A phase II study of adjuvant S-1/cisplatin chemotherapy followed by S-1-based chemoradiotherapy for D2-resected gastric cancer.

PURPOSE: Surgery is the only possible curative treatment for gastric cancer. However, the high recurrence rate makes gastric cancer difficult to cure by surgery alone. The present study was conducted to evaluate the clinical outcomes and toxicity of adjuvant treatment, including S-1/cisplatin chemotherapy followed by radiotherapy with concurrent S-1. METHODS: Patients with radically D2-resected adenocarcinoma of the stomach of stage IB-IV (M0) were eligible. Patients were treated with S-1 (40-60 mg depending on the patient's body surface area) twice daily for 3 weeks and cisplatin (60 mg/m(2)) intravenously on day 1 every 5 weeks. Patients received CRT (45 Gy of radiation at 1.8 Gy/day, 5 days per week, for 5 weeks with the same dose of S-1 during radiation) followed by two additional cycles of S-1/cisplatin. The primary endpoint was the 3-year disease-free survival (DFS) rate; the secondary endpoints were the 3-year overall survival rate and toxicities. RESULTS: Until May 2012, 46 patients were enrolled, and 34 (73.9%) completed the planned treatment. The median age was 53 years (range: 31-69 years), and the numbers of patients with stage IB, II, III and IV disease were 0, 17, 25 and 4, respectively. Main grade 3-4 toxicities were as follows: neutropenia (28.2%), nausea (17.4%), vomiting (8.7%) and anorexia (15.2%). At the time of analysis, after a median follow-up period of 56.5 months (3.03-74.0 months), 16 recurrence events and 15 deaths were reported. The estimated 3-year DFS and survival rates were 65.2 and 76.1%, respectively. The most common site of recurrence was the peritoneum (n = 12). CONCLUSIONS: The results of this phase II study show that intensified adjuvant treatment with S-1/cisplatin chemotherapy and S-1-based chemoradiotherapy was tolerable and effective in reducing disease recurrence. The addition of radiotherapy to chemotherapy may be effective in D2-resected gastric cancer. Although the data here are promising, a randomized trial is needed between patients treated with the current regimen and an appropriate comparator arm.

Comparison of the long-term results of patients who underwent laparoscopy versus open distal gastrectomy.

BACKGROUND: Survival data of patients who underwent laparoscopy assisted distal gastrectomy (LADG) compared with those of patients who underwent open distal gastrectomy (ODG) for gastric cancer are rarely presented. We compared long-term outcomes of LADG with those of ODG in patients with EGC who met the current indication for LADG. METHODS: A total of 2410 patients with early gastric cancer who underwent curative-intent gastric cancer surgery in three Korean tertiary hospitals between January 2003 and June 2009 were included in this multicenter, retrospective, propensity-score-matched cohort study. Cox proportional hazard regression models were used to evaluate the association between operation methods and survival. RESULTS: In the matched cohort, there were no significant differences in overall survival [hazard ratio (HR) for the LADG group 0.990; 95% confidence interval (CI) 0.675-1.453] or recurrence-free survival (HR 0.989; 95% CI 0.480-2.038). The patterns of recurrence were not different between the two groups. The most common pattern of recurrence was liver metastasis followed by metastasis to distant lymph nodes. The rate of complications in the LADG group was higher than that of the ODG group (6.7 vs. 4.6%, P = 0.045). Grade III or worse complications that required surgical intervention or were life-threatening showed a marginal difference between the two groups (1.7 vs. 2.2%, P = 0.052). There were no postoperative mortalities in either group. CONCLUSION: Laparoscopy assisted distal gastrectomy for patients with early gastric cancer is feasible in terms of the long-term results including survival and recurrence.

Safety and feasibility during the initial learning process of intracorporeal Billroth I (delta-shaped) anastomosis for laparoscopic distal gastrectomy.

BACKGROUND: Intracorporeal Billroth I (ICBI) (delta-shaped) anastomosis is being increasingly used for laparoscopic distal gastrectomy. However, few studies have focused on the safety and feasibility of adopting this new technique. The present study aimed to review the surgical outcomes after the initial experience of performing ICBI anastomosis and to evaluate whether this technique can be safely adopted without increasing operative risk during the early learning process. METHODS: Forty-two consecutive patients who underwent ICBI anastomosis with laparoscopic distal gastrectomy by a single surgeon were enrolled, and their operative outcomes and hospital course were compared with those of 179 patients who underwent conventional extracorporeal Billroth I (ECBI) anastomosis by the same operator. The learning curve was assessed by evaluating the moving average of anastomosis time. RESULTS: The operating time in the ICBI group was significantly longer than that in the ECBI group (142 vs. 116 min, p < 0.001). However, there were no significant differences in the postoperative hospital course such as gas passage, diet initiation, postoperative fever, and hospital stay between the two groups. Postoperative morbidity did not significantly differ between the ICBI and ECBI groups (7.1 vs. 12.3 %, p = 0.428). No anastomosis-related complications occurred in the ICBI group. The mean anastomosis time for ICBI anastomosis was 24 ± 5 min, and the anastomosis average time curve showed that it reached a plateau approximately after the 14th case. CONCLUSIONS: ICBI anastomosis has a steep learning curve without increasing operative risk in the early learning process, when performed by experienced laparoscopic surgeons. The technical feasibility and clinical advantages of intracorporeal anastomosis need to be proven in future clinical trials.

Efficacy of single-dose antimicrobial prophylaxis for preventing surgical site infection in radical gastrectomy for gastric carcinoma.

PURPOSE: Information regarding antimicrobial prophylaxis (AMP) for gastric cancer surgery is limited. The present study investigated the efficacy of single-dose AMP for the prevention of surgical site infection (SSI) in patients undergoing gastrectomy for gastric carcinoma. MATERIALS AND METHODS: Between 2011 and 2013, 1,330 gastric carcinoma surgery patients were divided into two AMP administration groups depending on the duration of treatment. Postoperative outcomes including morbidity and SSI were compared between the two groups overall and in matched patients. Risk factors for SSI were analyzed. RESULTS: The extended group (n=1,129) received AMP until postoperative day 1 and the single-dose group (n=201) received singledose AMP only during an operation. Postoperatively, there were no significant differences between the two groups with respect to overall morbidity, mortality, or length of hospital stay. The SSI rate of the single-dose group was not significantly different from that of the extended group overall (4.5% vs. 5.5%, respectively, P=0.556) or in matched patients (4.5% vs. 4.0%, respectively, P=0.801). There was no increase in the SSI rate of the single-dose group compared to the extended group in subgroups based on different clinicopathological and operative factors. Univariate and multivariate analyses revealed male gender, open surgery, and operating time (≥180 minutes) as independent risk factors for SSI. CONCLUSIONS: Single-dose AMP showed no increase in the postoperative SSI rate compared to postoperative extended use in patients undergoing gastrectomy for gastric carcinoma. The efficacy of single-dose AMP requires further investigation in randomized clinical trials specific to gastric cancer surgery.

Laparoscopic distal gastrectomy for gastric cancer in morbidly obese patients in South Korea.

PURPOSE: Laparoscopic gastrectomy in obese patients has been investigated in several studies, but its feasibility has rarely been examined in morbidly obese patients, such as in those with a body mass index (BMI) of ≥30 kg/m(2). The present study aimed to evaluate the technical feasibility and safety of laparoscopic gastrectomy in morbidly obese patients with gastric cancer. MATERIALS AND METHODS: A total of 1,512 gastric cancer patients who underwent laparoscopic distal gastrectomy (LDG) were divided into three groups: normal (BMI<25 kg/m(2), n=996), obese (BMI 25~30 kg/m(2), n=471), and morbidly obese (BMI≥30 kg/m(2), n=45). Short-term surgical outcomes, including the course of hospitalization and postoperative complications, were compared between the three groups. RESULTS: The morbidly obese group had a significantly longer operating time (240 minutes vs. 204 minutes, P=0.010) than the normal group, but no significant differences were found between the groups with respect to intraoperative blood loss or other complications. In the morbidly obese group, the postoperative morbidity and mortality rates were 13.3% and 0%, respectively, and the mean length of hospital stay was 8.2 days, which were not significantly different from those in the normal group. Subgroup analysis showed that postoperative complication rates were not high in morbidly obese patients, independent of the type of anastomosis technique used and level of lymph node dissection. CONCLUSIONS: LDG is technically feasible and safe in morbidly obese patients with a BMI of ≥30 kg/m(2) and early gastric carcinoma. Except for a longer operating time, LDG might represent a reasonable treatment option in these patients.

Risk factors and learning curve associated with postoperative morbidity of laparoscopic total gastrectomy for gastric carcinoma.

BACKGROUND: Laparoscopic total gastrectomy (LTG) is a challenging surgical procedure that has substantial technical difficulties and complications. In this study, we investigated risk factors for morbidity and mortality after LTG, and the learning curve associated with postoperative morbidity. METHODS: Prospectively constructed data of 203 patients undergoing LTG between 2004 and 2013 were retrospectively reviewed. The multivariate logistic regression model was used to analyze risk factors for postoperative morbidity. The Cumulative Sum (CUSUM) technique was used to assess the learning curve. RESULTS: Postoperative morbidity and mortality after LTG was 18.7 and 1.5 %, respectively. Of 38 patients with postoperative morbidity, 7 (3.4 %) were managed with reoperation, 8 (4.0 %) with radiologic or endoscopic intervention, and 23 (11.3 %) with a conservative treatment. Of local complications, gastrointestinal bleeding was the most common (12 patients), followed by anastomosis leakage (9 patients) and intra-abdominal abscess (9 patients). Respiratory complication was the most common of the systemic complications. There were 17 cases (8.4 %) of complications exceeding grade III severity, of which anastomosis leakage was the most common. CUSUM analysis showed that postoperative morbidity reached a plateau after around 45 cases. Univariate and multivariate analyses revealed that old age (over 65 years of age) and surgical experience (<45 cases) were independent factors for postoperative morbidity after LTG. CONCLUSION: LTG is a feasible technique with acceptable morbidity and mortality. However, substantial surgical experience is of most importance to reduce postoperative morbidity and mortality.

Prognostic significance of non-curative gastrectomy for incurable gastric carcinoma.

BACKGROUND: To date, there is no convincing evidence regarding the benefits of non-curative gastrectomy for gastric carcinoma. In the present study, we reviewed the outcomes of patients who underwent surgery for incurable gastric carcinoma and evaluated the prognostic significance of non-curative gastrectomy. METHODS: Between 2004 and 2011, a total of 197 patients undergoing elective surgery for incurable gastric carcinoma were divided into the gastric resection and non-resection groups. Patient survival was compared between the two groups, and the prognostic significance of non-curative gastrectomy was investigated using multivariate analysis. RESULTS: Overall, 162 (82.2 %) patients underwent non-curative gastrectomy with morbidity and mortality of 21.0 and 1.2 %, respectively. The median survival of patients undergoing non-curative gastrectomy was significantly longer than that of patients without gastrectomy (12.4 vs. 7.1 months, p = 0.003). Patients who received postoperative chemotherapy also showed significantly better survival than those without chemotherapy (13.2 vs. 4.3 months, p < 0.001). Multivariate analysis revealed that non-curative gastrectomy was an independent prognostic factor (hazard ratio 0.61, 95 % CI 0.40-0.93, p = 0.023) after adjusting for postoperative chemotherapy and other clinical factors. Median survival in patients receiving non-curative gastrectomy combined with postoperative chemotherapy was 13.9 months, which was significantly longer than gastrectomy alone (5.4 months), chemotherapy alone (9.6 months), and no treatment (3.2 months) (p < 0.001). CONCLUSION: Primary tumor resection and postoperative chemotherapy are the most important prognostic factors for incurable gastric carcinoma. The survival benefits of non-curative gastrectomy need to be confirmed in a large-scale, randomized trial.

The safety and feasibility of early postoperative oral nutrition on the first postoperative day after gastrectomy for gastric carcinoma.

BACKGROUND: Unlike the wide acceptance of early enteral nutrition after colorectal surgery, little information is available regarding the feasibility of immediate oral nutrition after gastric cancer surgery. This study evaluated the feasibility and safety of oral nutrition on the first postoperative day after gastrectomy. METHODS: From September 2010 to March 2011, 74 consecutive gastric cancer patients received an oral diet on the first postoperative day after gastrectomy. Surgical outcomes, including hospital stay, morbidity, and mortality, were compared with a conventional diet group (n = 96, before September 2010), in which an oral diet was started on the third or fourth postoperative day. RESULTS: No significant differences were found in the clinicopathological characteristics or operation types between the two groups. Average diet start times in the early diet (ED) and conventional diet (CD) groups were 1.8 and. 3.2, respectively (p < 0.001). The mean hospital stay was significantly shorter in the ED group (7.4 vs. 8.9 days, p = 0.004). There was no significant difference in postoperative morbidity (p = 0.947) between the two groups. Gastrointestinal-related complications, such as anastomosis leakage or postoperative ileus, were also similar in the two groups. Overall compliance to early oral nutrition in the ED group was 78.5 %, and an old age (≥70 years) was found to affect the compliance to early postoperative oral nutrition. CONCLUSIONS: Postoperative oral nutrition is safe and feasible on the first postoperative day after gastrectomy. However, elderly patients require careful monitoring when applying early oral nutrition after gastrectomy.

Corrigendum: laparoscopic distal gastrectomy for gastric cancer in morbidly obese patients in South Korea.

[This corrects the article on p. 187 in vol. 14, PMID: 25328764.].

A propensity score-matched case-control comparative study of laparoscopic and open extended (D2) lymph node dissection for distal gastric carcinoma.

BACKGROUND: Technical proficiency at laparoscopic D2 lymph node dissection (LND) is essential for extending the use of laparoscopic surgery beyond the treatment of early gastric cancer (EGC). The aim of this study was to evaluate the technical and oncological feasibility of laparoscopic distal gastrectomy (LDG) with D2 LND for distal gastric cancer. METHODS: Of 922 patients who underwent open or LDG with D2 LND for gastric carcinoma, 133 treated by LDG and 133 treated by open distal gastrectomy (ODG) were selected using the propensity score matching method. The short-term surgical outcomes and long-term survivals of these matched groups were compared. RESULTS: The two study groups were well matched with respect to age, sex, body mass index, comorbidity, ASA score, abdominal operation history, and tumor stage. The LDG group had a significantly longer mean operating time (227 vs. 161 min, p < 0.001) but showed significantly less intraoperative blood loss (149 vs. 189 ml, p = 0.007). Total numbers of collected lymph nodes were similar in the two groups. Postoperatively, no significant intergroup differences were found for hospital stay, morbidity, or mortality. Furthermore, overall survivals were similar in the two groups (p = 0.621). Multivariate analysis showed that male gender, age ≥70 years, and intraoperative blood loss of ≥200 ml were independent risk factors of postoperative morbidity. CONCLUSIONS: Laparoscopic D2 LND for distal gastric cancer is technically safe and feasible compared with ODG. A prospective randomized trial is warranted to evaluate long-term oncological outcomes in advanced gastric carcinoma.

The value of preoperative lung spirometry test for predicting the operative risk in patients undergoing gastric cancer surgery.

PURPOSE: We evaluated the predictive value of preoperative lung spirometry test for postoperative morbidity and the nature of complications related to an abnormal pulmonary function after gastric cancer surgery. METHODS: Between February 2009 and March 2010, 538 gastric cancer patients who underwent laparoscopic (n = 247) and open gastrectomy (n = 291) were divided into the normal (forced expiratory volume in 1 second [FEV(1)]/forced vital capacity [FVC] ≥ 0.7, n = 441) and abnormal pulmonary function group (FEV(1)/FVC < 0.7, n = 97), according to the preoperative lung spirometry test. The predictive value of lung spirometry for postoperative morbidity was evaluated using the univariate and multivariate analysis. RESULTS: After surgery, the abnormal pulmonary function group showed a significantly increased incidence of local (29.9% vs. 18.1%, P = 0.009) and systemic complications (8.2% vs. 2.0%, P = 0.005) than the normal group. Of local complications, anastomosis leakage and wound complication were found to be more common in the abnormal pulmonary function group. In the univariate and multivariate analysis, an abnormal pulmonary function was an independent predictor for postoperative local complication (odds ratio, 1.75; 95% confidence interval, 1.03 to 2.97) after adjusted by old age, total gastrectomy, open surgery, and tumor-node-metastasis stage. Meanwhile, an old age and a history of pulmonary disease were independent predictors for systemic complication. CONCLUSION: Preoperative lung spirometry is a simple and useful means to predict postoperative morbidity after gastric cancer surgery. In view of its simplicity and low cost, we recommend adding preoperative lung spirometry test to assess the operative risk and aid in proper perioperative treatment planning.

Comparison of short-term surgical outcomes between laparoscopic and open total gastrectomy for gastric carcinoma: case-control study using propensity score matching method.

BACKGROUND: To evaluate the technical feasibility and safety of laparoscopic total gastrectomy (LTG) for gastric carcinoma, this study compared short-term surgical outcomes between LTG and open total gastrectomy (OTG) using the propensity score matching method. STUDY DESIGN: After generating propensity scores given the covariates of age, sex, body mass index, comorbidity, American Society of Anesthesiologists (ASA) score, operators, and tumor stage, 122 patients with LTG were matched to 122 OTG patients using the nearest available score matching. Operative outcomes and hospital courses were compared in the matched groups and in the subgroups by the extent of lymph node dissection (LND). RESULTS: The 2 study groups were well balanced with respect to the baseline characteristics of the propensity score derivation model. In the analysis of overall patients, the LTG group showed significantly longer operating time (289 vs 203 min, p < 0.001), but postoperative outcomes, including hospital stay, morbidity, and mortality, were similar in the 2 groups. In the subgroup with D1 + ß LND (perigastric nodes + Nos. 7, 8a, 9, 11p), the LTG group showed no significant differences in hospital stay, morbidity, and mortality from the OTG group. However, in the subgroup with D2 LND (perigastric nodes + Nos. 7, 8a, 9, 10, 11p, 11d, 12a), the LTG group showed significantly increased morbidity (52.6% vs 21.0%, p = 0.007) and tendency toward increased length of hospital stay and mortality as compared with the OTG group. CONCLUSIONS: Laparoscopic total gastrectomy is a safe and feasible technique for treatment of upper gastric carcinoma. However, LTG with D2 LND for upper gastric cancer may increase the operative risk and requires considerable experience in laparoscopic surgery.

Short-term surgical outcomes and operative risks of laparoscopic total gastrectomy (LTG) for gastric carcinoma: experience at a large-volume center.

BACKGROUND: Despite the popularity of laparoscopic distal gastrectomy (LDG), laparoscopic total gastrectomy (LTG) remains a challenging procedure because of its technical difficulties and possible complications. In this study, the authors evaluated the short-term surgical outcomes and operative risks of LTG. METHODS: The records of 118 patients who underwent LTG for middle or upper gastric cancer were retrieved from a prospectively constructed database of 1,064 patients who underwent laparoscopic gastrectomy between 2007 and 2011. Surgical outcomes of LTG, such as operative results, postoperative courses, morbidities, and mortality, were investigated and compared with those of LDG patients. RESULTS: Of the 118 LTG patients, one underwent open conversion and three experienced an intraoperative complication. Mean operating time was 292 ± 88 min, and the mean total number of harvested lymph nodes was 41 ± 16. As compared with the LDG group, the LTG group had a significantly longer operation time (292 vs. 220 min, p < 0.001), and significantly more intraoperative blood loss (256 vs. 191 ml, p = 0.002). The overall morbidity rate after LTG was 22.9%, which was significantly higher than after LDG (12.7%, p = 0.002). There were two postoperative mortalities in the LTG group. The most common complications after LTG were anastomosis leakage (n = 9) and luminal bleeding (n = 9), which were followed by anastomosis stricture (n = 4) and abdominal infection (n = 3). Univariate and multivariate analysis revealed that old age [≥60 years, odds ratio (OR) = 2.55, 95% confidence interval (CI) = 0.95-6.84], intraoperative blood loss >200 ml (OR = 3.33, 95% CI = 1.14-9.70), and D2 lymphadenectomy (OR = 3.87, 95% CI = 1.30-11.55) were independent risk factors for postoperative complications after LTG. CONCLUSIONS: LTG is a feasible and acceptable procedure for treatment of middle or upper early gastric cancer. Further refinement of anastomosis techniques and considerable experience of laparoscopic gastrectomy are required for proper application of LTG in gastric carcinoma.

Outcomes of Abdominal Total Gastrectomy for Type II and III Gastroesophageal Junction Tumors: Single Center's Experience in Korea.

PURPOSE: The aim of this study was to evaluate the surgical outcomes of abdominal total gastrectomy, without mediastinal lymph node dissection for type II and III gastroesophageal junction (GEJ) cancers. MATERIALS AND METHODS: We retrospectively reviewed surgical outcomes in 67 consecutive patients with type II and III GEJ cancers that were treated by the surgical resection between 2004 and 2008. RESULTS: Thirty (45%) patients had type II and 37 (55%) had type III tumor. Among the 65 (97%) patients with curative surgery, 21 (31%) patients underwent the extended total gastrectomy with trans-hiatal distal esophageal resection, and in 44 (66%) patients, abdominal total gastrectomy alone was done. Palliative gastrectomy was performed in two patients due to the accompanying peritoneal metastasis. The postoperative morbidity and mortality rates were 21.4% and 1.5%, respectively. After a median follow up of 36 months, the overall 3-years was 68%, without any differences between the Siewert types or the operative approaches (transhiatal approach vs. abdominal approach alone). On the univariate analysis, the T stage, N stage and R0 resection were found to be associated with the survival, and multivariate analysis revealed that the N stage was a poor independent prognostic factor for survival. CONCLUSIONS: Type II and III GEJ cancers may successfully be treated with the abdominal total gastrectomy, without mediastinal lymph node dissection in the Korean population.

Prevalence, severity, and evolution of postsurgical anemia after gastrectomy, and clinicopathological factors affecting its recovery.

PURPOSE: Postsurgical anemia is one of the common unpleasant postoperative sequels during the early postoperative period after gastrectomy, for which no standard care has been established. To facilitate proper management, we investigated the clinical features of postsurgical anemia and sought to identify the factors affecting its subsequent recovery. METHODS: A retrospective review of 406 consecutive gastric cancer patients who underwent gastrectomy without systemic chemotherapy between August 2008 and September 2009. Clinical courses of postsurgical anemia were monitored at 3, 6, and 12 months post-surgery. Clinicopathological factors affecting recovery of postsurgical anemia were analyzed using a multivariate logistic regression model. RESULTS: The study subjects consisted of 265 males and 141 females (mean age, 61.8 years). After operation, 318 (78.3%) presented with postsurgical anemia, and 217 (66.7%) and 47 (11.6%) had mild or moderate anemia, respectively, at the time of discharge. During the follow-up, 173 (54.4%) of the 318 with postsurgical anemia showed a spontaneous recovery at 3 months post-surgery, but no significant changes were observed in postsurgical anemia at 6 or 12 months post-surgery. Univariate and multivariate analysis revealed that old age (≥60 years), preoperative anemia, anemia severity (moderate anemia), and total gastrectomy were independent factors that adversely affect the spontaneous recovery of post-surgical anemia after gastrectomy. CONCLUSION: Proper intervention may be required for postsurgical anemia that does not achieve a spontaneous recovery until postoperative 3 months. However, proper management, such as the use of iron or the best route for iron supplementation, needs to be evaluated in future clinical trials.

Feasibility study of early oral intake after gastrectomy for gastric carcinoma.

PURPOSE: Despite the compelling scientific and clinical data supporting the use of early oral nutrition after major gastrointestinal surgery, traditional bowel rest and intravenous nutrition for several postoperative days is still being used widely after gastric cancer surgery. MATERIALS AND METHODS: A phase II study was carried out to evaluate the feasibility and safety of postoperative early oral intake (water intake on postoperative days (POD) 1-2, and soft diet on POD 3) after a gastrectomy. The primary outcome was morbidity within 30 postoperative days, which was targeted at <25% based on pilot study data. RESULTS: The study subjects were 90 males and 42 females with a mean age 61.5 years. One hundred and four (79%) and 28 (21%) patients underwent a distal and total gastrectomy, respectively. The postoperative morbidity rate was within the targeted range (15.2%, 95% CI, 10.0~22.3%), and there was no hospital mortality. Of the 132 patients, 117 (89%) successfully completed a postoperative early oral intake regimen without deviation; deviation in 10 (8%) due to gastrointestinal symptoms and in five (4%) due to the management of postoperative complications. The mean times to water intake and a soft diet were 1.0±0.2 and 3.2±0.7 days, respectively, and the mean hospital stay was 10.0±6.1 days. CONCLUSIONS: Postoperative early oral intake after a gastrectomy is feasible and safe, and can be adopted as a standard perioperative care after a gastrectomy. Nevertheless, further clinical trials will be needed to evaluate the benefits of early oral nutrition after upper gastrointestinal surgery.

Accuracy of macroscopic intraoperative diagnosis of serosal invasion and risk of over- and underestimation in gastric carcinoma.

BACKGROUND: Accurate intraoperative diagnosis of serosal invasion is a prerequisite for proper application of invasive procedures, such as intraperitoneal chemohyperthermia, for serosa positive gastric carcinomas. METHODS: We reviewed the prospectively constructed data of 1,265 gastric cancer patients who underwent surgery between 2007 and 2009. Accuracies of macroscopic diagnoses of serosal invasion were determined by comparing with pathological findings. The risk factors of over- and underestimation of serosal invasion were analyzed in the univariate and multivariate model. RESULTS: The accuracy of macroscopic intraoperative diagnosis of serosal invasion was 88%. Serosal invasion was underestimated in 34 of 187 serosa positive patients and overestimated in 117 of 1,078 serosa negative patients; a sensitivity and specificity of 82 and 89%, respectively. When pT1 tumors were excluded, the accuracy, sensitivity, and specificity of macroscopic diagnosis of serosal invasion were 71.5, 81.8, and 65.3%, respectively. Univariate and multivariate analysis revealed that a tumor size of >4 cm and preoperative CT finding of serosa positive were independent risk factors for macroscopic overestimation as serosal invasion in pT2 gastric cancer. Meanwhile, Borrmann type 1, preoperative CT finding of serosa negative, lesser/posterior surface location, and tumor size of <4 cm were independent risk factors for underestimation of serosal invasion in pT3 gastric carcinoma. CONCLUSIONS: The macroscopic diagnosis of serosal invasion is largely consistent with pathological findings. However, great care should be taken with regard to the risk of over- and underestimation of serosal invasion when making a decision for invasive treatments based on macroscopic findings of serosal invasion.

The effect of low molecular weight heparin thromboprophylaxis on bleeding complications after gastric cancer surgery.

BACKGROUND: Low molecular weight heparin (LMWH) has been widely used to prevent venous thromboembolism in cancer surgical patients. However, relatively few studies have examined the safety aspects related to the use of LMWH after abdominal cancer surgery. This study was designed to investigate the relationship between bleeding complications and LMWH thromboprophylaxis after gastric cancer surgery. METHODS: From March to July in 2009, 179 consecutive patients who underwent gastric cancer surgery at our institution were administered LMWH (3200 U once daily from 2 to 6 h before surgery until discharge) perioperatively. A total of 182 patients consecutively treated before the introduction of LMWH prophylaxis were selected as controls. RESULTS: There were 234 men and 127 women (mean age, 60 +/- 12 years). No significant intergroup differences were observed with respect to clinicopathological features and operative procedures. No patient in the LMWH or control group developed symptomatic venous thromboembolism postoperatively. However, the LMWH group had a significantly higher surgical complication rate (27.4 versus 15.4%, P = 0.005). Among the surgical complications, postoperative bleeding and wound complications were significantly higher in the LMWH group, whereas other complications were similar in the two study groups. Multivariate analysis showed that LMWH administration was an independent risk factor (odds ratio, 2.83; 95% confidence interval, 1.28-6.23, P = 0.009) of postoperative bleeding. CONCLUSIONS: LMWH thromboprophylaxis was found to increase significantly the risk of bleeding complications after gastric cancer surgery. Optimal LMWH prophylaxis regimens, including the dosage and timing of treatment commencement, for gastric cancer surgery should be determined in further clinical trials.

Accuracy of surgical diagnosis in detecting early gastric cancer and lymph node metastasis and its role in determining limited surgery.

BACKGROUND: The aim of this study was to evaluate the accuracy of surgical diagnosis of early gastric cancer (EGC) and lymph node metastasis, and elucidate its role in determining limited surgery for EGC. STUDY DESIGN: We reviewed 369 patients undergoing gastrectomy for primary gastric carcinoma. Surgical diagnosis was evaluated by determining its sensitivity, specificity, and accuracy, and was compared with preoperative examinations. RESULTS: Sensitivity, specificity, and accuracy of intraoperative diagnosis for EGC were 74.5%, 95.7%, and 83.7%, respectively. The predictive value for EGC by intraoperative diagnosis was 95.7%. Surgical diagnosis of EGC showed higher specificity and predictive value than preoperative examinations did, which significantly reduced the risk of underestimating advanced gastric cancer (AGC) to EGC. The sensitivity, specificity, and accuracy for lymph node metastasis by surgical diagnosis were 73.2%, 78.1%, and 76.4%, respectively. In 70 patients with a discrepancy in the diagnosis of EGC between pre- and intraoperative diagnoses, surgical diagnosis was correct in 63 (90%) patients, but preoperative examination was correct in only 7 (10%) patients. CONCLUSIONS: Surgical diagnosis shows better accuracy than preoperative examinations do in detecting EGC and lymph node metastasis. Our results suggest that the decision to perform limited surgery based on surgical diagnosis might reduce the risk of undertreatment of AGC to EGC better than preoperative examinations.

Modified radical lymphadenectomy without splenectomy in patients with proximal gastric cancer: comparison with standard D2 lymphadenectomy for distal gastric cancer.

BACKGROUND AND OBJECTIVES: We assessed the optimal extent of lymph node dissection and the effect of splenectomy in patients with proximal gastric cancer. METHOD: Recurrence and survival rates were compared between 881 patients with proximal gastric cancer who underwent modified radical lymphadenectomy and 3,098 patients with distal gastric cancer who underwent standard D2 lymphadenectomy. RESULTS: The recurrence rate was significantly higher in the total than in the distal gastrectomy group (32.5% vs. 16.5%, P < 0.001), but the rates were similar after adjustment for TNM stage. The overall 5-year survival rate was significantly higher in the distal than in the total gastrectomy group (80.4% vs. 66.2%, P < 0.001), but this difference was not observed after adjustment for TNM stage. Multivariate analysis showed that patient age, number of retrieved lymph nodes, depth of invasion, and nodal metastasis were independent prognostic determinants for survival, whereas type of lymphadenectomy was not. CONCLUSION: Long-term outcomes were similar in patients with proximal gastric cancer who underwent modified lymphadenectomy without splenectomy and in patients with distal gastric cancer who underwent standard D2 lymphadenectomy. These findings indicate that modified radical lymphadenectomy without splenectomy is sufficient for optimal lymph node dissection in patients with proximal gastric cancer.