Impact of 18FFDG-PET/CT and Laparoscopy in Staging of Locally Advanced Gastric Cancer: A Cost Analysis in the Prospective Multicenter PLASTIC-Study.

BACKGROUND: Unnecessary D2-gastrectomy and associated costs can be prevented after detecting non-curable gastric cancer, but impact of staging on treatment costs is unclear. This study determined the cost impact of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18FFDG-PET/CT) and staging laparoscopy (SL) in gastric cancer staging. MATERIALS AND METHODS: In this cost analysis, four staging strategies were modeled in a decision tree: (1) 18FFDG-PET/CT first, then SL, (2) SL only, (3) 18FFDG-PET/CT only, and (4) neither SL nor 18FFDG-PET/CT. Costs were assessed on the basis of the prospective PLASTIC-study, which evaluated adding 18FFDG-PET/CT and SL to staging advanced gastric cancer (cT3-4 and/or cN+) in 18 Dutch hospitals. The Dutch Healthcare Authority provided 18FFDG-PET/CT unit costs. SL unit costs were calculated bottom-up. Gastrectomy-associated costs were collected with hospital claim data until 30 days postoperatively. Uncertainty was assessed in a probabilistic sensitivity analysis (1000 iterations). RESULTS: 18FFDG-PET/CT costs were €1104 including biopsy/cytology. Bottom-up calculations totaled €1537 per SL. D2-gastrectomy costs were €19,308. Total costs per patient were €18,137 for strategy 1, €17,079 for strategy 2, and €19,805 for strategy 3. If all patients undergo gastrectomy, total costs were €18,959 per patient (strategy 4). Performing SL only reduced costs by €1880 per patient. Adding 18FFDG-PET/CT to SL increased costs by €1058 per patient; IQR €870-1253 in the sensitivity analysis. CONCLUSIONS: For advanced gastric cancer, performing SL resulted in substantial cost savings by reducing unnecessary gastrectomies. In contrast, routine 18FFDG-PET/CT increased costs without substantially reducing unnecessary gastrectomies, and is not recommended due to limited impact with major costs. TRIAL REGISTRATION: NCT03208621. This trial was registered prospectively on 30-06-2017.

Multimodal Therapy Versus Primary Surgery for Gastric and Gastroesophageal Junction Diffuse Type Carcinoma, with a Focus on Signet Ring Cell Carcinoma: A Nationwide Study.

BACKGROUND: Diffuse type adenocarcinoma and, more specifically, signet ring cell carcinoma (SRCC) of the stomach and gastroesophageal junction (GEJ) have a poor prognosis and the value of neoadjuvant chemo(radio)therapy (nCRT) is unclear. METHODS: All patients who underwent surgery for diffuse type gastric and GEJ carcinoma between 2004 and 2015 were retrospectively included from the Netherlands Cancer Registry. The primary outcome was overall survival after surgery. Kaplan-Meier curves were plotted. Furthermore, multivariable Poisson and Cox regressions were performed, correcting for confounders. To comply with the Cox regression proportional hazard assumption, gastric cancer survival was split into two groups, i.e. <90 days and >90 days, postoperatively by adding an interaction variable. RESULTS: Analyses included 2046 patients with diffuse type cancer: 1728 gastric cancers (50% SRCC) and 318 GEJ cancers (39% SRCC). In the gastric cancer group, 49% received neoadjuvant chemotherapy (nCT) and 51% received primary surgery (PS). All-cause mortality within 90 days postoperatively was lower after nCT (hazard ratio [HR] 0.29, 95% confidence interval [CI] 0.20-0.44; p < 0.001). Also after 90 days, mortality was lower in the nCT group (HR for the interaction variable 2.84, 95% CI 1.87-4.30, p < 0.001; total HR 0.29*2.84 = 0.84). In the GEJ group, 38% received nCT, 22% received nCRT, and 39% received PS. All-cause mortality was lower after nCT (HR 0.63, 95% CI 0.43-0.93; p = 0.020) compared with PS. The nCRT group was removed from the Cox regression analysis since the Kaplan-Meier curves of nCRT and PS intersected. The results for gastric and GEJ carcinomas were similar between the SRCC and non-SRCC subgroups. CONCLUSION: For gastric and GEJ diffuse type cancer, including SRCC, nCT was associated with increased survival.

Pain and Opioid Consumption After Laparoscopic Versus Open Gastrectomy for Gastric Cancer: A Secondary Analysis of a Multicenter Randomized Clinical Trial (LOGICA-Trial).

BACKGROUND: Laparoscopic gastrectomy could reduce pain and opioid consumption, compared to open gastrectomy. However, it is difficult to judge the clinical relevance of this reduction, since these outcomes are reported in few randomized trials and in limited detail. METHODS: This secondary analysis of a multicenter randomized trial compared laparoscopic versus open gastrectomy for resectable gastric adenocarcinoma (cT1-4aN0-3bM0). Postoperative pain was analyzed by opioid consumption in oral morphine equivalents (OME, mg/day) at postoperative day (POD) 1-5, WHO analgesic steps, and Numeric Rating Scales (NRS, 0-10) at POD 1-10 and discharge. Regression and mixed model analyses were performed, with and without correction for epidural analgesia. RESULTS: Between 2015 and 2018, 115 patients in the laparoscopic group and 110 in the open group underwent surgery. Some 16 patients (14%) in the laparoscopic group and 73 patients (66%) in the open group received epidural analgesia. At POD 1-3, mean opioid consumption was 131, 118, and 53 mg OME lower in the laparoscopic group, compared to the open group, respectively (all p < 0.001). After correcting for epidural analgesia, these differences remained significant at POD 1-2 (47 mg OME, p = 0.002 and 69 mg OME, p < 0.001, respectively). At discharge, 27% of patients in the laparoscopic group and 43% patients in the open group used oral opioids (p = 0.006). Mean highest daily pain scores were between 2 and 4 at all PODs, < 2 at discharge, and did not relevantly differ between treatment arms. CONCLUSION: In this multicenter randomized trial, postoperative pain was comparable between laparoscopic and open gastrectomy. After laparoscopic gastrectomy, this was generally achieved without epidural analgesia and with fewer opioids. TRIAL REGISTRATION: NCT02248519.

Cost-effectiveness of Laparoscopic vs Open Gastrectomy for Gastric Cancer: An Economic Evaluation Alongside a Randomized Clinical Trial.

Importance: Laparoscopic gastrectomy is rapidly being adopted worldwide as an alternative to open gastrectomy to treat gastric cancer. However, laparoscopic gastrectomy might be more expensive as a result of longer operating times and more expensive surgical materials. To date, the cost-effectiveness of both procedures has not been prospectively evaluated in a randomized clinical trial. Objective: To evaluate the cost-effectiveness of laparoscopic compared with open gastrectomy. Design, Setting, and Participants: In this multicenter randomized clinical trial of patients undergoing total or distal gastrectomy in 10 Dutch tertiary referral centers, cost-effectiveness data were collected alongside a multicenter randomized clinical trial on laparoscopic vs open gastrectomy for resectable gastric adenocarcinoma (cT1-4aN0-3bM0). A modified societal perspective and 1-year time horizon were used. Costs were calculated on the individual patient level by using hospital registry data and medical consumption and productivity loss questionnaires. The unit costs of laparoscopic and open gastrectomy were calculated bottom-up. Quality-adjusted life-years (QALYs) were calculated with the EuroQol 5-dimension questionnaire, in which a value of 0 indicates death and 1 indicates perfect health. Missing questionnaire data were imputed with multiple imputation. Bootstrapping was performed to estimate the uncertainty surrounding the cost-effectiveness. The study was conducted from March 17, 2015, to August 20, 2018. Data analyses were performed between September 1, 2020, and November 17, 2021. Interventions: Laparoscopic vs open gastrectomy. Main Outcomes and Measures: Evaluations in this cost-effectiveness analysis included total costs and QALYs. Results: Between 2015 and 2018, 227 patients were included. Mean (SD) age was 67.5 (11.7) years, and 140 were male (61.7%). Unit costs for initial surgery were calculated to be €8124 (US $8087) for laparoscopic total gastrectomy, €7353 (US $7320) for laparoscopic distal gastrectomy, €6584 (US $6554) for open total gastrectomy, and €5893 (US $5866) for open distal gastrectomy. Mean total costs after 1-year follow-up were €26 084 (US $25 965) in the laparoscopic group and €25 332 (US $25 216) in the open group (difference, €752 [US $749; 3.0%]). Mean (SD) QALY contributions during 1 year were 0.665 (0.298) in the laparoscopic group and 0.686 (0.288) in the open group (difference, -0.021). Bootstrapping showed that these differences between treatment groups were relatively small compared with the uncertainty of the analysis. Conclusions and Relevance: Although the laparoscopic gastrectomy itself was more expensive, after 1-year follow-up, results suggest that differences in both total costs and effectiveness were limited between laparoscopic and open gastrectomy. These results support centers' choosing, based on their own preference, whether to (de)implement laparoscopic gastrectomy as an alternative to open gastrectomy.

Learning Curve of Laparoscopic Gastrectomy: A Multicenter Study.

OBJECTIVE: To evaluate the learning curve of laparoscopic gastrectomy (LG) after an implementation program. BACKGROUND: Although LG is increasingly being performed worldwide, little is known about the learning curve. METHODS: Consecutive patients who underwent elective LG for gastric adenocarcinoma with curative intent in each of the 5 highest-volume centers in the Netherlands were enrolled. Generalized additive models and a 2-piece model with a break point were used to determine the learning curve length. Analyses were corrected for casemix and were performed for LG and for the subgroups distal gastrectomy (LDG) and total gastrectomy (LTG). The learning curve effect was assessed for (1) anastomotic leakage; and (2) the occurrence of postoperative complications, conversions to open surgery, and short-term oncological parameters. RESULTS: In total 540 patients were included for analysis, 108 patients from each center; 268 patients underwent LDG and 272 underwent LTG. First, for LG, no learning effect regarding anastomotic leakage could be identified: the rate of anastomotic leakage initially increased, then reached a plateau after 36 cases at 10% anastomotic leakage. Second, the level of overall complications reached a plateau after 20 cases, at 38% overall complications, and at 5% conversions. For both LDG and LTG, each considered separately, fluctuations in secondary outcomes and anastomotic leakage followed fluctuations in casemix. CONCLUSION: On the basis of our study of the first 108 procedures of LG in 5 high-volume centers with well-trained surgeons, no learning curve effect could be identified regarding anastomotic leakage. A learning curve effect was found with respect to overall complications and conversion rate.

Body Composition Is a Predictor for Postoperative Complications After Gastrectomy for Gastric Cancer: a Prospective Side Study of the LOGICA Trial.

PURPOSE: There is a lack of prospective studies evaluating the effects of body composition on postoperative complications after gastrectomy in a Western population with predominantly advanced gastric cancer. METHODS: This is a prospective side study of the LOGICA trial, a multicenter randomized trial on laparoscopic versus open gastrectomy for gastric cancer. Trial patients who received preoperative chemotherapy followed by gastrectomy with an available preoperative restaging abdominal computed tomography (CT) scan were included. The CT scan was used to calculate the mass (M) and radiation attenuation (RA) of skeletal muscle (SM), visceral adipose tissue (VAT), and subcutaneous adipose tissue (SAT). These variables were expressed as Z-scores, depicting how many standard deviations each patient's CT value differs from the sex-specific study sample mean. Primary outcome was the association of each Z-score with the occurrence of a major postoperative complication (Clavien-Dindo grade ≥ 3b). RESULTS: From 2015 to 2018, a total of 112 patients were included. A major postoperative complication occurred in 9 patients (8%). A high SM-M Z-score was associated with a lower risk of major postoperative complications (RR 0.47, 95% CI 0.28-0.78, p = 0.004). Furthermore, high VAT-RA Z-scores and SAT-RA Z-scores were associated with a higher risk of major postoperative complications (RR 2.82, 95% CI 1.52-5.23, p = 0.001 and RR 1.95, 95% CI 1.14-3.34, p = 0.015, respectively). VAT-M, SAT-M, and SM-RA Z-scores showed no significant associations. CONCLUSION: Preoperative low skeletal muscle mass and high visceral and subcutaneous adipose tissue radiation attenuation (indicating fat depleted of triglycerides) were associated with a higher risk of developing a major postoperative complication in patients treated with preoperative chemotherapy followed by gastrectomy.

18F-Fludeoxyglucose-Positron Emission Tomography/Computed Tomography and Laparoscopy for Staging of Locally Advanced Gastric Cancer: A Multicenter Prospective Dutch Cohort Study (PLASTIC).

Importance: The optimal staging for gastric cancer remains a matter of debate. Objective: To evaluate the value of 18F-fludeoxyglucose-positron emission tomography with computed tomography (FDG-PET/CT) and staging laparoscopy (SL) in addition to initial staging by means of gastroscopy and CT in patients with locally advanced gastric cancer. Design, Setting, and Participants: This multicenter prospective, observational cohort study included 394 patients with locally advanced, clinically curable gastric adenocarcinoma (≥cT3 and/or N+, M0 category based on CT) between August 1, 2017, and February 1, 2020. Exposures: All patients underwent an FDG-PET/CT and/or SL in addition to initial staging. Main Outcomes and Measures: The primary outcome was the number of patients in whom the intent of treatment changed based on the results of these 2 investigations. Secondary outcomes included diagnostic performance, number of incidental findings on FDG-PET/CT, morbidity and mortality after SL, and diagnostic delay. Results: Of the 394 patients included, 256 (65%) were men and mean (SD) age was 67.6 (10.7) years. A total of 382 patients underwent FDG-PET/CT and 357 underwent SL. Treatment intent changed from curative to palliative in 65 patients (16%) based on the additional FDG-PET/CT and SL findings. FDG-PET/CT detected distant metastases in 12 patients (3%), and SL detected peritoneal or locally nonresectable disease in 73 patients (19%), with an overlap of 7 patients (2%). FDG-PET/CT had a sensitivity of 33% (95% CI, 17%-53%) and specificity of 97% (95% CI, 94%-99%) in detecting distant metastases. Secondary findings on FDG/PET were found in 83 of 382 patients (22%), which led to additional examinations in 65 of 394 patients (16%). Staging laparoscopy resulted in a complication requiring reintervention in 3 patients (0.8%) without postoperative mortality. The mean (SD) diagnostic delay was 19 (14) days. Conclusions and Relevance: This study's findings suggest an apparently limited additional value of FDG-PET/CT; however, SL added considerably to the staging process of locally advanced gastric cancer by detection of peritoneal and nonresectable disease. Therefore, it may be useful to include SL in guidelines for staging advanced gastric cancer, but not FDG-PET/CT.

Laparoscopic Versus Open Gastrectomy for Gastric Cancer (LOGICA): A Multicenter Randomized Clinical Trial.

BACKGROUND: The oncological efficacy and safety of laparoscopic gastrectomy are under debate for the Western population with predominantly advanced gastric cancer undergoing multimodality treatment. METHODS: In 10 experienced upper GI centers in the Netherlands, patients with resectable (cT1-4aN0-3bM0) gastric adenocarcinoma were randomly assigned to either laparoscopic or open gastrectomy. No masking was performed. The primary outcome was hospital stay. Analyses were performed by intention to treat. It was hypothesized that laparoscopic gastrectomy leads to shorter hospital stay, less postoperative complications, and equal oncological outcomes. RESULTS: Between 2015 and 2018, a total of 227 patients were randomly assigned to laparoscopic (n = 115) or open gastrectomy (n = 112). Preoperative chemotherapy was administered to 77 patients (67%) in the laparoscopic group and 87 patients (78%) in the open group. Median hospital stay was 7 days (interquartile range, 5-9) in both groups (P = .34). Median blood loss was less in the laparoscopic group (150 v 300 mL, P < .001), whereas mean operating time was longer (216 v 182 minutes, P < .001). Both groups did not differ regarding postoperative complications (44% v 42%, P = .91), in-hospital mortality (4% v 7%, P = .40), 30-day readmission rate (9.6% v 9.1%, P = 1.00), R0 resection rate (95% v 95%, P = 1.00), median lymph node yield (29 v 29 nodes, P = .49), 1-year overall survival (76% v 78%, P = .74), and global health-related quality of life up to 1 year postoperatively (mean differences between + 1.5 and + 3.6 on a 1-100 scale; 95% CIs include zero). CONCLUSION: Laparoscopic gastrectomy did not lead to a shorter hospital stay in this Western multicenter randomized trial of patients with predominantly advanced gastric cancer. Postoperative complications and oncological efficacy did not differ between laparoscopic gastrectomy and open gastrectomy.

Worldwide Practice in Gastric Cancer Surgery: A 6-Year Update.

OBJECTIVES: The aim of the study was to evaluate the current status of gastric cancer surgery worldwide and update the changes compared to a previous survey in 2014. METHODS: A cross-sectional survey was sent to surgical members of the International Gastric Cancer Association, pilot centers of the World Organization for Specialized Studies on Diseases of the Esophagus, and the Australian and New Zealand Gastric and Oesophageal Surgeons Association in addition to participants of the 2019 International Gastric Cancer and European Society for Diseases of the Esophagus congresses. Topics addressed included hospital volume, staging, perioperative treatment, surgical approach, anastomotic techniques, lymphadenectomy, and palliative management. RESULTS: Between June 2019 and January 2020, 165 respondents from 44 countries completed the survey. In total, 80% worked in a hospital performing >20 gastrectomies annually. Staging laparoscopy and 18F-fluorodeoxyglucose positron emission tomography with computed tomography were preferred by 68 and 26% for advanced cancer, and 90% offered perioperative chemo(radio)therapy to patients. For early cancer, a minimally invasive surgical approach was preferred by 65% for distal and by 50% for total gastrectomy. For advanced cancer, this was preferred by 39% for distal and by 33% for total gastrectomy. And 84% favored a stapled anastomosis, and 14% created a jejunal pouch as reconstruction during total gastrectomy. A D2 lymphadenectomy was preferred for distal as well as for total gastrectomy, in both early (62 and 71%) and advanced (84 and 89%) cancer. CONCLUSION: This international survey demonstrates that perioperative chemotherapy and a D2 lymphadenectomy have now become the preferred treatment for gastric cancer. A minimally invasive surgical approach has gained popularity.

Evaluation of the Implementation of FDG-PET/CT and Staging Laparoscopy for Gastric Cancer in The Netherlands.

BACKGROUND: The role of 18F-fluorodeoxyglucose positron emission tomography with computed tomography (FDG-PET/CT) and staging laparoscopy (SL) has increased in the preoperative staging of gastric cancer. Dutch national guidelines have recommended the use of FDG-PET/CT and SL for patients with locally advanced tumors since July 2016. OBJECTIVE: The aim of this study was to evaluate the implementation of FDG-PET/CT and SL in The Netherlands. METHODS: Between 2011 and 2018, all patients who underwent surgery for gastric cancer were included from the Dutch Upper GI Cancer Audit. The use of FDG-PET/CT and SL was evaluated before and after revision of the Dutch guidelines. Outcomes included the number of non-curative procedures (e.g. palliative and futile procedures) and the association of FDG-PET/CT and SL, with waiting times from diagnosis to the start of treatment. RESULTS: A total of 3310 patients were analyzed. After July 2016, the use of FDG-PET/CT (23% vs. 61%; p < 0.001) and SL (21% vs. 58%; p < 0.001) increased. FDG-PET/CT was associated with additional waiting time to neoadjuvant therapy (4 days), as well as primary surgical treatment (20 days), and SL was associated with 8 additional days of waiting time to neoadjuvant therapy. Performing SL or both modalities consecutively in patients in whom it was indicated was not associated with the number of non-curative procedures. CONCLUSION: During implementation of FDG-PET/CT and SL after revision of the guidelines, both have increasingly been used in The Netherlands. The addition of these staging methods was associated with increased waiting time to treatment. The number of non-curative procedures did not differ after performing none, solely one, or both staging modalities.

Refraining from resection in patients with potentially curable gastric carcinoma.

BACKGROUND: Surgical resection is the cornerstone of curative treatment for gastric cancer. The aim of this study was to evaluate reasons for and patient- and tumor characteristics that are associated with refraining from surgical resection in patients with potentially curable gastric cancer. MATERIALS AND METHODS: Between 2015 and 2017, all patients with potentially curable gastric adenocarcinoma (cT1-4a-x, cN0-3-x, cM0) were included from the Netherlands Cancer Registry (NCR). Patients were divided into a resection (RG) and a no-resection group (nRG). Reasons for not undergoing resection as registered by the NCR were evaluated. Using multivariable logistic regression analyses, patient and tumor characteristics associated with refraining from resection were assessed. RESULTS: Of the 1679 analyzed patients with potentially curable disease, 1127 patients (67%) underwent resection, and 552 patients (33%) did not. Most common registered reasons for refraining from surgery were patient refusal (25%), low performance status (23%), comorbidity and extent of disease (both 10%). Factors associated with not undergoing resection were: age ≥80 years (OR 4.77, [95%CI 2.27-10.06], p < 0.001), low Social-Economic-Status (SES) (OR 2.68 [95%CI 1.31-5.46], p = 0.007), WHO performance status 3-4 (OR 10.48 [95%CI 2.41-45.73], p = 0.002) with several accompanying comorbidities, unclassified Lauren classification (OR 3.93 [95%CI 1.61-9.56], p = 0.003) and overlapping/diffuse tumors (OR 3.51, [95%CI 1.54-8.05], p = 0.003). CONCLUSION: A third of patients with potentially curable gastric cancer did not undergo resection. Most frequent registered reasons for refraining from surgery were patient refusal, performance status, comorbidity and extent of disease. Additionally, multivariable analyses identified higher age, lower SES, and poor tumor characteristics as associated factors.

Non-curative gastrectomy for advanced gastric cancer does not result in additional risk of postoperative morbidity compared to curative gastrectomy.

BACKGROUND: Non-curative gastrectomy (nCG) for gastric cancer can be considered in selected cases to relieve symptoms. The aim of this study was to evaluate postoperative morbidity and mortality in patients who underwent nCG and compare these results with an intended curative gastrectomy (CG). MATERIALS AND METHODS: All patients who underwent both nCG and CG in the Netherlands were included from the Dutch Upper GI Cancer Audit (2011-2016). In this population-based cohort study postoperative morbidity, mortality, readmissions and short-term oncological outcomes were appraised. Propensity score matching (PSM) was applied to create comparable groups of patients who underwent nCG versus CG, using patient and tumor characteristics. RESULTS: Of the 2202 eligible patients, 115 patients underwent nCG and 2087 underwent CG. After PSM, 115 nCG-patients were matched to 227 CG-patients. More conversions from laparoscopic to open surgery occurred during nCG (10·4 versus 2·6%, p = 0·007). Although postoperative mortality was higher after nCG in the original cohort (9·6 versus 4·8%, p = 0·026), after PSM there was no difference between groups (9·6 versus 7·0%, p = 0·415). Postoperative morbidity, re-interventions and readmission rates did not differ significantly between groups. Resection of additional organs (30·4 versus 11·5%, p < 0·001) and R+ resections (65·2 versus 12·3%, p < 0·001) occurred more frequently during nCG. CONCLUSIONS: nCG does not lead to additional postoperative risks compared to CG in patients with similar characteristics, and may be considered in fit patients with advanced gastric cancer. However, randomized trials evaluating potential (survival) benefits of nCG should be awaited.

Identification of the clinically most relevant postoperative complications after gastrectomy: a population-based cohort study.

BACKGROUND: Postoperative complications frequently occur after gastrectomy for gastric cancer and are associated with poor clinical outcomes, such as mortality and reoperations. The aim of study was to identify the clinically most relevant complications after gastrectomy, using the population-attributable fraction (PAF). METHODS: Between 2011 and 2017, all patients who underwent potentially curative gastrectomy for gastric adenocarcinoma were included from the Dutch Upper GI Cancer Audit. Postoperative outcomes (morbidity, mortality, recovery and hospitalization) were evaluated. The prevalence of postoperative complications (e.g., anastomotic leakage and pneumonia) and of the study outcomes were calculated. The adjusted relative risk and Confidence Interval (CI) for each complication-outcome pair were calculated. Subsequently, the PAF was calculated, which represents the percentage of a given outcome occurring in the population, caused by individual complications, taking both the relative risk and the frequency in which a complication occurs into account. RESULTS: In total, 2176 patients were analyzed. Anastomotic leakage and pulmonary complications had the greatest overall impact on postoperative mortality (PAF 29.2% [95% CI 19.3-39.1] and 21.6% [95% CI 10.5-32.7], respectively) and prolonged hospitalization (PAF 12.9% [95% CI 9.7-16.0] and 14.7% [95% CI 11.0-18.8], respectively). Anastomotic leakage had the greatest overall impact on re-interventions (PAF 25.1% [95% CI 20.5-29.7]) and reoperations (PAF 30.3% [95% CI 24.3-36.3]). Intra-abdominal abscesses had the largest impact on readmissions (PAF 7.0% [95% CI 3.2-10.9]). Other complications only had a small effect on these outcomes. CONCLUSION: Surgical improvement programs should focus on preventing or managing anastomotic leakage and pulmonary complications, since these complications have the greatest overall impact on clinical outcomes after gastrectomy.

Imaging strategies in the management of gastric cancer: current role and future potential of MRI.

Accurate preoperative staging of gastric cancer and the assessment of tumor response to neoadjuvant treatment is of importance for treatment and prognosis. Current imaging techniques, mainly endoscopic ultrasonography (EUS), computed tomography (CT) and 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET), have their limitations. Historically, the role of magnetic resonance imaging (MRI) in gastric cancer has been limited, but with the continuous technical improvements, MRI has become a more potent imaging technique for gastrointestinal malignancies. The accuracy of MRI for T- and N-staging of gastric cancer is similar to EUS and CT, making MRI a suitable alternative to other imaging strategies. There is limited evidence on the performance of MRI for M-staging of gastric cancer specifically, but MRI is widely used for diagnosing liver metastases and shows potential for diagnosing peritoneal seeding. Recent pilot studies showed that treatment response assessment as well as detection of lymph node metastases and systemic disease might benefit from functional MRI (e.g. diffusion weighted imaging and dynamic contrast enhancement). Regarding treatment guidance, additional value of MRI might be expected from its role in better defining clinical target volumes and setup verification with MR-guided radiation treatment.

European validation of the Yonsei Gastric Cancer Prognosis Prediction Model after gastrectomy: Validation with the Netherlands Cancer Registry.

BACKGROUND: Recently, a novel model predicting 5-year survival after gastrectomy was developed, the Yonsei Gastric Cancer Prognosis Prediction Model, to overcome limitations of the tumor-node-metastases (TNM) staging system. This study aimed to validate this model in a European cohort. METHODS: All patients who underwent gastrectomy for gastric cancer were selected from the Netherlands Cancer Registry (2005-2015). Patients with 30-day mortality, co-existing cancer, neoadjuvant therapy, or missing data were excluded. The prediction model included gender, age, resection type, pT-stage, pM-stage, number of retrieved lymph nodes, number of metastatic lymph nodes, and tumor histology. The model was validated and compared to the 7th TNM staging system using calibration plots and the concordance index (c-statistic with 95% confidence interval (CI)). RESULTS: From the 5748 patients who underwent gastrectomy, 2253 were included in this study. Mean age was 72.1 years, most patients had advanced gastric cancer (88%), and in 1102 patients (49%) no proper TNM staging could be performed since <16 lymph nodes were retrieved. Median overall survival was 24.6 months, and the 5-year overall survival was 30%, respectively. Model calibration was accurate in predicting 5-year overall survival, and the degree of discrimination was high (c-statistic = 0.807, 95% CI (0.787-0.826)). The model was superior to the TNM staging system in patients who could be properly staged: c-statistic = 0.861, 95% CI (0.838-0.885) vs. 0.711, 95% CI (0.692-0.729), p < 0.0001. CONCLUSION: The Yonsei Gastric Cancer Prognosis Prediction Model was superior over the TNM staging system in predicting prognosis after gastrectomy in a European cohort, although it is not applicable to patients treated by neoadjuvant therapy.

Factors influencing health-related quality of life after gastrectomy for cancer.

AIM: Insight in health-related quality of life (HRQoL) may improve clinical decision making and inform patients about the long-term effects of gastrectomy. This study aimed to evaluate and identify factors associated with HRQoL after gastrectomy. METHODS: This cross-sectional study used prospective databases from seven Dutch centers (2001-2015) including patients who underwent gastrectomy for cancer. Between July 2015 and November 2016, European Organization for Research and Treatment of Cancer HRQoL questionnaires QLQ-C30 and QLQ-STO22 were sent to all surviving patients without recurrence. The QLQ-C30 scores were compared to a Dutch reference population using a one-sample t test. Spearman's rank test was used to correlate time after surgery to HRQoL, and multivariable linear regression was performed to identify factors associated with HRQoL. RESULTS: A total of 222 of 274 (81.0%) patients completed the questionnaires. Median follow-up was 29 months (range, 3-171) and 86.9% of patients had a follow-up >1 year. The majority of patients had undergone neoadjuvant treatment (64.4%) and total gastrectomy (52.7%). Minimally invasive gastrectomy (MIG) was performed in 50% of the patients. Compared to the general population, gastrectomy patients scored significantly worse on most functional and symptom scales (p < 0.001) and slightly worse on global HRQoL (78 vs. 74, p = 0.012). Time elapsed since surgery did not correlate with global HRQoL (Spearman's ρ = 0.06, p = 0.384). Distal gastrectomy, neoadjuvant treatment, and MIG were associated with better HRQoL (p < 0.050). CONCLUSION: After gastrectomy, patients encounter functional impairments and symptoms, but experience only a slightly impaired global HRQoL. Distal gastrectomy, the ability to receive neoadjuvant treatment, and MIG may be associated with HRQoL benefits.

Postoperative complications and weight loss following jejunostomy tube feeding after total gastrectomy for advanced adenocarcinomas.

OBJECTIVE: Patients undergoing total gastrectomy for cancer are at risk of malnourishment. The aim of this self-controlled study was to examine the effect of jejunostomy tube feeding (JTF) and other factors on postoperative weight and the incidence of jejunostomy-related complications in patients undergoing total gastrectomy for cancer. METHODS: All consecutive patients who underwent total gastrectomy for gastric cancer with jejunostomy placement were included from a prospective single-center database (2003-2014). Jejunostomy-related complications and postoperative weight changes were evaluated up to 12 months after surgery. Multivariable linear regression analysis was performed to identify factors associated with weight loss 12 months after gastrectomy. RESULTS: Of 113 patients operated in the study period, 65 received JTF after total gastrectomy for a median duration of 18 d [interquartile range (IQR), 10-55 d]. Jejunostomy-related complications occurred in 11 (17%) patients, including skin leakage (n=3) and peritoneal leakage (n=2), luxation (n=3), occlusion (n=2), infection (n=1) and torsion (n=1). In 2 (3%) patients, a reoperation was needed due to jejunostomy-related complications. The mean preoperative weight of patients was 71.8 kg (100%), and remained stable during JTF (73.9 kg, 103%, P=0.331). After JTF was stopped, the mean weight of patients decreased to 64.9 kg (90%) at 12 months after surgery (P<0.001). A high preoperative body mass index (BMI) (≥25 kg/m2) was associated with high postoperative weight loss compared to patients with a low BMI (<25 kg/m2) (16.3% vs. 8.6%, P=0.016). CONCLUSIONS: JTF can prevent weight loss in the early postoperative phase. However, this is at the prize of possible complications. As weight loss in the long term is not prevented, routine JTF should be re-evaluated and balanced against the selected use in preoperatively malnourished patients. Special attention should be paid to patients with a high preoperative BMI, who are at risk of more postoperative weight loss.

Surgical anatomy of the omental bursa and the stomach based on a minimally invasive approach: different approaches and technical steps to resection and lymphadenectomy.

BACKGROUND: It is imperative for surgeons to have a proper knowledge of the omental bursa in order to perform an adequate dissection during minimally invasive surgery (MIS) of the upper gastrointestinal (GI) tract. This study aimed to describe (1) the various approaches which can be used to enter the bursa and to perform a complete lymphadenectomy, (2) the boundaries and anatomical landmarks of the omental bursa as seen during MIS, and (3) whether a bursectomy should be performed for oncological reasons in upper GI cancer. METHODS: In this observational study, videos of 20 patients undergoing different MIS procedures were reviewed, and the findings were verified prospectively in 5 patients undergoing a total gastrectomy and in a transversely sectioned cadaver. A systematic literature review (PubMed) was performed on the additive value of bursectomy during gastrectomy for cancer. RESULTS: The omental bursa can be surgically entered through the hepatogastric ligament, gastrocolic ligament, gastrosplenic ligament or through the transverse mesocolon. Anatomical boundaries of the omental bursa could be clearly identified, and new anatomical landmarks were described (gastro-omental folds). The cranial part of the omental bursa consists of two compartments (splenic recess and superior recess), separated by the gastropancreatic fold, communicating at the level of the pancreas, and extending distally as the inferior recess. There is no clear evidence regarding beneficial effect of a bursectomy in upper GI oncology. CONCLUSIONS: The description of the omental bursa in this study may help surgeons perform a more adequate oncological dissection during MIS. Bursectomy should not be routinely performed during oncological resections.

Recurrent laryngeal nerve injury after esophagectomy for esophageal cancer: incidence, management, and impact on short- and long-term outcomes.

BACKGROUND: Recurrent laryngeal nerve (RLN) injury caused by esophagectomy may lead to postoperative morbidity, however data on long-term recovery are scarce. The aim of this study was to evaluate the consequences of RLN palsy (RLNP) in terms of pulmonary morbidity and long-term functional recovery. METHODS: Patients who underwent a 3-stage transthoracic (McKeown) or a transhiatal esophagectomy for esophageal carcinoma in the University Medical Center Utrecht (UMCU) between January 2004 and March 2016 were included from a prospective database. Multivariable analyses were conducted to assess the association between RLNP and pulmonary complications and hospital stay. Data regarding long-term recovery were summarized using descriptive statistics. RESULTS: Out of the 451 included patients, 47 (10%) were diagnosed with RLNP. Of the patients with RLNP, 34 (7%) had a unilateral lesion, 8 (2%) had a bilateral lesion, and in 5 (1%) the location of the lesion was unknown. The incidence of RLNP was 3/127 (2%) in the transhiatal group, and 44/324 (14%) in the McKeown group. RLNP after McKeown esophagectomy was associated with a higher incidence of pulmonary complications (OR 2.391; 95% CI 1.222-4.679; P=0.011), as well as a longer hospital stay (+4 days) (P=0.001). Of the RLNP patients with more than 6 months follow up almost half recovered fully {median follow-up of 17.5 [7-135] months}. Of the remainder, six required a surgical intervention and the others had residual symptoms. CONCLUSIONS: RLNP after McKeown esophagectomy is associated with an increased pulmonary complication rate, longer hospital stay, and a moderate long-term recovery. Further studies are necessary that examine technologies, which may reduce RLNP incidence and contribute to the early detection and treatment of RLNP.

Postoperative Outcomes of Minimally Invasive Gastrectomy Versus Open Gastrectomy During the Early Introduction of Minimally Invasive Gastrectomy in the Netherlands: A Population-based Cohort Study.

OBJECTIVE: To compare postoperative outcomes of minimally invasive gastrectomy (MIG) to open gastrectomy (OG) for cancer during the introduction of MIG in the Netherlands. BACKGROUND: Between 2011 and 2015, the use of MIG increased from 4% to 53% in the Netherlands. METHODS: This population-based cohort study included all patients with curable gastric adenocarcinoma that underwent gastrectomy between 2011 and 2015, registered in the Dutch Upper GI Cancer Audit. Patients with missing preoperative data, and patients in whom no lymphadenectomy or reconstruction was performed were excluded. Propensity score matching was applied to create comparable groups between patients receiving MIG or OG, using year of surgery and other potential confounders. Morbidity, mortality, and hospital stay were evaluated. RESULTS: Of the 1697 eligible patients, 813 were discarded after propensity score matching; 442 and 442 patients who underwent MIG and OG, respectively, remained. Conversions occurred in 10% of the patients during MIG. Although the overall postoperative morbidity (37% vs 40%, P = 0.489) and mortality rates (6% vs 4%, P = 0.214) were comparable between the 2 groups, patients who underwent MIG experienced less wound complications (2% vs 5%, P = 0.006). Anastomotic leakage occurred in 8% of the patients after MIG, and in 7% after OG (P = 0.525). The median hospital stay declined over the years for both procedures (11 to 8 days, P < 0.001). Overall, hospital stay was shorter after MIG compared with OG (8 vs 10 days, P < 0.001). CONCLUSIONS: MIG was safely introduced in the Netherlands, with overall morbidity and mortality comparable with OG, less wound complications and shorter hospitalization.