Genetic profiling of somatic alterations by Oncomine Focus Assay in Korean patients with advanced gastric cancer.

Gastric cancer is one of the leading causes of cancer-associated death; however, analysis of its molecular and clinical characteristics has been complicated by its histological and etiological heterogeneity. The present study aimed to estimate somatic mutation profiling in gastric cancer. To do so, targeted next-generation sequencing (NGS) was performed with the Oncomine Focus Assay to compare the clinicopathological characteristics with the mutation profiles in 50 patients with advanced gastric cancer (AGC). Among the 35 hotspot genes and 19 genes for copy number variations (CNVs), 18 single nucleotide variants (SNVs) or small insertions and deletions (14 missense and four frameshift mutations), and 10 amplifications were identified. To examine the association between mutation profiles and clinicopathological characteristics, each element of the clinicopathological characteristics was categorized into three groups: No alteration, PI3K catalytic subunit α (PIK3CA) alterations and alterations other than PIK3CA. Fisher's exact test identified no statistical differences between the clinicopathological characteristics, with the exception of the Tumor-Node-Metastasis (TNM) T stage between the three groups. Cases of AGC with somatic alterations but no PIK3CA exhibited a significant difference in the TNM T stage compared with those with no alterations or PIK3CA alterations (P=0.044). In addition, AGC with PIK3CA alterations was categorized by Lauren's classification to the intestinal type only. The distribution of Lauren's classification in AGC with PIK3CA alterations was statistically different compared with AGC with alterations other than PIK3CA (P=0.028), but not compared with AGC with no alterations (P=0.076). In conclusion, the present study demonstrated a molecular profiling approach that identified potential molecular classifications for gastric cancer and suggested a framework for precision medicine in AGC.

Genetic Characterization of Molecular Targets in Korean Patients with Gastrointestinal Stromal Tumors.

PURPOSE: Gastrointestinal stromal tumors (GISTs) frequently harbor activating gene mutations in either KIT or platelet-derived growth factor receptor A (PDGFRA) and are highly responsive to several selective tyrosine kinase inhibitors. In this study, a targeted next-generation sequencing (NGS) assay with an Oncomine Focus Assay (OFA) panel was used for the genetic characterization of molecular targets in 30 Korean patients with GIST. MATERIALS AND METHODS: Using the OFA that enables rapid and simultaneous detection of hotspots, single nucleotide variants (SNVs), insertion and deletions (Indels), copy number variants (CNVs), and gene fusions across 52 genes relevant to solid tumors, targeted NGS was performed using genomic DNA extracted from formalin-fixed and paraffin-embedded samples of 30 GISTs. RESULTS: Forty-three hotspot/other likely pathogenic variants (33 SNVs, 8 Indels, and 2 amplifications) in 16 genes were identified in 26 of the 30 GISTs. KIT variants were most frequent (44%, 19/43), followed by 6 variants in PIK3CA, 3 in PDGFRA, 2 each in JAK1 and EGFR, and 1 each in AKT1, ALK, CCND1, CTNNB1, FGFR3, FGFR4, GNA11, GNAQ, JAK3, MET, and SMO. Based on the mutation types, majority of the variants carried missense mutations (60%, 26/43), followed by 8 frameshifts, 6 nonsense, 1 stop-loss, and 2 amplifications. CONCLUSIONS: Our study confirmed the advantage of using targeted NGS with a cancer gene panel to efficiently identify mutations associated with GISTs. These findings may provide a molecular genetic basis for developing new drugs targeting these gene mutations for GIST therapy.

Current Status of Bariatric and Metabolic Surgery in Daejeon and Chungcheong Province: Early Experiences after Public Medical Insurance Coverage in 2019.

Purpose: This study aimed to investigate the current status of bariatric and metabolic surgery in Daejeon and Chungcheong province and to describe the early experiences after public medical insurance coverage in 2019. Materials and Methods: Between January 2019 and August 2019, 64 cases of bariatric and metabolic surgery were performed in patients with morbid obesity or uncontrolled type 2 diabetes. We prospectively collected and analyzed data regarding the patients' demographics and comorbidities, surgical results, and early complications. The patient information before and after the insurance coverage was also compared. Results: The number of surgeries in 9 years has been caught up only in the last 8 months after insurance coverage (58 vs. 64 patients). The mean body mass index was 37.7±5.8 kg/m2 (range, 22.7-52.1 kg/m2). The most frequently performed surgery was sleeve gastrectomy (53 cases, 82.8%), followed by Roux-en-Y gastric bypass (9 cases, 14.1%), and adjustable gastric banding (2 cases, 3.1%). Postoperative complications occurred in 6 patients (9.4%), and there was no mortality. The mean operation time (225.3±85.4 vs. 156.1±61.8 min, P<0.001) and postoperative stay (5.9±4.5 vs. 4.3±2.0 days, P=0.013) after the insurance coverage were significantly shorter than those before the insurance coverage. Conclusion: We could assess the patients who had bariatric and metabolic surgery in Daejeon and Chungcheong province after public medical insurance coverage in 2019.

Regional Lymph Node Dissection as an Additional Treatment Option to Endoscopic Resection for Expanded Indications in Gastric Cancer: a Prospective Cohort Study.

PURPOSE: Expanded indications for endoscopic submucosal dissection (ESD) in early gastric cancer (EGC) remain controversial due to the potential risk of undertreatment after adequate lymph node dissection (LND). Regional LND (RLND) is a novel technique used for limited lymphadenectomy to avoid gastrectomy. This study established the safety and effectiveness of RNLD as an additional treatment option after ESD for expanded indications. MATERIALS AND METHODS: A total of 69 patients who met the expanded indications for ESD were prospectively enrolled from 2014 to 2017. The tumors were localized using intraoperative esophagogastroduodenoscopy (EGD) before RLND. All patients underwent RLND first, followed by conventional radical gastrectomy with LND. The locations of the preoperative and intraoperative EGD were compared. Pathologic findings of the primary lesion and the RLND status were analyzed. RESULTS: The concordance rates of tumor location between the preoperative and intraoperative EGD were 79.7%, 76.8%, and 63.8% according to the longitudinal, circumferential, and regional locations, respectively. Of the 4 patients (5.7%) with metastatic LNs, 3 were pathologically classified as beyond the expanded indication for ESD and 1 had a single LN metastasis in the regional lymph node. CONCLUSIONS: RLND is a safe additional option for the treatment of EGC in patients meeting expanded indications after ESD.

Efficacy of an antiadhesive agent for the prevention of intra-abdominal adhesions after radical gastrectomy: A prospective randomized, multicenter trial.

BACKGROUND: Guardix-SG is a poloxamer-based antiadhesive agent. The aim of this study was to investigate its efficacy in preventing abdominal adhesions in gastric cancer patients undergoing gastrectomy. Few clinical studies have reported that antiadhesive agent reduces the incidence of adhesion after gastrectomy. METHODS: We conducted a multicenter trial from June 2013 and August 2015 in patients with gastric adenocarcinoma undergoing radical gastrectomy. Patients were randomly assigned to the Guardix treatment or control group. Postoperative adhesions were diagnosed based on postoperative symptoms, plain x-ray films, and computed tomography. The primary endpoint of the study was the incidence of small bowel obstruction in the first postoperative year. The secondary end-point was the safety of Guardix-SG. RESULTS: The study included 109 patients in the Guardix group and 105 patients in the control group. The groups were similarly matched with pathological stage, operation type, anastomosis method, midline incision length, and the extent of lymph node dissection. Eight in the Guardix group and 21 in the control group experienced intestinal obstruction during the 1-year follow-up period. The cumulative incidence of small bowel obstruction was significantly lower in the Guardix group compared to that seen in the control group (4.7% vs 8.6% at 6 months and 7.3% vs 20% at 1 year; P = .007, log-rank test). There were no differences in postoperative complications and adverse events. CONCLUSION: Guardix-SG significantly decreased the incidence of intestinal obstruction without affecting the incidence of postoperative complications.

Metabolic and Bariatric Surgery Accreditation Program and National Health Insurance System in Korea.

Since the first laparoscopic bariatric surgery in Korea introduced in January 2003, the number of metabolic and bariatric surgery has been steadily increasing. According to the report from National Health Insurance big data analysis, the prevalence of morbid and super obesity has greatly increased and metabolic and bariatric surgery also increased in the last 10 years. As the incidence of morbid obesity is more frequent in people of poor socioeconomic status, the need for a reimbursement by the government seemed to be necessary. Finally, the national health insurance system decided to financially cover metabolic and bariatric surgery from January 2019. In order to improve the safety and qualify of metabolic and bariatric surgery, the Korean Society for Bariatric and Metabolic Surgery (KSMBS) introduced surgeon's and institution's accreditation system. The authors intend to introduce comprehensive overview of accreditation system of bariatric surgery and discuss the contents of national health insurance for metabolic and bariatric surgery.

Radical Gastrectomy After Chemotherapy May Prolong Survival in Stage IV Gastric Cancer: A Korean Multi-institutional Analysis.

ABASTRACT: BACKGROUND: Despite the development of newer treatments, the prognosis for patients with stage IV gastric cancer remains grave. This study evaluated the efficacy of gastrectomy following response to chemotherapy in patients with stage IV gastric cancer. METHODS: A total of 419 patients who were diagnosed with stage IV gastric cancer were identified from the multi-institutional Catholic Gastric Cancer Study Group database. The patients were divided into four groups: 212 were in the chemotherapy only (CTx) group, 124 were in the chemotherapy after palliative gastrectomy (G-CTx) group, 23 were in the radical gastrectomy after chemotherapy (CTx-G) group, and 60 were in the best supportive care group. To compensate for the effects of chemotherapy, cases of chemotherapy responsive were analyzed separately. To identify factors affecting survival rates, cure rates for surgery in the surgery group were analyzed. RESULTS: The 3-year survival rate of the CTx-G group was significantly higher than that of the CTx group (42.8 vs. 12.0%, p = 0.001). Moreover, the CTx-G group's 3-year survival rate was greater than that of the G-CTx group (42.8 vs. 37.1%, p = 0.207). Chemotherapy-responsive patients in the CTx-G group had a better 3-year survival rate than those in the G-CTx group (46.1 vs. 18.4%, respectively, p = 0.011). In the surgery group, R0 resection led to a significantly better 3-year survival rate than palliative gastrectomy (61.1 vs. 16.2%, p = 0.003). CONCLUSIONS: Adjuvant surgery might improve the survival rate of patients with stage IV gastric cancer, particularly in R0 resection cases.

Acid Secretion and Its Relationship to Esophageal Reflux Symptom in Patients with Subtotal Gastrectomy.

BACKGROUND: Esophageal reflux symptom has been reported as common in patients with subtotal gastrectomy. Management of postoperative esophageal reflux symptom is not satisfactory. The aim of this study is to investigate prevalence of esophageal reflux symptom after subtotal gastrectomy and assess factors affecting esophageal reflux symptom in subtotal gastrectomy patients. METHODS: We prospectively enrolled 100 consecutive patients with subtotal gastrectomy who were regularly followed up by endoscopic examination. Acid secretory capacity was assessed by measuring messenger RNA (mRNA) expression of H+/K+-adenosine triphosphatase (ATPase) via real-time polymerase chain reaction (PCR) in biopsy specimens. RESULTS: In total, 47 % of patients had typical esophageal reflux symptom, where heartburn or regurgitation was experienced at least weekly. Age, sex, body mass index, and type of reconstruction did not differ between esophageal reflux and non-esophageal-reflux groups. The esophageal reflux group had longer duration from time of operation until study (median 5.0 versus 3.6 years; P = 0.017). Hill grade for gastroesophageal (GE) flap valve was higher in the esophageal reflux group than in the non-esophageal-reflux group (P = 0.027). H+/K+-ATPase mRNA expression was higher in the esophageal reflux group than in the non-esophageal-reflux group [3967.6 (± 7583.7) versus 896.2 (± 1456.0); P = 0.006]. Multivariate analysis revealed that postoperative duration, H+/K+-ATPase mRNA expression level, and GE flap valve disruption were significantly associated with esophageal reflux symptom development. CONCLUSIONS: Esophageal reflux symptom is common in patients after subtotal gastrectomy, possibly because of anti-reflux-barrier impairment and preservation of acid secretory capacity following surgery. Optimal acid suppression may be helpful in managing postoperative esophageal reflux symptom.

Distribution of somatic mutations of cancer-related genes according to microsatellite instability status in Korean gastric cancer.

In studies of the molecular basis of gastric cancer (GC), microsatellite instability (MSI) is one of the key factors. Somatic mutations found in GC are expected to contribute to MSI-high (H) tumorigenesis. We estimated somatic mutation distribution according to MSI status in 52 matched pair GC samples using the Ion Torrent Ion S5 XL with the AmpliSeq Cancer Hotspot panel.Seventy-five (9.8%) somatic variants consisting of 34 hotspot mutations and 41 other likely pathogenic variants were identified in 34 GC samples. The TP53 mutations was most common (35%, 26/75), followed by EGFR (8%, 6/75), HNF1A (8%, 6/75), PIK3CA (8%, 6/75), and ERBB2 (5%, 4/75). To determine MSI status, 52 matched pair samples were estimated using 15 MSI markers. Thirty-nine MS stable (S), 5 MSI-low (L), and 8 MSI-H were classified. GCs with MSI-H tended to have more variants significantly compared with GCs with MS stable (MSS) and MSI-L (standardized J-T statistic  =  3.161 for number of variants; P  =  .002). The mean number of all variants and hotspot mutations per tumor samples only in GCs with MSI-H were 3.9 (range, 1-6) and 1.1 (range, 0-3), respectively. Whereas, the mean number of all variants and hotspot mutations per tumor samples only in GCs with MSS/MSI-L were 1 (0-5)/0.8 (0-1) and 0.5 (0-3)/0.8 (0-1), respectively.In conclusion, GC with MSI-H harbored more mutations in genes that act as a tumor suppressor or oncogene compared to GC with MSS/MSI-L. This finding suggests that the accumulation of MSIs contributes to the genetic diversity and complexities of GC. In addition, targeted NGS approach allows for detection of common and also rare clinically actionable mutations and profiles of comutations in multiple patients simultaneously. Because GC shows distinctive patterns related to ethnics, further studies pertaining to different racial/ethnic groups or cancer types may reinforce our investigations.

Evaluation of the Three Customized MSI Panels to Improve the Detection of Microsatellite Instability in Gastric Cancer.

BACKGROUND: We designed and evaluated the suitability of three customized microsatellite instability (MSI) panels using a combination of mono- and dinucleotide markers to improve the detection of MSI status in 56 matched normal and gastric cancer specimens. METHODS: An MSI analysis was performed to optimize the panel of microsatellite markers to detect instability using two different microsatellite panels: (1) mononucleotide marker panel consisting of mononucleotide markers BAT25, BAT26, BAT40, BAT-RII, NR21, NR22, NR24, and NR27 and (2) dinucleotide marker panel containing D2S123, D5S346, D17S250, D17S261, D17S520, D18S34, and D18S58. The customized panels consisted of five, seven, or ten markers with two, three, or four mononucleotide markers, respectively, among fifteen MSI markers described above to fulfill the MSI-H and MSI-L definition based on the revised Bethesda Guidelines. The "Proposal5" panel consisted of BAT40, BAT26, D18S34, D2S123, and D17S520. "Proposal-7" consisted of "Proposal-5" with BAT25 and D18S58. "Proposal-10" consisted of "Proposal-7" with NR27, D17S250, and D17S261. RESULTS: Immunohistochemical staining for MMR protein expressions such as mutL homolog 1 (MLH1) and mutS homolog 2 (MSH2) revealed that among 56 matched specimens, 13 had defective DNA mismatch repair (MMR) proteins and 43 had proficient MMR proteins. Out of thirteen specimens with defective MMR expression, eight specimens (62%, 8/13) were classified as MSI-H with an instability at ≥ 6 markers and five (38%, 5/13) were MSIL with instability at ≤ 5 markers using all fifteen MSI markers. On the other hand, the analytical sensitivity and specificity of all three customized panels to detect MMR-deficient specimens were 92% (12/13) and 100% (43/43), respectively. In comparison, the sensitivity and specificity of the Bethesda and QMR panels were 62% (8/13) and 100% (43/43). All customized panels could represent the detection of MSI-L tumors rather than the Bethesda and the QMR panels. CONCLUSIONS: The increased sensitivity to detect MSI-unstable tumors with customized panels including BAT40 and D18S34 indicates that precise MSI screening to discriminate MSI-H from MSS and MSI-L may be feasible for gastric cancer.

Radiofrequency ablation for liver metastases in patients with gastric cancer as an alternative to hepatic resection.

BACKGROUND: The purpose of this retrospective study was to determine whether RFA could provide an alternative treatment modality for selected patients who are not candidates for hepatic resection. METHODS: A total of 18 consecutive patients with liver metastases alone from gastric cancer treated with radiofrequency ablation (RFA, n = 11) or hepatic resection (HR, n = 7) at Seoul St. Mary's Hospital, Korea, between January 2000 and September 2014, were enrolled. RESULTS: The median OS and DFS in the RFA group were 40.5 ± 22.3 and 10.3 ± 1.07 months, respectively. There was no significant difference between the RFA and HR groups in terms of baseline characteristics except for performance status. Mean survival and DFS times of all patients were 60.1 ± 9.4 and 40.9 ± 10.2 months, respectively. Mean OS times in the HR and RFA groups were 67.5 ± 15.4 and 51.1 ± 9.8 months (P = 0.671), respectively, and the mean DFS time in the HR group (74.1 ± 14.2 months) was longer than that in the RFA group (26.9 ± 9.2 months), but the difference was not significant (P = 0.076). CONCLUSIONS: In patients who are not candidates for surgical treatment, RFA may be an alternative to HR.

Fracture after gastrectomy for gastric cancer: A long-term follow-up observational study.

AIM: Gastrectomy is a known risk factor for decreased bone mass. We aimed to evaluate the cumulative incidence and predictive factors of fracture in gastric cancer patients who underwent gastrectomy. METHOD: We retrospectively reviewed the records of 1687 patients who underwent gastrectomy for gastric cancer at our hospital between September 1991 and December 2008. The exclusion criteria were stage IV gastric cancer, history of cancer recurrence, medical conditions that cause osteoporosis and high-energy injury. Fractures at sites considered to be associated with osteoporosis were diagnosed radiologically. RESULTS: In total, our analysis included the records of 1131 patients. The incidence of postgastrectomy fracture was 42.1 cases per 1000 person-years. Fractures typically occurred within 3.7 ± 0.5 years postoperatively. The cumulative incidence of fracture was 9.1%, 19.7%, and 37.3% by postoperative year 2, 4, and 6, respectively. During the following years, the cumulative incidence increased slowly, up to a final 40.6%. Multivariate analysis showed that older age (hazard ratio, 1.03; 95% confidence interval, 1.01-1.04) and smoking (hazard ratio, 1.35; 95% confidence interval, 1.05-1.73) were significantly associated with fracture, whereas sex, body mass index, percent weight loss, diabetes mellitus, tumour stage, and type of gastrectomy were not. CONCLUSION: The cumulative incidence of fracture is high in gastric cancer patients who have undergone gastrectomy, and fracture rate is higher during the early postoperative period. Old age and smoking are independent risk factors for postgastrectomy fracture in these patients. More detailed postoperative surveillance and pharmacological intervention should be considered to prevent fracture.

Limited significance of curative surgery in Borrmann type IV gastric cancer.

Borrmann type IV advanced gastric cancer has a poor prognosis. Although surgical resection remains the only hope for a cure, the role of curative surgery is questionable in this type of cancer. This study defined the role of curative surgery in the prognosis of type IV gastric cancer. We analyzed 168 patients with Borrmann type IV undergoing surgery at Seoul St. Mary's Hospital from 1989 to 2010. We categorized the patients into curative (R0) and non-curative (R1, R2, and non-resection) groups. The curative and non-curative groups comprised 88 and 80 patients, respectively. The preoperative predictive value of Borrmann type IV was 50.5, and 8.9 % of the patients had microscopic resection margin involvement. The 3- to 5-year overall survival (OS) of patients in the curative group was significantly higher than that of in the non-curative group (p < 0.001). However, in a multivariate analysis, curability was not a significant predictor of survival (p = 0.187). In the curative group, the most frequent recurrence site was the peritoneum (85.7 %). Most recurrences occurred within 2 years. The role of surgery for Borrmann type IV is quite limited. Such cases have a poor prognosis even after curative surgery. In addition, microscopic resection margin involvement is frequent in type IV cancer because it is difficult to diagnose preoperatively. Therefore, multimodal diagnostic tools and treatment strategies should be developed for Borrmann type IV gastric cancer.

Conditional survival analysis in Korean patients with gastric cancer undergoing curative gastrectomy.

BACKGROUND: Conditional survival (CS) measures the probability that patients will survive an additional number of years given that they have already survived for a certain period of time. METHODS: In total, 2935 gastric cancer patients who had undergone curative gastrectomy between 1995 and 2011 were enrolled. The Cox proportional hazard regression model was used to evaluate the factors associated with overall survival (OS). Three-year CS estimates at 't' years after surgery were calculated as follows: CS(t) = S(t + 3)/S(t). RESULTS: The 1-, 2-, 3-, 4- and 5-year OS rates of the 2935 patients were 96.6 %, 92.0 %, 88.7 %, 85.6 and 82.7 %, respectively. The probability of surviving an additional 3 years on the condition of having already survived 1, 2, 3, 4 and 5 years after surgery were 88.6 %, 89.9 %, 91.0 %, 92.2 % and 93.2 %, respectively. Patients with a higher risk at baseline showed a greater increase in CS over time. CONCLUSIONS: CS estimates provide important information about dynamic prognostic changes over time for Korean gastric cancer patients, and as such, can be used to guide long-term follow-up strategies.

Changes of lipid profiles after radical gastrectomy in patients with gastric cancer.

BACKGROUND: We investigated the changes of lipid profiles after radical gastrectomy. METHODS: We analyzed the lipid-profile changes after radical gastrectomy in 144 patients with gastric cancer. Their lipid profiles, including total cholesterol (TC), triglyceride (TG), LDL-cholesterol (LDL), and HDL-cholesterol (HDL), were evaluated preoperatively as well as 6 and 12 months postoperatively. We compared the changes of lipid profile according to the reconstruction type and resection extent. RESULTS: The TC level had decreased 6 months after surgery, and remained unchanged thereafter. The LDL level also had decreased 6 months after surgery, but had increased again after 12 months after surgery. The HDL level had increased 12 months after surgery, whereas the TG level was unchanged. In a comparison of the lipid levels according to the reconstruction type or resection extent, the HDL level significantly differed by reconstruction type 12 months after surgery: it was markedly higher in the total gastrectomy than in the subtotal gastrectomy group both 6 months and 12 months after surgery. Both the male gender and total gastrectomy were associated with probability of normalization of LDL after surgery. CONCLUSIONS: The lipid profiles including the TC, LDL and HDL levels were changed after radical gastrectomy; therefore, after this procedure, the lipid profiles of patients with hyperlipidemia should be evaluated.

The Platelet-to-Lymphocyte Ratio Versus Neutrophil-to-Lymphocyte Ratio: Which is Better as a Prognostic Factor in Gastric Cancer?

BACKGROUND: As indicators of the systemic inflammatory response, the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) have been proposed to predict the clinical outcome in some cancers. The purpose of this study was to investigate the impact of NLR and PLR on the prognosis of gastric cancer. METHODS: From 2000 to 2009, 1986 consecutive patients who underwent curative surgery for gastric cancer were enrolled. The optimal cutoff value of PLR and NLR was determined according to receiver operating characteristic analysis. We categorized the patients into the high or low PLR and NLR group based on the cutoff value, and the clinical features of these two groups were comparatively analyzed. RESULTS: The high NLR and PLR groups were significantly associated with poor prognosis. The NLR was an independent prognostic factor for overall survival [hazard ratio (HR) = 1.403; p = 0.023]; however, the PLR was not (p = 0.788). CONCLUSIONS: Although both the PLR and NLR can reflect the prognosis, the NLR is more predictive of overall survival than the PLR.

Gastric Malignant Peripheral Nerve Sheath Tumor: A Case Report.

Gastric malignant peripheral nerve sheath tumors (MPNSTs) are sarcomas arising within a peripheral nerve. Gastric MPNSTs are extremely rare with only a few cases. We herein describe the case of a 48-year-old man with a gastric MPNST for the first time in Korea, which was diagnosed histopathologically after surgery. The patient underwent curative subtotal gastrectomy with D1+ lymph node dissection and Billroth-II reconstruction. The postoperative recovery was uneventful, and he has had no recurrence until now. The ideal adjuvant treatment protocol is yet to be decided due to the relatively limited number of cases of these tumors previously reported.

Optimal prophylactic method of venous thromboembolism for gastrectomy in Korean patients: an interim analysis of prospective randomized trial.

BACKGROUND: Whereas routine prophylaxis for venous thromboembolism (VTE) is frequently utilized in the West, Asian physicians employ it much less often, based on its recorded rarity amongst their patients. This study was designed to examine the incidence of VTE and to determine the optimal method of thromboembolic prophylaxis following gastrectomy for cancer. METHODS: In this prospective, randomized trial, patients were assigned to either an intermittent pneumatic compression (IPC) only or an IPC plus enoxaparin. The primary end point of this study was to determine the VTE incidence rate within 30 days of surgery. A history with physical examinations for VTE and a serum d-dimer test was scheduled on postoperative days (POD) 0, 1, 4, and 7. Duplex ultrasonography (DUS) was performed as an objective test for deep vein thrombosis at POD 4. An interim analysis was performed to determine if it was ethical to continue the study. This clinical trial was registered at www.clinicaltrials.gov (NCT01448746). RESULTS: Among the 220 patients, 3 (all from the IPC group) were diagnosed with VTE; these cases were asymptomatic, having been detected only on DUS 4 days after surgery. Postoperative bleeding occurred in 12 cases, among which 11 patients were in the IPC plus enoxaparin group. CONCLUSIONS: This interim analysis showed a higher incidence of VTE in the IPC group but a higher bleeding rate in the IPC plus enoxaparin group. We expect that this study, once completed, will provide information key to the determination of the optimal method for preventing VTE in Korean gastric cancer patients.

Roux-en-Y gastrojejunostomy after totally laparoscopic distal gastrectomy: comparison with Billorth II reconstruction.

PURPOSE: The purpose of this study was to compare Roux-en-Y (R-Y) reconstruction with Billroth-II (B-II) reconstruction after a totally laparoscopic distal gastrectomy (TLDG). METHODS: Eighty-one consecutive TLDG procedures were performed by a single surgeon and subsequently examined. Postoperative outcomes, clinicopathologic features, and postoperative endoscopic findings between the 2 groups were evaluated and compared. RESULTS: The mean operation time was not significantly higher in the R-Y than in the B-II group (P=0.396). Postoperative hospital stay was longer in the R-Y than in the B-II group (P=0.037). The severities of gastritis and bile reflux were reduced significantly in the R-Y group as compared with that in the B-II group (P<0.001). There was no significant difference in the amount of residual food between the 2 groups. CONCLUSIONS: R-Y reconstruction after TLDG appears to be a safe and feasible procedure, and is associated with a reduced severity of gastritis and bile reflux in the remnant stomach.

Risk of limited lymph node dissection in patients with clinically early gastric cancer: indications of extended lymph node dissection for early gastric cancer.

BACKGROUND: Laparoscopic gastrectomy is usually indicated in T1 N0-1 early gastric cancer (EGC). Limited lymph node dissection, such as D1+, is applied in these cases. However, preoperative staging is not always correct, and the risk of undertreatment thus exists. METHODS: Patients with clinically early gastric cancer (cEGC) who underwent gastrectomy with lymph node dissection of D2 and over were selected from 4,021 patients with gastric cancer. The station numbers of all metastatic lymph nodes (MLNs) were identified, and MLNs were classified into groups 1 and 2 (including lymph nodes of second tier and over) on the basis of the system of the Japanese Gastric Cancer Association, irrespective of the number of MLNs. Clinicopathological data were compared according to the existence of lymph node metastasis and the classification of MLNs. RESULTS: Of 1,308 patients with cEGC who fulfilled the inclusion criteria, 1,184 (90.5 %) were diagnosed pathologically with EGC. Among 126 patients with cEGC who were diagnosed with lymph node metastasis, 93 patients had only group 1 MLNs and 33 patients had group 2 MLNs. Tumor location in the proximal third of the stomach (odds ratio 5.450) and ulceration (odds ratio 11.928) were significant factors for group 2 metastasis. CONCLUSIONS: Extended lymph node dissection is recommended in cEGC with ulceration or disease located in the proximal third of the stomach.