Korean Practice Guidelines for Gastric Cancer 2022: An Evidence-based, Multidisciplinary Approach

Gastric cancer is one of the most common cancers in Korea and the world. Since 2004, this is the 4th gastric cancer guideline published in Korea which is the revised version of previous evidence-based approach in 2018. Current guideline is a collaborative work of the interdisciplinary working group including experts in the field of gastric surgery, gastroenterology, endoscopy, medical oncology, abdominal radiology, pathology, nuclear medicine, radiation oncology and guideline development methodology. Total of 33 key questions were updated or proposed after a collaborative review by the working group and 40 statements were developed according to the systematic review using the MEDLINE, Embase, Cochrane Library and KoreaMed database. The level of evidence and the grading of recommendations were categorized according to the Grading of Recommendations, Assessment, Development and Evaluation proposition. Evidence level, benefit, harm, and clinical applicability was considered as the significant factors for recommendation. The working group reviewed recommendations and discussed for consensus. In the earlier part, general consideration discusses screening, diagnosis and staging of endoscopy, pathology, radiology, and nuclear medicine. Flowchart is depicted with statements which is supported by meta-analysis and references. Since clinical trial and systematic review was not suitable for postoperative oncologic and nutritional follow-up, working group agreed to conduct a nationwide survey investigating the clinical practice of all tertiary or general hospitals in Korea. The purpose of this survey was to provide baseline information on follow up. Herein we present a multidisciplinary-evidence based gastric cancer guideline.

Outcomes of Gastrectomy for Gastric Cancer in Patients Aged >80 Years:A Systematic Literature Review and Meta-Analysis

This meta-analysis examined the surgical management of older patients (>80 years) with gastric cancer, who were often excluded from randomized controlled trials. We analyzed 23 retrospective cohort studies involving 18,372 patients and found that older patients had a higher in-hospital mortality rate (relative risk [RR], 3.23; 95% confidence interval [CI], 1.46–7.17; P<0.01) and more post-operative complications (RR, 1.36; 95% CI, 1.19–1.56;P<0.01) than did younger patients. However, the surgical complications were similar between the two groups. Older patients were more likely to undergo less extensive lymph node dissection and longer hospital stays. Although older patients had statistically significant post-operative medical complications, they were not deprived of surgery for gastric cancer.The comorbidities and potential risks of post-operative complications should be carefully evaluated in older patients, highlighting the importance of careful patient selection. Overall, this meta-analysis provides recommendations for the surgical management of older patients with gastric cancer. Careful patient selection and evaluation of comorbidities should be performed to minimize the risk of post-operative complications in older patients, while recognizing that they should not be deprived of surgery for gastric cancer.

Comparison of Laparoscopic and Open Gastrectomy for Patients With Gastric Cancer Treated With Neoadjuvant Chemotherapy: A Multicenter Retrospective Study Based on the Korean Gastric Cancer Association Nationwide Survey

Purpose@#Despite scientific evidence regarding laparoscopic gastrectomy (LG) for advanced gastric cancer treatment, its application in patients receiving neoadjuvant chemotherapy remains uncertain. @*Materials and Methods@#We used the 2019 Korean Gastric Cancer Association nationwide survey database to extract data from 489 patients with primary gastric cancer who received neoadjuvant chemotherapy. After propensity score matching analysis, we compared the surgical outcomes of 97 patients who underwent LG and 97 patients who underwent open gastrectomy (OG). We investigated the risk factors for postoperative complications using multivariate analysis. @*Results@#The operative time was significantly shorter in the OG group. Patients in the LG group had significantly less blood loss than those in the OG group. Hospital stay and overall postoperative complications were similar between the two groups. The incidence of Clavien– Dindo grade ≥3 complications in the LG group was comparable with that in the OG group (1.03% vs. 4.12%, P=0.215). No statistically significant difference was observed in the number of harvested lymph nodes between the two groups (38.60 vs. 35.79, P=0.182). Multivariate analysis identified body mass index (odds ratio [OR], 1.824; 95% confidence interval [CI], 1.029–3.234; P=0.040) and extent of resection (OR, 3.154; 95% CI, 1.084–9.174; P=0.035) as independent risk factors for overall postoperative complications. @*Conclusions@#Using a large nationwide multicenter survey database, we demonstrated that LG and OG had comparable short-term outcomes in patients with gastric cancer who received neoadjuvant chemotherapy.

Early Clinical Outcomes of the Morbidly Obese Patients Who Underwent Laparoscopic Sleeve Gastrectomy by Gastric Cancer Surgeons: the Analysis of Fifty Consecutive Cases

Purpose@#The number of bariatric surgeries performed at our tertiary hospital has gradually increased since the national health insurance began to cover their expenses in January of 2019. This study examined the early surgical outcomes of laparoscopic sleeve gastrectomy (LSG) performed by experienced gastric cancer surgeons. @*Materials and Methods@#We retrospectively reviewed and analyzed data from 50 patients who underwent LSG between November of 2018 and April of 2020 at the Asan Medical Center by 1 of 5 experienced surgeons each of whom performed approximately 100–300 cases of gastrectomy annually. The age, body mass index (BMI), weight, presence of comorbidities, operation time, hospital stay after surgery, postoperative complications, postoperative excess weight loss (EWL), and resolution of comorbidities were examined. @*Results@#The mean age, BMI, and weight were 37.29±9.77 years, 37.12 kg/m2, and 102.00 kg, respectively. The mean operation time and postoperative length of hospital stay were 109.59±35.88 and 5.06±1.20 days, respectively. Two patients (4.00%) had early postoperative complications and postoperative leakage; bleeding and stenosis were not reported. The EWL after 1 and 6 months of operation was 26.55% and 60.34%, respectively. The resolution of diabetes, hypertension, and dyslipidemia after 6 months of operation was 88.89%, 54.54%, and 50.00%, respectively. @*Conclusion@#LSG is safe and effective when performed by an experienced gastric cancer surgeon; however, a long-term follow-up of patients is required.

A Case of Glomus Tumor Mimicking Neuroendocrine Tumor on 68 Ga-DOTATOC PET/CT / 대한핵의학회잡지

68 Ga-DOTA-peptide PET/CT is a valuable tool for diagnosing neuroendocrine tumors (NET). Various tumors and normal human tissue express the somatostatin receptor (SSTR), warranting attention to positive findings on 68  Ga-DOTA-peptide PET/CT. However, overexpression of SSTR in glomus tumors has not yet been reported. Gastric glomus tumors show many similar features of NET and are often misdiagnosed. We present the case of a 61-year-old male with a glomus tumor who underwent distal gastrectomy under the pretense of an NET grade 1 because the nodule showed focal intense uptake on preoperative 68  Ga-DOTATOC PET/CT.

Clinical Outcomes of Totally Laparoscopic Total Gastrectomy versus Open Total Gastrectomy for Remnant Gastric Cancer

PURPOSE: This study compares the feasibility and safety of Totally Laparoscopic Total Gastrectomy (TLTG) with Open Total Gastrectomy (OTG) for Remnant Gastric Cancer (RGC) in patients who had previously undergone gastrectomy. METHODS: We retrospectively collected and analyzed the data of 139 consecutive patients who underwent OTG along with 21 patients who underwent TLTG for RGC between January 2008 and December 2016. One-to-two Propensity Score Matching (PSM) was performed to compare the age, gender, body mass index, American Society of Anesthesiologists score, clinical tumor stage, previous gastric disease, previous gastrectomy type, previous reconstruction type, history of previous upper abdominal surgery except gastrectomy, and combined major operations. A total of sixty patients (21 who underwent TLTG and 39 who underwent OTG) were matched, and surgical outcomes and survival rates were compared. RESULTS: The TLTG patients were found to recover bowel movements sooner than the OTG group (OTG 3.74±0.88 vs TLTG 3.19±0.81 days, p=0.02). Post-operative surgical outcomes, including pathological features, clinical courses, complications and survival rates did not differ between the two groups (p>0.05). CONCLUSION: Although TLTG was not found to have any definitive clinical advantage over OTG except for more rapid recovery of bowel movement, TLTG should be considered as safe and feasible surgical procedure as OTG for the treatment of RGC.

Does operation order has impacts on postoperative complications in gastric cancer patients? A study of surgeon fatigue

PURPOSE: There is a growing concern that accumulated fatigue due to extended working hours may contribute to poor surgical outcomes. This study aimed to compare postoperative complications of gastric cancer patients according to operation chronology in a given day as a yardstick of a surgeon's fatigue.METHODS: The clinicopathologic data of gastric cancer patients who underwent a curative gastrectomy by one surgeon in Asan Medical Center from August 2012 to August 2014 were analyzed retrospectively. The patients were divided into 3 groups according to operation chronology in a given day. Perioperative data were collected by electronic medical records. Comorbidities were assessed using the Charlson comorbidity index. Postoperative complications were categorized according to the Clavien-Dindo classification.RESULTS: A total of 517 patients were divided into three groups according to chronological order of the surgery in one day. Each group exhibited similar characteristics except for operation time (P=0.001) and the America Society of Anesthesiologists score (P=0.01). Operations conducted late in the day tended to require more time and were associated with more comorbidities. However, no significant differences were detected between the chronological order of operation in a given day and postoperative complications.CONCLUSION: The chronological order of three gastrectomies performed by one surgeon in a day was not associated with postoperative complications rate.

Comparison of survival of surgical resection and conservative treatment in patients with gastric cancer aged 80 years or older: a single-center experience

PURPOSE: With the increase in the average life expectancy, the elderly population continues to increase rapidly. However, no consensus has been reached on the feasibility for surgical resection due to the high morbidity and mortality rate after surgical treatment in elderly patients caused by aging and underlying diseases. METHODS: This study was performed with patients aged 80 years and older. The subjects were classified into 2 groups as follows: the surgical resection group consisting of 61 patients, and the conservative treatment group consisting of 39 patients suitable for curative resection. RESULTS: Mean age and clinical stages in the conservative treatment group were higher than those in the surgical resection group. There was no significant difference in sex, location of the lesion, histological type, or underlying disease. The mean survival time of surgical resection group and conservative treatment group was respectively 52.1 ± 2.66 months and 37.1 ± 5.08 months (P < 0.05) for clinical stage 1 disease, 41.7 ± 5.16 months and 22.4 ± 6.07 months (P = 0.004) for stage 2 disease, and 31.7 ± 9.37 months and 10.6 ± 1.80 months (P = 0.049) for stage 3 disease. However, as for the extent of lymph node resection for the different stages, we observed no significant difference between the 2 groups. CONCLUSION: Surgical resection in all clinical stages, except stage 4, showed a higher survival rate than conservative treatment. To minimize postoperative surgery complications, limited lymph node dissection should also be considered.