015 and September 2021, 120 consecutive patients who underwent curative-intent laparoscopic gastrectomy with D2 lymph node dissection were retrospectively recruited and compared with 120 patients who received open gastrectomy. In order to obtain a comparison that was as homogeneous as possible, the equal control group of pairing (1:1) patients submitted to open gastrectomy who matched those of the laparoscopic group was statistically generated by using a propensity matched score method. The following potential confounder factors were aligned: age, gender, Body Mass Index (BMI), comorbidity, ASA, adjuvant therapy, tumour location, type of gastrectomy, and pT stage. Patient demographics, operative findings, pathologic characteristics, and short-term outcomes were analyzed. Results: In the case-control study, the two groups were clearly comparable with respect to matched variables, as was expected given the intentional primary selective criteria. No statistically significant differences were revealed in overall complications (16.7% vs. 20.8%, p = 0.489), rate of reoperation (3.3% vs. 2.5%, p = 0.714), and mortality (4.2% vs. 3.3%, p = 0.987) within 30 days. Pulmonary infection and wound complications were observed more frequently in the OG group (0.8% vs. 4.2%, p < 0.01, for each of these two categories). Anastomotic and duodenal stump leakage occurred in 5.8% of the patients after laparoscopic gastrectomy and in 3.3% after open procedure (p = 0.072). The laparoscopic approach was associated with a significantly longer operative time (212 vs. 192 min, p < 0.05) but shorter postoperative length of stay (9.1 vs. 11.6 days, p < 0.001). The mean number of resected lymph nodes after D2 dissection (31.4 vs. 33.3, p = 0.134) and clearance of surgical margins (97.5% vs. 95.8%, p = 0.432) were equivalent between the groups. Conclusion: Laparoscopic gastrectomy with D2 nodal dissection appears to be safe and feasible in terms of perioperative morbidity for locally advanced gastric cancer, with comparable oncological equivalency with respect to traditional open surgery.

Should total omentectomy be performed for advanced gastric cancer?: The role of omentectomy during laparoscopic gastrectomy for advanced gastric cancer.

In the era of minimally invasive surgery, laparoscopic partial omentectomy (LPO) has seen widespread use as a curative surgical procedure for early gastric cancer. However, scientific evidence of the extent of omentectomy during laparoscopic gastrectomy remains unclear for advanced gastric cancer (AGC). We analyzed 666 eligible patients who underwent laparoscopic gastrectomy for AGC with curative intent between 2014 and 2018. Surgical outcome and postoperative prognosis were compared between LPO and laparoscopic total omentectomy (LTO) groups after 2:1 propensity score matching with age, sex, body mass index, tumor size, pT stage, pN stage, gastrectomy type, and clinical T stage as covariates. After extensive matching, there was no significant difference in pathologic or clinical stages between the LPO (n = 254) and LTO (n = 177) groups. LPO provided a significantly shorter operation time than LTO (199.2 ± 64.8 vs. 248.1 ± 68.3min, P < 0.001). Pulmonary complication within postoperative 30days was significantly lower in the LPO group (4.4 vs. 10.3%, P = 0.018). In multivariate analysis, LTO was the independent risk factor for pulmonary complication (odds ratio [OR] 2.53, 95% confidence interval [95% CI] 1.12-5.73, P = 0.025), which became more obvious in patients with a Charlson's comorbidity index of 4 or higher (OR 27.43, 95% CI 1.35-558.34, P = 0.031). The 5-year overall survival rate (OS) and 3-year recurrence-free survival (RFS) rates were not significantly different between the two groups, even after stage stratification. LPO provided significantly shorter operation time and less pulmonary complication than LTO without compromising 5-year OS and 3-year RFS for AGC. LTO was the independent risk factor for pulmonary complications, which became more evident in patients with severe comorbidities.