Comparison of SOX and CAPOX in patients with advanced gastric cancer after laparoscopic D2 gastrectomy: A randomized controlled trial.

BACKGROUND: Optimal adjuvant chemotherapy after laparoscopic surgery in gastric cancer (GC) patients is still undefined. We aimed to evaluate the efficacy of S-1 plus oxaliplatin (SOX) and capecitabine plus oxaliplatin (CAPOX) in patients with GC after laparoscopic gastrectomy. METHODS: A non-inferiority randomized controlled clinical trial was performed in China. Patients with advanced GC who underwent laparoscopic D2 gastrectomy were randomly assigned to receive SOX and CAPOX regimens. RESULTS: In total, 191 patients were screened between May 2018 and June 2019, and 140 (73.3%) were included in the modified intent-to-treat analysis (mITT), of whom 69 and 71 were assigned to the SOX and CAPOX groups, respectively. The SOX group had similar 3-year overall survival (OS) and disease-free survival to the CAPOX group. Subgroup analysis revealed significantly better OS in the SOX group for male patients ([HR] = 0.395; 95% [CI], 0.153-1.019; p = 0.045), age >60 (HR = 0.219; 95% [CI], 0.064-0.753; p = 0.016), tumors in the gastric antrum (HR = 0.273; 95% [CI], 0.076-0.981; p = 0.047), and moderately differentiated tumors (HR = 0.338; 95% [CI], 0.110-1.041; p = 0.041). There were no significant differences observed in terms of adverse events and recurrence patterns between the two groups. CONCLUSION: Adjuvant SOX was non-inferior to CAPOX treatments for patients with GC who underwent curative laparoscopic D2 gastrectomy. For male patients, aged >60 years, tumors in the gastric antrum, and moderately differentiated tumors, adjuvant SOX may achieve an improvement compared with CAPOX.

Feasibility of laparoscopic proximal gastrectomy with piggyback jejunal interposition double-tract reconstruction for proximal gastric cancer: A propensity score-matching analysis.

Background: The feasibility of using laparoscopic proximal gastrectomy (LPG) for the treatment of proximal early gastric cancer (EGC) has not been addressed. This study aimed to comparatively evaluate the effects on LPG with piggyback jejunal interposition double-tract reconstruction (PJIDTR) versus laparoscopic total gastrectomy (LTG) with Roux-en-Y reconstruction (overlap method) using propensity score matching for proximal EGC. Materials and Methods: We examined the clinical outcomes of LPG with PJIDTR for proximal EGC. We retrospectively collected data from patients with proximal EGC who were treated at Shanxi Cancer Hospital between January 2012 and December 2015. The complication rate, nutritional indicators, reflux oesophagitis incidence and overall survival were compared between LTG and LPG with PJIDTR. Results: Of the 424 patients, 200 were excluded, and 50 of the remaining patients received LPG with PJIDTR. Fifty matched LTG patients were screened. The incidence of early complications was 14% in the LPG group and 16% in the LTG group (P > 0.05). At 1 year after surgery, nutrition indices in the LPG group were significantly better than those in the LTG group (P < 0.05). One year after surgery, the Visick score II rate was 2% and 4%, and the endoscopic oesophagitis rate was 4% and 6% in the LPG and LTG groups, respectively. No tumour recurrence was observed in either group. The 5-year overall survival rates of the two groups were 98% and 90% (P = 0.08). Conclusions: LPG with PJIDTR may be suitable for proximal EGC.

Comparison of three digestive tract reconstruction methods for the treatment of Siewert II and III adenocarcinoma of esophagogastric junction: a prospective, randomized controlled study.

BACKGROUND: The incidence of adenocarcinoma of esophagogastric junction (AEG) has recently risen worldwide, including in Eastern Asia. The aim of the study was to explore the short-term and long-term clinical efficacy of piggyback jejunal interposition reconstruction single-tract reconstruction (PJIRSTR), piggyback jejunal interposition reconstruction double-tract reconstruction (PJIRDTR), and total gastrectomy esophageal jejunal Roux-en-Y anastomosis (TGRY) for the treatment of Siewert II and III AEG patients. METHODS: A total of 300 Siewert II and III AEG patients admitted to Shanxi Tumor Hospital from June 2015 to December 2017 were prospectively selected. Patients were randomly divided into PJIRSTR group (n = 98), PJIRDTR group (n = 103), and TGRY group (n = 99) using the random number table method. RESULTS: There were no statistically significant differences in total operation time, intraoperative blood loss, time of first anal exhaust, and postoperative hospital stay among the three groups (F = 2.526, 0.457, 0.234, 0.453; P > 0.05). The reconstruction time of PJIRSTR group and PJIRDTR group was longer than that of TGRY group (P < 0.01). There were no significant differences in cases of anastomotic leakage, anastomotic bleeding, abdominal infection, incision infection, ileus, and dumping syndrome in three groups (P > 0.05). The incidence of reflux esophagitis at 3, 6, 12, and 18 months after surgery in the PJIRSTR group and the PJIRDTR group were significantly lower than TGRY group in the same period (P < 0.05). Compared with PJIRDTR group and TGRY group, PJIRSTR group had a small fluctuation range of postoperative nutrition indexes and had basically recovered to the preoperative level at 18 months. Four patients of Visick grade IV presented in TGRY group 18 months postoperatively, which was significantly higher compared with the other two groups. CONCLUSION: Compared with PJIRDTR and TGRY, PJIRSTR can significantly reduce the incidence of postoperative reflux esophagitis and improve the long-term nutritional status of patients. TRIAL REGISTRATION: Chinese Clinical Trial Registry, ChiCTR-IIR-16007733. Registered 07 November 2015 - Retrospectively registered, http://www.chictr.org.cn/searchproj.aspx.

Anatomical variation of infra-pyloric artery origination: A prospective multicenter observational study (IPA-Origin).

OBJECTIVE: Infra-pyloric artery (IPA) is an important anatomical landmark in treatment of gastric cancer and is the key vessel for pylorus-preserving gastrectomy and subgroup of infra-pyloric lymph nodes. However, its anatomical variation is not thoroughly understood. Our study aimed to clarify the origination of the IPA. METHODS: We did this prospective, multicenter, open-label, observational study at gastric surgery departments of 34 hospitals in China. Gastric cancer patients aged 18 years or older and scheduled to undergo elective total or distal gastrectomy were assigned. During the surgery, IPA dissecting and exposing the origination point with photographs or video clips were required. The primary outcome was the origination of the IPA. Analysis of variance, χ2 tests and Fisher's tests were used to analyze the differences between groups. The study is registered at Clinicaltrials.gov (No. NCT03071237). RESULTS: Between May 8 and July 31, 2017, 429 patients were assigned for the study, and 419 (97.7%) patients had the IPA dissected and recorded through photograph or video and were included in the primary outcome analysis. The median age was 62 years old, and 73.7% were male. Among the patients, 78.5% received laparoscopic surgery. Single IPA origination was identified in 398 (95.0%) patients, including gastroduodenal artery (GDA) in 154 (36.8%) patients, anterior superior pancreaticoduodenal artery (ASPDA) in 130 (31.0%) patients, and right gastroepiploic artery (RGEA) in 114 (27.2%) patients. Fifteen (3.6%) patients were identified with multiple IPA and 6 (1.4%) patients were identified as IPA absence. The differences in the distribution of surgical approach (P=0.003) and geographic area (P=0.030) were statistically significant. No difference was shown in sex, age, gastrectomy type, tumor location, and clinical T, N and M stage. CONCLUSIONS: Our study found that the IPA originates from GDA, ASPDA and RGEA in similar proportions. Laparoscopic surgery may be more helpful in dissection of the IPA than open surgery.

Significance of preoperative ischemia- modified albumin in operable and advanced gastric cancer.

BACKGROUND: Oxidative stress plays an important role in promoting proliferation and metastases of cancer, which can be represented by ischemia-modified albumin (IMA). The purpose of this study was to evaluate serum IMA level in patients with operable advanced gastric cancer and analyze its prognostic significance. MATERIALS AND METHODS: A total of 274 patients with primary stage III gastric cancer underwent curative operation were enrolled in this study. Serum IMA level was measured within 24 hours before surgery, comparing with 112 healthy donors. The correlation between serum IMA level and survival outcome was analyzed by the Kaplan-Meier with Log-Rank test and Cox's regression methods, respectively. RESULTS: Serum IMA level from gastric cancer was higher than healthy control (0.41 ± 0.12 VS 0.23 ± 0.08; P< 0.001). Finally, 173 and 181 patients out of all 274 patients studied had died and recurrent, respectively. All patients were stratified into two groups using the optimal cutoff value (0.45) of IMA level using a sensitivity of 92.5% and a specificity of 65.2% as optimal conditions from receiver operating curve analysis. Patients with a IMA ⩾ 0.45 had poorer mean overall survival (44.68 months VS 30.94 months, P= 0.010) and mean recurrence free survival (42.36 months VS 28.82 months, p= 0.01) than patients with a IMA < 0.45 in univariate analysis and IMA also been confirmed as independent predictor for survival for GC patients in multivariate analysis (OR, 0.731; 95% CI: 0.329-1.282; p= 0.023). CONCLUSIONS: Serum IMA level can be considered as an independent prognostic factor for operable and advanced gastric cancer.

Tumor LXR Expression is a Prognostic Marker for Patients with Hepatocellular Carcinoma.

Liver X receptor (LXR) activation exerts an anti-tumor effect. However, whether the tumor LXR expression has prognostic significance in hepatocellular carcinoma (HCC) patient has not been addressed yet. Primary HCC and the adjacent non-tumor tissues were obtained from 169 patients who underwent routine curative surgical treatment. All patients were followed for prognosis analyses. Tumor LXR was detected by immunohistochemical analysis. In in vitro study, several HCC cell lines were cultured for cellular protein detection of LXR and other cytokines, including nuclear factor kappa (NFκB), Matrix metalloproteinases 2 and 9 (MMP-2 and -9). Meanwhile, the invasion ability of cultured HCC cell lines was performed. We found that LXR expression status in tumor samples is associated with the clinical characteristics, such as tumor stage and metastasis, of HCC patients. Prognosis analysis shows that tumor LXR expression status is closely related to the post-operative outcome in HCC patients who underwent surgical treatment. Patients with low LXR expression have a significantly lower mean 5-year overall survival rate and mean overall survival period than those with high LXR level. Our in vitro data reveal that HCC cell lines had increased NF-κB, MMP2, MMP9 and invasive ability than normal cell line, which are suppressed by LXR activation via NFκB pathway. Our data suggest that LXR could be used as a biomarker for HCC prognosis. Further study is warranted to explore the molecular mechanism under which LXR regulates tumor behaves.

Two giant peritoneal loose bodies were simultaneously found in one patient: A case report and review of the literature.

INTRODUCTION: Peritoneal loose body(PLB) is usually small, therefore giant Peritoneal loose body(gPLB) with a diameter >5cm has rarely been described in the literatures. We report a case of two gPLB simultaneously found in one patient. PRESENTATION OF CASE: A healthy 79-year-old man palpated himself a solid mass with alternating localizations in his peritoneal cavity 6 months ago. It was not the complaint of frequency of urinatior until he saw the doctor a week ago. Surprisingly, two oval-shaped masses were simultaneously discovered by computed tomography (CT). One was in the peritoneal cavity, measuring 10.4*8.3cm, weight 182.5g, another was in the pelvic cavity, measuring 7.6*6.0cm, weight 98.4g. The case was confirmed by surgical operation. DISCUSSION: The gPLB is considered as uncommon. Two gPLB which were simultaneously discovered in one patient have never been reported in the literatures. The small PLB is usually asmptomatic, occasionally, the gPLB can cause symptoms with acute retention of urine or intestinal obstruction. It is crucial to diagnosis the peritoneal loose body. CONCLUSION: Two gPLB that situated in one patient are rare findings. Clinically, if a solid mass alternating localizations cound be palpated in the Peritoneal cavity, CT or other imaging shows an oval-shaped mass with calcifications in the central region, PLB should be considered. Surgical removal is recommended for the patient with acute retention of urine or intestinal obstruction or unclear diagnosis.

[Clinical research of delta-shaped anastomosis technology in laparoscopic distal gastrectomy and digestive tract reconstruction].

OBJECTIVE: To evaluate the feasibility and safety of the delta-shaped anastomosis in laparoscopic distal gastrectomy and digestive tract reconstruction. METHODS: Clinical data of 34 gastric cancer patients undergoing laparoscopic distal gastrectomy with the delta-shaped anastomosis for digestive tract reconstruction (delta-shaped group) and 83 gastric cancer patients undergoing laparoscopic distal gastrectomy with Billroth I( for digestive tract reconstruction (Billroth group) by same surgeon team from July 2013 to July 2015 at the Department of Digestive Surgery, Affiliated Tumor Hospital of Shanxi Medical University were retrospectively analyzed. Data of two groups were compared. RESULT: Age, gender, tumor stage were not significantly different between the two groups(all P>0.05). Operation time of the first 15 cases in delta-shaped group was longer than that in Billroth group [(254.7±35.4) min vs. (177.8±33.0) min, t=11.190, P=0.000], while after above 15 cases, the operation time of delta-shaped group was significantly shorter than that of Billroth group [(142.1±14.6) min vs. (177.8±33.0) min, t=-4.109, P=0.001]. Delta-shaped group had less blood loss during operation [(87.1±36.7) ml vs. (194.0±55.1) ml, t=-10.268, P=0.000], and shorter length of incision [(4.1±0.4) cm vs. (6.1±1.0) cm, t=-10.331, P=0.000] than Billroth group. Compared with Billroth group, delta-shaped group presented faster postoperative bowel function return [(2.8±0.6) d vs. (3.3±0.5) d, t=-3.755, P=0.000], earlier liquid food intake [(7.4±1.5) d vs. (8.1±1.7) d, t=-4.135, P=0.000], earlier ambulation [(4.0±1.6) d vs. (6.8±1.4) d, t=-7.197, P=0.000] and shorter postoperative hospital stay [(12.6±1.9) d vs.(13.6±2.0) d, t=-20.149, P=0.000]. Morbidity of postoperative complication was 5.9%(2/34) in delta-shaped group, including anastomotic fistula in 1 case and incision infection in 1 case, and 6.0%(5/83) in Billroth group, including anastomotic fistula, incision infection, anastomotic stricture and dumping syndrome, without significant difference(P>0.05). Difference value of total protein and albumin between pre-operation and post-operation, and average decreased value of total protein, albumin, body weight between pre-operation and postoperative 6-month were not significantly different between two groups(all P>0.05). As for patients with BMI > 25 kg/m2, compared to Billroth group, delta-shaped group presented less blood loss during operation [(94.1±36.7) ml vs. (203.0±55.1) ml, t=-10.268, P=0.000], lower injective dosage of postoperative analgesics [(1.9±1.1) ampule vs.(3.3±2.0) ampule, t=-2.188, P=0.032], faster intestinal recovery [(2.9±0.7) d vs. (3.2±0.9) d, t=-3.755, P=0.009], shorter hospital stay [(10.5±1.2) d vs. (11.7±1.5) d, t=-2.026, P=0.004], and lower morbidity of postoperative complication [7.1%(1/14) vs. 13.6%(3/22), χ2=4.066, P=0.031]. CONCLUSION: In laparoscopic distal gastrectomy and digestive tract reconstruction, the delta-shaped anastomosis is safe and feasible, especially suitable for obese patients.