Laparoscopic vs Open Distal Gastrectomy for Locally Advanced Gastric Cancer: 5-Year Outcomes of the KLASS-02 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.

Development and external validation of nomogram associated with gastroparesis syndrome after subtotal gastrectomy depending on random forest and traditional model: does robotic surgery have advantages?

Postsurgical gastroparesis syndrome (PGS) significantly diminishes the quality of life for patients following surgery. With the evolution of robotic surgery, there is a debate on whether it can offer a novel treatment modality for gastric cancer and reduce the incidence of gastric paralysis syndrome. This study utilizes machine learning techniques and traditional logistic regression to construct and validate predictive models, with the aim of providing guidance for clinical practitioners. This study included two cohorts from one medical centers based on the surgical timing for division (Cohort 1: n = 619 for model building and internal validation; Cohort 2: n = 312 for external validation). In Cohort 1, a 3:1 ratio was used for training and validation in random forest and a 7:3 ratio for logistic regression. After analyzing the Receiver Operating Characteristic curves (ROC), we chose classical logistic regression to build the prediction model followed by evaluation with calibration and decision curve analysis (DCA). Finally, we performed external validation on Cohort 2. The model incorporated 7 factors including: Pre-operative TBIL (OR = 2.99), Pre-operative DBIL (OR = 2.35), Pre-operative potassium (OR = 6.8), Surgical type (OR = 3.76), Gastric tube removal time (OR = 3.48), Reconstruction mode (OR = 4.63) and Operative time (OR = 2.21). The model performed well in ROC, with AUC values of 0.892 in the training set, 0.858 in the inner validation set (Cohort 1), and 0.849 in the exterior validation set (Cohort 2). All three datasets' calibration curves revealed a high level of agreement between projected and actual probability. DCA suggested that the model had great clinical usefulness. We have established a more reliable predictive model for PGS which can provide guidance for clinical practitioners. Robotic surgery is also considered to be one of the factors that can reduce the occurrence of PGS.

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.

Comparison of laparoscopic and open gastrectomy after neoadjuvant chemotherapy for locally advanced gastric cancer: a propensity score matching analysis

BACKGROUND

We investigated the safety and efficacy of laparoscopic gastrectomy (LG) in patients with locally advanced gastric cancer who underwent neoadjuvant chemotherapy (NAC).

METHODS

This study included 247 consecutive patients with advanced gastric cancer who underwent NAC followed by gastrectomy between 2007 and 2017 at one of six institutions. The patients were divided into the open gastrectomy (OG) and LG groups. The short- and long-term outcomes in both groups were investigated after propensity score matching.

RESULTS

After propensity score matching, 72 pairs of patients were selected. The baseline characteristics were not significantly different after matching. Compared with the OG group, the LG group had a significantly longer operative time (360 vs. 305 min, P = 0.002) and less intraoperative blood loss (271 vs. 652 mL, P < 0.001). The LG group had more harvested lymph nodes than the OG group (57.4 vs. 45.1, P < 0.001). The frequency of Clavien-Dindo grade ≥ 2 postoperative complications was not significantly different (26% vs. 22%, P = 0.698). The interval between surgery and postoperative chemotherapy was significantly shorter in the LG group (48.7 vs. 68.6 days, P = 0.048). The 5-year overall survival rates in the OG and LG groups were 54.4% and 53.5%, respectively. The overall survival was similar between the two groups (P = 0.773). No significant differences were observed between the two groups in terms of the type of recurrence, including lymph node, hematogenous, and peritoneal recurrences (P = 1.000, P = 1.000, and P = 0.686, respectively).

CONCLUSIONS

Based on both short- and long-term results, LG is a potential therapeutic option for patients with gastric cancer who undergo NAC.

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.

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.

Safety and feasibility of laparoscopic stomach-partitioning gastrojejunostomy combined with neoadjuvant chemotherapy followed by minimally invasive gastrectomy for resectable gastric cancer with gastric outlet obstruction

BACKGROUND

Advanced gastric cancer with gastric outlet obstruction (GOO) causes malnutrition and medication adherence issues, leading to a poor prognosis. We developed a novel multimodal, less invasive treatment approach for gastric cancer patients with symptomatic GOO: laparoscopic stomach-partitioning gastrojejunostomy (LSPGJ) combined with neoadjuvant chemotherapy (NAC), followed by minimally invasive gastrectomy with reuse of gastrojejunostomy. This study is a retrospective analysis of the safety and feasibility of our treatment strategy.

METHODS

In this single-institution retrospective study, we enrolled 54 patients (NAC group, n = 26; upfront gastrectomy group, n = 28) who achieved R0 resection through a minimally invasive approach between 2007 and 2020 and evaluated their short- and long-term outcomes.

RESULTS

After LSPGJ, the Gastric Outlet Obstruction Scoring System score significantly improved (p < 0.001). The median relative dose intensity of NAC was 88.2%. Regarding short-term outcomes, there were no differences in postoperative complications, length of postsurgical hospital stay, and adjuvant chemotherapy administration. Although overall survival and relapse-free survival showed trends toward improvement in the NAC group, these differences were not statistically significant. The cumulative incidence curve for recurrence in the NAC group was significantly lower than that of the upfront gastrectomy group (p = 0.041). Recurrence and hematogenous metastasis were significantly lower in the NAC group (p = 0.031 and 0.041, respectively) than in the upfront gastrectomy group. A forest plot revealed that NAC yielded favorable outcomes, particularly for patients with a body mass index (BMI) < 18.5 kg/m2, cT4, or cN1.

CONCLUSIONS

LSPGJ combined with NAC followed by minimally invasive gastrectomy was a safe and feasible treatment strategy for patients with advanced gastric cancer with symptomatic GOO. This procedure may contribute to the early recovery of oral intake and help maintain NAC dose intensity, potentially improving prognosis, particularly for patients with low BMI and advanced-stage disease.

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.

Development of a modified nutritional index model based on nutritional status and sarcopenia to predict long-term survival and chemotherapy benefits in elderly patients with advanced gastric cancer

BACKGROUND

Elderly patients with advanced gastric cancer have poor prognoses. This study aims to develop a prediction model for long-term survival after radical surgery and to identify patients who may benefit from chemotherapy.

METHODS

Data from 555 elderly patients with advanced gastric cancer admitted to two medical centers from 2009 to 2018 were retrospectively analyzed. Sarcopenia was combined with the Controlling Nutritional Status (CONUT) score to create a modified nutritional index (mCONUT). Cox regression analyses were used to develop a novel nomogram prediction model (mCNS) that combined mCONUT, pN, and tumor size, and its performance was further verified both internally and externally.

RESULTS

Multivariate Cox analysis revealed that tumor size, pN, and mCONUT were independent prognostic risk factors for overall survival (OS). The mCNS model showed good fit and high predictive value (AUC: training set 0.711; validation set 0.707), outperforming the pTNM model (p < 0.05). To further investigate the association between the model and adjuvant chemotherapy, we categorized the model into two risk groups: a high-risk group and a low-risk group. Further analysis revealed that, in the low-risk group, the OS and recurrence-free survival(RFS) for patients receiving adjuvant chemotherapy was significantly better than that of those who did not receive chemotherapy (p = 0.047,p = 0.019). In the high-risk group, this result was not observed (p = 0.120, p = 0.053).

CONCLUSION

The mCNS model has high predictive value in predicting long-term survival of elderly patients with advanced gastric cancer. Patients with mCNS-L were able to benefit from chemotherapy after laparoscopic radical gastrectomy.

Minimally Invasive Distal Gastrectomy: Evolving Surgical Techniques

Surgical management of gastric cancer has evolved over the years. Incorporation of minimally invasive techniques has led to shorter hospital stays, reduced wound complications, and earlier return to functional activity. Nevertheless, the development of minimally invasive total gastrectomy as a repertoire in the management of proximal or diffuse gastric cancer requires significant commitment and support owing to the complexity of the procedure. Here the authors describe the evolution of total gastrectomy with particular focus on laparoscopic and robotic approaches. In addition, they outline the data comparing minimally invasive total gastrectomy with traditional open surgical approaches.

Efficacy analysis of prophylactic hyperthermic intraperitoneal chemotherapy in patients with locally advanced gastric cancer: a retrospective study

Purpose

This study aims to evaluate the effectiveness and safety of prophylactic hyperthermic intraperitoneal chemotherapy (P-HIPEC) in patients with locally advanced gastric cancer (AGC) after laparoscopic radical gastrectomy. Additionally, it explores how the frequency and timing of P-HIPEC influence treatment outcomes.

Methods

A retrospective analysis was conducted on 227 patients with locally AGC who underwent laparoscopic surgery at Maoming People's Hospital from January 2016 to December 2022. Patients were stratified into the HIPEC group (n=101) and the non-HIPEC group (n=126), based on whether they received postoperative P-HIPEC. Propensity score matching (PSM) was used to adjust for baseline characteristics, facilitating a comparative analysis of survival outcomes, postoperative complications and recurrence patterns. Cox regression analysis was performed to identify prognostic factors. Furthermore, the impact of varying P-HIPEC frequencies and initiation timings was evaluated.

Results

No significant differences in overall survival (OS) or postoperative complication rates were observed between the two groups in the original and PSM cohorts. But the disease-free survival (DFS) of the HIPEC group was significantly higher than that of the non-HIPEC group (HR 0.569; 95% CI 0.362-0.894; p = 0.013) in the PSM cohort, with 1-year, 3-year, and 5-year DFS rates showing notable improvement (77.9% vs. 69.7%, 60.1% vs. 43.0%, and 46.2% vs. 25.5%). The incidence of isolated peritoneal metastasis (PM) was significantly lower in the HIPEC group (5.3% vs. 17.3%, p = 0.039). Multivariate Cox regression analysis identified P-HIPEC as an independent protective factor for DFS. Further analysis indicated that neither the number of P-HIPEC sessions had a significant impact on OS (p = 0.388) or DFS (p = 0.735), nor did the timing of P-HIPEC initiation affect OS (p = 0.620) or DFS (p = 0.488). Likewise, different P-HIPEC frequencies or initiation timings had no significant impact on postoperative complication rates or recurrence patterns.

Conclusion

P-HIPEC effectively reduces the risk of postoperative PM and improves DFS in patients with locally AGC without increasing postoperative complications. However, it does not significantly impact OS. Additionally, variations in the frequency and timing of P-HIPEC initiation do not significantly affect survival outcomes, postoperative complications, or recurrence patterns.

Advantages of adjuvant chemotherapy using S-1 following minimally invasive gastrectomy for gastric cancer versus open surgery: a propensity score-matched analysis

BACKGROUND

It is essential to ensure optimal adherence to adjuvant chemotherapy regimens following gastric cancer surgery. However, treatment intensity for S-1 as adjuvant chemotherapy has not as yet been compared between minimally invasive (MI) and open (Open) surgery.

METHODS

We retrospectively compared dose modification of adjuvant S-1 between MI and Open surgery in patients undergoing R0 gastrectomy for gastric or esophago-gastric junction cancer at the Cancer Institute Hospital Tokyo, Japan, during the period from 2012 to 2022, and receiving S-1 for pStage II or S-1 plus docetaxel for pStage III as adjuvant chemotherapy. Propensity score matching (PSM) was conducted to adjust for possible confounders.

RESULTS

In total, 323 patients were initially included. After PSM, 158 patients remained, 79 in each group. The adjuvant chemotherapy completion rates were similar in the two groups. However, the proportion of patients who required S-1 dose reduction was significantly lower in the MI than in the Open group (43.0% vs. 65.8%, p = 0.004). In addition, the MI group had significantly fewer patients requiring suspension of S-1 than the Open group (46.8% vs. 64.6%, p = 0.025). Moreover, the frequency of adverse events of grade ≥ 3 was significantly lower in the MI than in the Open group (17.7% vs. 31.7%, p = 0.042).

CONCLUSIONS

In adjuvant chemotherapy for gastric cancer, minimally invasive surgery may offer better treatment intensity for oral S-1 administration than open surgery.

Short- and long-term outcomes following perioperative ERAS management in patients undergoing minimally invasive radical gastrectomy after neoadjuvant chemotherapy: A single-center retrospective propensity score matching study

INTRODUCTION

Gastric cancer patients receiving neoadjuvant chemotherapy (NACT) are more vulnerable to perioperative stress. Enhanced recovery after surgery (ERAS) is widely used in surgical patients aiming at reducing stress responses. However, whether this approach is safe and feasible for gastric cancer patients received minimally invasive radical gastrectomy after NACT remained determined. So, the objective of this study is to investigate the effects of ERAS for this special group of gastric cancer patients.

MATERIAL AND METHODS

The data of gastric cancer patients who underwent minimally invasive radical gastrectomy after NACT were collected. Patients were divided into an ERAS group and a conventional group based on whether they received perioperative ERAS management. Propensity score matching was conducted to eliminate bias. Pre- and postoperative inflammatory and nutritional marker levels, postoperative complications, recovery indices and 3-year OS and RFS were observed.

RESULTS

A total of 252 patients were analyzed after 1:1 PSM, including 126 patients in the ERAS group and 126 in the conventional group. The results showed that the implementation of ERAS significantly reduced the levels of novel inflammatory indicators, improve nutritional status and accelerate postoperative recovery. We found that the 3-year OS (72.2 % vs. 66.7 %) and RFS (67.5 % vs. 61.9 %) in the ERAS group showed an improvement trend compared to those in the traditional group, especially for stage III patients, although these differences were not significant.

CONCLUSION

The perioperative ERAS program is safe and feasible for gastric cancer patients received minimally invasive radical gastrectomy after NACT.

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.

Korean Gastric Cancer Association-Led Nationwide Survey on Surgically Treated Gastric Cancers in 2023

PURPOSE

Since 1995, the Korean Gastric Cancer Association (KGCA) has been periodically conducting nationwide surveys on patients with surgically treated gastric cancer. This study details the results of the survey conducted in 2023.

MATERIALS AND METHODS

The survey was conducted from March to December 2024 using a standardized case report form. Data were collected on 86 items, including patient demographics, tumor characteristics, surgical procedures, and surgical outcomes. The results of the 2023 survey were compared with those of previous surveys.

RESULTS

Data from 12,751 cases were collected from 66 institutions. The mean patient age was 64.6 years, and the proportion of patients aged ≥71 years increased from 9.1% in 1995 to 31.7% in 2023. The proportion of upper-third tumors slightly decreased to 16.8% compared to 20.9% in 2019. Early gastric cancer accounted for 63.1% of cases in 2023. Regarding operative procedures, a totally laparoscopic approach was most frequently applied (63.2%) in 2023, while robotic gastrectomy steadily increased to 9.5% from 2.1% in 2014. The most common anastomotic method was the Billroth II procedure (48.8%) after distal gastrectomy and double-tract reconstruction (51.9%) after proximal gastrectomy in 2023. However, the proportion of esophago-gastrostomy with anti-reflux procedures increased to 30.9%. The rates of post-operative mortality and overall complications were 1.0% and 15.3%, respectively.

CONCLUSIONS

The results of the 2023 nationwide survey demonstrate the current status of gastric cancer treatment in Korea. This information will provide a basis for future gastric cancer research.

Enhancing Preoperative Diagnosis Accuracy of Stage III Gastric Cancer with Circulating circRNAs

BACKGROUND

The prognosis remains poor for stage III gastric cancer, and neoadjuvant chemotherapy is increasingly used to improve outcomes. Accurate diagnosis prior to treatment is essential to develop appropriate treatment strategies for poor prognosis subgroups. This study aims to enhance the accuracy of pre-treatment gastric cancer diagnosis using a biological approach centered on circulating circular RNA (circRNA).

MATERIALS AND METHODS

We conducted a comprehensive analysis of circRNA expression profiles using two Gene Expression Omnibus datasets to identify circRNA candidates associated with stage III gastric cancer. Subsequently, we validated these circRNA biomarkers in two independent clinical cohorts comprising a total of 174 patients with gastric cancer and non-disease controls through real-time polymerase chain reaction (PCR).

RESULTS

Genome-wide circRNA analysis identified a panel of four biomarkers capable of diagnosing pathologically confirmed stage III (pStage III) gastric cancer. In a training cohort (n = 83), a clinically applicable panel of four circRNAs was developed (AUC 0.81), which was successfully validated in an independent clinical cohort (n = 82; AUC 0.76). To assess clinical utility, we combined clinical imaging (cStage) with the circRNA panel. Among those initially diagnosed as cStage III but later confirmed as pStage I/II, 86% were accurately diagnosed using the molecular biological approach with circRNAs.

CONCLUSIONS

We have developed a circRNA-based non-invasive liquid biopsy that can improve the diagnostic performance of pStage III gastric cancer before treatment. Our circRNA model could provide a sophisticated and personalized approach to assist in treatment planning for patients with advanced gastric cancer.

Conversion Therapy for Stage IV Gastric Cancer: Report From the Expert Consensus Meeting at KINGCA WEEK 2024

Conversion therapy is a treatment strategy that shifts from palliative systemic therapy to curative surgical treatment for primary and/or metastatic stage IV gastric cancer (GC). To address its clinical statements, the Korean Gastric Cancer Association aims to present a consensus on conversion therapy among experts attending KINGCA WEEK 2024. The KINGCA Scientific Committee and Development Working Group for Korean Practice Guidelines prepared preformulated topics and 9 clinical statements for conversion therapy. The Delphi method was applied to a panel of 17 experts for consensus and opinions. The final comments were announced after the statement presentation and discussed during the consensus meeting session of KINGCA WEEK 2024. Most experts agreed that conversion therapy provides a survival benefit for selected patients who respond to systemic therapy and undergo R0 resection (88.3%). Patients with limited metastases were considered good candidates (94.2%). The optimal timing was based on the response to systemic therapy (70.6%). The regimen was recommended to be individualized (100%) and the duration to be at least 6 months (88.3%). A minimally invasive approach (82.3%) and D2 lymph node dissection (82.4%) were considered for surgery. However, resection for metastases with a complete clinical response after systemic therapy was not advocated (41.2%). All experts agreed on the need for large-scale randomized-controlled trials for further evidence (100%). Recent advancements in treatment may facilitate radical surgery for patients with stage IV GC. Further evidence is warranted to establish the safety and efficacy of conversion therapy.

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.

Metachronous Schnitzler's Metastasis of Gastric Adenocarcinoma 13 Years After Curative Resection: A Case Report

A 54-year-old man presented with constipation with a six-month duration and a 5 kg weight loss over 10 months. He had undergone a subtotal gastrectomy and chemotherapy for advanced gastric cancer 13 years earlier. A colonoscopy revealed a firm, circular, in-growing mass in the rectum. A computed tomography (CT) scan showed a 3.0×1.2 cm invasive mass near the prostate, abutting the rectal wall and invading the right ureterovesical junction, causing hydroureteronephrosis. A positron emission tomography-CT scan indicated low fluorodeoxyglucose uptake in the rectal or prostate area. The biopsy results showed poorly differentiated carcinoma. An immunohistochemistry study confirmed CK7 positive, CK20 negative, MUC2 negative, and CDX2 focally positive immune phenotype for cancer cells, suggesting a diagnosis of metastatic adenocarcinoma with a gastric origin rather than a prostate and rectal origin.

Robotic vs laparoscopic distal gastrectomy with Billroth I and II reconstruction: a systematic review and meta-analysis

Robotic distal gastrectomy (RDG) has been increasingly used for the treatment of gastric cancer, however, its comparative safety and efficacy against the laparoscopic approach (LDG), remains unclear, especially when accounting the reconstruction method as a confounder. This systematic review and meta-analysis aims to evaluate the short-term outcomes of RDG vs LDG In patIents with gastric cancer, undergoing Billroth I and II reconstruction. A systematic review was conducted in accordance with PRISMA guidelines. We searched Pubmed, Scopus and the Cochrane Library, up to October 22nd, 2024. The primary outcomes analyzed were the blood loss, operative duration, and the number of harvested lymph nodes and the secondary outcomes included overall complications, time to oral intake, duration of hospitalization and time to first flatus. Random-effects models were used to calculate weighted mean differences (WMD) and Odds ratios (OR) with 95% confidence intervals (CI), and heterogeneity was assessed using the I2 statistic. P values were also calculated. Sensitivity analysis was performed for outcomes with moderate to high heterogeneity. Five studies were included, involving 811 patients (RDG: n = 289, LDG: n = 522). RDG was associated with a significantly longer operative duration compared to LDG (WMD = 34.14 min, 95%CI 10.92 to 57.35, P = 0.004, I2 = 91%). RDG patients initiated oral intake earlier (WMD = -0.20 days, 95%CI -0.39 to -0.01, P = 0.03, I2 = 45%). RDG resulted in shorter hospital stays (WMD = -1.48 days, 95%CI -2.91 to -0.04, P = 0.04, I2 = 86%). RDG patients had a faster return to bowel function (time to first flatus) (WMD = -0.33 days, 95%CI -0.50 to -0.15, P = 0.00003, I2 = 57%). No statistically significant differences were observed regarding blood loss between RDG and LDG (WMD = -3.88 mL, 95%CI -21.63 to 13.87, P = 0.67, I2 = 78%). There was no statistically significant difference in complication rates (OR = 0.61, 95%CI 0.36 to 1.03, P = 0.06, I2 = 0%). No significant differences were observed regarding the number of lymph nodes harvested (WMD = -0.49, 95%CI -3.02 to 2.04, P = 0.70, I2 = 24%). Sensitivity analysis confirmed the robustness of the findings of operative duration and time to first flatus. RDG with BI/ BII requires longer operative duration, but it associated with faster recovery compared to LDG. No differences were observed between RDG and LDG with regards to overall complications, number of harvested lymph nodes and blood loss, showing that RDG is as safe and oncological equivalent to LDG. Future studies particularly, multi-center randomized clinical trials, should have a longer follow up period and examine the type of reconstruction separately. PROSPERO registration: CRD42024605895.

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.

Possible muscle-sparing advantage and bodyweight maintenance of laparoscopic gastrectomy for older patients with locally advanced gastric cancer

PURPOSE

Laparoscopic gastrectomy (LG) is a promising approach for older patients who require less invasive surgery because of their reduced functional reserve and increased comorbidities, with the expansion of its indication to locally advanced gastric cancer. However, the specific benefits of LG in older patients remain unclear. We evaluated whether LG positively influences the postoperative maintenance of skeletal muscle (SM) and bodyweight (BW).

METHODS

We retrospectively analyzed the data of consecutive patients aged ≥ 75 years who underwent open gastrectomy (OG) and LG for cStage II or III gastric cancer between 2016 and 2021. After adjustment using propensity score matching, surgical and postoperative outcomes were compared between the groups including the postoperative changes of SM index (%SMI) and BW (%BW).

RESULTS

A total of 167 patients who underwent OG (n = 93) and LG (n = 74) were included in the study. After matching, 48 patients in each group were eligible. No significant difference in postoperative complications was observed. Both %SMI and %BW after LG were significantly maintained compared with those after OG during the postoperative first year. LG had consistently positive effects on the maintenance of %SMI and %BW across the prespecified subgroups. Notably, patients with body mass index < 25, performance status 0-1, non-total gastrectomy, and absence of adjuvant chemotherapy benefited from LG in the maintenance of %SMI and %BW.

CONCLUSION

LG offers greater advantages over OG in maintaining postoperative SM mass as well as BW in patients aged ≥ 75 with locally advanced gastric cancer.

Long-term relative survival of patients with gastric cancer from a large-scale cohort: a period-analysis

BACKGROUND

Gastric cancer poses a significant global health challenge. We aim to use period analysis to assess the changes in gastric cancer treatment at our center over the past 15 years. This study reflects the current state of gastric cancer treatment at our center and provides valuable data to support clinical advancements.

METHOD

We used period analysis to evaluate the survival status of 3915 patients with gastric cancer at Nanfang Hospital, Southern Medical University, over a 15-year period spaning from 2008 to 2022. The 5-year relative survival rates were analyzed.

RESULT

Our findings indicate that the 5-year relative survival rate at our center from 2018 to 2022 is 71.4%. From 2018 to 2022, the 5-year relative survival rates for patients aged < 40, 40-54, 55-69, and ≥ 70 reached 67.5%, 73.5%, 72.0%, and 67.1%, respectively. For stage IV patients, the 5-year relative survival rate reached 29% in 2018-2022. For stage I-III patients, the 5-year relative survival rate reached 89.7% in 2018-2022. The five-year relative survival rate for patients who underwent laparoscopic surgery at our center rose from 50.3% in 2008-2012 to 71.4% in 2018-2022. Overall, there has been a notable increase in the 5-year relative survival rates, regardless of age, gender, region, or tumor stage.

CONCLUSION

Period analysis over the past 15 years shows significant improvement in the 5-year survival rate for gastric cancer at our center. This progress is due to standardized surgical techniques, perioperative management, and immunotherapy, providing robust data for evaluating the efficacy of recent treatments.

Impact of visceral fat obesity (obesity disease) on short- and long-term outcomes of laparoscopic gastrectomy in gastric cancer

BACKGROUND

As the incidence of obesity increases worldwide, laparoscopic gastrectomy (LG) in obese patients with gastric cancer is more common. It is unclear how visceral fat obesity (obesity disease [OD]) may influence short- and long-term outcomes after LG.

METHODS

This study included 170 gastric cancer patients who underwent curative LG at Minoh City Hospital from 2008 to 2020. Patients were classified based on preoperative body mass index (BMI) and visceral fat area (VFA): normal (N; n = 95), visceral fat accumulation alone (VF; n = 35), obesity with visceral fat accumulation (OD; n = 35), and obesity alone (n = 5).

RESULTS

Compared with normal VFA, high preoperative VFA (≥100 cm2) was significantly associated with longer operation time, greater blood loss, more frequent postoperative complications, and longer hospital stay. Multivariate analysis revealed the following independent risk factors for postoperative intra-abdominal infectious complications: Charlson Comorbidity Index ≥4 (odds ratio [OR]: 3.1, 95% confidence interval [CI]: 1.2-8.5), dissected lymph node area (D2) (OR: 3.0, 95% CI: 1.2-7.1), and preoperative VFA (≥100 cm2) (OR: 3.7, 95% CI: 1.6-8.8). Intraoperative and postoperative courses were comparable between groups VF and OD. The 3-year overall survival rate was significantly worse in group VF (73.2%) compared with groups OD (96.7%) and N (96.7%) (p < .0001). Recurrence-free survival and cancer-specific survival were comparable between groups VF, OD, and N.

CONCLUSION

Visceral fat accumulation strongly predicted postoperative morbidity. Despite increased perioperative risk, OD did not negatively impact successful lymphadenectomy or survival following LG.

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.

Exploring Individualized Follow-up of Gastric Cancer After Radical Surgery Based on pTNM Stage: A Retrospective Cohort Study From China

Background

Patients with gastric cancer (GC) who underwent radical surgery require long-term follow-up (usually 5 years). The purpose of this study was to explore individualized follow-up strategies for patients with GC.

Methods

This is a retrospective cohort study that established a clinicopathologic database of patients who underwent gastrectomy from January 2010 to December 2020 at Ningbo No. 2 Hospital. Follow-up was performed until March 2023. The rate of new-onset recurrence of patients with GC was explored annually according to different pTNM stages, defining a recurrence rate of less than 1% as adequate follow-up time.

Results

Of the 1606 patients who were eligible, the total number of patients who completed the 5- and 10-year follow-up was 1107 and 586, respectively. A total of 444 cases were diagnosed with recurrence. The recurrence rate for stage IA patients was consistently less than 1% during the follow-up time. The adequate follow-up time (the rate of new-onset recurrence less than 1%) was 5 years for stage IB and IIA patients, and 8 years for stage IIB and IIIA patients, respectively. In contrast, stage IIIB patients were always at risk of recurrence during the follow-up time (>1%). Time to a new recurrence rate for stage IIIC patients was 6 years.

Conclusion

Among patients who underwent radical gastrectomy, the rate of new-onset recurrence varied among patients with different pTNM stages. This study suggests that the follow-up of GC can be individualized and refer to pTNM stage.

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.

Long-term outcomes of laparoscopic versus open total gastrectomy in patients with advanced gastric cancer after neoadjuvant chemotherapy: a retrospective cohort study

BACKGROUND

This study was conducted to investigate the long-term outcomes of laparoscopic total gastrectomy (LTG) versus open total gastrectomy (OTG) in patients with advanced gastric cancer (AGC) after neoadjuvant chemotherapy (NACT).

METHODS

Patients with AGC who received NACT before surgery were enrolled in either the LTG or OTG group. Propensity score matching (PSM) (1:2) was performed between the two groups based on the propensity score using a 0.15 calliper width. Three-year overall survival (OS) and disease-free survival (DFS) were compared between these two groups before and after PSM. OS and DFS rates were calculated by the Kaplan‒Meier method, and any differences in survival were evaluated with a log-rank test. Univariate and multivariate Cox proportional hazards analyses were used to estimate the simultaneous effects of prognostic factors on survival and the hazard ratio (HR) between LTG and OTG patients.

RESULTS

A total of 144 patients completed the follow-up, with 24 patients in the LTG group and 120 patients in the OTG group. After a mean follow-up of 64.40 months, there were no significant differences in the 3-year OS or DFS rates between the two groups before (P = 0.453 and P = 0.362, respectively) or after PSM (P = 0.972 and P = 0.884, respectively). Multivariate Cox proportional hazards analysis indicated that ypN stage was an independent risk factor for worse OS (P = 0.013).

CONCLUSIONS

This study showed that LTG with D2 lymphadenectomy performed by an experienced surgical team resulted in comparable 3-year OS and DFS compared with OTG in patients with AGC after NACT.

TRIAL REGISTRATION

This study is not registered.

Comparison of Short-Term Outcomes after Robotic Surgery for Gastric Cancer in Elderly and Younger Patients: A Retrospective Cohort Study

Robot-assisted surgery has recently been introduced to overcome some drawbacks and technical limitations in performing laparoscopic gastrectomy. The aim of the present study was to evaluate the feasibility and safety of robotic gastrectomy in elderly patients. The study enrolled 143 patients who underwent robotic gastrectomy in a single high-volume centre. All patients were divided into two groups based on age: elderly group ≥ 75 years old (EG; n = 64) and non-elderly group < 75 years old (NEG; n = 79). Comorbidities were significantly more frequent in the EG (95.3%) than in the NEG (81%) (p = 0.011). Similarly, the percentage of ASA 3 patients was significantly higher in the EG than in the NEG (43.8% vs. 24.0%, respectively; p = 0.048). Nevertheless, the incidence of Clavien-Dindo grade III and IV complications did not differ significantly between the two groups (10.9% in the EG and 6.3% in the NEG; p = 0.852). Moreover, operative time, re-operation rate, mean number of harvested lymph nodes, 30-day mortality, and median hospital stay were similar within the two groups. Our study suggests that robotic gastrectomy can be performed safely for elderly patients. In particular, chronological age does not seem to affect either the clinical or oncological short-term outcomes after robotic gastrectomy.

Fewer Feedback Opportunities and Health Perception of Gastric Cancer Survivors: Opportunities for Patient Education

This study aimed to estimate the impact of having fewer opportunities for patient education on health perception of gastric cancer survivors by examining quality-of-life (QoL) responses from patients who had been away for chemotherapy for a year. The full-surveillance (FullSV) group was comprised of gastric cancer survivors with stage I cancer who completed preoperative and postoperative 3-, 6-, 9-, and 12-month surveillances. The returning (RTN) group was comprised of 1-year survivors of stage II cancer who had been away for chemotherapy for a year. Surveillance periods were utilized to provide patient education about expected postoperative weight changes. The European Organisation for Research and Treatment of Cancer QoL questionnaires were used to assess QoL. The study included a total of 278 patients (243 in the FullSV group and 35 in the RTN group). The baseline QoL was not significantly different between the groups. Significant differences in postoperative QoL were revealed by some scales (global health status/QoL, physical functioning, fatigue, financial difficulties, anxiety, dry mouth, and body image), all in favor of the FullSV group. Despite no significant difference in their actual weight changes, stronger weight dissatisfaction was revealed among the RTN group. Patients with fewer educational inputs for postoperative adjustment of weight perception were the ones with stronger dissatisfaction about current weight. The health perception of cancer survivors is under the constant influence of clinician feedback during patient education. For the best cancer survivorship care, sufficient opportunities for adjustment of health perception through patient education need to be ensured.

Development and validation of a machine learning-based 18F-fluorodeoxyglucose PET/CT radiomics signature for predicting gastric cancer survival

BACKGROUND

Survival prognosis of patients with gastric cancer (GC) often influences physicians' choice of their follow-up treatment. This study aimed to develop a positron emission tomography (PET)-based radiomics model combined with clinical tumor-node-metastasis (TNM) staging to predict overall survival (OS) in patients with GC.

METHODS

We reviewed the clinical information of a total of 327 patients with pathological confirmation of GC undergoing 18 F-fluorodeoxyglucose (18 F-FDG) PET scans. The patients were randomly classified into training (n = 229) and validation (n = 98) cohorts. We extracted 171 PET radiomics features from the PET images and determined the PET radiomics scores (RS) using the least absolute shrinkage and selection operator (LASSO) and random survival forest (RSF). A radiomics model, including PET RS and clinical TNM staging, was constructed to predict the OS of patients with GC. This model was evaluated for discrimination, calibration, and clinical usefulness.

RESULTS

On multivariate COX regression analysis, the difference between age, carcinoembryonic antigen (CEA), clinical TNM, and PET RS in GC patients was statistically significant (p < 0.05). A radiomics model was developed based on the results of COX regression. The model had the Harrell's concordance index (C-index) of 0.817 in the training cohort and 0.707 in the validation cohort and performed better than a single clinical model and a model with clinical features combined with clinical TNM staging. Further analyses showed higher PET RS in patients who were older (p < 0.001) and those who had elevated CEA (p < 0.001) and higher clinical TNM (p < 0.001). At different clinical TNM stages, a higher PET RS was associated with a worse survival prognosis.

CONCLUSIONS

Radiomics models based on PET RS, clinical TNM, and clinical features may provide new tools for predicting OS in patients with GC.

Adherence to Guidelines for Diagnosis, Staging, and Treatment for Gastric Cancer in Italy According to the View of Surgeons and Patients

Background: Despite the strong declining trends in incidence and mortality over the last decades, gastric cancer (GC) is still burdened with high mortality, even in high-income countries. To improve GC prognosis, several guidelines have been increasingly published with indications about the most appropriate GC management. The Italian Society of Digestive System Pathology (SIPAD) and Gastric Cancer Italian Research Group (GIRCG) designed a survey for both surgeons and patients with the purpose of evaluating the degree of application and adherence to guidelines in GC management in Italy. Materials and Methods: Between January and May 2022, a questionnaire has been administered to a sample of Italian surgeons and, in a simplified version, to members of the Patient Association "Vivere Senza Stomaco" (patients surgically treated for GC between 2008 and 2021) to investigate the diagnosis, staging, and treatment issues. Results: The survey has been completed by 125 surgeons and 125 patients. Abdominal CT with gastric hydro-distension before treatment was not widespread in both groups (47% and 42%, respectively). The rate of surgeons stating that they do not usually perform minimally invasive gastrectomy was 15%, but the rate of patients who underwent a minimally invasive approach was 22% (between 2011 and 2022). The percentage of surgeons declaring to perform extended lymphadenectomy (>D2) was 97%, although a limited lymph node dissection rate was observed in about 35% of patients. Conclusions: This survey shows several important discrepancies from surgical attitudes declared by surgeons and real data derived from the reports available to the patients, suggesting heterogeneous management in clinical practice and, thus, a not rigorous adherence to the guidelines.

Robotic gastrectomy using hinotori™ Surgical Robot System: Initial case series

BACKGROUND

This study aims to prove the feasibility and safety of robotic gastrectomy using the hinotori™ Surgical Robot System (Medicaroid Corporation, Kobe, Japan).

METHODS

We retrospectively enrolled the 16 patients who underwent gastrectomy by the hinotori™ Surgical Robot System for gastric cancer at our hospital between June 2023 and January 2024. Console surgeons performed almost all lymphadenectomies, including the clipping of vessels. Assistant surgeons supported the lymphadenectomy using vessel sealing devices and during reconstruction.

RESULTS

Thirteen patients were cStage I, one patient was cStage II, and two patients were cStage III. Distal gastrectomy, proximal gastrectomy, and total gastrectomy were performed in 11, 1, and 4 patients, respectively. D1+ and D2 lymphadenectomies were performed in 11 and 5 patients, respectively. Billroth-I, Billroth-II, Roux-en-Y, and esophagogastrostomy were performed in three, six, six, and one patients, respectively. The median operation time was 282 (245-338) min, and the median console time was 226 (185-266) min. The median blood loss was 28 (12-50) mL, and the median amylase levels in drainage fluid were 280 (148-377) U/L on postoperative day 1 and 74 (42-148) U/L on postoperative day 3. There was anastomotic leakage (Clavien-Dindo [CD] IIIa) in one patient who underwent proximal gastrectomy. The median postoperative hospital stay was 12.5 (12-14) days.

CONCLUSION

In this initial case series, the hinotori™ Surgical Robot System was found to be safe and feasible for patients with gastric cancer and is suggested to be appropriate for gastrectomy, including distal gastrectomy and total gastrectomy.

Long-term survival outcomes of robotic total gastrectomy for locally advanced proximal gastric cancer: a prospective study

BACKGROUND

Robotic gastrectomy is a safe and feasible approach for gastric cancer (GC); however, its long-term oncological efficacy remains unclear. The authors evaluated the long-term survival outcomes and recurrence patterns of patients with locally advanced proximal GC who underwent robotic total gastrectomy (RTG).

METHODS

This prospective study (FUGES-014 study) enrolled 48 patients with locally advanced proximal GC who underwent RTG between March 2018 and February 2020 at a tertiary referral teaching hospital. Patients who underwent laparoscopic total gastrectomy (LTG) in the FUGES-002 study were enrolled in a 2:1 ratio to compare the survival outcomes between RTG and LTG. The primary endpoint of the FUGES-014 study was postoperative 30-day morbidity and has been previously reported. Here, the authors reported the results of 3-year disease-free survival (DFS), 3-year overall survival (OS), and recurrence patterns.

RESULTS

After propensity score matching, 48 patients in the RTG and 96 patients in the LTG groups were included. The 3-year DFS rates were 77.1% (95% CI: 66.1-89.9%) for the RTG and 68.8% (95% CI: 60.1-78.7%) for the LTG groups ( P =0.261). The 3-year OS rates were not significantly different between the groups (85.4 vs. 74.0%, P =0.122). Recurrence occurred in nine patients (18.8%) in the RTG and 27 (28.1%) patients in the LTG groups ( P =0.234). Recurrence patterns and causes of death were similar between the groups ( P >0.05).

CONCLUSIONS

The oncological outcome of RTG was noninferior to that of LTG. Thus, RTG might be an alternative surgical treatment for locally advanced proximal GC.

Top advances of the year: Gastroesophageal cancer

The advancement of minimally invasive surgery, a clearer definition of the role of radiation therapy, and the incorporation of immunotherapy have changed the management of esophagogastric cancers. Novel agents targeting new pathways continue to move forward.

Evaluating surgical expertise with AI-based automated instrument recognition for robotic distal gastrectomy

Introduction

Complexities of robotic distal gastrectomy (RDG) give reason to assess physician's surgical skill. Varying levels in surgical skill affect patient outcomes. We aim to investigate how a novel artificial intelligence (AI) model can be used to evaluate surgical skill in RDG by recognizing surgical instruments.

Methods

Fifty-five consecutive robotic surgical videos of RDG for gastric cancer were analyzed. We used Deeplab, a multi-stage temporal convolutional network, and it trained on 1234 manually annotated images. The model was then tested on 149 annotated images for accuracy. Deep learning metrics such as Intersection over Union (IoU) and accuracy were assessed, and the comparison between experienced and non-experienced surgeons based on usage of instruments during infrapyloric lymph node dissection was performed.

Results

We annotated 540 Cadiere forceps, 898 Fenestrated bipolars, 359 Suction tubes, 307 Maryland bipolars, 688 Harmonic scalpels, 400 Staplers, and 59 Large clips. The average IoU and accuracy were 0.82 ± 0.12 and 87.2 ± 11.9% respectively. Moreover, the percentage of each instrument's usage to overall infrapyloric lymphadenectomy duration predicted by AI were compared. The use of Stapler and Large clip were significantly shorter in the experienced group compared to the non-experienced group.

Conclusions

This study is the first to report that surgical skill can be successfully and accurately determined by an AI model for RDG. Our AI gives us a way to recognize and automatically generate instance segmentation of the surgical instruments present in this procedure. Use of this technology allows unbiased, more accessible RDG surgical skill.

Comprehensive assessment of body mass index effects on short-term and long-term outcomes in laparoscopic gastrectomy for gastric cancer: a retrospective study

To examine the influence of Body Mass Index (BMI) on laparoscopic gastrectomy (LG) short-term and long-term outcomes for gastric cancer. A retrospective analysis was conducted on gastric cancer patients undergoing LG at the Third Hospital of Nanchang City from January 2013 to January 2022. Based on WHO BMI standards, patients were categorized into normal weight, overweight, and obese groups. Factors such as operative time, intraoperative blood loss, postoperative complications, and overall survival were assessed. Across different BMI groups, it was found that an increase in BMI was associated with longer operative times (average times: 206.22 min for normal weight, 231.32 min for overweight, and 246.78 min for obese), with no significant differences noted in intraoperative blood loss, postoperative complications, or long-term survival among the groups. The impact of BMI on long-term survival following LG for gastric cancer was found to be insignificant, with no notable differences in survival outcome between different BMI groups. Although higher BMI is associated with increased operative time in LG for gastric cancer, it does not significantly affect intraoperative blood loss, postoperative complications, recovery, or long-term survival. LG is a feasible treatment choice for obese patients with gastric cancer.

Predicting peritoneal recurrence after radical gastrectomy for gastric cancer: Validation of a prediction model (PERI-Gastric 1 and PERI-Gastric 2) on a Korean database

BACKGROUND

Peritoneal recurrence is a significant cause of treatment failure after radical gastrectomy for gastric cancer. The prediction of metachronous peritoneal recurrence would have a significantly impact risk stratification and tailored treatment planning. This study aimed to externally validate the previously established PERI-Gastric 1 and 2 models to assess their generalizability in an independent population.

METHODS

Retrospective external validation was conducted on a cohort of 8564 patients who underwent elective gastrectomy for stage Ib-IIIc gastric cancer between 1998 and 2018 at the Yonsei Cancer Center. Discrimination was tested using the area under the receiver operating characteristic curves (AUROC). Accuracy was tested by plotting observations against the predicted risk of peritoneal recurrence and analyzing the resulting calibration plots. Clinical usefulness was tested with a decision curve analysis.

RESULTS

In the validation cohort, PERI-Gastric 1 and PERI-Gastric 2 exhibited an AUROC of 0.766 (95 % C.I. 0.752-0.778) and 0.767 (95 % C.I. 0.755-0.780), a calibration-in-the-large of 0.935 and 0.700, a calibration belt with a 95 % C.I. over the bisector in the risk range of 24%-33 % and 35%-47 %. The decision curve analysis revealed a positive net benefit in the risk range of 10%-42 % and 15%-45 %, respectively.

CONCLUSIONS

This study presents the external validation of the PERI-Gastric 1 and 2 scores in an Eastern population. The models demonstrated fair discrimination and satisfactory calibration for predicting the risk of peritoneal recurrence after radical gastrectomy, even in Eastern patients. PERI-Gastric 1 and 2 scores could also be applied to predict the risk of metachronous peritoneal recurrence in Eastern populations.

Top Gastric Cancer Articles from 2022 and 2023 to Inform Your Cancer Practice

BACKGROUND

The multimodality management of patients with gastroesophageal cancers is rapidly evolving, with the introduction of new therapies against potential molecular targets paving the way to personalized medicine for patients with both resectable and metastatic disease. Over the past 2 years, several important studies evaluating these new targeted therapies, as well as minimally invasive surgical approaches to gastric cancer, have been published.

METHODS

This review article summarizes the top studies published in gastric cancer over the past 2 years that are fundamentally changing our practice approach to gastric cancer patients.

RESULTS

First, the long-term safety and efficacy of laparoscopic distal gastrectomy as compared with open gastrectomy for locally advanced gastric cancer was confirmed with the publication of the 5-year outcomes of the CLASS-01 and KLASS-02 randomized clinical trials. In addition, several important studies of perioperative immunotherapy for patients with resectable gastric or gastroesophageal junction cancers are ongoing, and in 2022, an interim analysis of the DANTE trial and the final results of the GERCOR NEONIPIGA study were reported. Lastly, the KEYNOTE-859 and SPOTLIGHT trials address an unmet need for additional targeted therapies for patients with previously untreated, human epidermal growth factor receptor-2 (HER2)-negative, unresectable or metastatic gastroesophageal cancers, incorporating immune checkpoint inhibitors and targeting Claudin-18 isoform 2 (CLDN18.2) with the monoclonal antibody zolbetuximab, respectively.

CONCLUSIONS

This article summarizes the findings and implications of several important studies published over the past 2 years that are fundamentally changing the way we treat patients with gastroesophageal cancer.

Laparoscopic Versus Open Gastrectomy for Advanced Gastric Cancer: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Laparoscopy-assisted gastrectomy (LAG) is a well-established surgical technique in treating patients with early gastric cancer. However, the efficacy and safety of LAG versus open gastrectomy (OG) in patients with advanced gastric cancer (AGC) remains unclear.

METHODS

We systematically searched PubMed, Embase, and Cochrane Library in June 2023 for RCTs comparing LAG versus OG in patients with AGC. We pooled risk ratios (RR) and mean differences (MD) with 95% confidence intervals (CI) for binary and continuous endpoints, respectively. We performed all statistical analyses using R software version 4.3.1 and a random-effects model.

RESULTS

Nine RCTs comprising 3827 patients were included. There were no differences in terms of intraoperative complications (RR 1.14; 95% CI 0.72 to 1.82), number of retrieved lymph nodes (MD -0.54 lymph nodes; 95% CI -1.18 to 0.09), or mortality (RR 0.91; 95% CI 0.30 to 2.83). LAG was associated with a longer operative time (MD 49.28 minutes; 95% CI 30.88 to 67.69), lower intraoperative blood loss (MD -51.24 milliliters; 95% CI -81.41 to -21.06), shorter length of stay (MD -0.83 days; 95% CI -1.60 to -0.06), and higher incidence of pancreatic fistula (RR 2.44; 95% CI 1.08 to 5.50). Postoperatively, LAG was also superior to OG in reducing bleeding rates (RR 0.44; 95% CI 0.22 to 0.86) and time to first flatus (MD -0.27 days; 95% CI -0.47 to -0.07), with comparable results in anastomotic leakage, wound healing issues, major complications, time to ambulation, or time to first liquid intake. In the long-term analyses at 3 and 5 years, there were no significant differences between LAG and OG in terms of overall survival (RR 0.99; 95% CI 0.96 to 1.03) or relapse-free survival (RR 0.99; 95% CI 0.94 to 1.04).

CONCLUSION

This meta-analysis of RCTs suggests that LAG may be an effective and safe alternative to OG for treating AGC; albeit, it may be associated with an increased risk for pancreatic fistula.

Robotic versus laparoscopic distal gastrectomy for resectable gastric cancer: a randomized phase 2 trial

Robotic surgery may be an alternative to laparoscopic surgery for gastric cancer (GC). However, randomized controlled trials (RCTs) reporting the differences in survival between these two approaches are currently lacking. From September 2017 to January 2020, 300 patients with cT1-4a and N0/+ were enrolled and randomized to either the robotic (RDG) or laparoscopic distal gastrectomy (LDG) group (NCT03313700). The primary endpoint was 3-year disease-free survival (DFS); secondary endpoints reported here are the 3-year overall survival (OS) and recurrence patterns. The remaining secondary outcomes include intraoperative outcomes, postoperative recovery, quality of lymphadenectomy, and cost differences, which have previously been reported. There were 283 patients in the modified intention-to-treat analysis (RDG group: n = 141; LDG group: n = 142). The trial has met pre-specified endpoints. The 3-year DFS rates were 85.8% and 73.2% in the RDG and LDG groups, respectively (p = 0.011). Multivariable Cox regression model including age, tumor size, sex, ECOG PS, lymphovascular invasion, histology, pT stage, and pN stage showed that RDG was associated with better 3-year DFS (HR: 0.541; 95% CI: 0.314-0.932). The RDG also improved the 3-year cumulative recurrence rate (RDG vs. LDG: 12.1% vs. 21.1%; HR: 0.546, 95% CI: 0.302-0.990). Compared to LDG, RDG demonstrated non-inferiority in 3-year DFS rate.

Laparoscopic versus open gastrectomy for nonmetastatic T4a gastric cancer: a meta-analysis of reconstructed individual participant data from propensity score-matched studies

BACKGROUND

​The applicability of laparoscopy to nonmetastatic T4a patients with gastric cancer remains unclear due to the lack of high-quality evidence. The purpose of this study was to compare the survival rates of laparoscopic gastrectomy (LG) versus open gastrectomy (OG) for these patients through a meta-analysis of reconstructed individual participant data from propensity score-matched studies.

METHODS

PubMed, Embase, Web of Science, Cochrane library and CNKI were examined for relevant studies without language restrictions through July 25, 2023. Individual participant data on overall survival (OS) and disease-free survival (DFS) were extracted from the published Kaplan-Meier survival curves. One-stage and two-stage meta-analyses were performed. In addition, data regarding surgical outcomes and recurrence patterns were also collected, which were meta-analyzed using traditional aggregated data.

RESULTS

Six studies comprising 1860 patients were included for analysis. In the one-stage meta-analyses, the results demonstrated that LG was associated with a significantly better DFS (Random-effects model: P = 0.027; Restricted mean survival time [RMST] up to 5 years: P = 0.033) and a comparable OS (Random-effects model: P = 0.135; RMST up to 5 years: P = 0.053) than OG for T4a gastric cancer patients. Two-stage meta-analyses resulted in similar results, with a 13% reduced hazard of cancer-related death (P = 0.04) and 10% reduced hazard of overall mortality (P = 0.11) in the LG group. For secondary outcomes, the pooled results showed an association of LG with less estimated blood loss, faster postoperative recovery and more retrieved lymph nodes.

CONCLUSION

Laparoscopic surgery for patients with nonmetastatic T4a disease is associated with a potential survival benefit and improved surgical outcomes.

Gastric Cancer Surgery: Balancing Oncological Efficacy against Postoperative Morbidity and Function Detriment

Significant progress has been made in the surgical management of gastric cancer over the years, and previous discrepancies in surgical practice between different parts of the world have gradually lessened. A transition from the earlier period of progressively more extensive surgery to the current trend of a more tailored and evidence-based approach is clear. Prophylactic resection of adjacent anatomical structures or neighboring organs and extensive lymph node dissections that were once assumed to increase the chances of long-term survival are now performed selectively. Laparoscopic gastrectomy has been widely adopted and its indications have steadily expanded, from early cancers located in the distal part of the stomach, to locally advanced tumors where total gastrectomy is required. In parallel, function-preserving surgery has also evolved and now constitutes a valid option for early gastric cancer. Pylorus-preserving and proximal gastrectomy have improved the postoperative quality of life of patients, and sentinel node navigation surgery is being explored as the next step in the process of further refining the minimally invasive concept. Moreover, innovative techniques such as indocyanine green fluorescence imaging and robot-assisted gastrectomy are being introduced in clinical practice. These technologies hold promise for enhancing surgical precision, ultimately improving the oncological and functional outcomes.

Short-Term Outcomes Analysis Comparing Open, Laparoscopic, Laparoscopic-Assisted, and Robotic Distal Gastrectomy for Locally Advanced Gastric Cancer: A Randomized Trials Network Analysis

BACKGROUND

Minimally invasive surgery for the treatment of locally advanced gastric cancer (AGC) is debated. The aim of this study was to execute a comprehensive assessment of principal surgical treatments for resectable distal gastric cancer.

METHODS

Systematic review and randomized controlled trials (RCTs) network meta-analysis. Open (Op-DG), laparoscopic-assisted (LapAs-DG), totally laparoscopic (Lap-DG), and robotic distal gastrectomy (Rob-DG) were compared. Pooled effect-size measures were the risk ratio (RR), the weighted mean difference (WMD), and the 95% credible intervals (CrIs).

RESULTS

Ten RCTs (3823 patients) were included. Overall, 1012 (26.5%) underwent Lap-DG, 902 (23.6%) LapAs-DG, 1768 (46.2%) Op-DG, and 141 (3.7%) Rob-DG. Anastomotic leak, severe complications (Clavien-Dindo > 3), and in-hospital mortality were comparable. No differences were observed for reoperation rate, pulmonary complications, postoperative bleeding requiring transfusion, surgical-site infection, cardiovascular complications, number of harvested lymph nodes, and tumor-free resection margins. Compared to Op-DG, Lap-DG and LapAs-DG showed a significantly reduced intraoperative blood loss with a trend toward shorter time to first flatus and reduced length of stay.

CONCLUSIONS

LapAs-DG, Lap-DG, and Rob-DG performed in referral centers by dedicated surgeons have comparable short-term outcomes to Op-DG for locally AGC.

[Cancer of the Esophagogastric Junction: Double Tract Reconstruction - Evidence and Technique]

Adenocarcinoma of the esophagogastric junction (AEG) still represent a certain surgical challenge. In contrary to the trend of thoracoabdominal surgery for AEG I and AEG II cancer, the proximal gastrectomy is regaining popularity through new reconstruction methods such as the double tract reconstruction. Proximal gastrectomy followed by double tract reconstruction represents an alternative for the thoracoabdominal approach for suitable AEG II cancer and an alternative to the total gastrectomy for AEG III cancers. Latest studies suggest a functional benefit of proximal gastrectomy and double tract reconstruction in comparison to total gastrectomy. The accurate indication for proximal gastrectomy for locally advanced cancers has to be established in the near future as well as the influence of the size of the remnant stomach on the outcome, as Asian techniques for early lesions sometimes significantly differ from European. The following article reflects the present evidence on proximal gastrectomy and double tract reconstruction as well as technical aspects in the context of cancer of the esophagogastric junction.

Synchronous tumors of gastric carcinoma combined gallbladder cancer and pseudotumor chronic pancreatitis

INTRODUCTION AND IMPORTANCE

Synchronous primary cancers in the stomach and gallbladder were not previously reported in the medical literature. Pseudotumor pancreatitis was also described many years ago. It was misdiagnosed and required surgery for pancreatic head neoplasms.

PRESENTATION OF CASE

A 57-year-old male patient went to our hospital for abdominal pain. He was indicated for gastroduodenal endoscopy, and the result was adenocarcinoma. Abdominal ultrasound and Ctscan detected the gallbladder fundus's localized thickening structure and the pancreatic head's hyperechoic structure. The endoscopic ultrasound and MRI showed a gallbladder + pancreatic head tumor with chronic pancreatitis with pancreatic stones. The patient underwent distal gastrectomy, cholecystectomy, and pancreaticoduodenectomy.

CLINICAL DISCUSSION

The detection of gastric cancer is often based on upper gastrointestinal endoscopy and biopsy results. Gallbladder cancer is often diagnosed at an advanced stage, and only very few patients are diagnosed early. Pancreatic cancer often occurs in the head of the pancreas. Symptoms may include obstruction of the common bile and Wirsung duct, often in advanced stages. Surgery for the gallbladder, distal stomach, and head of pancreatic tumors are related to each other located in a neighboring location in the anatomy, so surgery to remove all three tumors is relatively similar to a pancreaticoduodenectomy procedure.

CONCLUSION

Synchronous tumors of gastric carcinoma combined with gallbladder cancer and pseudotumor chronic pancreatitis are rare. The attitude of treating these three diseases at the same time requires a tumor board. Simultaneous surgery for gallbladder, stomach, and pancreatic head tumors can be performed if the tumors are still in the resectable stage.

Safety and feasibility of minimally invasive gastrectomy following preoperative chemotherapy for highly advanced gastric cancer

BACKGROUND

This study aimed to determine the safety and feasibility of minimally invasive gastrectomy in patients who underwent preoperative chemotherapy for highly advanced gastric cancer.

METHODS

Preoperative chemotherapy was indicated for patients with advanced large tumors (≥ cT3 and ≥ 5 cm) and/or bulky node metastasis (≥ 3 cm × 1 or ≥ 1.5 cm × 2). Between January 2009 and March 2022, 150 patients underwent preoperative chemotherapy followed by gastrectomy with R0 resection, including conversion surgery (robotic, 62; laparoscopic, 88). The outcomes of these patients were retrospectively examined.

RESULTS

Among them, 41 and 47 patients had stage IV disease and underwent splenectomy, respectively. Regarding operative outcomes, operative time was 475 min, blood loss was 72 g, morbidity (grade ≥ 3a) rate was 12%, local complication rate was 10.7%, and postoperative hospital stay was 14 days (Interquartile range: 11-18 days). Fifty patients (33.3%) achieved grade ≥ 2 histological responses. Regarding resection types, total/proximal gastrectomy plus splenectomy (29.8%) was associated with significantly higher morbidity than other types (distal gastrectomy, 3.2%; total/proximal gastrectomy, 4.9%; P < 0.001). Specifically, among splenectomy cases, the rate of postoperative complications associated with the laparoscopic approach was significantly higher than that associated with the robotic approach (40.0% vs. 0%, P = 0.009). In the multivariate analysis, splenectomy was an independent risk factor for postoperative complications [odds ratio, 8.574; 95% confidence interval (CI), 2.584-28.443; P < 0.001].

CONCLUSIONS

Minimally invasive gastrectomy following preoperative chemotherapy was feasible and safe for patients with highly advanced gastric cancer. Robotic gastrectomy may improve surgical safety, particularly in the case of total/proximal gastrectomy combined with splenectomy.

Surgical Outcomes of Laparoscopic-assisted Distal Gastrectomy Versus Totally Laparoscopic Distal Gastrectomy Billroth I for Gastric Cancer

OBJECTIVE

The present study aimed to compare intraoperative and postoperative outcomes of laparoscopic-assisted distal gastrectomy versus totally laparoscopic distal gastrectomy (TLDG) Billroth I (BI) for gastric cancer and to assess the impact of the initial introduction phase of TLDG BI anastomosis.

PATIENTS AND METHODS

The study analyzed the prospectively collected data of patients who underwent laparoscopic distal gastrectomy BI from 2014 to 2021 at Seoul National University Hospital.

RESULTS

Among 1116 patients, laparoscopic-assisted distal gastrectomy BI was performed in 566 patients and TLDG BI was performed in 550 patients. The total laparoscopic arm had a faster mean operative time (190 vs 208 min; P < 0.001) and a shorter postoperative hospital stay (7.4 vs 7.9 d; P < 0.001). Local complications were higher in the total laparoscopic group (17.6% vs 9.9%; P = 0.008) during the early introduction phase.

CONCLUSION

The total laparoscopic approach for BI reconstruction is safe and effective with faster operative time, shorter hospital stays, and less wound infection, but it may be associated with an increase in postoperative surgical complications and hospital stay in the early introduction phase.