Identifying the best candidates for reduced port gastrectomy Chung, Jae Hun; Hwang, Jawon; Park, Sung Hyun ...
Gastric cancer : official journal of the International Gastric Cancer Association and the Japanese Gastric Cancer Association,
01/2024, Volume:
27, Issue:
1
Journal Article
Peer reviewed
Open access
Background
Previous studies have focused on the non-inferiority of RPG compared with conventional port gastrectomy (CPG); however, we assumed that some candidates might derive more significant ...benefit from RPG over CPG.
Methods
We retrospectively analyzed the clinicopathological and perioperative parameters of 1442 patients with gastric cancer treated by gastrectomy between 2009 and 2022. The C-reactive protein level on postoperative day 3 (CRPD3) was used as a surrogate parameter for surgical trauma. Patients were grouped according to the extent of gastrectomy subtotal gastrectomy (STG) or total gastrectomy (TG) and lymph node dissection (D1+ or D2). The degree of surgical trauma, bowel recovery, and hospital stay between RPG and CPG was compared among those patient groups.
Results
Of 1442 patients, 889, 354, 129, and 70 were grouped as STGD1+, STGD2, TGD1+, and TGD2, respectively. Compared with CPG, RPG significantly decreased CRPD3 only among patients in the STGD1+ group (CPG:
n
= 653, 84.49 mg/L, 95% CI 80.53–88.45 vs. RPG: n = 236, 70.01 mg/L, 95% CI 63.92–76.09,
P
< 0.001). In addition, the RPG method significantly shortens bowel recovery and hospital stay in the STGD1+ (
P
< 0.001 and
P
< 0.001), STGD2 (
P
< 0.001 and
P
< 0.001), and TGD1+ (
P
= 0.026 and
P
= 0.007), respectively. No difference was observed in the TGD2 group (
P
= 0.313 and
P
= 0.740).
Conclusions
The best candidates for RPG are patients who undergo STGD1+, followed by STGD2 and TG D1+, considering the reduction in CRPD3, bowel recovery, and hospital stay.
Rationale: Small bowel diaphragm disease (SBDD) is a rare case, caused by long-term administration of nonsteroidal anti-inflammatory drugs (NSAIDs). The circumferential diaphragm in the lumen of ...small bowel causing mechanical obstruction is the characteristic finding. Patient concerns: A 74-year-old male was transferred to Pusan National University Yangsan Hospital (PNUYH) due to abdominal pain lasting for 2 months. He was treated in the local medical center (LMC) with Levin tube insertion and Nil Per Os (NPO) but showed no improvement. Diagnosis: According to abdomen-pelvis computed tomography (CT) result, small bowel obstruction due to the adhesion band was identified, showing dilatation of the small bowel with abrupt narrowing of the ileum. Interventions: Laparoscopic exploration was done but failed to find an adhesion band. An investigation of the whole small bowel was done with mini-laparotomy. At the transitional zone, the intraluminal air could not pass so the segmental resection of small bowel including the transitional zone and end-to-end anastomosis was done. Outcomes: After surgery, every laboratory finding recovered to the normal range in 4 days, but the patient’s ileus lasted for 8 days. The patient’s symptoms were relieved after defecation, he was discharged on postoperative day 10. Lessons: For patients who show mechanical obstruction without an operation history but with long-term administration of NSAIDs, the clinicians should suspect small bowel diaphragm disease.
Background
With improved short-term surgical outcomes, laparoscopic distal gastrectomy has rapidly gained popularity. However, the safety and feasibility of laparoscopic total gastrectomy (LTG) has ...not yet been proven due to the difficulty of the technique. This single-arm prospective multi-center study was conducted to evaluate the use of LTG for clinical stage I gastric cancer.
Methods
Between October 2012 and January 2014, 170 patients with pathologically proven, clinical stage I gastric adenocarcinoma located at the proximal stomach were enrolled. Twenty-two experienced surgeons from 19 institutions participated in this clinical trial. The primary end point was the incidence of postoperative morbidity and mortality at postoperative 30 days. The severity of postoperative complications was categorized according to Clavien–Dindo classification, and the incidence of postoperative morbidity and mortality was compared with that in a historical control.
Results
Of the enrolled patients, 160 met criteria for inclusion in the full analysis set. Postoperative morbidity and mortality rates reached 20.6% (33/160) and 0.6% (1/160), respectively. Fifteen patients (9.4%) had grade III or higher complications, and three reoperations (1.9%) were performed. The incidence of morbidity after LTG in this trial did not significantly differ from that reported in a previous study for open total gastrectomy (18%).
Conclusions
LTG performed by experienced surgeons showed acceptable postoperative morbidity and mortality for patients with clinical stage I gastric cancer.
Background
This retrospective cohort study compared proximal gastrectomy (PG) with double-tract reconstruction (DTR) versus total gastrectomy (TG) with Roux-en-Y reconstruction in terms of clinical ...outcomes.
Methods
All consecutive patients with upper early gastric cancer (EGC) who underwent PG-DTR or TG in 2008–2016 were selected. TG patients who matched PG-DTR patients in age, sex, body mass index, clinical stage, and ASA score were selected by propensity score matching. Groups were compared in terms of clinicopathological characteristics, clinical outcomes, early (≤ 30 days), late (> 30 days), and severe (Clavien-Dindo grade ≥ III) postoperative complications, 1-year reflux morbidity, recurrence, and mortality.
Results
Of 322 patients, 52 underwent PG-DTR. A matching TG group of 52 patients was selected. The PG-DTR group had smaller tumors (
p
= 0.02), smaller proximal and distal resection margins (
p
= 0.01,
p
< 0.01), and fewer retrieved lymph nodes (
p
< 0.01). PG-DTR associated with shorter times to diet and hospital stay (both
p
= 0.02). Groups did not differ in early (11.3 vs. 19.2%,
p
= 0.19), late (1.9 vs. 5.7%,
p
= 0.31), or severe complication rates (7.7 vs. 13.5%,
p
= 0.34). At 1 year, the groups did not differ in reflux symptoms (Visick score) or endoscopic esophagitis (Los Angeles Classification). There were no recurrences. Five-year overall survival rates were 100 and 81.6% (
p
= 0.02), respectively.
Conclusion
PG-DTR associated with better clinical outcomes and survival. Complication and reflux rates were similar. PG-DTR may be suitable for upper EGC.
Background
Laparoscopic distal gastrectomy for early gastric cancer has been widely accepted, but laparoscopic total gastrectomy has still not gained popularity because of technical difficulty and ...unsolved safety issue. We conducted a single-arm multicenter phase II clinical trial to evaluate the safety and the feasibility of laparoscopic total gastrectomy for clinical stage I proximal gastric cancer in terms of postoperative morbidity and mortality in Korea. The secondary endpoint of this trial was comparison of surgical outcomes among the groups that received different methods of esophagojejunostomy (EJ).
Methods
The 160 patients of the full analysis set group were divided into three groups according to the method of EJ, the extracorporeal circular stapling group (EC;
n
= 45), the intracorporeal circular stapling group (IC;
n
= 64), and the intracorporeal linear stapling group (IL;
n
= 51). The clinicopathologic characteristics and the surgical outcomes were compared among these three groups.
Results
There were no significant differences in the early complication rates among the three groups (26.7% vs. 18.8% vs. 17.6%, EC vs. IC vs. IL;
p
= 0.516). The length of mini-laparotomy incision was significantly longer in the EC group than in the IC or IL group. The anastomosis time was significantly shorter in the EC group than in the IL group. The time to first flatus was significantly shorter in the IL group than in the EC group. The long-term complication rate was not significantly different among the three groups (4.4% vs. 12.7% vs. 7.8%; EC vs. IC vs. IL;
p
= 0.359), however, the long-term incidence of EJ stenosis in IC group (10.9%) was significantly higher than in EC (0%) and IL (2.0%) groups (
p
= 0.020).
Conclusions
The extracorporeal circular stapling and the intracorporeal linear stapling were safe and feasible in laparoscopic total gastrectomy, however, intracorporeal circular stapling increased EJ stenosis.
Background
The goal of this study was to identify the clinical outcomes of uncut Roux-en-Y reconstruction in patients who underwent totally laparoscopic distal gastrectomy (TLDG) over 3-year ...follow-up.
Methods
From January 2016 to December 2017, 269 patients who underwent TLDG were enrolled in the study and analyzed retrospectively. They were classified into two groups according to the reconstruction method: uncut Roux-en-Y reconstruction (uncut RY) (
n
= 154) and Billroth II with Braun anastomosis (B-II/Braun) (
n
= 115). Postoperative endoscopic findings (residual food, bile reflux, gastritis, and esophagitis) and nutritional status (body weight, serum hemoglobin, total protein, and albumin levels) were assessed every 6 months for 3 years.
Results
Residual food was less frequent in the uncut RY group in the 6th month after TLDG (
p
= 0.022), but there were no differences between the two groups for the rest of the study period. The incidence of bile reflux and gastritis was low in the uncut RY group during all postoperative periods (all
p
< 0.001). In the B-II/Braun group, the frequency of reflux esophagitis was high in the 30th and 36th months after TLDG (both
p
< 0.001), and there were no differences between the two groups during the preceding periods. No significant differences were found with respect to nutritional status, such as body weight, serum hemoglobin, total protein, and albumin levels during all postoperative periods.
Conclusions
Three-year follow-up outcomes showed that uncut RY can effectively reduce the incidence of bile reflux and gastritis in the remnant stomach compared to B-II/Braun after TLDG.
Background
Gastric cancer stem cells (GCSCs) have been successfully isolated from patients. However, the molecular mechanisms underlying the self-renewal of GCSCs and their relationship with the ...microenvironment are poorly characterized.
Methods
GCSCs and cancer-associated fibroblasts (CAFs) were cultured directly from gastric cancer patients. The self-renewal of GCSCs was assayed by sphere formation assay and in vivo tumorigenicity. Expression of neuregulin1 (NRG1) was examined by immunohistochemistry, real-time PCR and western blotting.
Results
CAFs increased the self-renewal of GCSCs by secreting NRG1. NRG1 activated NF-κB signaling and this activation regulated GCSC self-renewal. Moreover, NF-κB-active GCSCs were tumorigenic, however NF-κB-inactive GCSCs were not. The overexpression of NRG1 in stromal cells and cancer cells was observed in the tumor tissues of gastric cancer patients and was associated with clinical stage lymph node metastasis and survival in gastric cancer patients. In addition, we also found that NRG1 can regulate the proliferation and invasion of gastric cancer cells.
Conclusions
These results indicate that NRG1, which can be secreted by CAFs or cancer cells, promotes progression of gastric cancer by regulating the self-renewal of GCSCs and its overexpression is associated with a prognosis of gastric cancer.
Cancer stem cells have been hypothesized to drive the growth and metastasis of tumors. Because they need to be targeted for cancer treatment, they have been isolated from many solid cancers. However, ...cancer stem cells from primary human gastric cancer tissues have not been isolated as yet. For the isolation, we used two cell surface markers: the epithelial cell adhesion molecule (EpCAM) and CD44. When analyzed by flow cytometry, the EpCAM
+
/CD44
+
population accounts for 4.5% of tumor cells. EpCAM
+
/CD44
+
gastric cancer cells formed tumors in immunocompromised mice; however, EpCAM
−
/CD44
−
, EpCAM
+
/CD44
−
and EpCAM
−
/CD44
+
cells failed to do so. Xenografts of EpCAM
+
/CD44
+
gastric cancer cells maintained a differentiated phenotype and reproduced the morphological and phenotypical heterogeneity of the original gastric tumor tissues. The tumorigenic subpopulation was serially passaged for several generations without significant phenotypic alterations. Moreover, EpCAM
+
/CD44
+
, but not EpCAM
−
/CD44
−
, EpCAM
+
/CD44
−
or EpCAM
−
/CD44
+
cells grew exponentially in vitro as cancer spheres in serum-free medium, maintaining the tumorigenicity. Interestingly, a single cancer stem cell generated a cancer sphere that contained various differentiated cells, supporting multi-potency and self-renewal of a cancer stem cell. EpCAM
+
/CD44
+
cells had greater resistance to anti-cancer drugs than other subpopulation cells. The above in vivo and in vitro results suggest that cancer stem cells, which are enriched in the EpCAM
+
/CD44
+
subpopulation of gastric cancer cells, provide an ideal model system for cancer stem cell research.
Background
Total laparoscopic distal gastrectomy for early gastric cancer has been widely accepted; however, reduced-port laparoscopic distal gastrectomy has not gained the same popularity because of ...technical difficulties and oncologic safety issues. This study aimed to analyze the oncologic safety and short-term surgical outcomes of patients who underwent reduced-port laparoscopic distal gastrectomy (RpLDG) for gastric cancer.
Methods
Consecutive patients who underwent surgical treatment between January 2016 and May 2018 were included in this study. Of the 833 patients enrolled, 158 underwent RpLDG and were propensity-matched with 158 patients who underwent conventional port laparoscopic distal gastrectomy (CpLDG). The groups were compared in terms of short-term outcomes and disease-free and overall survival rates.
Results
The RpLDG group had shorter operation times (161.8 min vs. 189.0 min,
p
< 0.00) and shorter postoperative hospital stays (7.6 days vs. 9.1 days,
p
= 0.04) compared to the CpLDG group. Estimated blood loss was lower in the RpLDG group than in the CpLDG group (52.6 mL vs. 73.7 mL,
p
< 0.00), while hospital costs incurred by the RpLDG group were lower than those of the CpLDG group (10,033.7 vs. 11,016.8 USD,
p
< 0.00). No statistical differences were found regarding overall morbidity and occurrence of surgical complications of grade III or higher, as defined by the Clavien-Dindo classification. Furthermore, no significant differences between RpLDG and CpLDG were found in 3-year disease-free (99.4% vs. 98.1%;
p
= 0.42) and 3-year overall survival rates (98.7% vs. 96.8%;
p
= 0.25).
Conclusion
Patients who underwent RpLDG had better short-term surgical outcomes than those who underwent CpLDG in terms of operation time, estimated blood loss, duration of hospital stay, and hospital costs. The oncologic safety of RpLDG was satisfactory.
Securing an appropriate proximal resection margin (PRM) is crucial for oncological safety in treating gastric cancer. This study investigated the clinicopathological characteristics of patients with ...incomplete PRM length of <2 cm in early gastric cancer. Clinicopathological data of 1,493 patients who underwent subtotal gastrectomy for early gastric cancer in 2012 to 2021 were retrospectively reviewed. Patients were divided into the PRM length of <2 cm and ≥2 cm groups based on pathological results. Univariate and multivariate analyses evaluated factors for incomplete PRM length. Factors related to patients with a relative PRM positive were also analyzed. The proportion of patients with a PRM length of <2 cm was 17.9% (267/1,493). Multivariate regression analysis revealed that age <50, preoperative endoscopic size of ≥3 cm, size discrepancy of ≥2 cm, and midbody tumor with a lesser curvature significantly contributed to the PRM length of <2 cm. Twenty-four patients had a relative PRM positive (24/1493, 1.6%). An incomplete PRM was the only risk factor for a positive relative PRM. Surgical treatment for early gastric cancer requires an accurate preoperative endoscopic tumor size and location evaluation. A more aggressive resection is recommended for patients with age <50, preoperative endoscopic size of ≥3 cm, size discrepancy of ≥2 cm, and midbody tumor with a lesser curvature.
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