Because of the increased risk of gastric cancer in adults aged over 40 years in China, screening of this high-risk population is important.1 However, the financial burden of doing so would be high, ...because 45·2% of the population of China is aged over 40 years.
Waki et al also reported that skeletal muscle quality, i.e. high IMAC, was significantly associated with poor survival after curative gastrectomy and had the strongest influence among the other ...parameters including muscle quality, i.e. psoas muscle index. 2 To date, the significance of sarcopenia in the clinical setting has been well-recognized by physicians. Recent studies revealed that the loss of skeletal muscle after gastrectomy was associated with poor prognosis, and the most reduction was observed after total gastrectomy as compared to the other procedures in which a part of the stomach can be preserved. 5 Therefore, total gastrectomy should be avoided, especially for elderly patients, to prevent the post-gastrectomy sarcopenia as far as the oncological margin is guaranteed. Changes of operative procedures of gastric cancer at the University of Tokyo Hospital DISCLOSURE Conflict of Interest: The author declares no conflicts of interest for this article.
Obesity as a surgical risk factor Ri, Motonari; Aikou, Susumu; Seto, Yasuyuki
Annals of gastroenterological surgery,
January 2018, Volume:
2, Issue:
1
Journal Article
Peer reviewed
Open access
In recent years, both the actual number of overweight/obese individuals and their proportion of the population have steadily been rising worldwide and obesity‐related diseases have become major ...health concerns. In addition, as obesity is associated with an increased incidence of gastroenterological cancer, the number of obese patients has also been increasing in the field of gastroenterological surgery. While the influence of obesity on gastroenterological surgery has been widely studied, very few reports have focused on individual organs or surgical procedures, using a cross‐sectional study design. In the present review, we aimed to summarize the impacts of obesity on surgeries for the esophagus, stomach, colorectum, liver and pancreas. In general, obesity prolongs operative time. As to short‐term postoperative outcomes, obesity might be a risk for certain complications, depending on the procedure carried out. In contrast, it is possible that obesity doesn't adversely impact long‐term surgical outcomes. The influences of obesity on surgery are made even more complex by various categories of operative outcomes, surgical procedures, and differences in obesity among races. Therefore, it is important to appropriately evaluate perioperative risk factors, including obesity.
The influences of obesity on gastroenterological surgeries were summarized. In general, obesity prolongs operative time. Obesity might be a risk for certain complications. However, obesity may not adversely impact long‐term surgical outcomes.
Key papers to treatment of esophageal cancer surgery and reduction of postoperative complications after esophagectomy published between 2018 and 2019 were reviewed. Within this review there was a ...focus on minimally invasive esophagectomy (MIE), robot‐assisted MIE (RAMIE), and centralization to high‐volume center. Advantages of MIE, irrespectively of hybrid or total MIE, to prevent postoperative complications, especially pneumonia, were shown in comparison to open procedure. However, whether total MIE has evident effects or not, as compared to hybrid MIEs, still remains unclear. Differences between RAMIE and MIE were reported to be marginal, though the advantage of lymphadenectomy, especially along recurrent laryngeal nerve, has been suggested. Centralization to high‐volume center evidently benefits esophageal cancer patients by improving short‐term outcomes. The definition of high‐volume center has not been established yet, though institutional structure and quality are thought to be important. Transmediastinal esophagectomy, currently developed, has a potential to be one radical option of MIE for esophageal cancer.
The key papers to treatment of esophageal cancer surgery and reduction of the postoperative complications published worldwide in the period between 2018 and 2019 were reviewed.
Cancer cells use PD-L1 to evade antitumor immunity through interaction with programmed cell death protein 1 (PD-1) on T cells. Recent whole-genome sequence studies revealed frequent gene ...amplification of PD-L1 in Epstein-Barr virus-associated gastric cancer (EBVaGC). To investigate the significance of PD-L1 in cancer cells and their microenvironment in EBVaGC, we studied PD-L1 expression by analysis of the public database and immunohistochemistry with fluorescent in situ hybridization (FISH) of the PD-L1 gene. Analysis of the database from The Cancer Genome Atlas also disclosed high expression of PD-L1 in EBVaGC compared with other molecular subtypes of GC. Expression of PD-L1 was frequently detected in cancer cells of EBVaGC (33/96; 34%), with infiltration of PD-L1
immune cells in its stroma (43/96; 45%). Both expression of PD-L1 in cancer cells and PD-L1
immune cell infiltration in EBVaGC were significantly correlated with diffuse histology according to Lauren's classification and tumor invasion (pT1b or more). As a prognostic indicator, PD-L1 expression in cancer cells correlated with poor outcomes in both overall survival and disease-specific survival (P=0.0498, 0.007). PD-L1-positive cancers had dense infiltration of PD-L1
immune cells as well as CD8
and PD-1
cells in EBVaGC. FISH analysis of representative samples of the tumor demonstrated gene amplification of PD-L1 in 11% of cases. PD-L1-amplified cells corresponded to PD-L1-positive cells showing high-intensity immunohistochemical staining among cancer cells showing weak or moderate intensities. Taken together, PD-L1 expression in cancer cells and their microenvironment may contribute to the progression of EBVaGC, and gene amplification occurs as clonal evolution during progression. This specific subtype of GC infected with EBV is potentially a good candidate for immunotherapy targeting of the PD-L1/PD-1 axis.
Purpose
This study aimed to compare short-term outcomes of minimally invasive esophagectomy (MIE) with those of open esophagectomy (OE) for thoracic esophageal cancer using a nationwide Japanese ...database.
Methods
Overall, 9584 patients with thoracic esophageal cancer who underwent esophagectomy at 864 hospitals in 2011–2012 were evaluated. We performed one-to-one matching between the MIE and OE groups on the basis of estimated propensity scores for each patient.
Results
After propensity score matching, operative time was significantly longer in the MIE group (
n
= 3515) than in the OE group (
n
= 3515) 526 ± 149 vs. 461 ± 156 min,
p
< 0.001, whereas blood loss was markedly less in the MIE group than in the OE group (442 ± 612l vs. 608 ± 591 ml,
p
< 0.001). The populations of patients who required more than 48 h of postoperative respiratory ventilation was significantly less in the MIE group than in the OE group (8.9 vs. 10.9%,
p
= 0.006); however, reoperation rate within 30 days was significantly higher in the MIE group than in the OE group (7.0 vs. 5.3%,
p
= 0.004). There were no significant differences between the MIE and OE groups in 30-day mortality rates (0.9 vs. 1.1%) and operative mortality rates (2.5 vs. 2.8%, respectively).
Conclusions
MIE was comparable with conventional OE in terms of short-term outcome after esophagectomy. It was particularly beneficial in reducing postoperative respiratory complications, but may be associated with higher reoperation rates.
...the estimated coverages of NCD were reported to be 90%‐95% by comparison with regional government report data and medical charts, and the audit works verified the NCD's data and found high ...accuracy of data entry. Konno et al. demonstrated that the board‐certificated surgeons contribute to favorable outcomes of gastroenterological surgery in Japan and the number of board‐certificated surgeons per hospital is a surrogate marker of operative mortality, while some papers based on NCD have recently reported the importance of the hospital volume to reduce mortality in esophagectomy, distal gastrectomy, hepatectomy, and pancreaticoduodenectomy. Number of institutions performing the procedure (2011‐2017) Procedure 2011 2012 2013 2014 2015 2016 2017 Esophagectomy 683 741 731 723 695 675 656 Distal gastrectomy 1713 1907 1921 1899 1922 1879 1877 Total gastrectomy 1563 1750 1717 1717 1734 1699 1668 Right hemicolectomy 1644 1839 1848 1841 1885 1888 1855 Low anterior resection 1588 1786 1775 1784 1810 1800 1770 Hepatectomy 963 1055 1053 1032 1040 1030 1017 Pancreaticoduodenectomy 1126 1184 1209 1207 1199 1181 1162 Acute diffuse peritonitis surgery 1223 1385 1385 1432 1473 1448 1449 ACKNOWLEDGEMENTS The data of Table 2 were prepared by Arata Takahashi, Department of Health Policy and Management, Keio University, and Hiraku Kumamaru, Department of Healthcare Quality Assessment, The University of Tokyo.
We aimed to elucidate whether minimally invasive esophagectomy (MIE) can be safely performed by reviewing the Japanese National Clinical Database.
MIE is being increasingly adopted, even for advanced ...esophageal cancer that requires various preoperative treatments. However, the superiority of MIE's short-term outcomes compared with those of open esophagectomy (OE) has not been definitively established in general clinical practice.
This study included 24,233 esophagectomies for esophageal cancer conducted between 2012 and 2016. Esophagectomy for clinical T4 and M1 stages, urgent esophagectomy, 2-stage esophagectomy, and R2 resection were excluded. The effects of preoperative treatment and surgery on short-term outcomes were analyzed using generalized estimating equations logistic regression analysis.
MIE was superior or equivalent to OE in terms of the incidence of most postoperative morbidities and surgery-related mortality, regardless of the type of preoperative treatment. Notably, MIE performed with no preoperative treatment was associated with significantly less incidence of any pulmonary morbidities, prolonged ventilation ≥48 hours, unplanned intubation, surgical site infection, and sepsis. However, reoperation within 30 days in patients with no preoperative treatment was frequently observed after MIE. The total surgery-related mortality rates of MIE and OE were 1.7% and 2.4%, respectively (P < 0.001). Increasing age, low preoperative activities of daily living, American Society of Anesthesiologists physical status ≥3, diabetes mellitus requiring insulin use, chronic obstructive pulmonary disease, congestive heart failure, creatinine ≥1.2 mg/dL, and lower hospital case volume were identified as independent risk factors for surgery-related mortality.
The results suggest that MIE can replace OE in various situations from the perspective of short-term outcome.
Background
This study aims to elucidate whether increasing the number of examined lymph nodes (NELN) is mandatory for the accurate prognosis of node-negative gastric cancer (GC) patients after ...curative gastrectomy in Eastern countries (China and Japan).
Methods
The clinicopathological data of 2455 GC patients (including 1137 node-negative cases) were included to demonstrate whether a minimum NELN is inevitable for guaranteeing the accurate prognosis of node-negative GC patients after curative gastrectomy.
Results
Survival analyses revealed that the NELN significantly positively correlated with overall survival (
p
< 0.001) and was an independent prognostic predictor (hazard ratio 0.447;
p
= 0.025) of 1137 node-negative GC patients. Stratum analysis within the Kaplan–Meier method showed that sex, tumor size, and extent of lymphadenectomy did not affect the NELN in predicting the prognosis of all node-negative GC patients. Stage migration was mainly detected in the subgroup of node-negative GC Chinese patients who presented considerably lower mean NELN and more advanced staging than patients from Japan. The NELN was identified as the most intensively independent predictor of prognosis of 600 node-negative GC patients from China, with the smallest Akaike information criterion (176.964) and Bayesian information criterion values (194.552). These findings indicate that increasing the NELN is a prerequisite to guaranteeing precise TNM classification.
Conclusions
The NELN should be considered a mandatory requirement for improving the accuracy of prognostic evaluation of GC patients, especially for advanced-stage patients.
Background
The morbidity rate after pancreaticoduodenectomy remains high. The objectives of this retrospective cohort study were to clarify the risk factors associated with serious morbidity ...(Clavien–Dindo classification grades IV–V), and create complication risk calculators using the Japanese National Clinical Database.
Methods
Between 2011 and 2012, data from 17,564 patients who underwent pancreaticoduodenectomy at 1,311 institutions in Japan were recorded in this database. The morbidity rate and associated risk factors were analyzed.
Results
The overall and serious morbidity rates were 41.6% and 4.5%, respectively. A pancreatic fistula (PF) with an International Study Group of Pancreatic Fistula (ISGPF) grade C was significantly associated with serious morbidity (P < 0.001). Twenty‐one variables were considered statistically significant predictors of serious complications, and 15 of them overlapped with those of a PF with ISGPF grade C. The predictors included age, sex, obesity, functional status, smoking status, the presence of a comorbidity, non‐pancreatic cancer, combined vascular resection, and several abnormal laboratory results. C‐indices of the risk models for serious morbidity and grade C PF were 0.708 and 0.700, respectively.
Conclusions
Preventing a PF grade C is important for decreasing the serious morbidity rate and these risk calculations contribute to adequate patient selection.
HighlightAoki and colleagues clarified the risk factors associated with serious morbidity (Clavien‐Dindo classification grades IV–V) and created risk calculators using a Japanese nationwide database of 17,564 patients after pancreaticoduodenectomy. Preventing pancreatic fistula grade C is important for reducing serious morbidity and these risk calculations contribute to more appropriate patient selection.
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