Short-term outcomes of distal gastrectomy versus total gastrectomy for gastric cancer under enhanced recovery after surgery: a propensity score-matched analysis.

Enhanced recovery after surgery (ERAS) has been used safely and effectively in patients with gastric cancer. Our aim was to evaluate the short-term outcomes of total gastrectomy (TG) versus distal gastrectomy (DG) for gastric cancer under ERAS. A prospectively collected database of 1349 patients with gastric cancer who underwent TG or DG between January 2016 and September 2022 was retrospectively analyzed. Propensity score matching analysis was used at a ratio of 1:1 to reduce confounding effects, and perioperative clinical outcomes were compared between the two groups. The primary outcome was overall postoperative complications (POCs). Secondary outcomes comprised time to bowel function recovery, postoperative hospital stay, mortality, and 30-day readmission rate. Of 1349 identified patients, 296 (21.9%) experienced overall POCs. Before matching, multivariable analysis revealed that age, body mass index, diabetes, operation time, and extent of gastrectomy were independent risk factors for overall POCs. After matching, each group comprised 495 patients, and no significant differences were observed between the groups for all parameters except tumor location. Compared with TG, DG was associated with significantly earlier days to first flatus and to eating a soft diet, and shorter postoperative hospital stay (P < 0.05). The incidence of overall- and severe POCs (Clavien-Dindo grade ≥ IIIa) in the TG group was significantly higher vs. the DG group (P < 0.05). There was no significant difference in the number of days to eating a liquid diet, or mortality and 30-day readmission rates between the groups (P > 0.05). In the subgroup analysis for middle-third gastric cancer, the TG group experienced higher rates of overall- and severe POCs, with a longer postoperative hospital stay. Compared with DG, patients who underwent TG had higher POC rates, slower recovery of bowel function, and longer duration of hospitalization under ERAS. Therefore, caution is needed when initiating early feeding for patients who undergo TG.

Development of an individualized model for predicting postoperative delirium in elderly patients with hepatocellular carcinoma.

Postoperative delirium (POD) is a common complication in older patients with hepatocellular carcinoma (HCC) that adversely impacts clinical outcomes. We aimed to evaluate the risk factors for POD and to construct a predictive nomogram. Data for a total of 1481 older patients (training set: n=1109; validation set: n=372) who received liver resection for HCC were retrospectively retrieved from two prospective databases. The receiver operating characteristic (ROC) curve, calibration plot, and decision curve analysis (DCA) were used to evaluate the performance. The rate of POD was 13.3% (148/1109) in the training set and 16.4% (61/372) in the validation set. Multivariate analysis of the training set revealed that factors including age, history of cerebrovascular disease, American Society of Anesthesiologists (ASA) classification, albumin level, and surgical approach had significant effects on POD. The area under the ROC curves (AUC) for the nomogram, incorporating the aforementioned predictors, was 0.798 (95% CI 0.752-0.843) and 0.808 (95% CI 0.754-0.861) for the training and validation sets, respectively. The calibration curves of both sets showed a degree of agreement between the nomogram and the actual probability. DCA demonstrated that the newly established nomogram was highly effective for clinical decision-making. We developed and validated a nomogram with high sensitivity to assist clinicians in estimating the individual risk of POD in older patients with HCC.

A predictive nomogram model for low anterior resection syndrome after rectal cancer resection.

BACKGROUND: The aim of this study was to identify risk factors associated with the low anterior resection syndrome (LARS) and to construct a nomogram capable of predicting the risk of LARS in patients who undergo rectal cancer resection. METHODS: About 538 patients who had undergone anterior resection were recruited as a development set. In addition, 114 patients with rectal cancer were analysed as a validation set to test the new nomogram. Patients in the development set were grouped into two separate cohorts: those with major LARS and those with minor or no LARS. Multiple logistic regression was conducted to detect risk factors for major LARS. RESULTS: The prevalence of major LARS was 40.7%, of minor LARS was 28.6% and the proportion with no LARS was 30.7% in the development set. In multivariate analysis, female gender, preoperative chemoradiation, low tumour height, diverting ileostomy, postoperative anastomotic leakage were shown to be independently associated with major LARS occurring in patients after rectal cancer resection. The area under the curve (AUC) values of the nomogram were 0.726 (95% CI: 0.682-0.769) and 0.750 (95% CI: 0.655-0.845) in the development and validation sets, respectively. The calibration curves and Hosmer-Lemeshow goodness of fit tests showed that the model was acceptably accurate. CONCLUSION: A nomogram model based on risk factors could be valuable as a predictor of the probability of major LARS after rectal cancer surgery, and provides a guide that clinical staff can use to take preventive measures for high-risk patients.

Nomogram for prediction of prolonged postoperative ileus after colorectal resection.

BACKGROUND: Prolonged postoperative ileus (PPOI) is a major complication in patients undergoing colorectal resection. The aim of this study was to analyze the risk factors contributing to PPOI, and to develop an effective nomogram to determine the risks of this population. METHODS: A total of 1,254 patients with colorectal cancer who underwent radical colorectal resection at Fujian Cancer Hospital from March 2016 to August 2021 were enrolled as a training cohort in this study. Univariate analysis and multivariate logistic regressions were performed to determine the correlation between PPOI and clinicopathological characteristics. A nomogram predicting the incidence of PPOI was constructed. The cohort of 153 patients from Fujian Provincial Hospital were enrolled as a validation cohort. Internal and external validations were used to evaluate the prediction ability by area under the receiver operating characteristic curve (AUC) and a calibration plot. RESULTS: In the training cohort, 128 patients (10.2%) had PPOI after colorectal resection. The independent predictive factors of PPOI were identified, and included gender, age, surgical approach and intraoperative fluid overload. The AUC of nomogram were 0.779 (95% CI: 0.736-0.822) and 0.791 (95%CI: 0.677-0.905) in the training and validation cohort, respectively. The two cohorts of calibration plots showed a good consistency between nomogram prediction and actual observation. CONCLUSIONS: A highly accurate nomogram was developed and validated in this study, which can be used to provide individual prediction of PPOI in patients after colorectal resection, and this predictive power can potentially assist surgeons to make the optimal treatment decisions.

Comparison of prolonged postoperative ileus between laparoscopic right and left colectomy under enhanced recovery after surgery: a propensity score matching analysis.

BACKGROUND: There were differences in the recovery of bowel function and prolonged postoperative ileus (PPOI) between laparoscopic right colectomy (RC) and left colectomy (LC) under the guidance of enhanced recovery after surgery. METHODS: We selected 870 patients who underwent elective laparoscopic colectomy from June 2016 to December 2021, including 272 patients who had RC and 598 who had LC. According to 1:1 proportion for propensity score matching and correlation analysis, 247 patients who had RC and 247 who had LC were finally enrolled. RESULTS: The incidence of PPOI in all patients was 13.1%. Age, sex, smoking habit, preoperative serum albumin level, operation type, and operation time were the important independent risk factors based on multivariate logistic regression and correlation analysis for PPOI (p<0.05). Age, sex, body mass index, preoperative serum albumin level, operation time, and degree of differentiation between the two groups were significantly different before case matching (p<0.05). There were no statistically significant differences in baseline characteristics and preoperative biochemical parameters between the two groups after case matching (p>0.05). The incidence of PPOI in patients who had RC was 21.9%, while that in patients who had LC was 13.0%. The first flatus, first semi-liquid, and length of stay in LC patients were lower than those in RC patients (p<0.05). CONCLUSION: The return of bowel function in LC was faster than that in RC, and the incidence of PPOI was relatively lower. Therefore, caution should be taken during the early feeding of patients who had laparoscopic RC.

Erratum: MicroRNA-451a targets caveolin-1 in stomach cancer cells.

[This corrects the article on p. 2524 in vol. 13, PMID: 33165443.].

MicroRNA-451a targets caveolin-1 in stomach cancer cells.

MicroRNA-451 (miR-451) is lowly expressed in stomach cancer cells and improves their metastatic ability by down-regulating extracellular signal-regulated kinase 2 (ERK2). Many studies have found that caveolin-1 (CAV1) plays an important role in cancer progression. Additionally, miR-451 has been reported to regulate the expression of CAV1 in chronic obstructive pulmonary disease. Therefore, this study aims to determine if miR-451 regulates the biological functions of stomach cancer cells by regulating CAV1 expression. Through a bioinformatics analysis, we found that miR-451a regulates CAV1 expression, and miR-451a expression is relatively low in stomach cancer cells. Next, we confirmed that miR-451a negatively regulates CAV1 expression using a dual-luciferase reporter assay. Then MTT, 5-ethynyl-2'-deoxyuridine (EdU), propidium iodide (PI), an Annexin V-FITC/PI apoptosis kit, and transwell assays were used to measure the changes in cell proliferation, the cell cycle, apoptosis, cell migration, and invasiveness in stomach cancer cells overexpressing miR-451a or both miR-451a and CAV1. It was found that increasing the miR-451a expression in stomach cancer cells inhibits cell growth, migration, and invasiveness, and promotes apoptosis. After restoring the CAV1 expression, these biological processes resumed. In summary, in stomach cancer cells, the overexpression of miR-451a can restrain cell growth and promote apoptosis, so it is a potential treatment for stomach cancer.

[Feasibility of No.8p lymphadenectomy for the patients with advanced gastric cancer].

OBJECTIVE: To analyze the feasibility of No.8p lymphadenectomy for the patients with advanced gastric cancer and to preliminaryly explore its value in improving prognosis. METHODS: Clinical data of 1158 patients with advanced gastric cancer undergoing radical gastrectomy plus D2 or above D2 lymphadenectomy (No.8 lymphadenectomy) from July 2003 to July 2013 at Department of Gastrointestinal Surgery, Fujian Cancer Hospital were collected. A retrospective cohort study was carried out. Among 1158 patients, 343 patients from July 2003 to June 2008 only received No.8a lymph node dissection (No.8a group), and 815 patients from July 2008 to July 2013 received No.8a+No.8p lymph node dissection (No.8a+No.8p group). Patients in No.8a group received the dissection of the lymph nodes in the upper margin of the pancreas and the front of total hepatic artery, and those in No.8a+No.8p group, on the basis of No.8a group, received the dissection of lymph nodes in the common hepatic artery and the left lymph nodes behind the hepatic artery and the portal vein. The metastasis degree and metastasis rate of lymph node(No.8a and No.8p), as well as intraoperative and postoperative presentations in both groups were investigated. The prognosis of two groups were analyzed with Kaplan-Meier method and Log-rank test. RESULTS: Among 1158 patients with advanced gastric cancer, 849 were males and 309 were females with aged 17 to 83(58.5 ±11.7) years. Radical distal gastrectomy was performed in 325 cases (28.1%) and radical total gastrectomy in 833 cases(71.9%). All the patients completed operations successfully. A total of 2587 No.8a lymph nodes were removed, and the lymph node metastasis rate and metastasis degree of No.8a were 20.6% (239/1158) and 13.0%(336/2587), respectively. A total of 2170 No.8p lymph nodes were removed, and the lymph node metastasis rate and metastasis degree of No.8p were 10.9%(89/815) and 7.2%(156/2170), respectively. The operation time of the No.8a+No.8p group was longer than that of No.8a group [(180.2±40.3) minutes vs. (168.4±41.8) minutes], and the difference was statistically significant (t=-4.627, P=0.000). However, intraoperative blood loss [(222.8±92.8) ml vs. (215.6±91.1) ml], postoperative 1-day peritoneal drainage volume [(257.7±120.0) ml vs. (270.3±121.0) ml], time to withdraw of gastric tube [(2.1±0.9) days vs. (2.2±0.8) days], time to withdraw of peritoneal tube [(6.8±1.1) days vs. (6.9±1.1) days], time to withdraw of nasal feeding tube[(6.5±1.2) days vs. (6.4±1.1) days], the morbidity of complications [19.8%(68/343) vs. 16.0%(130/815)] and postoperative hospital stay [(8.1±3.0) days vs.(8.3±3.1) days] in No.8a group and No.8a+No.8p group were not significantly different(all P>0.05). The average follow-up period was 41(2 to 144) months. The median postoperative survival was 83.0 months, and the 1-, 2-, and 5-year survival rates were 90.9%, 78.8% and 56.9% in No.8a group respectively. The median survival was 94.8 months, 1-, 2-, and 5-survival rates were 94.9%, 82.3% and 63.0% in No.8a+No.8p group respectively. The survival rate of No.8a+No.8p group was significantly higher than that of No.8a group (P=0.016). The stratified analysis showed that in stage II patients, the survival rate of No.8a+No.8p lymph node dissection was significantly higher than that of only No.8a lymph node dissection(P=0.021), but difference of survival between two groups was not significantly different in stage I patients(P=0.469) and stage III patients (P=0.820). CONCLUSION: For the patients with advanced gastric cancer, the dissection of No.8a+No.8p is safe and feasible, and may improve the prognosis, especially for those with stage II, suggesting that No.8a+No.8p lymphadenectomy should be performed for selected patients with advanced gastric cancer.

[D2 radical resection of omental bursa and No.12p and No.8p for gastric carcinoma: a retrospectively analysis from a single center in China].

OBJECTIVE: To evaluate the safty and feasibility of the D2 radical resection of omental bursa and No.12p and No.8p for gastric carcinoma (GC). METHODS: Clinical data of 1801 GC patients undergoing D2 radical resection of omental bursa and No.12p and No.8p at Fujian Medical University Cancer Hospital from January 2000 to January 2010 were analyzed retrospectively. Inclusion case criteria: (1)age of 18 to 90 years;(2)pathologically diagnosed as GC and receiving D2 radical resection of omental bursa and No.12p and No.8p;(3)complete clinical, pathological and follow-up data; (4)operation performed by same leading surgeon;(5)exclusion of other gastric malignancies, postoperative relapse of GC, and other simultaneous or heterochronous primary malignancies. Surgical procedure points: (1)The outer part of the peritoneum of duodenum descending was cut; the serosa was migrated to the anterior leaf of the gastrointestinal ligament. (2)The posterior lobe of the gastrocolic ligament and the transverse mesocolon were separated bluntly from left side to reach the omentum attaching to the colon portion; incision was made at the edge of the omentum attaching to the transverse colon behind the gastrocolic ligament; the leaves were turned to the anterior mesenteric anterior leaflets, and the entire anterior leaflet of the transverse mesentery was free.(3)The pancreas was separated, and resection of the posterior wall of the omentum sac continued up so that the entire retinal capsule was free; along the edge of the liver the attachment of the omentum was cut to reach the front of esophagus, and transverse incision was made in abdominal peritoneal layer of the esophagus, and then turned to the spleen on the pole; from the obturator to the esophagus incision was performed behind the peritoneum for the net; the uppermost edge of the resection of the capsule was performed as the posterior peritoneal incision to the right edge of the esophagus and was connected with the posterior parietal lobe of the previous resection; the posterior peritoneum was attached along the right edge of the esophagus and descended to the celiac artery; the posterior wall of the omental sac was removed. In the meantime, the liver duodenum ligament was cut, and the portal vein, hepatic artery trilocular was formed. Then the ligament lymph nodes were cleared.(4)The lymph nodes of celiac artery and its major branches were cleared; the envelope in front of pancreas and the part of the pancreas in posterior abdomen were resected; spleen and part of the pancreas tail were free. RESULTS: A total of 1801 cases were enrolled, including 1292 males and 509 females with a ratio of 2.54 with a mean age of(58.9±11.5)(18 to 89) years. The proportion of cases with T1a, T1b, T2, T3, T4a and T4b was 4.8% (87 cases), 6.6% (118 cases), 10.7% (193 cases), 17.5% (315 cases), 55.7% (1003 cases) and 4.7%(85 cases) respectively. All the patients completed operations successfully. The mean number of harvested lymph node was 28.5±13.7(10 to 85). Lymph node metastasis was found in 1439 cases (79.9%), including 180 cases (10.0%) in No.12p and 232 cases(12.9%) in No.8p respectively. Subgroup analysis showed that in T1a, T1b, T2, T3, T4a and T4b stage, the proportion of No.12p was 0, 1.7% (2/118), 5.2%(10/193), 10.5% (33/315), 12.4% (124/1003) and 12.9%(11/85) respectively, and the proportion of No.8p was 0, 0.8%(1/118), 2.1%(4/193), 4.8%(15/315), 18.9%(190/1003), and 25.9%(22/85) respectively. Postoperative complications were found in 195 patients (10.8%), including 63 cases(3.5%) of peritoneal infection, 52 cases (2.9%) of pulmonary infection, 33 cases(1.8%) of pancreatic leakage, 37 cases (2.1%) of anastomotic fistula, 45 cases (2.5%) of intestinal obstruction and 13 cases(0.7%) of gastroplesia. The 5-year overall survival rate was 53.6%. CONCLUSION: D2 radical resection of omental bursa and No.12p and No.8p is safe and feasible in the treatment of gastric cancer.

[Analysis of risk factors and prognosis of No.8p lymph node metastasis in cases with advanced gastric cancer].

OBJECTIVE: To explore the risk factors and prognosis of No.8p lymph node metastasis in cases with advanced gastric cancer. METHODS: Clinicopathological and follow-up data of 790 cases with advanced gastric cancer undergoing gastrectomy (including No.8p lymphadenectomy) from October 2003 to October 2013 in Fujian Provincial Tumor Hospital were analyzed retrospectively. Patients receiving neoadjuvant chemotherapy were excluded. Associations of No.8p lymph node metastasis with clinicopathological characteristics and metastasis in other regional lymph node were analyzed. Prognostic difference between positive No.8p group and negative No.8p group was examined. RESULTS: Positive No.8p lymph node was found in 93 cases (11.8%) among 790 cases with advanced gastric cancer. Univariate analysis showed that gender [male 9.8%(56/572) vs. female 17.0%(37/218), P=0.005], preoperative CEA level [<5 µg/L 28.0%(61/218) vs. ≥5 µg/L 5.6%(32/572), P=0.005], tumor size[diameter <5 cm 3.8%(13/346) vs. ≥5 cm 18.0%(80/445), P=0.000], tumor location [gastric fundus and cardiac 10.7% (26/244) vs. gastric body 13.5% (30/222) vs. gastric antrum 10.1% (31/308) vs. total gastric 37.5%(6/16), P=0.007], Borrmann staging [type II( 1.9%(4/211) vs. type III( 11.6% (54/464) vs. type IIII( 30.4%(35/115), P=0.000], tumor differentiation [high 0/8 vs. moderate 6.7%(25/372) vs. low 16.6%(68/410), P=0.000], T staging [T2 2.4%(4/170) vs. T3 13.1%(35/267) vs. T4 15.3%(54/353), P=0.000], N staging [N0 0 (0/227) vs. N1 2.2%(5/223) vs. N2 15.2%(26/171) vs. N3 36.7%(62/169), P=0.000] were closely associated with the No.8p lymph node metastasis. Multivariate analysis that revealed gender (OR=1.762, 95%CI: 1.020-3.043), tumor size (OR=1.107, 95%CI: 1.020-1.203), N staging (OR=4.093, 95%CI: 2.929-5.718), tumor differentiation (OR=1.782, 95%CI:1.042-3.049), and metastasis in No.8a(OR=5.370, 95%CI: 3.425-8.419), No.3(OR=1.127, 95%CI:1.053-1.206), No.6(OR=1.221,95%CI: 1.028-1.450), No.7(OR=2.149, 95%CI: 1.711-2.699), No,11p(OR=2.085, 95%CI: 1.453-2.994), No.14v(OR=2.604, 95%CI: 1.038-6.532) group lymph nodes were the independent risk factors of No.8p lymph node metastasis. One-year, 3-year and 5-year survival rates in positive No.8p group were 85.7%, 47.5% and 22.6%, and those in negative No.8p group were 96.2%, 82.5% and 70.3% respectively, whose differences were significant (χ2=109.767, P<0.05). CONCLUSIONS: Metastasis in Np.8p lymph nodes is an important factor affecting the prognosis of patients with advanced gastric cancer. In patients with female gender, tumor diameter ≥5 cm, preoperative late N staging, low tumor differentiation or metastasis in No.8a, No.3, No.6, No.7, No.11p, No.14v group lymph nodes, thorough clean rance of No.8p group lymph node should be considered.

Prognostic significance of pretreatment serum carcinoembryonic antigen levels in gastric cancer with pathological lymph node-negative: A large sample single-center retrospective study.

AIM: To assess whether elevated serum carcinoembryonic antigen (CEA) is in the inferior prognosis for pathological lymph node-negative (pN0) gastric cancer (GC) patients who underwent D2 gastrectomy. METHODS: About 469 pN0 GC patients, who received D2 radical gastrectomy were retrospectively analyzed. The X-tile plots cut-off point for CEA were 30.02 ng/mL using minimum P-value from log-rank χ2 statistics, and pN0 GC patients were assigned to two groups: those more than 30.02 ng/mL (n = 48; CEA-high group) and those less than 30.02 ng/mL (n = 421; CEA-low group). Clinicopathologic characteristics were compared using Pearson's χ2 or Fisher's exact tests, and survival curves were so manufactured using the Kaplan-Meier method. Univariate and multivariate analysis were carried out using the logistic regression method. RESULTS: The percentage of vessel carcinoma embolus (31.35% vs 17.1%) and advanced GC (T2-4b) (81.25% vs 65.32%) were higher in CEA-high group than CEA-low group. The CEA-positive patients had a significantly poorer prognosis than the CEA-nagetive patients in terms of overall survival (57.74% vs 90.69%, P < 0.05), and no different was found between subgroup of T category, differentiation, nerve invasion, and vessel carcinoma embolus (all P > 0.05). Multivariate survival analysis showed that CEA (OR = 4.924), and T category (OR = 2.214) were significant prognostic factors for stage pN0 GC (all P < 0.05). Besides, only T category (OR = 1.962) was an independent hazard factor in the CEA-high group (P < 0.05). CONCLUSION: Those pretreatment serum CEA levels over 30.02 ng/mL on behalf of worse characteristics and unfavourable tumor behavior, and a poor prognosis for a nearly doubled risk of mortality in GC patients.