Effect of Laparoscopic Distal Gastrectomy vs Open Distal Gastrectomy on Long-term Survival Among Patients With Stage I Gastric Cancer: The KLASS-01 Randomized Clinical Trial

Robotic and laparoscopic gastrectomy for gastric cancer: comparative insights into perioperative performance and three-year survival outcomes

BACKGROUND

The primary treatment for gastric cancer (GC) is surgical resection, particularly for locally advanced cases. While laparoscopic gastrectomy (LG) has shown short- and long-term benefits, robotic gastrectomy (RG) offers enhanced precision and may lead to better outcomes, especially in advanced-stage disease.

METHODS

This retrospective study analyzed data from 1538 patients with pathological Stage I-III GC who underwent RG or LG between 2014 and 2021. Propensity score matching created 466 matched pairs. Perioperative outcomes, 3 year overall survival (OS), 3 year recurrence-free survival (RFS), and recurrence patterns were compared between RG and LG.

RESULTS

RG demonstrated significantly shorter operative time (235.5 vs. 242.5 min, p = 0.001), less blood loss (19.1 vs. 33.4 ml, p < 0.001), and shorter hospital stay (7.9 vs. 9.7 days, p < 0.001). Overall complications did not differ significantly (p = 0.183), but RG had lower rates of anastomotic leakage (p = 0.045) and pancreatic fistula (p = 0.024). No significant differences in OS were observed in the overall cohort or by stage. Similarly, RFS showed no significant differences in the overall cohort (3 year RFS: RG 86.81% vs. LG 83.04%, p = 0.1347). By stage, no differences were found in stage I or II, but in stage III, RG showed better 3 year RFS (67.52% vs. 52.97%, p = 0.0424). RG also had lower recurrence rates (9.0% vs. 14.8%, p = 0.0061), with fewer liver (p = 0.0069) and lymph node metastases (p = 0.0223).

CONCLUSION

RG demonstrated superior short-term outcomes and comparable three-year OS to laparoscopic gastrectomy, with improved three-year RFS and reduced recurrence in Stage III, likely facilitated by earlier adjuvant chemotherapy initiation.

Clinical outcomes of robotic and laparoscopic gastrectomy using propensity score matching method: Data of 5-year period in a Korean high-volume gastric cancer center

INTRODUCTION

Despite the theoretical advantages of Robotic gastrectomy (RG) over laparoscopic gastrectomy (LG), the benefit of RG compared to LG remains controversial. To address this controversy, we evaluated the outcomes of RG compared to LG in the high-volume gastric cancer center.

MATERIALS AND METHODS

This single-center retrospective cohort study enrolled patients of RG and LG from January 2013 to December 2017 using propensity score matching. Results of operation, and overall survival were analyzed.

RESULTS

For RG, 268 patients were enrolled, and 733 patients with LG were matched. The four gastric methods were matched at the following ratios; Distal gastrectomy (RG: 35.8 % vs LG: 38.7 %), Total gastrectomy (RG: 16.0 % vs LG: 13.9 %), Pylorus-preserving gastrectomy (RG: 46.3 % vs LG: 44.7 %), Proximal gastrectomy (RG: 1.9 % vs LG: 2.6 %) The median number of retrieved lymph nodes (RG: 36.0 vs LG: 37.0, p = 0.247) and supra-pancreatic lymph nodes (RG: 8.0 vs LG: 7.0, p = 0.647), showed no difference. No difference was observed in complications (RG: 21.3 % vs LG: 21.4 %, p = 1.000), and severe complications (RG: 13.1 % vs LG: 12.7 %, p = 0.961) The 5-year overall survival was not significantly different (RG: 94.8 % vs LG: 93.1 %, hazard ratio: 0.76, 95 % confidence interval: 0.41-1.40, p = 0.379).

CONCLUSION

Our study observed no advantage in RG compared to LG regarding short-term and oncologic outcomes. To take advantage of RG, developing new articulating efficient devices would be necessary.

Impact of Routine Follow-Ups After Curative Gastrectomy in Elderly Patients with Early Gastric Cancer

INTRODUCTION

Elderly patients with early gastric cancer exhibit a relatively shorter life expectancy and lower recurrence risk, prompting consideration of whether the regular follow-up strategy should apply to this demographic. This study was designed to determine the effect of routine postoperative follow-up on the elderly patients, specifically those pathologically diagnosed with stage I gastric cancer.

METHODS AND MATERIALS

This retrospective analysis was conducted at a single tertiary center and enrolled patients aged ≥ 75 years who underwent curative gastrectomy for stage I gastric cancer between January of 2007 and December of 2016. The patients were divided into routine and nonroutine follow-up groups, depending on whether the recommended follow-up examinations (endoscopy, CT, and blood tests) were complete. Propensity score matching was performed to compare the overall survival (OS) and disease-specific survival (DSS) between the two study groups.

RESULTS

Among 385 patients enrolled, 301 (78.2%) were routine and 84 (21.8%) were nonroutine follow-up patients. After propensity score matching, each study group consisted of 83 patients. There was no significant difference in OS (85.5% vs. 83.1%, p = 0.47) and DSS (98.6% vs. 98.3%, p = 0.57) between the two study groups. There were six (1.5%) recurrences in the entire cohort: four in the routine and two in the nonroutine follow-up group.

CONCLUSIONS

Regular follow-up of elderly patients with stage I gastric cancer did not significantly impact the OS and DSS rates.

Preoperative visceral fat area predicts intraoperative adverse events during lymphadenectomy in laparoscopic gastrectomy for gastric cancer: a post hoc analysis

BACKGROUND

Visceral obesity has been increasingly recognized as a potential risk factor for surgical complications in gastric cancer surgery, yet its impact on lymphadenectomy during laparoscopic gastrectomy remains undefined. This study aimed to investigate the influence of visceral fat area (VFA) on intraoperative adverse events (iAEs) during lymphadenectomy in laparoscopic gastrectomy.

METHODS

A post hoc analysis was performed using data from two previous prospective studies ([NCT02327481] and [NCT01609309]). The patients were divided into high and low VFA groups based on preoperative computed tomography images at the umbilical level. All iAEs were reviewed from the surgical videos and graded using ClassIntra. The factors influencing iAEs were identified, and predictive models for iAEs were constructed.

RESULTS

This study included 490 patients, with 244 and 246 patients in the high and low VFA groups, respectively. Restricted cubic splines demonstrated a positive linear association between VFA and iAEs. Compared with the low VFA group, the high VFA group exhibited a significantly higher incidence of iAEs (29% vs. 12%, p < 0.001), primarily in the infrapyloric (9.0% vs. 2.0%) and suprapancreatic (23.4% vs. 9.3%) regions and higher rates of ClassIntra I-III. Multivariate logistic regression identified high VFA as an independent risk factor for iAEs (hazard ratio [HR] 2.16, 95% confidence interval [CI]: 1.22 - 3.83). Based on the VFA, nomograms were developed to predict iAEs (training area under the curve [AUC] 0.722, validation AUC 0.730). Meanwhile, a web-based calculator was developed to facilitate clinical application.

CONCLUSIONS

High preoperative VFA is independently correlated with iAEs after laparoscopic gastrectomy for gastric cancer. Nomograms based on VFA showed potential in predicting iAEs, helping identify high-risk patients early and facilitating tailored perioperative management.

Oncoplastic breast reconstruction with single-port laparoscopically harvested omental flap: insights from a ten-year tertiary center experience

PURPOSE

To evaluate the 10-year functional and oncological outcomes of single-port laparoscopically harvested omental flap (SLOF) for immediate breast reconstruction after breast cancer surgery. The technical feasibility and oncologic safety of breast reconstruction using a laparoscopically harvested omental flap remain controversial.

METHODS

We examined 236 patients with breast cancer (including 2 patients with malignant phyllodes tumors) who underwent nipple-sparing mastectomy or breast-conserving surgery followed by immediate SLOF reconstruction between February 2015 and March 2024 at our institution. Short- and long-term outcomes were assessed. Cosmetic outcomes were evaluated using a three-panel assessment and the Seoul Breast Esthetic Scoring Tool and compared with those of a matched cohort of patients who underwent deep inferior epigastric perforator (DIEP) flap breast reconstruction.

RESULTS

The rate of clinically significant complications of Clavien-Dindo grade IIIa or greater was 3.8% (9/236). Two patients with flap failure required flap removal and conversion to other reconstruction procedures. The cosmetic satisfaction rates were 82.5% and 76.4% in the SLOF and DIEP groups, respectively (P = 0.467). Over a median 59-month follow-up, the local, regional, and systemic recurrence rates were 3%, 2.1%, and 3%, respectively. All patients underwent annual screening for gastric cancer via esophagogastroduodenoscopy, and there were no cases of delayed flap removal due to gastrectomy.

CONCLUSIONS

Oncoplastic breast reconstruction using SLOF is safe and feasible. The natural contour and texture of the reconstructed breast and the nearly invisible scar at the abdominal single-port incision provide excellent cosmetic outcomes that are superior to those of other reconstruction methods.

Impact of distal or pylorus preserving gastrectomy on postoperative quality of life in T1 stage middle third gastric cancer patients

Pylorus-preserving gastrectomy (PPG) and distal gastrectomy (DG) are widely utilized surgical approaches for the treatment of gastric cancer. In this study, we employed questionnaire surveys and follow-up assessments to examine the effects of these surgical procedures on postoperative quality of life and pancreatic exocrine function in patients with stage T1 middle-third gastric cancer. A retrospective cohort study was conducted to analyze clinical and follow-up data from 63 gastric cancer patients who underwent distal gastrectomy and 21 who underwent pylorus-preserving gastrectomy at Nanjing University Drum Tower Hospital between January 2019 and January 2023. Patients were categorized into two groups: distal gastrectomy (n = 63) and pylorus-preserving gastrectomy (n = 21). The primary outcome measure was postoperative quality of life assessed at 1 year using the Gastric Resection Syndrome Assessment Scale, Gastroparesis Cardinal Symptom Index (GSCI), and Pancreatic Exocrine Insufficiency Questionnaire (PEI-Q). Secondary outcomes included intraoperative and postoperative conditions, incidence of complications, and changes in nutritional status at 6 and 12 months post-surgery. Compared to the DG group, the PPG group exhibited fewer lymph node dissections [20 (17, 26) vs. 25 (19.5, 32), Z = 2.013, P = 0.052], shorter distances from the upper resection margin [2.0 (1.3, 3.0) vs. 3.5 (2.5, 4.75), Z = 4.664, P = 0.0002], and shorter distances from the lower resection margin [2.0 (1.4, 3.0) vs. 4.5 (4.0, 5.5), Z = 6.691, P < 0.001]. However, they experienced longer operative times [270 (240, 300) vs. 220 (187.5, 257.5), Z = 4.133, P = 0.0002], postoperative gas discharge times [4 (4, 5) vs. 4 (3, 4), Z = 5.96, P < 0.0001], and postoperative hospital stays [12 (10, 14) vs. 10 (9, 12), Z = 1.493, P = 0.0098]. One year postoperatively, patients in the PPG group demonstrated superior quality of life scores compared to the DG group in terms of the dumping symptom scale [1.0 (1.0, 1.33) vs. 2.5 (1.75, 2.5), Z = 7.192, P < 0.001], amount of food intake per meal [6 (6, 7) vs. 6 (4, 6), Z = 4.724, P = 0.0008], and meal quality scale [4.0 (3.67, 4.0) vs. 2.33 (1.67, 2.67), Z = 11.554, P < 0.0001]. Additionally, preoperative serum albumin levels were higher in the PPG group compared to the DG group [41.7 (40.3, 43) vs. 40.2 (39.15, 41.3), Z = 2.916, P = 0.006], and the PPG group had a lower rate of postoperative chemotherapy requirement (P = 0.024). Compared to distal gastrectomy (DG), pylorus-preserving gastrectomy (PPG) results in fewer dumping symptoms and an improved quality of life for patients following surgery. This makes PPG a highly favorable surgical option for treating stage T1 middle-third gastric cancer.

Effect of Minimally Invasive versus Open Distal Gastrectomy on Long-Term Survival in Patients with Gastric Cancer: Individual Patient Data Meta-analysis

BACKGROUND

Minimally invasive distal gastrectomy (MIDG) has been shown to improve short-term outcomes compared with open distal gastrectomy (ODG) in patients with early (EGC) and locally advanced gastric cancer (LAGC). The impact of MIDG on patient survival remains debated. This study aimed to compare the effect of MIDG versus ODG on long-term survival.

PATIENTS AND METHODS

Randomized clinical trial (RCTs) individual patient data (IPD) meta-analysis with restricted mean survival time difference (RMSTD) estimation. Scopus, MEDLINE, Web of Science, and ClinicalTrials.gov were searched. Primary outcomes were 5-year overall (OS), disease free survival (DFS), and cancer specific survival (CSS). RMSTD and 95% confidence intervals (CI) were used as pooled effect size measures. The certainty of evidence was categorized with the Grading of Recommendations, Assessment, Development, and Evaluation framework.

RESULTS

Overall, ten RCTs (5297 patients) were included; 50.4% of patients underwent MIDG. At 60-months follow-up, the OS and DFS estimates for ODG versus MIDG were 0.41 months (95% CI - 0.17, 0.99; high level of certainty) and 0.42 months (95% CI - 0.38, 1.23; high level of certainty). CSS was specified in two RCTs, hence quantitative analysis was not practicable. The 60-month OS and DFS estimates for LAGC (five studies) were 0.32 months (95% CI - 0.80, 1.44; high level of certainty) and 0.31 months (95% CI - 2.02, 1.33; high level of certainty), respectively. The 36-month DFS appraisal for stage III patients (three studies) was - 0.41 months (95% CI - 26.1, 38.2; low level of certainty).

CONCLUSIONS

This meta-analysis found high-certainty evidence that MIDG and ODG demonstrate similar 5-year OS and DFS in patients with both EGC and LAGC.

Factor analysis of postsurgical gastroparesis syndrome after right hemicolectomy for colon cancer

The present study aimed to investigate factors influencing postsurgical gastroparesis syndrome (PGS) in patients with right-sided colon cancer. In total, 260 patients who underwent complete mesocolic excision for right-sided colon cancer were included in the present analysis. Among the included patients, 69 underwent open radical right-sided colon resection, 175 underwent laparoscopic radical right-sided colon resection and 16 underwent robot-assisted radical right-sided colon resection. The occurrence of PGS was observed, and both the χ2 test and multivariate regression analysis were conducted to identify influencing factors. Among the 260 patients, 32 experienced PGS, with an incidence rate of 12.3%. Univariate analysis demonstrated that age, perioperative blood glucose levels, self-rated anxiety scale scores and surgical approach were significantly associated with PGS (P<0.05), whereas sex, surgical duration, diabetes and perioperative albumin levels were not significant factors (P>0.05). Multivariate logistic regression analysis showed that age >70 years, perioperative blood glucose ≥11.1 mmol/l, a self-rating anxiety scale score ≥50 and radical extended right-sided colon resection were risk factors for PGS occurrence. In conclusion, the occurrence of PGS in patients with right-sided colon cancer was revealed to be associated with age, perioperative blood glucose levels, self-rated anxiety scale scores and surgical approach.

LGALS9B stabilizes EEF1D protein and activates the PI3K/AKT signaling pathway to promote gastric cancer occurrence and metastasis

Gastric cancer ranks among the most prevalent malignancies globally, characterized by limited treatment efficacy and high recurrence rates. Effective management of this disease requires a comprehensive understanding of its underlying pathogenic mechanisms. Galectins have emerged as promising targets in gastric cancer therapy, with Galectin-9 (LGALS9) receiving considerable attention in recent years. However, Galectin-9B (LGALS9B) remains relatively under-explored in gastric cancer research. Our study investigates the role of LGALS9B in gastric cancer progression, demonstrating that its over-expression enhances cellular proliferation, migration, and invasion, while its knockdown inhibits these processes both in vitro and in vivo. We further elucidate that LGALS9B competes with the E3 ligase HERC5 for binding to eukaryotic translation elongation factor 1 delta (EEF1D), thereby preventing its protein degradation. This interaction results in the enrichment of EEF1D, which activates the PI3K/AKT signaling pathway and ultimately promotes gastric cancer progression. These findings highlight the regulatory role of LGALS9B in the pathogenesis of gastric cancer, offering valuable insights into potential novel therapeutic strategies for managing this challenging disease.

Clinical Value of Nomograms Integrating Circulating Lipid and Inflammation Risk Score in Predicting Long-Term Outcomes After Radical Gastrectomy in Gastric Cancer: A Multicenter Real-World Study

BACKGROUND

The clinical value of incorporating lipid and inflammatory factors to predict long-term survival in patients with gastric cancer (GC) is unreported. This study aimed to investigate the clinical value of nomograms integrating the Circulating Lipid and Inflammation Risk Score (CLIRS) for predicting the long-term outcome of patients with GC.

METHODS

A retrospective analysis included patients with GC who underwent radical resection at four tertiary medical centers. Patients were divided into training and validation cohorts, with least absolute shrinkage and selection operator regression selecting optimal lipid and inflammatory indicators related to GC prognosis. The CLIRS was developed from six indicators: lymphocyte, triglycerides, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and apolipoprotein B.

RESULTS

Overall, 2534 patients were studied, including 1910 in the training cohort and 624 in the validation cohort. The CLIRS was an independent risk factor for overall survival (OS; hazard ratio [HR] 1.529, 95% confidence interval [CI] 1.271-1.839; p < 0.001) and disease-free survival (DFS; HR 1.511, 95% CI 1.267-1.801; p < 0.001) in GC patients. The OS nomogram (area under the receiver operating characteristic curve 0.823 vs. 0.785; p < 0.05) and DFS nomogram (AUC 0.804 vs. 0.770; p < 0.05) based on the CLIRS outperformed pTNM stage. High-risk patients had earlier and more sustained recurrence, with higher rates of local, peritoneal, and distant recurrences (p < 0.05).

CONCLUSIONS

The CLIRS, combining circulating lipid and inflammatory factors, is an independent prognostic factor for patients with GC. Nomograms incorporating the CLIRS are superior to pTNM stage in predicting postoperative survival and recurrence in patients with GC.

Cost-effectiveness of open vs. laparoscopic gastrectomy for locally advanced gastric cancer in China

Locally advanced gastric cancer (LAGC) poses a significant surgical challenge. While laparoscopic gastrectomy (LG) offers potential advantages, its cost-effectiveness relative to open gastrectomy (OG) in China remains uncertain. To compare the cost-effectiveness of LG and OG for LAGC in China. A Markov model compared the cost-effectiveness of LG and OG for LAGC. Probabilities and utilities were derived from published literature. Direct medical costs were obtained from the First Hospital of Lanzhou University. The primary outcome was the incremental cost-effectiveness ratio (ICER), expressed as the cost per quality-adjusted life-year (QALY) gained, using a willingness-to-pay threshold of ¥268,074/QALY. Sensitivity analyses assessed model robustness. Across 1-, 3-, and 5-year time horizons, OG had lower total costs and greater effectiveness than LG for LAGC. At 5 years, OG had a total cost of ¥128,259 and 7.20 QALYs versus LG's ¥136,668 and 7.18 QALYs; the ICER for OG was -¥474,758/QALY. OG dominated at the ¥268,074 willingness-to-pay threshold. Sensitivity analysis indicated that variations in LG and OG costs minimally influenced the cost-effectiveness. Probabilistic sensitivity analysis, performed across 10,000 iterations, consistently identified OG as the optimal strategy (100% of iterations). From a Chinese health economics perspective-a framework essential for informing national healthcare resource allocation-OG consistently demonstrated a superior cost-effectiveness compared with LG for LAGC across 1, 3, and 5 years. This longitudinal observation of sustained cost-effectiveness persisted despite the statistically insignificant differences in overall costs and effectiveness between the two procedures.

Survival Outcomes Between Minimally Invasive and Open Gastrectomy in Early and Locally Advanced Gastric Adenocarcinoma in a Western Center

PURPOSE

While minimally invasive gastrectomy (MIS) is well-utilized in Asia, its adoption in the West to treat gastric adenocarcinoma has been slower. We compare survival outcomes between open gastrectomy and MIS in a high-volume Western US center.

METHODS

In this retrospective review, demographic and clinical characteristics of gastric adenocarcinoma patients who underwent curative-intent MIS (robotic or laparoscopic approaches) or open surgery were compared via descriptive statistics. Multivariable Cox hazard regression models were constructed to assess the effects of gastrectomy type on overall survival (OS) and recurrence-free survival (RFS) in the overall cohort and a locally advanced subgroup (pathologic stage 2-3 patients).

RESULTS

A total of 135 gastric adenocarcinoma patients were studied; 67% underwent MIS. Open patients experienced lower lymph node retrieval (p = 0.004) and neoadjuvant chemotherapy administration (p = 0.037) than MIS. OS (p = 0.18) and RFS (p = 0.74) were not different between MIS and open over a 5-year period. In multivariable survival models, gastrectomy type was not associated with OS (open hazard ratio (HR) = 1.78, p = 0.8 (compared to MIS)) or RFS (HR = 1.46, p = 0.7), while positive nodes (HR = 21.7, p = 0.003) and pathologic stage 3 (HR = 1.6, p = 0.025) were associated with poorer OS. Within the locally advanced cohort (N = 66, 67% MIS), OS (p = 0.43) and RFS (p = 0.72) were similarly not different between MIS and open patients.

CONCLUSIONS

This study contributes to the growing body of evidence supporting the efficacy of MIS to manage gastric cancer within Western populations. Importantly, these data highlight the utility of MIS as a treatment option for locally advanced disease where uptake has been slowest.

Life expectancy of patients with early gastric cancer who underwent curative gastrectomy: comparison with the general population

Despite long-term survival reports in early gastric cancer, comparative life expectancy data with the general population is scarce. This study aimed to estimate patients' life expectancy and analyze disparities between early gastric cancer patients and the general population. Patients with stage 1 gastric cancer who underwent curative gastrectomy at Asan Medical Center were enrolled. Survival status was tracked via national health insurance records. Life expectancy was compared with general population data from the Korean Statistical Information Service database. The cohort comprised 8,637 patients (64.7% men, 17.3% aged 70+). Approximately 20% of patients underwent total gastrectomy. Life expectancy was favorable among women. Across all age groups, women's life expectancy generally exceeded 80 years. Male patients showed a reduced life expectancy, typically 4-10 years shorter than their female counterparts. The average life expectancy of male patients aged over 80 years who underwent total gastrectomy was about 5 years, whereas that of their female counterparts was approximately 7 years. Female patients undergoing distal gastrectomy did not demonstrate a statistically significant variance in life expectancy compared to the general population. This study provided comprehensive life expectancy data, organized by age, sex, and type of gastrectomy in a large stage 1 gastric cancer cohort. Our findings are expected to alleviate uncertainties and anxieties for individuals diagnosed with early gastric cancer.

Pancreas-left gastric artery angle predicts difficulty of suprapancreatic lymph node dissection in gastrectomy for gastric cancer: a cross-sectional study

PURPOSE

Suprapancreatic lymph node dissection is one of the most challenging procedures performed in the treatment of gastric cancer. This study aimed to investigate whether the pancreas-left gastric artery angle (PLA) can be used to predict the difficulty of the procedure.

METHODS

This was a single-center cross-sectional study. Before gastrectomy, the patients were classified according to the size of the PLA into the small PLA (s-PLA; < 30°) and large PLA (l-PLA; ≥ 30°) groups in a surgeon-blinded manner. After gastrectomy, a surgeon evaluated suprapancreatic lymph node dissection as hard, normal, or easy to perform.

RESULTS

Seventy-three patients were enrolled in the study. Surgeons evaluated lymph node dissection as hard in 43.8 and 8.7% of patients in the s-PLA and l-PLA groups, respectively (p = 0.002). The time taken for suprapancreatic lymph node dissection was also significantly longer in the s-PLA group than in the l-PLA group (p = 0.040). In patients who underwent laparoscopic gastrectomy, the time for node dissection in the s-PLA group was also significantly longer than that in the s-PLA group (p = 0.021), while there was no difference in those who underwent robotic surgery (p = 0.815).

CONCLUSION

PLA is useful for predicting the degree of difficulty of suprapancreatic lymph node dissection during gastrectomy for gastric cancer.

Minimally Invasive Gastrectomy

The surgical management of gastric cancer has changed significantly from the first open partial gastrectomy in 1881 to contemporary minimally invasive approaches. The approach has shifted from open surgeries to laparoscopic and robotic-assisted gastrectomies, with evidence of reduced pain, quicker recovery, and lower morbidity with these methods. Multiple randomized trials have confirmed that laparoscopic surgeries yield oncologically safe results. Moreover, robotic surgeries, while more expensive, provide similar outcomes with some procedural benefits. Herein, we discuss surgical techniques, preoperative planning, and postprocedure care, emphasizing the role of careful clinical assessment and tailored surgical approaches based on tumor location and patient condition.

Open Gastric Surgery for Gastric Cancer

Gastric cancer is a leading cause of cancer and cancer-related mortality worldwide, especially in East Asia. It is often diagnosed at an advanced stage, which carries a poor prognosis. Patients with advanced gastric cancer typically receive systemic therapy and best supportive care. For patients with locally advanced gastric cancer, a combination of systemic therapy and surgical resection is recommended, while surgical resection-alone is recommended for patients with early-stage localized tumors. Surgical resection, including total gastrectomy, distal gastrectomy, and proximal gastrectomy, is recommended for resection of localized tumors based on tumor location. Herein, the authors provide an overview of open gastrectomy resection and reconstruction techniques.

Rare epithelial gastric cancers: a review of the current treatment knowledge

Gastric cancer (GC), one of the tumours with the highest mortality worldwide, is not a homogeneous disease, showing different features according to location, macroscopic aspect, histotype and molecular alterations. Adenocarcinoma is the most frequent epithelial GC (95%), the remaining 5% comprising rare epithelial tumours with their peculiarities, behaviour and incidence <6 cases/100,000/year. Due to the low number of cases, many aspects must be elucidated in this context. In this narrative review, we highlight the importance of a better understanding of rare GCs to personalize the cures in the light of the precision medicine concept. Our main aim is to translate the scarce evidence from the literature into daily clinical practice, never forgetting that all the clinicians dedicated to rare GCs should encourage such patients' enrolment in clinical trials and promote international collaborations. Hence, we focused on the treatment of the following rare GCs: rare gastric adenocarcinomas (hepatoid adenocarcinoma, medullary carcinoma with lymphoid stroma, Paneth cell carcinoma and Salivary Gland carcinoma); squamous cell carcinoma; adenosquamous carcinoma; neuroendocrine gastric neoplasms; gastroblastoma.

Complications Following Open Versus Minimally Invasive Resection of Gastric Adenocarcinoma

BACKGROUND AND OBJECTIVES

Gastric adenocarcinoma (GA) is commonly treated with open or minimally invasive surgery (MIS). The preferred surgical approach remains unclear. This study sought to assess utilization over time, compare complication rates by surgical approach, and identify predictors of experiencing complications.

METHODS

Patients who underwent GA resection from 2016 to 2022 were identified in the American College of Surgeons National Surgical Quality Improvement Program and compared based on receipt of open gastrectomy versus MIS. Complication rates were compared with χ2 tests. Predictors of experiencing complications or receiving MIS were assessed using multivariable Poisson regressions with robust variance.

RESULTS

Out of 4,429 patients, most underwent open gastrectomy versus MIS (84.2% vs. 15.9%). MIS uptake did not increase. Open gastrectomy patients experienced more major complications (18.5% vs. 13.1%), higher perioperative mortality (1.53% vs. 0.57%), and longer hospital stays (7 vs. 5 days) compared to MIS patients (all p values < 0.01). MIS patients had a decreased risk of experiencing any complications (RR: 0.7, 95% CI: 0.5-0.8). Non-white patients were less likely to receive MIS.

CONCLUSIONS

MIS is associated with a decreased risk of experiencing complications compared to open gastrectomy for GA, yet its utilization has plateaued. Sociodemographic predictors of receipt of MIS indicate potential disparities in accessing certain treatments.

SUMMARY

The preferred surgical approach for gastric cancer is unclear. This analysis of the American College of Surgeons National Surgical Quality Improvement Program compared complication rates of open gastrectomy with minimally invasive surgery (MIS). MIS was associated with a decreased risk of experiencing complications, yet utilization has plateaued.

Surgical outcomes and long-term survival of laparoscopic distal gastrectomy at high-volume centers in Korea and China: a two-centered retrospective analysis

PURPOSE

Laparoscopic distal gastrectomy is now widely used in East Asia and worldwide with different preferences and outcomes. This study aimed to compare the short- and long-term outcomes and preferences between two high-volume gastric cancer centers in Korea and China.

METHODS

Patients who underwent laparoscopic-assisted distal gastrectomy (LADG) and totally laparoscopic distal gastrectomy (TLDG) for gastric cancer from Seoul National University Hospital (SNUH) and the First Affiliated Hospital of Nanjing Medical University (NMUH) from 2017 to 2020 were enrolled in this study.

RESULTS

A total of 1166 SNUH cases and 847 NMUH cases enrolled in this study. The overall complication rate of SNUH (14.49%) did not differ from that of NMUH after LADG or TLDG (12.28%). The anastomosis-related complications rate (2.74%) did not show a significant difference with that of NMUH (2.01%) either. The median postoperative hospital stay for SNUH (7,(7,10)) was shorter than that for NMUH (8,(7,9)). The 5-year overall survival (OS) rate of SNUH was not significantly different from that of NMUH.

CONCLUSION

There was no significant difference in the overall complication rate, anastomosis-related complication rate, resected lymph nodes, and 5- year overall survival rate between SNUH and NMUH except for the postoperative stay. Both the LADG and TLDG achieved satisfactory short- and long-term outcomes when performed by surgeons with adequate experience.

Comparison of Clinical Outcomes Between Delta-Shaped and Circular Anastomoses After Laparoscopic Distal Gastrectomy

INTRODUCTION

Laparoscopic distal gastrectomy (LDG) is the standard treatment for gastric cancer, during which the laparoscopic Billroth I anastomosis technique, also known as the delta-shaped anastomosis (DA), is widely performed. This study aimed to evaluate the differences in short- and long-term symptoms between DA and traditional circular anastomosis (CA) techniques.

METHODS

We retrospectively compared DA and CA procedures in patients undergoing LDG and subsequent reconstruction using the Billroth I method at the Kanagawa Cancer Center from 2017 to 2022.

RESULTS

Other than blood loss, no significant differences were observed in the short-term outcomes between the two groups. However, 1-year post-surgery, the DA group had a higher incidence of diarrhea, lower incidence of remnant gastritis, and higher weight loss than the CA group.

CONCLUSION

Both DA and CA techniques were similar in terms of safety. However, the DA group had a higher incidence of diarrhea and a lower incidence of remnant gastritis than the CA group 1-year after surgery.

Proximal Gastrectomy Is Associated with Lower Incidence of Anemia and Vitamin B12 Deficiency Compared to Total Gastrectomy in Patients with Upper Gastric Cancer

PURPOSE

Proximal gastrectomy is an alternative to total gastrectomy (TG) for early gastric cancer (EGC) treatment in the upper stomach. However, its benefits in terms of perioperative and long-term outcomes remain controversial. The aim of this study was to compare the perioperative, body compositional, nutritional, and survival outcomes of patients undergoing proximal gastrectomy with double-tract reconstruction (PG-DTR) and TG for pathological stage I gastric cancer in upper stomach.

MATERIALS AND METHODS

The study included 506 patients who underwent gastrectomy for pathological stage I gastric cancer in the upper stomach between 2015 and 2019. Clinicopathological, perioperative, body compositional, nutritional, and survival outcomes were compared between the PG-DTR and TG groups.

RESULTS

The PG-DTR and TG groups included 197 (38.9%) and 309 (61.1%) patients, respectively. The PG-DTR group had a lower rate of early complications (p=0.041), lower diagnosis rate of anemia and vitamin B12 deficiency (all p < 0.001), and lower replacement rate of iron and vitamin B12 compared to TG group (all p < 0.001). The PG-DTR group showed reduced incidence of sarcopenia at 6-months postoperatively, preserved higher amount of visceral fat after surgery (p=0.032 and p=0.040, respectively), and showed a higher hemoglobin level (p=0.007). Oncologic outcomes were comparable between the groups.

CONCLUSION

The PG-DTR for EGC located in the upper stomach offered advantages of fewer complications, lower incidence of anemia and vitamin B12 deficiency, less decrease in visceral fat volume, and similar survival compared to TG. Consequently, PG-DTR may be considered a superior alternative treatment option to TG.

Morbidity and quality of life of totally laparoscopic versus laparoscopy-assisted distal gastrectomy for early gastric cancer: a multi-center prospective randomized controlled trial (CKLASS01)

BACKGROUND

There is a paucity of confirmatory randomized controlled trials (RCTs) comparing the effectiveness of totally laparoscopic distal gastrectomy (TLDG) vs laparoscopy-assisted distal gastrectomy (LADG) for early gastric cancer (EGC).

METHODS

A phase III, prospective, multi-center RCT was conducted, wherein patients (n = 442) with clinical stage I gastric cancer eligible for laparoscopic distal gastrectomy were randomized 1:1 to the TLDG or the LADG group. Postoperative morbidity and quality of life (QoL) were compared.

RESULTS

In total, 422 patients were assessed (TLDG, 216; LADG, 206) in the modified intention-to-treat (mITT) analysis. The morbidity rate did not differ significantly between the two groups (TLDG, 6.0%; LADG, 5.8%; P = 0.93). The 90-day mortality rate was comparable between the groups (TLDG, 0.5%; LADG, 0.0%; P > 0.99). TLDG was significantly associated with a lower pain score compared with LADG in patients with a BMI of ≥ 25 kg/m2 (P = 0.002) at 24 h postoperatively. Moreover, TLDG significantly improved QoL in terms of C30 social functioning at 3 and 6 months (P = 0.03 and P = 0.04), C30 global health status at 3 months (P = 0.02), and STO22 body image at 3 months (P = 0.01), with differences dissipating at 12 months.

CONCLUSIONS

TLDG is not superior to LADG in terms of postoperative morbidity and mortality, but it provides better C30 social functioning at 3 and 6 months, C30 global health status and STO22 body image at 3 months, and reduces early postoperative pain for patients with a BMI of ≥ 25 kg/m2.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03393182.

KLASS (Korean Laparoendoscopic Gastrointestinal Surgery Study Group) trials: a 20-year great journey in advancing surgical clinical research for gastric cancer

The Korean Laparoendoscopic Gastrointestinal Surgery Study Group (KLASS) trial series represents a comprehensive body of surgical clinical trials and studies focused on laparoscopic techniques in the treatment of gastric cancer. These trials, conducted and overseen by the KLASS, began with KLASS 01 in 2006 and have progressed to their 14th series as of December 2024. To date, approximately 36 papers, including pivotal publications, have been featured in high-impact journals, significantly advancing the field of gastric cancer treatment. Their findings have been incorporated into gastric cancer treatment guidelines in Korea, Japan, and China, underscoring their influence and clinical relevance. I take immense pride in being part of this remarkable journey, alongside esteemed seniors, colleagues, and numerous clinical researchers who initiated KLASS in 2004. This paper aims to review the studies conducted within the KLASS series to date and provide insights insight into the ongoing the ongoing research initiatives being developed by this esteemed group on their behalf.

Korean Practice Guidelines for Gastric Cancer 2024: An Evidence-based, Multidisciplinary Approach (Update of 2022 Guideline)

Gastric cancer is one of the most common cancers in both Korea and worldwide. Since 2004, the Korean Practice Guidelines for Gastric Cancer have been regularly updated, with the 4th edition published in 2022. The 4th edition was the result of a collaborative work by an interdisciplinary team, including experts in gastric surgery, gastroenterology, endoscopy, medical oncology, abdominal radiology, pathology, nuclear medicine, radiation oncology, and guideline development methodology. The current guideline is the 5th version, an updated version of the 4th edition. In this guideline, 6 key questions (KQs) were updated or proposed after a collaborative review by the working group, and 7 statements were developed, or revised, or discussed based on a systematic review using the MEDLINE, Embase, Cochrane Library, and KoreaMed database. Over the past 2 years, there have been significant changes in systemic treatment, leading to major updates and revisions focused on this area. Additionally, minor modifications have been made in other sections, incorporating recent research findings. The level of evidence and grading of recommendations were categorized according to the Grading of Recommendations, Assessment, Development and Evaluation system. Key factors for recommendation included the level of evidence, benefit, harm, and clinical applicability. The working group reviewed and discussed the recommendations to reach a consensus. The structure of this guideline remains similar to the 2022 version. Earlier sections cover general considerations, such as screening, diagnosis, and staging of endoscopy, pathology, radiology, and nuclear medicine. In the latter sections, statements are provided for each KQ based on clinical evidence, with flowcharts supporting these statements through meta-analysis and references. This multidisciplinary, evidence-based gastric cancer guideline aims to support clinicians in providing optimal care for gastric cancer patients.

A Comprehensive and Comparative Review of Global Gastric Cancer Treatment Guidelines: 2024 Update

Differences in demographics, medical expertise, and patient healthcare resources across countries have led to significant variations in guidelines. In light of these differences, in this review, we aimed to explore and compare the most recent updates to gastric cancer treatment from five guidelines that are available in English. These English-version guidelines, which have been recently published and updated for journal publication, include those published in South Korea in 2024, Japan in 2021, China in 2023, the United States in 2024, and Europe in 2024. The South Korean and Japanese guidelines provide a higher proportion of content to endoscopic and surgical treatments, reflecting their focus on minimally invasive techniques, function-preserving surgeries, and systemic therapy. The Chinese guidelines provide recommendations addressing not only surgical approaches but also perioperative chemotherapy and palliative systemic therapy. Meanwhile, in the United States and European guidelines, a higher proportion of the content is dedicated to perioperative and palliative systemic therapy, aligning with their approaches to advanced-stage disease management. All guidelines address surgical and systemic chemotherapy treatments; however, the proportion and emphasis of content vary based on the patient distribution and treatment approaches specific to each country. With emerging research findings on gastric cancer treatment worldwide, the national guidelines are being progressively revised and updated. Understanding the commonalities and differences among national guidelines, along with the underlying evidence, can provide valuable insights into the treatment of gastric cancer.

Artificial intelligence model for perigastric blood vessel recognition during laparoscopic radical gastrectomy with D2 lymphadenectomy in locally advanced gastric cancer

BACKGROUND

Radical gastrectomy with D2 lymphadenectomy is standard surgical protocol for locally advanced gastric cancer. The surgical experience and skill in recognizing blood vessels and performing lymph node dissection differ between surgeons, which may influence intraoperative safety and postoperative oncological outcomes. Hence, the aim of this study was to develop an accurate and real-time deep learning-based perigastric blood vessel recognition model to assist intraoperative performance.

METHODS

This was a retrospective study assessing videos of laparoscopic radical gastrectomy with D2 lymphadenectomy. The model was developed based on DeepLabv3+. Static performance was evaluated using precision, recall, intersection over union, and F1 score. Dynamic performance was verified using 15 intraoperative videos.

RESULTS

The study involved 2460 images captured from 116 videos. Mean(s.d.) precision, recall, intersection over union, and F1 score for the artery were 0.9442(0.0059), 0.9099(0.0163), 0.8635(0.0146), and 0.9267(0.0084) respectively. Mean(s.d.) precision, recall, intersection over union, and F1 score for the vein were 0.9349(0.0064), 0.8491(0.0259), 0.8015(0.0206), and 0.8897(0.0127) respectively. The model also performed well in recognizing perigastric blood vessels in 15 dynamic test videos. Intersection over union and F1 score in difficult image conditions, such as bleeding or massive surgical smoke in the field of view, were reduced, while images from obese patients resulted in satisfactory vessel recognition.

CONCLUSION

The model recognized the perigastric blood vessels with satisfactory predictive value in the test set and performed well in the dynamic videos. It therefore shows promise with regard to increasing safety and decreasing accidental bleeding during laparoscopic gastrectomy.

LONG-TERM SURVIVAL AFTER LAPAROSCOPIC TOTAL GASTRECTOMY FOR EARLY AND ADVANCED GASTRIC CANCER. SINGLE CENTER EXPERIENCE IN 100 CASES

BACKGROUND

Laparoscopic gastrectomy offers advantages in the postoperative period compared to the open approach. Most studies have been performed on distal gastrectomies; however, laparoscopic total gastrectomy (LTG) is not universally accepted. AIM: The aim of this study was to assess the results of LTG, on postoperative morbidity outcomes and long-term survival.

METHODS

This is a retrospective cohort study from a prospective database of patients who underwent LTG, from 2005 to 2022, due to early and advanced gastric cancer. A totally laparoscopic technique was utilized, and the Roux-en-Y reconstruction was performed in all cases. Postoperative complications and long-term survival were evaluated.

RESULTS

A total of 100 patients were included (men 57, age 64 years, and body mass index 26). A D2 lymphadenectomy was performed in 68 cases. The postoperative hospitalization period was 8 days (6-62 days). Postoperative complications occurred in 26%, with 7% esophago-jejunal anastomosis leak, 4% abdominal collections, and 2% gastrointestinal bleeding. In 7% of cases, the complication was considered Clavien 3 or greater. Operative mortality was 1%. The pathology findings confirmed advanced gastric cancer in 50 cases. The median lymph node count was 38, and surgery was considered R0 in 99%. The median follow-up was 50 months. Overall 5-year survival was 74%. Survival in T1 cases was 95% at 5 years. For stage I, survival was 95%, and for stages II and III, it was 52% and 43%, at 5 years, respectively.

CONCLUSIONS

These results support the feasibility and oncological adequacy of minimally invasive total gastrectomy. Postoperative morbidity has an acceptable rate. Long-term survival was in accordance with the disease stage.

Minimally Invasive Versus Open Distal Gastrectomy for Locally Advanced Gastric Cancer: Trial Sequential Analysis of Randomized Trials

BACKGROUND

Minimally invasive distal gastrectomy (MIDG) has been shown to be associated with improved short-term outcomes compared to open distal gastrectomy (ODG) in patients with locally advanced gastric cancer (LAGC). The impact of MIDG on long-term patient survival remains debated. Aim was to compare the MIDG vs. ODG effect on long-term survival.

METHODS

Systematic review and trial sequential analysis (TSA) of randomized controlled trials (RCTs). Web of Science, Scopus, MEDLINE, the Cochrane Central Library, and ClinicalTrials.gov were queried. Hazard ratio (HR) and 95% confidence intervals (CI) were used as pooled effect size measures. Five-year overall (OS) and disease-free survival (DFS) were primary outcomes.

RESULTS

Five RCTs were included (2835 patients). Overall, 1421 (50.1%) patients underwent MIDG and 1414 (49.9%) ODG. The ages ranged from 48 to 70 years and 63.4% were males. The pooled 5-year OS (HR = 0.86; 95% CI 0.70-1.04; I2 = 0.0%) and 5-year DFS (HR = 1.03; 95% CI 0.87-1.23; I2 = 0.0%) were similar for MIDG vs. ODG. The TSA shows a cumulative z-curve without crossing the monitoring boundaries line (Z = 1.96), thus suggesting not conclusive 5-year OS and DFS results because the total information size was not sufficient.

CONCLUSIONS

MIDG and ODG seem to have equivalent 5-year OS and DFS in patients with LAGC. However, the cumulative evidence derived from the TSA showed that the actual information size is not sufficient to provide conclusive data.

A comprehensive overview of gastric cancer management from a surgical point of view

Despite advancements in medical care, surgical technologies, and the development of novel treatments over the past decade, the prognosis for patients with gastric cancer (GC) has only modestly improved. This is primarily due to the fact that the majority of patients are diagnosed at advanced stages or present with metastatic disease. Radical resection remains the cornerstone of potentially curative treatment, yet the overall 5-year survival rate remains below 35%. The management of GC varies globally, influenced by factors such as geographical disparities, patient comorbidities and performance status, surgical approaches, and available medical resources. Multidisciplinary collaboration and a multimodal treatment approach are essential for optimizing patient outcomes. Surgeons must stay updated on emerging surgical concepts and make informed decisions regarding patient selection, timing of intervention, and the adoption of appropriate surgical techniques to improve both quality of life and prognosis. This review aims to provide a surgical perspective on the management of GC across all stages, highlighting the importance of a comprehensive treatment approach. Endoscopic resection may be a viable option for early GC in patients with minimal risk of lymph node metastasis, particularly in elderly patients with high surgical risk or severe comorbidities. For advanced GC, neoadjuvant therapy followed by surgery could be a promising strategy to improve patient outcomes. Conversion surgery offers a potential survival benefit for patients who respond to treatment with tumor downstaging. The treatment of peritoneal carcinomatosis remains challenging; however, hyperthermic intraperitoneal chemotherapy combined with complete cytoreductive surgery or pressurized intraperitoneal aerosolized chemotherapy may prolong survival or improve quality of life in highly selected patients.

Reconstruction Techniques and Associated Morbidity in Minimally Invasive Gastrectomy for Cancer: Insights From the GastroBenchmark and GASTRODATA databases

OBJECTIVE/BACKGROUND

Various anastomotic and reconstruction techniques are used for minimally invasive total (miTG) and distal gastrectomy (miDG). Their effects on postoperative morbidity have not been extensively studied.

METHODS

MiTG and miDG patients were selected from 9356 oncological gastrectomies performed in 2017-2021 in 43 centers. Endpoints included anastomotic leakage (AL) rate and postoperative morbidity tested by multivariable analysis.

RESULTS

Three major anastomotic techniques [circular stapled (CS); linear stapled (LS); and hand sewn (HS)], and 3 major bowel reconstruction types [Roux (RX); Billroth I (BI); Billroth II (BII)] were identified in miTG (n=878) and miDG (n=3334). Postoperative complications, including AL (5.2% vs 1.1%), overall (28.7% vs 16.3%), and major morbidity (15.7% vs 8.2%), as well as 90-day mortality (1.6% vs 0.5%) were higher after miTG compared with miDG. After miTG, the AL rate was higher after CS (4.3%) and HS (7.9%) compared with LS (3.4%). Similarly, major complications (LS: 9.7%, CS: 16.2%, and HS: 12.7%) were lowest after LS. Multivariate analysis confirmed anastomotic technique as a predictive factor for AL, overall, and major complications. In miDG, AL rate (BI: 1.4%, BII 0.8%, and RX 1.2%), overall (BI: 14.5%, BII: 15.0%, and RX: 18.7%), and major morbidity (BI: 7.9%, BII: 9.1%, and RX: 7.2%), and mortality (BI: 0%, BII: 0.1%, and RY: 1.1%%) were not affected by bowel reconstruction.

CONCLUSIONS

In oncologically suitable situations, miDG should be preferred to miTG, as postoperative morbidity is significantly lower. LS should be a preferred anastomotic technique for miTG in Western Centers. Conversely, bowel reconstruction in DG may be chosen according to the surgeon's preference.

Patient-reported gastrointestinal symptoms in gastric cancer after laparoscopic distal gastrectomy

Purpose

This study aimed to compare postoperative gastrointestinal symptoms between patients who underwent laparoscopic distal gastrectomy with Roux-en-Y (R-Y) and Billroth-II with Braun (B-II B) reconstruction.

Methods

This observational study retrospectively analyzed 151 patients (110 in R-Y group and 41 in B-II B group) who underwent laparoscopic distal gastrectomy from January 2020 to December 2021. A comparison was made regarding surgical outcomes, perioperative nutritional and inflammatory markers, postoperative dietary patterns, and gastrointestinal symptoms between the two groups.

Results

The operation time was longer in the R-Y group than the B-II B group (261.00 ± 56.17 min versus 239.88 ± 57.78 min, p = 0.046). However, there were no significant differences in the length of hospital stay, ASA classification, complications, nutritional and inflammatory indexes, or recovery of postoperative diet between the two groups. Additionally, there were no significant differences in the occurrence of postoperative gastrointestinal symptoms in the post-discharge week (PDW) 1 and postoperative month (POM) 1 between the B-II B and R-Y groups.

Conclusions

Abdominal distention emerged as the main gastrointestinal symptom burden in patients with gastric cancer undergoing laparoscopic distal gastrectomy. Both Billroth-II with Braun and R-Y reconstructions exhibited a high and similar incidence of gastrointestinal symptoms in the short term. Therefore, medical staff should pay attention to the management of gastrointestinal symptoms in these patients postoperatively.

Development and Feasibility Assessment of Mobile Application-Based Digital Therapeutics for Postoperative Supportive Care in Gastric Cancer Patients Following Gastrectomy

PURPOSE

This study aimed to develop and assess the feasibility and effectiveness of digital therapeutics for supportive care after gastrectomy.

MATERIALS AND METHOD

The study included 39 patients with gastric cancer who underwent minimally invasive gastrectomy and were able to use a mobile application (app) on their smartphones. The developed research app automatically calculates and provides daily targets for calorie and protein intake based on the patient's body mass index (BMI). Patients recorded their daily diets, weights, and symptoms in the app and completed special questionnaires to assess the feasibility of the app in real-world clinical practice.

RESULTS

At the 10-week follow-up, the mean questionnaire scores for ease of learning, usability, and effectiveness of the app (primary endpoint) were 2.32±0.41, 2.35±0.43, and 2.4±0.39 (range: 0-3), respectively. Patients were classified as underweight (<18.5, n=4), normal (18.5-24.9, n=24), or overweight (≥25.0, n=11) according to predischarge BMI. Underweight patients showed higher compliance with app usage and a higher rate of achieving the target calorie and protein intake than normal weight and overweight patients (98% vs. 77% vs. 81%, p=0.0313; 102% vs. 75% vs. 61%, P=0.0111; 106% vs. 79% vs. 64%, P=0.0429). Two patients transitioned from underweight to normal weight (50.0%), one patient (4.3%) transitioned from normal weight to underweight, and two patients (22.2%) transitioned from overweight to normal weight.

CONCLUSIONS

The mobile app is feasible and useful for postoperative supportive care in terms of ease of learning, usability, and effectiveness. Digital therapeutics may be an effective way to provide supportive care for postgastrectomy patients, particularly in terms of nutrition.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04800991.

Impact of robotic gastrectomy in patients with primary T3 or more advanced gastric cancer

BACKGROUND

The use of robotic surgery (RS) for gastric cancer (GC) has been rapidly increasing. However, the utility of RS for advanced GC (AGC), especially T3 or more AGC, is unclear.

METHODS

Ninety patients who underwent curative upfront minimally invasive surgery (MIS) (D2 lymph node dissection) for fStage II or III GC were enrolled in this study. Among these patients, 68 underwent MIS for T3 or more AGC. Thirty-six patients underwent RS, and 32 patients underwent laparoscopic surgery (LS). The short-term and long-term surgical outcomes were compared between the two groups.

RESULTS

In the T3 or more AGC cohort, there were no significant intergroup differences in the operative time or blood loss volume. The number of retrieved lymph nodes tended to be higher in the RS than LS group (38.5 vs. 33.0, p = .11). The drain amylase content on postoperative day 1 was significantly lower in the RS than LS group (243.5 vs. 521.0 IU/L, p < .01). The morbidity rate (Clavien-Dindo grade ≥2) was similar between the groups. There were no significant differences between the LS and RS groups in the 3-year overall survival rate (80.7% vs. 74.5%, respectively; p = .95) or 3-year disease-free survival rate (75.0% vs. 69.7%, respectively; p = .95).

CONCLUSIONS

RS for primary T3 or more AGC was safe and contributed to similar short-term and long-term outcomes compared with LS.

Low incidence of postoperative infectious complications following laparoscopic distal gastrectomy for locally advanced gastric cancer in older adult patients above 75 years: Propensity score-matched comparison with open distal gastrectomy

INTRODUCTION

This study compared the short-term outcomes of older adult patients with locally advanced gastric cancer who underwent open distal gastrectomy (ODG) with those who underwent laparoscopic distal gastrectomy (LDG) using propensity score matching analysis.

METHODS

Overall, 341 consecutive older adult patients aged 75 years with gastric cancer who underwent ODG or LDG between January 2013 and December 2020 were retrospectively assessed. Among them, 121 patients with locally advanced gastric cancer were included. To compare short-term outcomes, a 1:1 propensity score matching analysis was performed.

RESULTS

After matching, 29 patients were included in both groups. Compared with the ODG group, the LDG group had a longer operative time (mean, 290 vs. 190 min; p < .0001) and lower estimated blood loss (mean, 39 vs. 223 mL; p < .0001). Overall postoperative complications of grade 2 and higher were observed in 2 (6.9%) and 12 (41%) patients in the LDG and ODG groups, respectively (p = .0046). Of these, the LDG group had a significantly lower incidence rate of infectious complications than the ODG group (3.4% vs. 27.6%; p = .025). Furthermore, in multivariate analysis, the laparoscopic approach was an independent protective factor against postoperative complications (p = .029).

CONCLUSIONS

LDG is safe and feasible for locally advanced gastric cancer in patients aged ≥75 years. Moreover, it may be a promising alternative to ODG with better short-term outcomes, including significantly lower incidence rates of postoperative complications.

Long-term Oncologic Outcomes of Robotic Total Gastrectomy for Advanced Gastric Cancer

PURPOSE

Although laparoscopic distal gastrectomy has rapidly replaced open distal gastrectomy, laparoscopic total gastrectomy (LTG) is less frequently performed owing to technical difficulties. Robotic surgery could be an appropriate minimally invasive alternative to LTG because it alleviates the technical challenges posed by laparoscopic procedures. However, few studies have compared the oncological safety of robotic total gastrectomy (RTG) with that of LTG, especially for advanced gastric cancer (AGC). Herein, we aimed to assess the oncological outcomes of RTG for AGC and compare them with those of LTG.

MATERIALS AND METHODS

We retrospectively reviewed 147 and 204 patients who underwent RTG and LTG for AGC, respectively, between 2007 and 2020. Long-term outcomes were compared using inverse probability of treatment weighting (IPTW).

RESULTS

After IPTW, the 2 groups exhibited similar clinicopathological features. The 5-year overall survival was comparable between the 2 groups (88.5% [95% confidence interval {CI}, 79.4%-93.7%] after RTG and 87.3% [95% CI, 80.1%-92.0%]) after LTG; log-rank P=0.544). The hazard ratio (HR) for death after RTG compared with that after LTG was 0.73 (95% CI, 0.40-1.33; P=0.304). The 5-year relapse-free survival was also similar between the 2 groups (75.7% [95% CI, 65.2%-83.4%] after RTG and 76.4% [95% CI, 67.9%-83.0%] after LTG; log-rank P=0.850). The HR for recurrence after RTG compared with that after LTG was 0.93 (95% CI, 0.60-1.46; P=0.753).

CONCLUSIONS

Our findings revealed that RTG and LTG for AGC had similar long-term outcomes. RTG is an oncologically safe alternative to LTG and has technical advantages.

Impact of the endoscopic surgical skill qualification system on the oncological safety of laparoscopic gastrectomy for gastric cancer: A single-center retrospective cohort study

BACKGROUND

This study aimed to investigate the laparoscopic gastrectomy (LG) performance of non-Endoscopic Surgical Skill Qualification System (ESSQS)-qualified surgeons under the ESSQS-qualified surgeon guidance and compare oncological outcomes of gastric cancer to LG performed by the ESSQS-qualified surgeons.

METHODS

This study enrolled 1,030 patients diagnosed with both clinical and pathological stage ≤ III gastric cancer and undergoing LG from January 2009 to June 2019. ESSQS-qualified surgeons served as the operator or the instructive assistant in all LG procedures involving them. A propensity score-matched analysis was used to retrospectively compare the long-term outcomes between the ESSQS-qualified and non-ESSQS-qualified surgeons.

RESULTS

Each group included 315 pairs after propensity score matching. The 3-year recurrence-free survival rates were 84.4% and 81.7% in the non-ESSQS and ESSQS groups, respectively. The difference was 2.7% (95% confidence interval: - 3.20%-8.44%, P < 0.001), and the non-ESSQS group statistically demonstrated noninferiority as the lower 95% confidence limit was greater than the prespecified margin of -10%, indicating the achieved primary endpoint. No significant differences in 5-year recurrence-free survival (non-ESSQS: 78.5% vs. ESSQS: 77.4%, P = 0.627) and 5-year overall survival (non-ESSQS: 80.9% vs. ESSQS: 79.3%, P = 0.475) were found between the two groups. The oncological outcomes stratified according to the presence of pathological stage I, II, and III disease did not significantly differ between the two groups.

CONCLUSIONS

LG performed by non-ESSQS-qualified surgeons achieved comparable oncological outcomes to the ESSQS-qualified surgeons, as long as ESSQS-qualified surgeons provided intraoperative instructions, in a high-volume center.

Impact of Minimally Invasive Surgery on Early and Late Outcomes of Patients With Gastric Cancer Treated Using Neoadjuvant Chemotherapy

BACKGROUND

Gastric cancer is the fifth most common neoplasm and the third leading cause of cancer-related death worldwide. Neoadjuvant chemotherapy is recommended for Stages II-III resectable tumors, but the comparative effectiveness of minimally invasive surgery (MIS) versus open gastrectomy (OG) post-neoadjuvant therapy has not been adequately investigated.

METHODS

A retrospective cohort analysis was performed on patients with clinical Stage II and III gastric adenocarcinoma who underwent neoadjuvant chemotherapy followed by either MIS or OG between 2007 and 2020. Propensity score matching was utilized to compare the clinical and surgical outcomes, morbidity, and mortality, and the influence of MIS on 3-year survival rates was evaluated.

RESULTS

After matching, no statistical differences in clinical aspects were noted between the two groups. MIS was associated with increased D2 lymphadenectomy, curative intent, and complete neoadjuvant therapy. Furthermore, this therapeutic approach resulted in reduced transfusion rates and shorter hospital stays. Nonetheless, no significant differences were observed in global, clinical, or surgical complications or mortality between the two groups. Weight loss emerged as a significant risk factor for complications, but MIS did not independently affect survival rates. Extended resection and higher American Society of Anesthesiology scores were independent predictors of reduced survival.

CONCLUSION

MIS after neoadjuvant chemotherapy for gastric cancer appears to be a viable option, with oncological outcomes comparable to those of OG, less blood loss, and shorter hospital stays. Although MIS did not independently affect long-term survival, it offered potential benefits in terms of postoperative recovery and morbidity. Further studies are needed to validate these findings, especially across diverse populations.

Dysregulation of systemic immunity and its clinical application in gastric cancer

Immunotherapy has profoundly changed the treatment of gastric cancer, but only a minority of patients benefit from immunotherapy. Therefore, numerous studies have been devoted to clarifying the mechanisms underlying resistance to immunotherapy or developing biomarkers for patient stratification. However, previous studies have focused mainly on the tumor microenvironment. Systemic immune perturbations have long been observed in patients with gastric cancer, and the involvement of the peripheral immune system in effective anticancer responses has attracted much attention in recent years. Therefore, understanding the distinct types of systemic immune organization in gastric cancer will aid personalized treatment designed to pair with traditional therapies to alleviate their detrimental effects on systemic immunity or to directly activate the anticancer response of systemic immunity. Herein, this review aims to comprehensively summarize systemic immunity in gastric cancer, including perturbations in systemic immunity induced by cancer and traditional therapies, and the potential clinical applications of systemic immunity in the detection, prediction, prognosis and therapy of gastric cancer.

Analysis of Clinical Efficacy and Quality of Life of Braun Anastomosis in Gastrointestinal Reconstruction in Totally Laparoscopic Distal Gastrectomy: A Single-Center Retrospective Study

OBJECTIVE

This study aimed to compare the clinical efficacy and quality of life of B-IIB (Billroth-II with Braun anastomosis) and B-II (Billroth-II anastomosis) in the alimentary tract reconstruction postoperative totally laparoscopic distal gastrectomy (TLDG) for gastric cancer.

METHODS

From February 2016 to January 2022, 158 patients underwent totally laparoscopic distal gastrectomy and D2 lymphadenectomy in Northern Jiangsu People's Hospital, with Billroth-II with Braun anastomosis for 93 patients and Billroth-II anastomosis for 65 patients. The patients' data were collected prospectively and reviewed retrospectively.

RESULTS

In this study, the post-op hospital stay of B-IIB group were shorter than B-II group (12.70 ± 3.08 days in the B-IIB group versus 14.12 ± 4.90 days in the B-II group, p < 0.05) and the first post-op flatus time of the B-IIB group were shorter than B-II group (3.49 ± 1.02 days versus 4.08 ± 1.85 days, p < 0.05). Two groups did differ significantly in hemoglobin on postoperative 3 months, albumin at 3 months after operation, and serum sodium on postoperative 3 days and 3 months (p < 0.05), and the B-IIB had an advantage; the complications incidence (Clavien-Dindo grade II or even a higher grade) of the B-IIB group and B-II group were 10.75% and 29.23%, respectively. There being a statistical difference between the two groups. The B-IIB group and the B-II group both had different degrees of weight loss at 3 months after operation compared with preoperative weight. The weight of B-IIB group was 4.04 ± 1.33 kg, which was less than B-II group (8.08 ± 1.47 kg). The difference was statistically significant (p < 0.05). According to the PGSAS (Postgastrectomy Syndrome Assessment Scale), the score of the B-IIB group is lower than that of the B-II group for esophageal reflux gastritis, dyspepsia, and dumping syndrome group (1.84 ± 0.92 VS 2.15 ± 0.85, P = 0.031; 1.86 ± 1.10 VS 2.22 ± 0.91, P = 0.034; 1.98 ± 1.06 VS 2.32 ± 0.94, P = 0.037, respectively).

CONCLUSION

Totally laparoscopic distal gastrectomy with Billroth-II Braun reconstruction is a safe and technically feasible method for gastric cancer patients, which can reduce the incidence of postoperative reflux esophagitis and dumping syndrome. Compared with Billroth-II reconstruction, it has advantages in maintaining postoperative nutritional status and electrolyte balance and improving quality of life.

Long-term outcomes of laparoscopic versus open distal gastrectomy for patients with advanced gastric cancer in North China: a multicenter randomized controlled trial

BACKGROUND

Laparoscopic distal gastrectomy (LDG) has become a common procedure for treating advanced gastric cancer (AGC) in China. However, there is uncertainty regarding its oncological outcomes compared to open distal gastrectomy (ODG). This study aims to compare the 3-year disease-free survival (DFS) rates among patients who underwent surgery for AGC in northern China.

METHODS

A multicenter, non-inferiority, open-label, parallel, randomized clinical trial was conducted to evaluate patients with AGC who were eligible for distal gastrectomy at five tertiary hospitals in North China. In this trial, patients were randomly assigned preoperatively to receive either LDG or ODG in a 1:1 allocation ratio. The primary endpoint was postoperative morbidity and mortality within 30 days and the secondary endpoint was the 3-year DFS rate. This trial has been registered at ClinicalTrials.gov (Identifier: NCT02464215).

RESULTS

A total of 446 patients were randomly allocated to LDG (n = 223) or ODG group (n = 223) between March 2014 and August 2017. After screening, a total of 214 patients underwent the open surgical approach, while 216 patients underwent laparoscopic surgery. The 3-year DFS rate was 85.9% for the LDG group and 84.72% for the ODG group, with no significant statistical difference (Hazard ratio 1.12; 95% CI 0.68-1.84, P = 0.65). Body mass index (BMI) < 25 kg/m2, advanced pathologic T4, and pathologic N2-3 category were confirmed as independent risk factors for DFS in the Cox regression.

CONCLUSIONS

In comparison to ODG, LDG with D2 lymphadenectomy yielded similar outcomes in terms of 3-year DFS rates among patients diagnosed with AGC.

Enlightenment of robotic gastrectomy from 527 patients with gastric cancer in the minimally invasive era: 5 years of optimizing surgical performance in a high-volume center - a retrospective cohort study

BACKGROUND

Learning curves have been used in the field of robotic gastrectomy (RG). However, it should be noted that the previous study did not comprehensively investigate all changes related to the learning curve. This study aims to establish a learning curve for radical RG and evaluate its effect on the short-term outcomes of patients with gastric cancer.

METHODS

The clinicopathological data of 527 patients who underwent RG between August 2016 and June 2021 were retrospectively analyzed. Learning curves related to the operation time and postoperative hospital stay were determined separately using cumulative sum (CUSUM) analysis. Then, the impact of the learning curve on surgical efficacy was analyzed.

RESULTS

Combining the CUSUM curve break points and technical optimization time points, the entire cohort was divided into three phases (patients 1-100, 101-250, and 251-527). The postoperative complication rate and postoperative recovery time tended to decrease significantly with phase advancement ( P <0.05). More extraperigastric examined lymph nodes (LN) were retrieved in phase III than in phase I (I vs. III, 15.12±6.90 vs. 17.40±7.05, P =0.005). The rate of LN noncompliance decreased with phase advancement. Textbook outcome (TO) analysis showed that the learning phase was an independent factor in TO attainment ( P <0.05).

CONCLUSION

With learning phase advancement, the short-term outcomes were significantly improved. It is possible that our optimization of surgical procedures could have contributed to this improvement. The findings of this study facilitate the safe dissemination of RG in the minimally invasive era.

Safety and feasibility of single-incision laparoscopic distal gastrectomy in overweight and obese gastric cancer patients: a propensity score-matched analysis

BACKGROUND

The technical challenges and safety concerns of single-incision laparoscopic gastrectomy for overweight and obese gastric cancer patients remain unclear. This study aimed to evaluate the safety and feasibility of single-incision laparoscopic distal gastrectomy (SIDG) compared to multiport laparoscopic distal gastrectomy (MLDG) in overweight and obese gastric cancer patients.

METHODS

This study retrospectively analyzed overweight and obese patients (body mass index ≥ 25 kg/m2) and pathologic stage T1 primary gastric adenocarcinoma treated with either SIDG or MLDG. The SIDG and MLDG groups were propensity score matched at a 1:2 ratio using age, sex, height, body weight, American Society of Anesthesiologists classification, year of surgery, pathologic N stage, and anastomosis method as covariates.

RESULTS

After 1:2 matching, the study included patients who underwent SIDG (n = 179) and MLDG (n = 358). No significant difference in the number of retrieved lymph nodes was found between the SIDG and MLDG groups (52.8 ± 19.3 vs. 53.9 ± 21.0, P = 0.56). Operation times were significantly shorter in the SIDG group (170.8 ± 60.0 min vs. 186.1 ± 52.6 min, P = 0.004). The postoperative hospital length of stay was comparable between the 2 groups (SIDG: 5.9 ± 3.4 days vs. MLDG: 6.3 ± 5.1 days, P = 0.23), as was postoperative complication rate (SIDG: 13.4% vs. MLDG: 12.8%, P = 0.89).

CONCLUSIONS

SIDG was shown to be as safe and feasible as MLDG for overweight and obese gastric cancer patients, with comparable early postoperative complication rates without compromising operation time compared to MLDG.

Impact of treatment guidelines and pivotal clinical trial results on a surgeon's decision regarding treatment for gastric cancer: a retrospective cohort study using the National Clinical Database

PURPOSES

The present study evaluated the impact of clinical guidelines for gastric cancer surgery on surgeons' choice of procedure in real-world practice. We focused on the 2014 guideline revision recommending laparoscopic surgery and the evidence concerning splenectomy for prophylactic lymphadenectomy reported in 2015 using the National Clinical Database, which is the most comprehensive database in Japan.

METHODS

We investigated the monthly percentages of laparoscopic distal gastrectomies performed for stage I gastric cancer (LDG%) and splenectomies performed during total gastrectomy for advanced cancer (TGS%) between 2014 and 2017. We evaluated the descriptive statistics of the time-series changes in the LDG%, TGS%, and annual trends of outcomes.

RESULTS

In total, 124,787 patients were enrolled. The mean LDG% and TGS% were 69.8% and 9.2%, respectively. The LDG% and TGS% were 66.4% and 16.7%, respectively, in January 2014 and 73.1% and 5.9%, respectively, in December 2017. LDG% consistently increased, and TGS% showed a consistent downward trend throughout the observation period. There was no significant change in this trend after the publication of the guideline recommendations or clinical trial results.

CONCLUSION

No significant changes in surgical procedures were observed after publication of the guidelines or results of clinical trials.

Robotic versus laparoscopic gastrectomy for gastric cancer: A Western propensity score matched analysis

BACKGROUND

Robot-assisted gastrectomy (RG) has been shown to be safe and feasible in the treatment of gastric cancer (GC). However, it is unclear whether RG is equivalent to laparoscopic gastrectomy (LG), especially in the Western world. Our objective was to compare the outcomes of RG and LG in GC patients.

METHODS

We reviewed all gastric adenocarcinoma patients who underwent curative gastrectomy by minimally invasive approach in our institution from 2009 to 2022. Propensity score matching (PSM) analysis was conducted to reduce selection bias. DaVinci Si platform was used for RG.

RESULTS

A total of 156 patients were eligible for inclusion (48 RG and 108 LG). Total gastrectomy was performed in 21.3% and 25% of cases in LG and RG, respectively. The frequency of stage pTNM II/III was 48.1%, and 54.2% in the LG and RG groups (p = 0.488). After PSM, 48 patients were matched in each group. LG and RG had a similar number of dissected lymph nodes (p = 0.759), operative time (p = 0.421), and hospital stay (p = 0.353). Blood loss was lower in the RG group (p = 0.042). The major postoperative complications rate was 16.7% for LG and 6.2% for RG (p = 0.109). The 30-day mortality rate was 2.1% and 0% for LG and RG, respectively (p = 1.0). There was no significant difference between the LG and RG groups for disease-free survival (79.6% vs. 61.2%, respectively; p = 0.155) and overall survival (75.9% vs. 65.7%, respectively; p = 0.422).

CONCLUSION

RG had similar surgical and long-term outcomes compared to LG, with less blood loss observed in RG.

Totally laparoscopic versus laparoscopy-assisted distal gastrectomy: the KLASS-07: a randomized controlled trial

BACKGROUNDS

Strong evidence is lacking as no confirmatory randomized controlled trials (RCTs) have compared the efficacy of totally laparoscopic distal gastrectomy (TLDG) with laparoscopy-assisted distal gastrectomy (LADG). The authors performed an RCT to confirm if TLDG is different from LADG.

METHODS

The KLASS-07 trial is a multi-centre, open-label, parallel-group, phase III, RCT of 442 patients with clinical stage I gastric cancer. Patients were enroled from 21 cancer care centres in South Korea between January 2018 and September 2020 and randomized to undergo TLDG or LADG using blocked randomization with a 1:1 allocation ratio, stratified by the participating investigators. Patients were treated through R0 resections by TLDG or LADG as the full analysis set of the KLASS-07 trial. The primary endpoint was morbidity within postoperative day 30, and the secondary endpoint was quality of life (QoL) for 1 year. This trial is registered at ClinicalTrials.gov (NCT03393182).

RESULTS

Four hundred forty-two patients were randomized (222 to TLDG, 220 to LADG), and 422 patients were included in the pure analysis (213 and 209, respectively). The overall complication rate did not differ between the two groups (TLDG vs. LADG: 12.2% vs. 17.2%). However, TLDG provided less postoperative ileus and pulmonary complications than LADG (0.9% vs. 5.7%, P= 0.006; and 0.5% vs. 4.3%, P= 0.035, respectively). The QoL was better after TLDG than after LADG regarding emotional functioning at 6 months, pain at 3 months, anxiety at 3 and 6 months, and body image at 3 and 6 months (all P< 0.05). However, these QoL differences were resolved at 1 year.

CONCLUSIONS

The KLASS-07 trial confirmed that TLDG is not different from LADG in terms of postoperative complications but has the advantages to reduce ileus and pulmonary complications. TLDG can be a good option to offer better QoL in terms of pain, body image, emotion, and anxiety at 3-6 months.

Analyzing risk factors for second malignancies in early gastric carcinoma from the SEER database

This retrospective study analyzed a large population of gastric cancer (GC) patients treated between 2010 and 2015 to investigate the clinical features and predictive risk factors for developing secondary primary malignancies (SPMs). The cumulative incidence of SPM was assessed using Kaplan-Meier analysis. Competing risk analyses adjusted for mortality were conducted using stratified Cox proportional hazard regression models and multivariate analyses to identify independent predictors of SPM. A total of 3289 out of 167,747 GC patients were included in the analytic cohort, with 155 patients diagnosed with SPM. Patients whose histologic type other than adenocarcinomas (AC) and signet ring cell carcinoma (SRCC) emerged as an independent risk factor for developing SPM (hazard ratio [HR] 2.262, 95% confidence interval [CI] 1.146-4.465, P = 0.019) in multivariate Cox regression analysis. The surgical method, including biopsy/local excision (HR 2.3, [CI] 1.291-4.095, P = 0.005) and subtotal/total resection ([HR] 1.947, [CI] 1.028-3.687, P = 0.041), chemotherapy ([HR] 1.527, [CI] 1.006-2.316, P = 0.047), and histologic type ([HR] 2.318, [CI] 1.193-4.504, P = 0.013)), were identified as independent risk factors in the competitive risk model. Subgroup analyses, stratified by chemotherapy, revealed an increased risk of SPM among older patients. Furthermore, a nomogram was developed and internally validated to predict the cumulative incidence of SPM in GC patients (C-index = 0.73 for 72 months). These findings suggested that in specific histologic types of GC, the lymph node infiltration region missed after local surgical resection, and concomitant chemotherapy would have an increased risk of SPM for cancer survivors.

The safety and efficacy of neoadjuvant immunochemotherapy following laparoscopic gastrectomy for gastric cancer: a multicentre real-world clinical study

BACKGROUND

The safety and efficacy of neoadjuvant immunochemotherapy (nICT) for locally advanced gastric cancer (LAGC) remain controversial.

METHODS

Patients with LAGC who received either nICT or neoadjuvant chemotherapy (nCT) at 3 tertiary referral teaching hospitals in China between January 2016 and October 2022 were analyzed. After propensity-score matching (PSM), comparing the radiological response, pathological response rate, perioperative outcomes, and early recurrence between the two groups.

RESULTS

After PSM, 585 patients were included, with 195 and 390 patients comprising the nICT and nCT groups, respectively. The nICT group exhibited a higher objective response rate (79.5% vs. 59.0%; P <0.001), pathological complete response rate (14.36% vs. 6.41%; P =0.002) and major pathological response rate (39.49% vs. 26.15%; P =0.001) compared with the nCT group. The incidence of surgical complications (17.44% vs. 16.15%, P =0.694) and the proportion of perioperative textbook outcomes (80.0% vs. 81.0%; P =0.767) were similar in both groups. The nICT group had a significantly lower proportion of early recurrence than the nCT group (29.7% vs. 40.8%; P =0.047). Furthermore, the multivariable logistic analysis revealed that immunotherapy was an independent protective factor against early recurrence [odds ratio 0.62 (95% CI 0.41-0.92); P =0.018]. No significant difference was found in neoadjuvant therapy drug toxicity between the two groups (51.79% vs. 45.38%; P =0.143).

CONCLUSIONS

Compared with nCT, nICT is safe and effective, which significantly enhanced objective and pathological response rates and reduced the risk for early recurrence among patients with LAGC.

TRIAL REGISTRATION

Clinical Trials.gov.