Trends in vitamin D level and risk of vitamin D deficiency after gastrectomy for gastric cancer: A retrospective study of a single high-volume center experience.

BACKGROUND & AIMS: Post-gastrectomy vitamin D deficiency can result in osteoporosis and fractures, which can decrease patient quality of life and increase their socioeconomic burden. However, because there is no consensus around preoperative measurement and regular postoperative monitoring of serum vitamin D [25(OH)vitD] level for gastric cancer patients, we performed a retrospective study with a single high-volume center experience. METHODS: We reviewed a database of 614 gastric cancer patients who underwent curative gastrectomy between December 2015 and December 2019. Multivariate analyses were performed to identify risk factors for 25(OH)vitD deficiency after one year postoperative (n = 546). A linear mixed model was used to evaluate changes between preoperative (n = 585) and postoperative (6 [n = 504] and 12 months [n = 572]) 25(OH)vitD values. RESULTS: Preoperative 25(OH)vitD deficiency occurred in 67.7% of patients with gastric cancer. Patients who underwent postoperative chemotherapy for advanced pathologic disease were more likely to be 25(OH)vitD deficient at postoperative year one than those who did not receive chemotherapy (P = 0.005). Postoperative chemotherapy was an independent risk factor along with preoperative 25(OH)vitD level for one year postoperative 25(OH)vitD deficiency (P = 0.002). Meanwhile, there was significant change in 25(OH)vitD level after surgery according to reconstruction (increased in Billroth I group compared to gastrojejunostomy group, P = 0.016), pathologic stage (increased in stage I group, decreased in stage II and III group, P = 0.005), postoperative chemotherapy (increased in non-chemotherapy group, decreased in chemotherapy group, P = 0.001), and season of surgery (increased when the blood tests were performed at summer, decreased when tested in non-summer season, P = 0.009). CONCLUSION: More than half of gastric cancer patients had preoperative 25(OH)vitD deficiency, and those who had postoperative chemotherapy were at risk for 25(OH)vitD deficiency one year after surgery. There was a significant change in 25(OH)vitD level after surgery according to reconstruction method and postoperative chemotherapy. Preoperative measurement and regular postoperative monitoring should be considered for high-risk patients.

Comparison of Open and Laparoscopic Gastrectomy in Elderly Patients.

PURPOSE: The purpose of this study was to estimate surgical outcomes of elderly patients older than 80 years who received laparoscopic or open gastrectomy for gastric cancer and to identify risk factors for postoperative complications. METHODS: Two hundred forty-two elderly patients older than 80 years underwent gastric cancer surgery between January 2010 and December 2016 in three tertiary hospitals. They were divided into two groups: laparoscopic gastrectomy (N = 59) and open gastrectomy (N = 183). The surgical outcomes and risk factors for postoperative complication were evaluated. RESULTS: Among the elderly patients, 24.4% showed an ASA score of 3 or 4, and 20.7% showed a Charlson comorbidity index (CCI) score of 2 or more. 46.3% of patients had hypertension and 15.3% had diabetes. The laparoscopic gastrectomy group showed similar operation time, less intraoperative blood loss, and faster postoperative gastrointestinal recovery compared to the open gastrectomy group. The incidence of postoperative complications was 30.1% in the open group and 22.0% in the laparoscopic group (P = 0.249). One patient died for pulmonary complication in the open gastrectomy group. In multivariate analysis, older age, male, higher CCI score, and open approach were found to be correlated with increased risk for postoperative complications. CONCLUSIONS: Although elderly patients over 80 years had a high incidence of comorbidity, gastric cancer surgery can be safely performed. The laparoscopic approach might be feasible for open surgery in improving quality of life in these patients, given a faster postoperative intestinal recovery period, with similar risk for postoperative complications.

A Randomized Controlled Trial of Vagus Nerve-preserving Distal Gastrectomy Versus Conventional Distal Gastrectomy for Postoperative Quality of Life in Early Stage Gastric Cancer Patients.

OBJECTIVE: To compare the postoperative quality of life of vagus nerve preserving distal gastrectomy (VPG) vs conventional distal gastrectomy (CG) in patients with early-stage gastric cancer. DESIGN: Randomized controlled clinical trial. SETTING: Large tertiary comprehensive cancer center in Korea. PARTICIPANTS: One hundred sixty-three patients with early gastric cancer 18 years of age or older expected to undergo curative gastric resection. INTERVENTION: Patients were randomized 1:1 to VPG (n = 85) or CG (n = 78). MAIN OUTCOME MEASURES: European Organization for Research and Treatment of Cancer (EORTC) gastric module (STO22). RESULTS: Patients assigned to VPG showed less diarrhea 3 and 12 months after surgery (P = 0.040 and 0.048, respectively) and less appetite loss at 12 months (P = 0.011) compared with those assigned to CG. In both groups, fatigue, anxiety, eating restriction, and body image deteriorated at 3 months after surgery and did not regain baseline levels 12 months after surgery. There were no significant differences between the 2 groups in cancer recurrence and death over 5 years of follow-up. CONCLUSIONS: Early gastric cancer patients undergoing VPG reported significantly less diarrhea and appetite loss at 12 months postsurgery compared with those undergoing CG, with no differences in long-term clinical outcomes. VPG may improve the quality of life after gastrectomy in early gastric cancer patients compared with CG.

Improvement of the Light Extraction Efficiency of InGaN/GaN Blue Light Emitting Diodes Using ZnO Nanostructures.

Herein, we report the effects of geometric morphology of ZnO nanostructures on the extraction efficiency of GaN-based light emitting diodes (LEDs). We performed numerical analysis based on the two-dimensional (2D) finite difference of time domain (FDTD) method that was utilized to calculate the light extraction efficiency of the LEDs. We found that the extraction efficiency of the LED increased upon changing the shape of ZnO nanostructure from nanorods to pencil-likenanorods. The current-voltage characteristics of the LED with ZnO nanorods or pencil-like nanorods were similar to those of the LED that did not contain any ZnO nanostructures. The light output power of the LEDs containing ZnO nanorods or pencil-like nanorods at 100 mA increased additionally to 28% and 39%, respectively, relative to that of the LED that did not contain any ZnO nanostructures. These results confirm that the geometric morphology of the ZnO nanostructure plays an important role in improving the extraction efficiency of the LEDs.

Effect of triclosan-coated sutures on surgical site infection after gastric cancer surgery via midline laparotomy.

PURPOSE: Surgical site infection (SSI) after open abdominal surgery is still a frequently reported nosocomial infection. To reduce the incidence of SSI, triclosan-coated sutures with antiseptic activity (Vicryl Plus) were developed. The aim of this study was to analyze the effect of Vicryl Plus on SSI after gastric cancer surgery via midline laparotomy. METHODS: A total of 916 patients who underwent gastric cancer surgery at Samsung Medical Center between December 2009 and September 2011 were prospectively collected. We examined the occurrence of SSI (primary endpoint), assessments of wound healing (secondary endpoint). They were evaluated postoperatively on days 3, 7, and 30. RESULTS: Of the 916 patients, 122 were excluded postoperatively by screening (out of the study protocol, adverse events, etc.). The remaining 794 patients were enrolled and monitored postoperatively. The cumulative SSI incidence was 11 cases (1.39%; 95% confidence interval [CI], 0.77-2.50) on day 30. Seromas were most frequently detected in wound healing assessments, with a cumulative incidence of 147 cases (18.51%; 95% CI, 15.98-21.39) on day 30. CONCLUSION: The use of triclosan-coated sutures (Vicryl Plus) for abdominal wall closure can reduce the number of SSIs in gastric cancer surgery.

Ultrasonically activated shears versus electrocautery in open gastrectomy for gastric cancer: a randomized controlled trial.

BACKGROUND: Use of ultrasonically activated shears (UAS) is gaining popularity in open surgery but without concrete evidence. We conducted a prospectively randomized study to assess the efficacy of ultrasonic dissection in open gastrectomy for gastric cancer. METHODS: Patients with gastric cancer who were to undergo gastrectomy with D2 lymph node dissection were enrolled and assigned to either the conventional surgery group (n = 125) or the UAS group (n = 128). RESULTS: The mean operating time was significantly reduced in the UAS group (89.3 ± 15.6 min) when compared to the conventional group (97.8 ± 17.2 min; p < 0.001). However, we did not find any significant difference in operative blood loss, the amount of postoperative abdominal drainage, or the rate of postoperative complications between the groups. A multivariate analysis for operating time revealed that the use of UAS, female gender and BMI less than 25 were significantly associated with reduced operating time. The operating time was significantly longer in the conventional group than in the UAS group (B 7.786; 95 % CI 4.103-11.468; p < 0.001). In the subgroup analysis, the use of UAS significantly reduced the operating time, especially in male patients, regardless of the BMI status. CONCLUSIONS: The use of UAS in gastrectomy for gastric cancer was a safe and efficient method, especially in terms of reducing operating time for male patients.

The predictors and clinical impact of positive resection margins on frozen section in gastric cancer surgery.

PURPOSE: The aim of this study is to compare the characteristics of tumor and prognosis, depending on the status of resection margin involvement, on the frozen section diagnosis in gastric cancer. MATERIALS AND METHODS: This study was conducted retrospectively, in 83 margin-positive patients on the frozen section diagnosis, who underwent gastrectomy from July 1995 to September 2006. The control group was selected by matching the age, gender, TNM stage and status of adjuvant chemoradiotherapy, among those who had shown clear resection margins. The characteristics of tumor and patient survival are investigated, and they were analyzed between the two groups. RESULTS: The tumor size was significantly larger in the study group than that of the control group (P=0.037). There was significant difference between the two groups in location of the tumors (P=0.003). Multivariate analysis indicated that only the location and Lauren's classification are independent factors, which affected the resection margin involvement. Median survival was 41.0±11.5 months in the study group and 93.0±30.3 months in the control group (P=0.049). In the survival analysis, it was investigated that TNM stage and the resection margin involvement of the frozen section diagnosis were the critical variables. CONCLUSIONS: When the tumor is located at the middle or the upper third, or the Lauren's indeterminate type, they are highly likely to show the resection margin involvement on the frozen section diagnosis, and it can, therefore, have negative effects on the prognosis. It is considered as good to perform more extensive resection as possible, during the initial resection.

Circular stapler size and risk of anastomotic complications in gastroduodenostomy for gastric cancer.

BACKGROUND: A Billroth I reconstruction with a mechanically sutured anastomosis is commonly performed in gastric cancer patients. Some surgeons prefer to use large circular staplers during suturing to minimize risks for anastomotic stricture and gastric stasis after surgery. The effect of stapler size on anastomotic complications has not been validated. METHODS: This study was conducted with 1,031 patients who underwent gastrectomy and Billroth I reconstruction at Samsung Medical Center in Seoul, Korea, between January 2007 and October 2008. Patients were assigned to group A (384 patients) or group B (647 patients) depending on the size of the circular stapler that the surgeon selected for mechanical anastomosis. A 25 mm circular stapler was used for patients in group A, and a 28 or 29 mm circular stapler was used for patients in group B. Postoperative complications were analyzed retrospectively. RESULTS: The incidence of complications (e.g., gastric stasis, anastomotic stricture, and bleeding) did not differ significantly between groups. Age greater than 60 years was the only significant risk factor for anastomotic complications identified in univariate and multivariate analyses. CONCLUSIONS: Stapler size was unrelated to complications, such as stricture and gastric stasis. Age was the only significant risk factor for anastomotic complications after gastroduodenostomy.

Nutritional risk index as a predictor of postoperative wound complications after gastrectomy.

AIM: To investigate the correlation between the nutritional risk index (NRI) and postoperative wound complications. METHODS: From January 2008 through June 2008, 669 patients who underwent curative gastrectomy for gastric cancer were included in a retrospective study. Medical records of consecutive patients were collected and analyzed to determine postoperative wound complication rates. The NRI was assessed on the fifth postoperative day and other possible risk factors for the incidence of wound complications were analyzed to identify the factors affecting postoperative wound complications. Patients with other postoperative complications were excluded from the study. RESULTS: On the 5th postoperative day, the NRI sh-owed a malnutrition rate of 84.6% among postoperative patients. However, postoperative wound complications occurred in only 66/669 (9.86%) patients. Of the patients with wound complications, 62/66 (94%) belonged to the malnourished group (NRI < 97.5), and 4/66 (6%) patients to the non-malnourished group (NRI ≥ 97.5). The only factor correlated with wound complications was the NRI on the 5th postoperative day (odds ratio of NRI ≥ 97.5 vs NRI < 97.5: 0.653; 95% confidence interval: 0.326-0.974; P = 0.014) according to univariate analysis as well as multivariate analysis. CONCLUSION: This study suggests that malnutrition immediately after surgery may play a significant role in the development of wound complications.

Long-term results and prognostic factors of gastric cancer patients with only positive peritoneal lavage cytology.

BACKGROUND AND OBJECTIVES: The purpose of the present study was to investigate clinicopathologic features of gastric cancer patients with only positive peritoneal cytology in the absence of overt peritoneal metastases, and which might distinguish patients with poorer prognosis. METHODS: Between September 1994 and August 2006, clinicopathological features were retrospectively evaluated in 37 consecutive patients with gastric cancer who underwent a curative resection and had positive peritoneal cytology in the absence of overt peritoneal metastases. Survival including disease-free survival (DFS) and overall survival (OS), and recurrence patterns were analyzed according to clinicopathologic characteristics. RESULTS: The median follow-up period was 16.1 months (range, 3-45 months). The median DFS and OS of patients after curative resection were 10 months (range, 1-33 months) and 15 months (range, 2-45 months), respectively. All patients had recurred, in 34 (92%) with peritoneal dissemination. The overall 1-, 2-, 3-, and 5-year survival rates for the 37 consecutive patients were 43.2%, 45.9%, 5.4%, and 0%, respectively. Multiple linear regression analysis revealed that Borrmann type IV was an independent predictor for poorer prognosis. CONCLUSIONS: A Borrmann type IV carcinoma may be the candidates for intraperitoneal chemotherapy among advanced gastric cancer patients.

Validation of seventh edition AJCC gastric cancer staging modifications.

BACKGROUND AND OBJECTIVES: The seventh edition of the AJCC has more detailed staging categories for gastric cancer than does the sixth edition. The aim of our study was to compare the prognostic accuracies of the sixth and seventh AJCC editions for gastric cancer patients. METHODS: We analyzed survival rates by category using the sixth and seventh editions of the AJCC in 10,060 patients with gastric cancer who had undergone gastrectomy between 1994 and 2007 at Samsung Medical Center. RESULTS: Significant differences in prognosis were seen when comparing the new stages of the seventh edition of the AJCC that are subgroups of stages IB, II, IIIA, and IV in the sixth edition. In particular, stage IV of the AJCC sixth edition is divided into stages IIB, IIIA, IIIB, IIIC and IV in the seventh edition, and the 5-year survival rates of these respective stages were 80.2%, 45.3%, 23.5%, 17.2%, and 10.1% (P < 0.001). CONCLUSIONS: Each category of the AJCC sixth edition has been divided into multiple stages in the AJCC seventh edition, each with a different prognosis. The newly divided subgroups from AJCC sixth edition stage IV showed more accurate outcome classification based on AJCC seventh edition staging stratification.

Impact of body mass index on surgical outcomes in radical total gastrectomy.

BACKGROUND/AIMS: In this study, the authors evaluated the impact of body mass index (BMI) on surgical outcomes in patients undergoing total gastrectomy for upper third early gastric cancer. METHODOLOGY: Sixty-one consecutive patients with upper third early gastric cancer that underwent radical total gastrectomy from May 2009 to December 2009 were included in this prospective cohort study. Patients were stratified by BMI (in accordance with the WHO guidelines) into a normal group (18.5-24.9kg/m2), and an overweight group (≥25.0kg/m2). These two groups were compared with respect to stomach specimen weight (g), operative time (min), number of lymph nodes harvested, length of postoperative hospital stay (day), and postoperative complication rate (%). RESULTS: Thirty-seven (61%) patients had a normal weight and 24 (39%) were overweight. According to multivariate analysis, the only factor correlated with BMI was the weight of stomach extirpated en bloc with omentum, and the weight of stomach extirpated en bloc with omentum was also significantly correlated with operative time. However, BMI was not found to be significantly correlated with postoperative complications. CONCLUSIONS: This study suggested that an elevated BMI was significantly associated with increased weight of stomach extirpated en bloc with omentum, which was found to elongate operative times.

Adenocarcinoma derived from gastric hamartomatous polyps.

Most hamartomatous polyps in the stomach occur in patients with adenomatous polyposis coli and dysplasia. The authors report a case of a 57-year-old man without prior history of polyposis coli who presented with adenocarcinomas derived from hamartomatous polyps in the stomach. The patient underwent a radical subtotal gastrectomy with Billroth I anastomosis. Pathology revealed adenocarcinomas with moderate differentiation without evidence of lymph node metastasis in 60 nodes. We report a case of gastric cancers arising from de novo gastric hamartomatous polyps.

Early gastric cancer arising from heterotopic gastric mucosa in the gastric submucosa.

The incidence of heterotopic gastric mucosa located in the submucosa in resected stomach specimens has been reported to be 3.0 to 20.1%. Heterotopic gastric mucosa is thought to be a benign disease, which rarely becomes malignant. Heterotopic gastric mucosa exists in the gastric submucosa, and gastric cancer rarely occurs in heterotopic gastric mucosa. Since tumors are located in the normal submucosa, they appear as submucosal tumors during endoscopy, and are diagnosed through endoscopic biopsies with some difficulty. For such reasons, heterotopic gastric mucosa is mistaken as gastric submucosal tumor. Recently, two cases of early gastric cancer arising from heterotopic gastric mucosa in the gastric submucosa were treated. Both cases were diagnosed as submucosal tumors based on upper gastrointestinal endoscopy, endoscopic ultrasound, and computed tomography findings, and in both cases, laparoscopic wedge resections were performed, the surgical findings of which also suggested submucosal tumors. However, pathologic assessment of the surgical specimens led to the diagnosis of well-differentiated intramucosal adenocarcinoma arising from heterotopic gastric mucosa in the gastric submucosa.

The relationships between perioperative CEA, CA 19-9, and CA 72-4 and recurrence in gastric cancer patients after curative radical gastrectomy.

BACKGROUND AND OBJECTIVES: The correlation between perioperative CEA, CA 19-9, and CA 72-4 and recurrence of gastric cancer has not been clarified. The aim of this study was to investigate the relationships between perioperative CEA, CA 19-9, and CA 72-4 and recurrence of gastric cancer. METHODS: We retrospectively analyzed the relationships between the tumor markers CEA, CA 19-9, and CA 72-4 and recurrence of gastric cancer. RESULTS: In patients with early gastric cancer, the recurrence sensitivity of postoperative CEA, CA 19-9, and CA 72-4 was 40.0, 5.6, and 2.8%, respectively. And in patients with advanced gastric cancer, the recurrence sensitivity of postoperative CEA, CA 19-9, and CA 72-4 was 100.0, 68.2, and 51.3%, respectively. Multivariate analyses showed that an increase in postoperative CEA in early gastric cancer was an independent prognostic factor of recurrence. In patients with advanced gastric cancer, age >60 years, stage III, and postoperative CEA increase and CA 72-4 increase were independent prognostic factors of recurrence. CONCLUSIONS: For patients with advanced gastric cancer, CEA, CA 19-9, and CA 72-4 are considered useful for follow-up tests. Although, CEA is considered useful for follow-up test for patients with early gastric cancer, but CA19-9 and CA72-4 are less useful due to their low sensitivity.

Stapling technique for performing Billroth II anastomosis after distal gastrectomy.

The circular stapling technique has been widely applied for gastrointestinal anastomosis in gastrectomies (open or laparoscopic) for distal gastric cancers. We describe this method for use in performing Billroth II anastomosis in distal gastrectomies. From 2002-2009, we report the results following the use of the circular stapling technique performed in 520 patients at a single institution. The median time of completing the anastomosis was shorter using the stapling technique compared to the hand-sewn technique. The use of the stapler resulted in two cases of minor intraluminal bleeding at the anastomotic site. The circular stapling method can be applied safely and more efficiently in performing Billroth II reconstruction after distal gastrectomy compared to the hand-sewn method in patients with gastric cancer.

Frequency and predictive factors of lymph node metastasis in mucosal cancer.

PURPOSE: The incidence of lymph node metastasis has been reported to range from 2.6 to 4.8% in early stage gastric cancer with mucosal invasion (T1a cancer). Lymph node metastasis in early stage gastric cancer is known as an important predictive factor. We analyzed the prediction factors of lymph node metastasis in T1a cancer. MATERIALS AND METHODS: A total of 9,912 patients underwent radical gastrectomy due to gastric cancer from October 1994 to July 2006 in the Department Of Surgery at Samsung Medical Center. We did a retrospective analysis of 2,524 patients of these patients, ones for whom the cancer was confined within the mucosa. RESULTS: Among the 2,524 patients, 57 (2.2%) were diagnosed with lymph node metastasis, and of these, cancer staging was as follows: 41 were N1, 8 were N2, and 8 were N3a. Univariate analysis of clinicopathological factors showed that the following factors were significant predictors of metastasis: tumor size larger than 4 cm, the presence of middle and lower stomach cancer, poorly differentiated adenocarcinoma and signet-ring cell carcinoma, diffuse type cancer (by the Lauren classification), and lymphatic invasion. Multivariate analysis showed that lymphatic invasion and tumor larger than 4 cm were significant factors with P<0.001 and P=0.024, respectively. CONCLUSIONS: The frequency of lymph node metastasis is extremely low in early gastric cancer with mucosal invasion. However, when lymphatic invasion is present or the tumor is larger than 4 cm, there is a greater likelihood of lymph node metastasis. In such cases, surgical treatments should be done to prevent disease recurrence.