Textbook Outcome of Delta-Shaped Anastomosis in Minimally Invasive Distal Gastrectomy for Gastric Cancer in 4,505 Consecutive Patients.

PURPOSE: Textbook outcome is a comprehensive measure used to assess surgical quality and is increasingly being recognized as a valuable evaluation tool. Delta-shaped anastomosis (DA), an intracorporeal gastroduodenostomy, is a viable option for minimally invasive distal gastrectomy in patients with gastric cancer. This study aims to evaluate the surgical outcomes and calculate the textbook outcome of DA. MATERIALS AND METHODS: In this retrospective study, the records of 4,902 patients who underwent minimally invasive distal gastrectomy for DA between 2009 and 2020 were reviewed. The data were categorized into three phases to analyze the trends over time. Surgical outcomes, including the operation time, length of post-operative hospital stay, and complication rates, were assessed, and the textbook outcome was calculated. RESULTS: Among 4,505 patients, the textbook outcome is achieved in 3,736 (82.9%). Post-operative complications affect the textbook outcome the most significantly (91.9%). The highest textbook outcome is achieved in phase 2 (85.0%), which surpasses the rates of in phase 1 (81.7%) and phase 3 (82.3%). The post-operative complication rate within 30 d after surgery is 8.7%, and the rate of major complications exceeding the Clavien-Dindo classification grade 3 is 2.4%. CONCLUSIONS: Based on the outcomes of a large dataset, DA can be considered safe and feasible for gastric cancer.

Efficacy of Hyperthermic Pressurized Intraperitoneal Aerosol Chemotherapy in an In Vitro Model Using a Human Gastric Cancer AGS Cell Line and an Abdominal Cavity Model.

PURPOSE: Peritoneal carcinomatosis (PC) presents a major challenge in the treatment of late-stage, solid tumors, with traditional therapies limited by poor drug penetration. We evaluated a novel hyperthermic pressurized intraperitoneal aerosol chemotherapy (HPIPAC) system using a human abdominal cavity model for its efficacy against AGS gastric cancer cells. MATERIALS AND METHODS: A model simulating the human abdominal cavity and AGS gastric cancer cell line cultured dishes were used to assess the efficacy of the HPIPAC system. Cell viability was measured to evaluate the impact of HPIPAC under 6 different conditions: heat alone, PIPAC with paclitaxel (PTX), PTX alone, normal saline (NS) alone, heat with NS, and HPIPAC with PTX. RESULTS: Results showed a significant reduction in cell viability with HPIPAC combined with PTX, indicating enhanced cytotoxic effects. Immediately after treatment, the average cell viability was 66.6%, which decreased to 49.2% after 48 hours and to a further 19.6% after 120 hours of incubation, demonstrating the sustained efficacy of the treatment. In contrast, control groups exhibited a recovery in cell viability; heat alone showed cell viability increasing from 90.8% to 94.4%, PIPAC with PTX from 82.7% to 89.7%, PTX only from 73.3% to 74.8%, NS only from 90.9% to 98.3%, and heat with NS from 74.4% to 84.7%. CONCLUSIONS: The HPIPAC system with PTX exhibits a promising approach in the treatment of PC in gastric cancer, significantly reducing cell viability. Despite certain limitations, this study highlights the system's potential to enhance treatment outcomes. Future efforts should focus on refining HPIPAC and validating its effectiveness in clinical settings.

Hyperthermic pressurized intraperitoneal aerosol drug delivery system in a large animal model: a feasibility and safety study.

BACKGROUND: We developed a novel drug delivery system called hyperthermic pressurized intraperitoneal aerosol chemotherapy (HPIPAC) that hybridized Hyperthermic intraperitoneal chemotherapy (HIPEC) and pressurized intraperitoneal aerosol chemotherapy (PIPAC). The present study aims to assess the feasibility and safety of HPIPAC system in a large animal survival model. METHODS: Eleven pigs (eight non-survival models and three survival models) were used in the experiment. The heat module in the HPIPAC controller circulates hyperthermic CO2 in a closed-loop circuit and creates gas-based dry intraperitoneal hyperthermia. Three 12 mm trocars were placed on the abdomen. The afferent CO2 tube wound with heat generating coil was inserted into a trocar, and the efferent tube was inserted into another trocar. Heated CO2 was insufflated and circulated in a closed circuit until the intra-abdominal and peritoneal surface temperature reached 42 °C. 100 ml of 5% dextrose in water was nebulized for 5 min and the closed-loop circulation was resumed for 60 min at 42 °C. Tissue biopsies were taken from several sites from the pigs in the survival model. RESULTS: The average change in core temperature of the pigs was 2.5 ± 0.08 °C. All three pigs displayed no signs of distress, and their vital signs remained stable, with no changes in their diet. In autopsy, inflammatory and fibrotic responses at the biopsy sites were observed without serious pathologic findings. CONCLUSIONS: We successfully proved the feasibility and safety of our novel HPIPAC system in an in-vivo swine survival model.

Survey of Information Acquisition and Satisfaction after Bariatric Surgery at a Tertiary Hospital in Korea.

Background: To determine how patients who underwent bariatric surgery at a tertiary hospital in Korea first considered and then decided to get the surgery and identify information gaps among patients and healthcare professionals. Methods: This study included 21 patients who underwent bariatric surgery to treat morbid obesity (body mass index [BMI] ≥35 or ≥30 kg/m2 together with obesity-related comorbidities) between August 2020 and February 2022. A telephone interview was conducted with the patients after at least 6 months had elapsed since the surgery. We asked how the patients decided to undergo bariatric surgery. We also inquired about their satisfaction with and concerns about the surgery. Results: Seventy-one percent of the patients were introduced to bariatric surgery following a recommendation from healthcare professionals, acquaintances, or social media. Most of the patients (52%) decided to undergo bariatric surgery based on recommendations from healthcare professionals in non-surgical departments. Satisfaction with the information provided differed among the patients. Post-surgical concerns were related to postoperative symptoms, weight regain, and psychological illness. Conclusion: Efforts are needed to raise awareness about bariatric surgery among healthcare professionals and the public. Tailored pre- and postoperative consultation may improve quality of life after bariatric surgery.

The Shorr Versus Modified Ultrafast Papanicolaou Method for Intraoperative Diagnosis of Peritoneal Washing Cytology in Advanced Gastric Cancer: A Phase II Study.

PURPOSE: According to the American Joint Committee on Cancer cancer staging system, positive peritoneal washing cytology (PWC) indicates stage IV gastric cancer. However, rapid intraoperative diagnosis of PWC has no established reliable method. This study evaluated and compared the diagnostic accuracy of the Shorr and the modified ultrafast Papanicolaou (MUFP) methods for intraoperative PWC. MATERIALS AND METHODS: This study included patients with gastric cancer who were clinically diagnosed with stage cT3 or higher. The Shorr and MUFP methods were performed on all PWC specimens, and the results were compared with those of conventional Papanicolaou (PAP) staining with carcinoembryonic antigen immunohistochemistry. Sensitivity, specificity, and partial likelihood tests were used to compare the 2 methods. RESULTS: Forty patients underwent intraoperative PWC between November 2019 and August 2021. The average time between specimen reception and slide preparation using Shorr and MUFP methods was 44.4±4.5 minutes, and the average time between specimen reception and pathologic diagnosis was 53.9±8.9 minutes. Eight patients (20.0%) had positive cytology in PAP staining. The Shorr method had a sensitivity of 75.0% and specificity of 93.8%; the MUFP method had 62.5% sensitivity and 100.0% specificity. The area under the curve was 0.844 for Shorr and 0.813 for MUFP. In comparing the C-indices of each method with overall survival, no difference was found among the Shorr, MUFP, and conventional PAP methods. CONCLUSIONS: The Shorr and MUFP methods are acceptable for the intraoperative diagnosis of PWC in advanced 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.

Postoperative major bleeding risk in patients using oral antiplatelets and/or anticoagulants after laparoscopic gastric cancer surgery.

Purpose: The use of antiplatelet and/or anticoagulant therapies has become common. In rare cases, these therapies may increase the risk of dangerous postoperative bleeding. We investigated the association of antiplatelets and/or anticoagulants with postoperative major bleeding risk in laparoscopic gastric cancer surgery. Methods: We retrospectively enrolled 3,663 gastric cancer patients (antiplatelet/anticoagulant group, 518; control group, 3,145) who had undergone laparoscopic surgery between January 2012 and December 2017. To minimize selection bias, 508 patients in each group were matched using propensity score matching (PSM) method. The primary outcome was postoperative major bleeding. Secondary outcomes were intraoperative, postoperative transfusion and early complications. Results: After PSM, postoperative major bleeding occurred in 10 (2.0%) and 3 cases (0.6%) in the antiplatelets/anticoagulants and control groups, respectively (P = 0.090). Intraoperative and postoperative transfusions were not significantly different between 2 groups (2.4% vs. 1.4%, P = 0.355 and 5.5% vs. 4.3%, P = 0.469). Early complications developed in 58 (11.4%) and 43 patients (8.5%) in the antiplatelets/anticoagulants and control groups, respectively (P = 0.142). The mean amounts of intraoperative and postoperative transfusions were not significantly different between the groups (366.67 ± 238.68 mL vs. 371.43 ± 138.01 mL, P = 0.962; 728.57 ± 642.25 mL vs. 508.09 ± 468.95 mL, P = 0.185). In multivariable analysis, male (P = 0.008) and advanced stage (III, IV) (P = 0.024) were independent significant risk factors for postoperative major bleeding. Conclusion: Preoperative antiplatelets and/or anticoagulants administration did not significantly increase the risk of postoperative major bleeding after laparoscopic gastric cancer surgery.

Safety and Efficacy of Intraperitoneal Paclitaxel Plus Intravenous Fluorouracil, Leucovorin, and Oxaliplatin (FOLFOX) for Gastric Cancer with Peritoneal Metastasis.

BACKGROUND: Peritoneal metastasis (PM) remains a major obstacle in the treatment of stage IV gastric cancer. This is a dose-escalation study of intraperitoneal (IP) paclitaxel combined with intravenous (IV) fluorouracil, leucovorin, and oxaliplatin (FOLFOX) to determine the recommended phase II dose in gastric cancer patients. METHODS: Patients with gastric adenocarcinoma and PM were enrolled. The recommended phase II dose of IP paclitaxel was determined using the standard "3 + 3" dose escalation with planned doses ranging from 40 to 100 mg/m2. IV FOLFOX was administered on the same day (oxaliplatin 100 mg/m2 (day 1), leucovorin 100 mg/m2 (day 1), fluorouracil 2,400 mg/m2 over 46 hours (day 1)). Both IP and IV regimens were repeated every 2 weeks. RESULTS: Among the 13 patients, there was no DLT at 40 and 60 mg/m2. Two patients had grade 3 febrile neutropenia at 80 mg/m2, and the recommended phase II dose was 60 mg/m2. Other patients underwent IP paclitaxel and FOLFOX without serious adverse events. Seven patients underwent second-look diagnostic laparoscopy, and the average change in PCI score was -7.0 ± 9.7. Conversion surgery rate was 23.1% (n = 3). The median overall survival was 16.6 months (95% confidence interval, 16.6-N/A), and progression-free survival was 9.6 months (95% confidence interval, 4.7-N/A). All adverse events were tolerable and manageable. CONCLUSIONS: The biweekly regimen of IP paclitaxel and FOLFOX is safe and the recommended dose of IP paclitaxel for a phase II trial is 60 mg/m2.

Prognostic significance of surgery-induced sarcopenia in the survival of gastric cancer patients: a sex-specific analysis.

BACKGROUND: Preoperative sarcopenia is associated with a poor long-term prognosis in patients with gastric cancer (GC). Most GC patients rapidly lose muscle mass after gastrectomy. This retrospective cohort study analysed the effect of postoperative muscle loss and surgery-induced sarcopenia on the long-term outcomes of patients with GC. METHODS: Preoperative and postoperative 1 year abdominal computed tomography scans were available for 1801 GC patients who underwent curative gastrectomy between January 2009 and December 2013 at Seoul National University Bundang Hospital. The patients were categorized into normal, presarcopenia, and sarcopenia groups according to the skeletal muscle index (SMI) measured on computed tomography scans. Patients who were not sarcopenic prior to gastrectomy but became sarcopenic after surgery were defined as the surgery-induced sarcopenia group. RESULTS: There were 1227 men and 574 women included in the study. The mean age of the patients was 59.5 ± 12.3 years. Multivariable Cox-regression analyses showed that preoperative SMI was not associated with overall survival (OS). However, postoperative sarcopenia was associated with significantly worse OS only in men [hazard ratio (HR), 1.75; 95% confidence interval (CI), 1.08-2.85]. SMI loss was an independent risk factor for OS in the entire cohort and in men (HR, 1.01; 95% CI, 1.00-1.02, for the entire cohort; HR, 1.02; 95% CI, 1.01-1.04, for men). The surgery-induced sarcopenia group was associated with significantly higher mortality (HR, 1.84; 95% CI, 1.16-2.90, for the cohort; HR, 2.73; 95% CI, 1.54-4.82, for men), although SMI loss and surgery-induced sarcopenia were not risk factors in women. Similar results were obtained for relapse-free survival. CONCLUSIONS: Postoperative muscle mass loss and surgery-induced sarcopenia are prognostic factors for survival in patients with GC. Impact of postoperative muscle mass loss and surgery-induced sarcopenia on survival outcomes is dependent on the sex.

Comparing the short-term outcomes and cost between solo single-incision distal gastrectomy and conventional multiport totally laparoscopic distal gastrectomy for early gastric cancer: a propensity score-matched analysis.

PURPOSE: Single-incision laparoscopic distal gastrectomy (SIDG) requires experienced camera operators for a stable image. Since it is difficult for skilled camera operators to participate in all SIDG, we began performing solo surgery using mechanical camera holders. We aimed to compare the short-term outcomes and cost between solo SIDG and conventional multiport laparoscopic distal gastrectomy (MLDG) for early gastric cancer (EGC). METHODS: From January 2014 to December 2016, a total of 938 consecutive patients underwent laparoscopic gastrectomy for EGC. Solo SIDG (n = 99) and MLDG patients (n = 198) were selected and 1:2 propensity score matching was done to compare the quality of operation and cost-effectiveness. All solo SIDG was performed by a surgeon using a camera holder, without any assistant. RESULTS: Mean operation time (120 ± 35.3 vs. 178 ± 53.4 minutes, P = 0.001) and estimated blood loss (24.6 ± 47.4 vs. 46.7 ± 66.5 mL, P = 0.001) were significantly lower in the solo SIDG group. Hospital stay, use of analgesics, and postoperative inflammatory markers (WBC, CRP) were similar between the 2 groups. The early (<30 days) complication rate in solo SIDG and MLDG groups was 21.2% and 23.7%, respectively (P = 0.240); the late (≥30 days) complication rate was 7.1% and 11.1%, respectively (P = 0.672). The manpower cost of solo SIDG was significantly lower than that of MLDG (P = 0.001). CONCLUSION: This study demonstrated that solo SIDG performed by experienced laparoscopic surgeons is safe and feasible for EGC. Solo SIDG is expected to be a promising potential treatment for EGC.

Quality of life after laparoscopic sentinel node navigation surgery in early gastric cancer: a single-center cohort study.

OBJECTIVE: To investigate the quality of life (QOL) of patients after laparoscopic sentinel node navigation surgery (SNNS) compared to conventional laparoscopy-assisted distal gastrectomy (LADG) in early gastric cancer patients. METHODS: Patients recruited for laparoscopic SNNS surgery between July 2010 and April 2013 were assessed for their QOL. A historical control group was established, consisting of patients who underwent conventional LADG with radical lymphadenectomy from the same institution. QOL questionnaire was taken serially from preoperative week 1 until 12 months postoperatively (1, 3, 6, and 12 months) using the Korean version of the European Organization for Research and Treatment of Cancer (EORTC) QOL questionnaire-core (QLQ-C30) and gastric cancer-specific questionnaire (STO22). RESULTS: A total of 80 prospectively gathered patients who received SNNS were categorized into the comparison group (SNNS group). The QOL was compared with 78 patients identified to have received LADG from the gastric cancer database of our institution and were sorted into the control group (LADG group). In QLQ-C30, SNNS group showed better functioning scales in all except role functioning and better scores from the symptom scales in fatigue, insomnia, and diarrhea compared to the LADG group. In QLQ-STO22, scores on dysphagia, eating restriction, anxiety, and body image disturbance were better in SNNS group. CONCLUSIONS: Postoperative QOL in laparoscopic gastrectomy combined with SNNS is superior compared to conventional laparoscopic distal gastrectomy in patients with stage I gastric cancer.

Three-dimensional (3D) visualization provides better outcome than two-dimensional (2D) visualization in single-port laparoscopic distal gastrectomy: a propensity-matched analysis.

PURPOSE: There are currently no reports on the application of three-dimensional (3D) vision to single-incision laparoscopic surgery. This study compared 3D vision to the previous two-dimensional (2D) system in single-incision laparoscopic distal gastrectomy (SIDG). METHODS: Medical charts of 179 gastric cancer patients who underwent SIDG from February 2014 to December 2017 were retrospectively reviewed. Patients were grouped into either a 2D group or 3D group depending on the type of camera that was used. All operations were performed using a flexible camera (Olympus, Japan). Operative data and postoperative outcome were analyzed. RESULTS: There were 90 patients in the 2D group and 89 patients in the 3D group. No differences were found in terms of the age, body mass index, staging, and other demographics of the patients. Operative time was significantly faster in the 3D group (115.6 ± 34.0 vs. 129.4 ± 38.5 min, p = 0.012), and estimated blood loss (EBL) was less in the 3D group (20.7 ± 30.0 vs. 35.1 ± 56.0 ml, p = 0.034). Patients in the 3D group were able to start a small fluid diet earlier (2.5, range 1-6 vs. 3.0, range 2-8 postoperative days, p = 0.006) and were discharged faster (5.4, range 3-12 vs. 6.2, range 4-24 postoperative days, p = 0.024). There was no statistical difference between early and late complications. CONCLUSION: The use of the 3D camera shortened operative time with possible clinical benefits for patients undergoing SIDG.

Laparoscopic gastrectomy and metastasectomy for stage IV gastric cancer.

BACKGROUND: The standard recommended treatment of stage IV gastric cancer is palliative chemotherapy. The aim of this study is to evaluate the role of radical gastrectomy with metastasectomy in these patients, as well as to explore the feasibility and safety of a laparoscopic approach. METHODS: 117 consecutive patients with pathologically proven Stage IV gastric cancer who underwent radical gastrectomy with metastasectomy were enrolled in this study. We evaluated short-term and long-term outcomes, comparing laparoscopic surgery with open surgery by propensity score matching. RESULTS: The 5-year overall survival rate (OSR) was 23.2% and the median survival time (MST) was 19.8 months. After propensity scoring matching, the 5-year OSR and MST of laparoscopy group was 23.4%, 17.9 months and in the open group, it was 25.0%, 22.8 months (p = 0.882). The complication rate was 5.6% in the laparoscopy group and 23.4% in the open group (p = 0.069). In multivariate analysis, adjuvant chemotherapy, chemotherapy cycle, and postoperative complication were independent prognostic factors of overall survival. CONCLUSIONS: Radical gastrectomy with metastasectomy could have a potential role in stage IV gastric cancer. Laparoscopic gastrectomy with metastasectomy in selected stage IV gastric cancer patients is safe and feasible.

Single-Incision Proximal Gastrectomy With Double-Flap Esophagogastrostomy Using Novel Laparoscopic Instruments.

Background. The optimal type of anastomosis after proximal gastrectomy (PG) is still controversial. A novel technique termed "double-flap" esophagogastrostomy (EG) has been introduced. The application of this technique after PG is reported to have little gastroesophageal reflux without the need of creating an esophagojejunostomy. However, this procedure is technically challenging and hence difficult to apply in laparoscopic PG. This technical report describes in detail how to perform single-incision proximal gastrectomy (SIPG) with double-flap EG with the use of novel laparoscopic instruments. Methods. Two patients diagnosed with early gastric cancer underwent SIPG. A 2.5 cm incision was made, and a scope holder was used in place of a scopist. After performing PG with D1+ lymphadenectomy, double seromuscular flaps were created on the anterior wall of the stomach. After tagging the esophagus to the inferior edge of the flap window, the stomach and esophagus were opened through electrocautery. EG was performed intracorporeally using continuous barbed sutures, and the flap is then secured to the anastomosis. To facilitate this procedure, an intra-abdominal organ retractor and an articulating needle holder were used. The supplementary video illustrates in detail how these devices are used to perform the technique. Results. Total operation times were 190 and 110 minutes each, and anastomosis took 75 and 46 minutes each. Patients had no complications and were both discharged on postoperative day 6. Conclusion. Double-flap PG is technically feasible through a single incision with the use of articulating laparoscopic devices and intra-abdominal organ retractors to assist in intracorporeal anastomosis.

Prospective randomized controlled study for comparison of 2-dimensional versus 3-dimensional laparoscopic distal gastrectomy for gastric adenocarcinoma.

BACKGROUND: Due to the technological advance in resolution and stereoscopic depth, the 3-dimensional (3D) laparoscopic system has been widely used in real surgery. However, there have been few studies to confirm the clinical usefulness of the 3D laparoscopic distal gastrectomy (LDG). This study aimed to compare perioperative outcomes between the 2-dimensional (2D) and 3D LDG for gastric cancer patients. METHODS: This was a prospective, randomized controlled, single-center, and superiority trial. This study was carried in Seoul National University Bundang Hospital. Patients with histologically confirmed gastric adenocarcinoma which could be radically resected by LDG were randomly assigned (1:1) to the 2D or 3D group. From October 2016 to August 2018, 84 patients were included in this study and randomly assigned into the 2D group (44 patients) or the 3D group (40 patients). A total of 5 patients were excluded; 3 in the 2D group and 2 were in the 3D group. Consequently, the data from 79 patients were analyzed (2D: 41 cases; 3D: 38 cases). For the LDG procedure, 3D and 2D camera and display system were applied according to the assigned group. The primary end point was the duration of total laparoscopic operation time. Secondary end points included the amount of intraoperative blood loss (IBL), the number of harvested lymph nodes, postoperative complications and open conversion rate. RESULTS: There were no differences between 2 and 3D groups with respect to clinicopathologic characteristics. The total operation time in 3D groups was significantly shorter than 2D group (122 [106.5-161] versus 101 [77.75-125.5] minutes; P = 0.001). The postoperative complication rates in the 3D groups was significantly lower than 2D group (24.4% versus 7.9%, respectively; P = 0.045). CONCLUSION: 3D LDG shorten the operation time compared with 2D LDG in gastric cancer patients. And 3D laparoscopy provided the benefit of less postoperative complications. TRIAL REGISTRATION: cris.nih.go.kr number KCT0003717.

Frailty in Elderly Gastric Cancer Patients Undergoing Gastrectomy.

INTRODUCTION: There is a dearth of literature on frailty specifically in elderly (aged ≥65 years) gastric cancer patients undergoing gastrectomy. We aim to assess the effects of frailty on postoperative outcomes. METHODS: A review of a prospective database was performed from November 2011 to April 2019. Frailty was assessed by multidimensional frailty score (MFS). Outcomes assessed were early postoperative complications and mortality, and length of stay. RESULTS: 289 patients were included. The mean age was 77.3 (range 66-94) years. 183 (63.3%) were males and 172 (59.5%) had early cancer. 275 (95.2%) underwent minimally invasive gastrectomy. 79 (27.3%) patients suffered early postoperative complications, with 47 (16.3%) suffering from Clavien-Dindo grade ≥2 complications. One-year, 90-day, 30-day, and inhospital mortality were 6.6, 1.4, 0.7, and 0%, respectively. 111 (38.4%) of patients were classified as "frail" based on MFS > 5. "Frail" patients were associated with higher 1-year mortality (odds ratio (OR) 4.51, 95% CI 1.57-12.98, p = 0.005) on univariate analysis. On multivariate analysis, "frail" patients did not have significantly increased 1-year mortality. However, when definition of "frail" was changed from MFS > 5 to MFS > 6, frailty was significantly associated with increased 1-year mortality (OR 3.73, 95% CI 1.11-12.53, p = 0.033). CONCLUSIONS: Elderly gastric cancer patients undergoing gastrectomy with MFS > 5 do not have increased mortality risk. The influence of frailty on postoperative outcomes may vary based on the risk of the surgical procedure.

Clinicopathologic Characteristics of Young Gastric Cancer Patients: Diagnostic Staging Accuracy and Survival.

Purpose: The purpose of this study was to investigate the clinicopathologic characteristics of young gastric cancer patients and analyze the risk factors for stage underestimation and survival. Methods: Relevant data of 5029 patients who underwent surgery for gastric cancer at Seoul National University Bundang Hospital between 2003 to 2014 were collected. Patients were divided based on age (younger group and older group). Clinical stages were compared to pathologic stages for accuracy, and risk factors for underestimation were analyzed using univariate and multivariate analysis regression. Overall survival and cancer-specific survival were analyzed using the Kaplan-Meier method. Results: A total of 4396 patients were eligible for inclusion. The younger group was an independent risk factor for nodal metastasis (RR=1.44, 95% CI 1.06~1.95) and an independent risk factor for clinical N-stage underestimation (RR=1.50, 95% CI=1.14~1.98). However, there was no significant difference in 5-year cancer-specific survival for both age groups (92.2% vs 90.2%, p=0.306). Conclusion: In conclusion, intra-operative investigation of T-stage with standard operation should be done in young gastric cancer patients as they have a higher incidence of lymph node metastasis, with greater frequency of stage underestimation.

Nutritional safety of oncometabolic surgery for early gastric cancer patients: a prospective single-arm pilot study using a historical control group for comparison.

BACKGROUND: Oncometabolic surgery (OS) is a modification of the Roux-en Y reconstruction method, in which the lengths of the biliopancreatic and Roux limbs are longer than that with conventional surgery (CS). Although OS is performed to improve postoperative glycemic control in gastric cancer patients with type 2 diabetes mellitus (T2DM), its postoperative nutritional safety has not been clarified. This prospective pilot study evaluated the safety and feasibility of OS in early gastric cancer patients. METHODS: This study evaluated 20 patients with clinical T1N0 stage and preoperative body mass index (BMI) ≥ 32.5 kg/m2, or ≥ 27.5 kg/m2 with comorbidities, who underwent OS. Primary outcomes were cumulative incidences of anemia and deficiencies in iron and vitamin B12 after 1 year. The outcomes were compared to those of a matched historical control group. RESULTS: The cumulative incidences of anemia (15.0% vs. 10.0%, P = 0.99), iron deficiency (15.0% vs. 10.0%, P = 0.99), and vitamin B12 deficiency (10.0% vs. 0%, P = 0.47) did not differ significantly in the OS and CS groups. However, median vitamin B12 concentration tended to be lower (395.8 vs. 493.7 pg/mL, P = 0.06) and reductions in vitamin B12 concentration tended to be greater (174.7 vs. 123.0 pg/mL, P = 0.07) in the OS group. BMI loss was similar in the two groups (2.9 vs. 2.8 kg/m2, P = 0.80). Remission rates of hypertension (68.8% vs. 41.2%, P = 0.22) and T2DM (77.8% vs. 50.0%, P = 0.58) were higher in the OS group. CONCLUSION: Nutritional parameters did not differ significantly in the OS and CS groups. Vitamin B12 levels should be carefully monitored after OS.

15-year experience of laparoscopic gastrectomy in advanced gastric cancer: analysis on short-term and long-term oncologic outcome.

BACKGROUND: Laparoscopic gastrectomy (LG) is now a widely accepted treatment option for gastric cancer. However, there is insufficient evidence for LG for advanced gastric cancer (AGC). Many retrospective studies have shown that LG for AGC is safe and feasible, but very few studies have shown the actual outcome in general practice. The aim of this study is to analyze our last 15 years of experience in LG for AGC. METHODS: This is a retrospective review from May 2003 to May 2017 in Seoul National University Bundang Hospital. A total of 1592 patients who had LG for AGC were enrolled of which 109 patients with open conversion were excluded. We evaluated the short-term and long-term oncologic outcomes of LG for AGC. RESULTS: A total of 1483 patients were analyzed. There were 432 cases of total gastrectomy, 982 cases of distal gastrectomy, and 69 cases of proximal gastrectomy. The total complication rate was 9.1% (135/1483), which included wound-related complications (0.7%), postoperative bleeding (0.5%), anastomosis or stump leakage (2.2%), intestinal obstruction (0.9%), pancreatic fistula (0.1%), intra-abdominal abscess (1.6%), and lung morbidity (3.0%). The rate of Clavien-Dindo grade 3 and above complications was 4.9%. Age was the only significant risk factor in multivariate analysis (OR 1.02; 95% CI, 1.01-1.04, P = 0.01). 5-year overall survival stratified by stage was as follows: stage IB 88.9%, stage IIA 88.7%, stage IIB 84.2%, stage IIIA 71.7%, stage IIIB 56.8%, stage IIIC 45.4%, and stage IV 25%. Total recurrence rate was 14.4%, which included local recurrence (1.1%) and distant metastases (13.3%). CONCLUSIONS: During our 15 years of experience, we have successfully performed 1483 cases of AGC with laparoscopy. Our results showed short-term and long-term oncologic outcomes that were comparable with other studies. LG is safe and feasible in general practice for advanced gastric cancer when performed by experienced surgeons.