Superior lymph node harvest by fluorescent lymphography during minimally invasive gastrectomy for gastric cancer patients with high body mass index.

BACKGROUND: Fluorescent lymphography (FL) using indocyanine green (ICG) allows for the visualization of all draining lymph nodes (LNs), thereby increasing LN retrieval. However, no studies have assessed the efficacy of FL in high body mass index (BMI) gastric cancer patients, even as LN yield decreases with increasing BMI in gastrectomy. This study aimed to investigate the influence of FL on LN retrieval in high BMI gastric cancer patients. METHODS: Gastric cancer patients who underwent laparoscopic or robotic gastrectomies from 2013 to 2021 were included. Patients were classified into two groups, with FL (FL group) or without FL (non-FL group). The effect of FL on LN retrieval was assessed by BMI. Inverse probability of treatment weighting (IPTW) was used to ensure comparability between groups. RESULTS: Retrieved LN number decreased as BMI increased regardless of FL application (P < 0.001). According to the IPTW analysis, the mean retrieved LN number was significantly higher in the FL group (48.4 ± 18.5) than in the non-FL group (39.8 ± 16.3, P < 0.001), irrespective of BMI. The FL group exhibited a significantly higher proportion of patients with 16 or more LNs (99.5%) than the non-FL group (98.1%, P < 0.001). The FL group also had a significantly higher proportion of patients with 30 or more LNs (86.6%) than the non-FL group (72.2%, P < 0.001). In both the normal and high-BMI patients, the FL group had a significantly larger percentage of patients with a higher nodal classification than the non-FL group. CONCLUSION: FL resulted in more LN retrieval, even in high BMI patients. FL ensures accurate staging by maintaining the appropriate retrieved LN number in high BMI gastric cancer patients.

Identifying the best candidates for reduced port gastrectomy.

BACKGROUND: Previous studies have focused on the non-inferiority of RPG compared with conventional port gastrectomy (CPG); however, we assumed that some candidates might derive more significant benefit from RPG over CPG. METHODS: We retrospectively analyzed the clinicopathological and perioperative parameters of 1442 patients with gastric cancer treated by gastrectomy between 2009 and 2022. The C-reactive protein level on postoperative day 3 (CRPD3) was used as a surrogate parameter for surgical trauma. Patients were grouped according to the extent of gastrectomy [subtotal gastrectomy (STG) or total gastrectomy (TG)] and lymph node dissection (D1+ or D2). The degree of surgical trauma, bowel recovery, and hospital stay between RPG and CPG was compared among those patient groups. RESULTS: Of 1442 patients, 889, 354, 129, and 70 were grouped as STGD1+, STGD2, TGD1+, and TGD2, respectively. Compared with CPG, RPG significantly decreased CRPD3 only among patients in the STGD1+ group (CPG: n = 653, 84.49 mg/L, 95% CI 80.53-88.45 vs. RPG: n = 236, 70.01 mg/L, 95% CI 63.92-76.09, P < 0.001). In addition, the RPG method significantly shortens bowel recovery and hospital stay in the STGD1+ (P < 0.001 and P < 0.001), STGD2 (P < 0.001 and P < 0.001), and TGD1+ (P = 0.026 and P = 0.007), respectively. No difference was observed in the TGD2 group (P = 0.313 and P = 0.740). CONCLUSIONS: The best candidates for RPG are patients who undergo STGD1+, followed by STGD2 and TG D1+, considering the reduction in CRPD3, bowel recovery, and hospital stay.

Investigating Distinct Skin Microbial Communities and Skin Metabolome Profiles in Atopic Dermatitis.

Atopic dermatitis (AD) is a chronic inflammatory skin disorder influenced by genetic predisposition, environmental factors, immune dysregulation, and skin barrier dysfunction. The skin microbiome and metabolome play crucial roles in modulating the skin's immune environment and integrity. However, their specific contributions to AD remain unclear. We aimed to investigate the distinct skin microbial communities and skin metabolic compounds in AD patients compared to healthy controls (HCs). Seven patients with AD patients and seven HCs were enrolled, from whom skin samples were obtained for examination. The study involved 16S rRNA metagenomic sequencing and bioinformatics analysis as well as the use of gas chromatography time-of-flight mass spectrometry (GC-TOF-MS) to detect metabolites associated with AD in the skin. We observed significant differences in microbial diversity between lesional and non-lesional skin of AD patients and HCs. Staphylococcus overgrowth was prominent in AD lesions, while Cutibacterium levels were decreased. Metabolomic analysis revealed elevated levels of several metabolites, including hypoxanthine and glycerol-3-phosphate in AD lesions, indicating perturbations in purine metabolism and energy production pathways. Moreover, we found a positive correlation between hypoxanthine and glycerol-3-phosphate and clinical severity of AD and Staphylococcus overgrowth. These findings suggest potential biomarkers for monitoring AD severity. Further research is needed to elucidate the causal relationships between microbial dysbiosis, metabolic alterations, and AD progression, paving the way for targeted therapeutic interventions.

Increased Risk of Dementia in Patients with Atopic Dermatitis: A Nationwide Population-Based Cohort Study.

Atopic dermatitis (AD) is a chronic inflammatory skin disorder with bimodal incidence peaks in early childhood and middle-aged and older adults. Few studies have focused on the risk of dementia in AD. The aims of this study were to analyse the incidence, and risk factors for dementia in patients with AD. This nationwide population-based retrospective cohort study enrolled 38,391 adults ≥ 40 years of age with AD and 2,643,602 controls without AD from the Korean National Health Insurance System (NHIS) database from 2009 to 2016. The cumulative incidence probability of all-cause dementia, Alzheimer's disease, or vascular dementia at 8 years was 50, 39, and 7 per 1,000 person-years in patients with AD, respectively. The adjusted risks of all-cause dementia (hazard ratio (HR), 1.072; 95% confidence interval (95% CI) 1.026-1.120), and Alzheimer's disease (HR 1.051; 95% CI 1.000-1.104) were increased in patients with AD. The effect of AD on the development of all-cause dementia and Alzheimer's dementia varied according to age and diabetes mellitus (all p for interaction, < 0.05). The risks of all-cause dementia and Alzheimer's disease were increased in patients with AD. Management of modifiable risk factors is important for preventing dementia in patients with AD.

Metformin: A Potential Treatment for Acne, Hidradenitis Suppurativa and Rosacea.

Metformin is a widely used drug for treatment of diabetes mellitus, due to its safety and efficacy. In addition to its role as an antidiabetic drug, numerous beneficial effects of metformin have enabled its use in various diseases. Considering the anti-androgenic, anti-angiogenic, anti-fibrotic and antioxidant properties of metformin, it may have the potential to improve chronic inflammatory skin diseases. However, further evidence is needed to confirm the efficacy of metformin in dermatological conditions, This review focuses on exploring the therapeutic targets of metformin in acne vulgaris, hidradenitis suppurativa and rosacea, by studying their pathogeneses.

Trends in clinical outcomes and long-term survival after robotic gastrectomy for gastric cancer: a single high-volume center experience of consecutive 2000 patients.

BACKGROUND: Minimally invasive surgery is now a standard treatment for gastric cancer. Many retrospective studies have reported that robotic gastrectomy is safe and feasible, with similar short- and long-term outcomes as laparoscopic gastrectomy. However, no studies have reported the details of surgical and survival outcomes for robotic gastrectomy. This study aimed to evaluate the surgical trends and techniques of robotic gastrectomy and analyze the surgical outcomes of 2000 consecutive patients with gastric cancer who underwent robotic gastrectomy over 14 years. METHODS: Between July 2005 and January 2019, 2000 consecutive robotic gastrectomies were performed. We evaluated short- and long-term outcomes as well as surgical trends after robotic gastrectomy. RESULTS: There were 1,560 subtotal gastrectomies (78%), 324 total gastrectomies (16.2%), 83 proximal gastrectomies (4.2%), and 33 completion total gastrectomies (1.7%). The rates of major complications and mortality were 3.1% and 0.3%, respectively. In a subgroup analysis, there were no significant differences in the rate of complications over time (P = 0.696). Five-year overall survival rates were 97.6% for stage I, 91.9% for stage II, and 69.2% for stage III, with a total recurrence rate of 5.3%. Since its adoption in 2005, the proportion of robotic gastrectomies, as well as technically demanding procedures have increased over time. CONCLUSIONS: Our 14 years' experience of 2000 robotic gastrectomies has shown the proportion, as well as the number of robotic gastrectomies, have tended to increase and trends toward to technically demanding procedures. Outcomes of robotic gastrectomy appear safe and feasible with acceptable short- and long-term outcomes.

Fluorescent lymphography during minimally invasive total gastrectomy for gastric cancer: an effective technique for splenic hilar lymph node dissection.

BACKGROUND: Fluorescent lymphography is an excellent technique for complete lymph node dissection during minimally invasive surgery for gastric cancer. This study aimed to evaluate the role of fluorescent lymphography in splenic hilar lymph node dissection during minimally invasive total gastrectomy. METHODS: We retrospectively analyzed 168 gastric cancer patients who underwent minimally invasive total gastrectomy with D2 + No. 10 lymph node dissection from 2013 to 2018. Fluorescent lymphography was used whenever it is possible. However, when near-infrared imaging system and endoscopic indocyanine green injection were not available, we performed surgery without fluorescent lymphography. A total of 74 patients underwent surgery with fluorescent lymphography (FL group) and 94 underwent surgery without it (non-FL group). Perioperative and long-term outcomes including the number of retrieved lymph nodes at each nodal station were compared between groups. RESULTS: The median number of retrieved lymph nodes at the splenic hilum was larger in the FL group {2.5 [Interquartile range (IQR), 1-5]} than in the non-FL group [1 (IQR, 1-3); P = 0.012]. The negative predictive value of fluorescent lymphography for lymph node metastasis at the splenic hilum was 97.1%, although the sensitivity was 66.7%. The overall survival (FL: 96.9% vs. non-FL: 88.9%; P = 0.334) and relapse-free survival (FL: 90.5% vs. non-FL: 65.5%; P = 0.054) were higher in the FL group, although there were no statistical differences. However, among the patients without lymph node metastasis, the relapse-free survival was significantly higher in the FL group (100%) than in the non-FL group (67.1%; P = 0.017). CONCLUSIONS: Fluorescent lymphography is an effective tool for complete lymph node dissection at the splenic hilum. Moreover, it may help select patients who do not need splenic hilar lymph node dissection during a total gastrectomy.

Applicability of endoscopic submucosal dissection for patients with early gastric cancer beyond the expanded indication for endoscopic submucosal dissection.

BACKGROUND: Endoscopic submucosal dissection (ESD) application for patients with tumors beyond the expanded indication for ESD is inconclusive. This study aimed to identify the preoperative clinical features that can be curatively treated with ESD in patients with early gastric cancer (EGC) beyond the indication of ESD. METHODS: From 2006 to 2016, 673 patients who underwent gastrectomy for EGC beyond the expanded indication for ESD based on preoperative assessments were retrospectively reviewed. We identified tumors curatively resected by ESD based on the postoperative pathologic findings. We also analyzed the clinical and pre-treatment features to determine the risk factors associated with curative resection of ESD. RESULTS: 39% of the patients (263/673) who had undergone gastrectomy had tumors of endoscopic curability A or B (eCuraA/B) that could be treated by ESD alone. In multivariate analysis, tumor size ≤ 10 mm (OR 0.240; 95% CI = 0.12-0.46), no ulceration (OR 0.500; 95% CI = 0.29-0.87), differentiated histology (OR 0.599; 95% CI = 0.43-0.84), and location in the distal two-thirds of the stomach (OR 0.499; 95% CI = 0.28-0.88) in pre-treatment assessment were identified as independent predictors of eCuraA/B. Considering the risk factors, 63.6% (7/11)/61.3% (19/31) of patients with a differentiated/undifferentiated tumor size ≤ 10 mm located in distal two-third of the stomach without ulceration were deemed as eCuraA/B. CONCLUSIONS: This study suggests that patients with EGC indicated for surgery can be treated by ESD by adding tumor locations in the indication for ESD. Thus, ESD can be applied for patients with a tumor size ≤ 10 mm located in the lower/middle stomach without ulceration.

Lymphovascular Invasion: Traditional but Vital and Sensible Prognostic Factor in Early Gastric Cancer.

BACKGROUND: Although patients with early gastric cancer have good prognosis, recurrence after treatment may occur. Lymphovascular invasion (LVI) in gastric cancer has long been suggested as a poor prognostic indicator. This study sought to evaluate the prognostic effect of LVI in patients with early gastric cancer. METHODS: From 2005 to 2016, 6516 patients with early gastric cancer who underwent radical gastrectomy were analyzed. The patients were categorized according to LVI and lymph node (LN) status. RESULTS: LVI was present in 853 patients (13.1%). Patients with LVI or LN metastasis had more aggressive tumor characteristics than patients without both LVI and LN metastasis. The overall and relapse-free survival in patients with LVI were significantly worse than in patients without LVI. When we compared the survival rate of patients stratified by LVI and LN status, there was a significant overall and relapse-free survival difference between patients without both LVI and LN metastasis compared with those with LVI but without LN metastasis (p < 0.001). The overall and relapse-free survival of patients with LVI but without LN metastasis were similar to those without LVI but with LN metastasis (p = 0.818). Patients with LVI or LN metastasis showed a high frequency of recurrence (p < 0.001). Multivariate analysis showed that LVI and LN status were independent risk factors for relapse-free survival of early gastric cancer patients. CONCLUSIONS: Early gastric cancer with LVI is associated with poor prognosis and frequent recurrence. When predicting the prognosis of patients with early gastric cancer, LVI should be considered.

Surgical Merits of Open, Laparoscopic, and Robotic Gastrectomy Techniques with D2 Lymphadenectomy in Obese Patients with Gastric Cancer.

BACKGROUND: Robotic surgery has been widely adopted for complex procedures to overcome technical limitations of open or laparoscopic methods. However, evidence of any subsequent benefit is lacking. This study was undertaken to compare open, laparoscopic, and robotic gastrectomy in technically demanding procedure-D2 dissection in obese patients with gastric cancer. METHODS: Data collected between 2010 and 2018 on D2 gastrectomy in obese patients with gastric cancer were used to conduct retrospective analysis, comparing short- and long-term outcomes of open, laparoscopic, and robotic techniques. RESULTS: In a total of 185 patients, there were 69 open, 62 laparoscopic, and 54 robotic gastrectomy procedures. Median ages for respective surgical groups were 66 (interquartile range [IQR]: 61-64 years), 63 (IQR: 59-63), and 59 years (IQR: 56-60 years) (p = 0.009). Early-stage gastric cancer ranked proportionately higher in the laparoscopic group (p = 0.005), but operative times were similar among groups. Estimated blood loss (p < 0.001) and drainage volumes (p = 0.001) were higher in the open group, relative to others. Although a robotic approach performed best in overall compliance and in mean number of retrieved lymph node, observed rates of early or late complications did not differ by technique. The open group experienced significantly poorer overall (p = 0.039) and relapse-free (p < 0.001) survival compared with the laparoscopic or robotic group. Robotic surgery emerged from multivariable Cox regression as a protective factor for relapse-free survival (HR = 0.314, 95% CI 0.116-0.851). CONCLUSIONS: In obese patients with gastric cancer, robotic gastrectomy with D2 lymphadenectomy proved comparable to open or laparoscopic technique short-term, yielding better long-term outcomes.

Assessment of diagnostic value of fluorescent lymphography-guided lymphadenectomy for gastric cancer.

BACKGROUND: Indocyanine green fluorescent lymphography helps visualize the lymphatic drainage pattern in gastric cancer; however, it is unknown whether fluorescent lymphography visualizes all metastatic lymph nodes. This study aimed to evaluate the sensitivity of fluorescent lymphography to detect metastatic lymph node stations and lymph nodes and the risk of false-negative findings. METHODS: Patients with clinical T1-4a gastric cancer were included. Indocyanine green was peritumorally injected the day prior to surgery by endoscopy. Gastrectomy with systematic D1+ or D2 lymphadenectomy was performed. Stations and lymph nodes were retrieved at the back-table using near-infrared imaging and classified as "fluorescent" or "non-fluorescent" and later matched with histopathological findings. RESULTS: Among 592 patients who underwent minimally invasive gastrectomy from September 2013 until December 2016, lymph node metastases were present in 150. The sensitivity of fluorescent lymphography in detecting all metastatic lymph node stations was 95.3% (143/150 patients), with a false-negative rate of 4.7% (7/150 patients) and the sensitivity in detecting all metastatic lymph nodes was 81.3% (122/150 patients). The negative predictive value was 99.3% for non-fluorescent stations and 99.2% for non-fluorescent LNs. For detecting all metastatic LN stations, subgroup analysis revealed 100% sensitivity for pT1a, 96.8% for pT1b, 100% for pT2, 91.3% for pT3, and 93.6% for pT4a tumors. CONCLUSIONS: Fluorescent lymphography-guided lymphadenectomy can be a useful method for radical lymphadenectomy by facilitating the complete dissection of all potentially positive LN stations. Fluorescent lymphography-guided lymphadenectomy appears to be a reasonable alternative to conventional systematic lymphadenectomy for gastric cancer.

Real-time identification of aberrant left hepatic arterial territories using near-infrared fluorescence with indocyanine green during gastrectomy for gastric cancer.

BACKGROUND: An aberrant left hepatic artery is frequently encountered during upper gastrointestinal surgery, and researchers have yet to propose optimal strategies with which to address this arterial variation. The objective of this study was to determine whether the areas perfused by an aberrant left hepatic artery can be visualized in real-time using near-infrared fluorescence imaging with indocyanine green. METHODS: Patients with gastric adenocarcinoma who underwent minimally invasive radical gastrectomy from May 2018 to August 2019 were enrolled and retrospectively analyzed at a single-center. Patients with an aberrant left hepatic artery and normal preoperative liver function were examined. After the clamping of an aberrant left hepatic artery, indocyanine green was administered via a peripheral intravenous route during surgery. Fluorescence at the liver was visualized under near-infrared fluorescence imaging. RESULTS: In 31 patients with aberrant left hepatic arteries, near-infrared fluorescence imaging was used without adverse events associated with indocyanine green. Six (19%) patients were reported to have an aberrant left hepatic artery upon preoperative CT imaging, while all other instances were detected during surgery. Fluorescence excitation on the liver was, on average, visible after 43 s (range, 25-65). Fluorescence across the entire surface of the liver was noted in 20 (65%) patients in whom the aberrant left hepatic artery could be ligated. Aberrant left hepatic arteries were safely preserved in 10 (32%) patients who showed areas of no or partial fluorescence excitation. Guided by near-infrared fluorescence imaging, ligation of aberrant left hepatic arteries elicited no significant changes in postoperative liver function. CONCLUSION: Near-infrared fluorescence imaging facilitates the identification of aberrant left hepatic arterial territories, guiding decisions on the preservation or ligation of this arterial variation.

Lower rate of conversion using robotic-assisted surgery compared to laparoscopy in completion total gastrectomy for remnant gastric cancer.

BACKGROUND: Completion total gastrectomy with radical lymphadenectomy for remnant gastric cancer is a technically demanding procedure. No previous studies have compared laparoscopic to robotic-assisted completion gastrectomy, whereas a few small case series have reported benefits of minimally invasive surgery over open surgery. The aim of this study is to assess the effectiveness and feasibility of robotic-assisted compared with laparoscopic completion gastrectomy for the treatment of remnant gastric cancer. METHODS: We retrospectively reviewed data from 55 patients who underwent minimally invasive completion gastrectomy for remnant gastric cancer at the Severance Hospital of Yonsei University Health System from April 2005 to July 2017. Of the 55 patients, 30 patients underwent laparoscopic and 25 underwent robotic-assisted completion total gastrectomy. We compared the patients' demographics, operative outcomes, and postoperative outcomes. RESULTS: Operation time was longer in the robotic-assisted surgery group (225 vs 292 min, P < 0.001), but both groups had similar estimated blood loss. The laparoscopic surgery group had a 13.3% (four patients) rate of conversion to open surgery because of severe adhesions, whereas no patients in the robotic group underwent conversion to laparoscopic or open surgery (P = 0.058). Mean hospital stay, postoperative complications, and recovery were similar in both groups. Pathology results, including the number of retrieved lymph nodes, did not differ between groups. CONCLUSION: Laparoscopic and robotic approaches are both feasible and safe for remnant gastric cancer, with comparable short-term outcomes. However, the robotic approach demonstrated a lower conversion rate than laparoscopy, although the statistical difference was marginal.

Intracorporeal esophagojejunostomy using a linear stapler in laparoscopic total gastrectomy: comparison with circular stapling technique.

BACKGROUND: Laparoscopic total gastrectomy for gastric cancer is feasible but less commonly performed compared to laparoscopic distal gastrectomy due to technical difficulties such as reconstruction. There is no standard esophagojejunal anastomosis technique in laparoscopic total gastrectomy due to a lack of evidence. METHODS: We retrospectively analyzed data from 213 patients with gastric cancer who underwent laparoscopic total gastrectomy from October 2012 to December 2016. Of these, 109 and 104 patients underwent esophagojejunostomy with linear and circular stapling, respectively. We compared short-term postoperative outcomes, including surgical complications and anastomosis costs between both groups. RESULTS: The mean operation time in the linear stapler group was longer than the circular stapler group (Linear stapler, 235.3 ± 57.9 vs. Circular stapler, 217.1 ± 55.8 min; P = 0.021); however, D2 lymph node dissection was performed more in the linear stapler group (Linear stapler, 36.7% vs. Circular stapler, 23.1%; P = 0.030). There were two anastomosis leakages in each group (Linear stapler, 1.8% vs. Circular stapler, 1.9%; P > 0.999). Anastomosis stenosis only occurred in the circular stapler group (Linear stapler, 0% vs. Circular stapler, 7.7%; P = 0.003). Although the linear stapling technique used more stapler cartridges (Linear stapler, 7.6 ± 1.1 vs. Circular stapler, 4.8 ± 0.9; P < 0.001), costs related to anastomosis were lower in the linear stapler group (Linear stapler, 1,904,679 ± 342,116 vs. Circular stapler, 2,246,150 ± 427,136KRW; P < 0.001). CONCLUSIONS: Esophagojejunostomy with the linear stapling technique reduces anastomosis stenosis in laparoscopic total gastrectomy. It can be recommended as a safe and more cost-effective method for esophagojejunal anastomosis.

Multi-institutional validation of the 8th AJCC TNM staging system for gastric cancer: Analysis of survival data from high-volume Eastern centers and the SEER database.

BACKGROUND: The clinical relevance and general applicability of the 8th American Joint Committee on Cancer TNM gastric cancer staging system vs the 7th version have not been examined using datasets from both the East and West. METHODS: Patients (n = 29 984) treated for gastric adenocarcinoma at two high-volume centers (Severance Hospital [SH] and Gangnam Severance Hospital [GSH]) in Korea and data from the Surveillance, Epidemiology, and End Results (SEER) database were retrospectively analyzed. Survival curves, the performance of tumor staging, and the homogeneity of modified subgroups were compared. RESULTS: Minute changes were noted in the stage IIB subgroup; most changes were noted in stage III. Applying the 8th staging system facilitated better prediction of survival than applying the 7th version for SH data according to the log-rank test, C-index, and AIC (8444.5 vs 9263.8, 0.796 vs 0.798, and 104152 vs 103909, respectively). Its performance was also superior for GSH and SEER data. In a subgroup analysis of stages IIB to IIIC in SH, GSH, and SEER data, the 8th staging system showed similar or more homogeneous survival for each sub-classification than the 7th version. CONCLUSION: Compared with the 7th gastric cancer staging system, the newer version more accurately predicted prognosis and stratified subgroups more homogeneously.

Robotic spleen-preserving splenic hilar lymph node dissection during total gastrectomy for gastric cancer.

BACKGROUND: Robotic system may have potential advantages to facilitate the technically challenging splenic hilar lymphadenectomy during gastrectomy for gastric cancer. However, robotic spleen-preserving splenic hilar lymphadenectomy is performed infrequently not only because of the limited availability of the robot but also because of its technical difficulty. In this study, we describe our technique of performing robotic spleen-preserving splenic hilar lymphadenectomy in detail to facilitate wider application and present operative outcomes and the follow-up results of the procedure. METHODS: From 2005 to 2015, 93 patients underwent robotic total gastrectomy with D2 lymphadenectomy. One patient with obvious lymph node (LN) metastasis received splenectomy and was excluded from the analysis. Intraoperative complications, operation and console time, estimated blood loss, postoperative morbidity and mortality, the number of harvested LNs in total and at the splenic hilum, and 5-year overall survival were analyzed, retrospectively. RESULTS: Among the 92 patients, robotic spleen-preserving splenic hilar lymphadenectomy was successfully performed in 91 patients except one who experienced intraoperative splenic artery injury which demanded splenectomy to be performed simultaneously. The overall mean operation time and console time were 287.2 ± 66.0 and 180.2 ± 47.2 min, respectively. Mean estimated blood loss was 141.1 ± 227.0 ml. The mortality was 1.1% (1/92). The overall postoperative morbidity rate was 16.3% (15/92). There was no case of pancreatic fistula, whole splenic infarction, or the delayed aneurysm of splenic artery. The mean numbers of harvested LNs in total and at the splenic hilum were 50.8 ± 18.1 and 1.9 ± 2.6. The 5-year overall survival was 86.3% and 5-year recurrence-free survival was 87.4%. CONCLUSION: This study suggests that robotic application for spleen-preserving splenic hilar lymphadenectomy could be a feasible and safe method.

Similar hematologic and nutritional outcomes after proximal gastrectomy with double-tract reconstruction in comparison to total gastrectomy for early upper gastric cancer.

BACKGROUND: Proximal gastrectomy offers theoretical benefits over total gastrectomy in terms of hematologic and nutritional outcomes. However, little evidence confirming these benefits has been reported. The aim of this study was to assess the hematologic and nutritional outcomes of proximal gastrectomy with double-tract reconstruction in comparison to those of total gastrectomy. METHODS: We retrospectively analyzed data from 80 patients with stage I gastric cancer who underwent proximal gastrectomy with double-tract reconstruction (n = 38) or total gastrectomy (n = 42) from September 2014 to December 2015. We compared hematologic (including hemoglobin, ferritin, vitamin B12, etc.) and nutritional outcomes [including body mass index (BMI), serum total protein, albumin, total cholesterol, and total lymphocyte count] between the two groups. RESULTS: We found no significant differences in changes in hemoglobin (P = 0.250) or cumulative incidence of iron deficiency anemia (P = 0.971) during a median follow-up period of 24 months (range 18-30 months) after surgery. Cumulative incidence of vitamin B12 deficiency also did not differ significantly between the proximal and total gastrectomy groups (P = 0.087). BMI changes from baseline were not significantly different between the two groups (P = 0.591). Likewise, there were no statistically significant differences in nutritional outcomes. CONCLUSIONS: Proximal gastrectomy with double-tract reconstruction exhibited similar outcomes in terms of hematologic and nutritional features in comparison to total gastrectomy.

Parameters for Predicting Surgical Outcomes for Gastric Cancer Patients: Simple Is Better Than Complex.

BACKGROUND: Various parameters are used to predict perioperative surgical outcomes. However, no comprehensive studies in gastrectomy have been conducted. This study aimed to compare the performance of each parameter in patients with gastric cancer. METHODS: The medical records of 1032 gastric cancer patients who underwent curative gastrectomy between 2009 and 2015 were reviewed. Laboratory values and associated parameters (neutrophil count, lymphocyte count, platelet count, albumin level, Prognostic Nutritional Index, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and Systemic Immune-Inflammation Index) as well as body weight-related data and associated parameters [body mass index (BMI), percentage of weight loss, Nutritional Risk Screening 2002 assessment, the Malnutrition Universal Screening Tool, and the Nutritional Risk Index] were measured and calculated. The study end points were major complications, operative mortality, prolonged hospital stay, overall survival (OS), and recurrence-free survival (RFS). RESULTS: Multivariable logistic regression analysis showed that male gender, total gastrectomy, advanced-stage gastric cancer, and low albumin level were risk factors for major complications. Old age, total gastrectomy, advanced-stage cancer, and high BMI were risk factors for operative mortality. Old age, open approach, and total gastrectomy were risk factors for prolonged hospital stay. Multivariable Cox proportional hazards models showed that old age, total gastrectomy, advanced-stage cancer, and high neutrophil count were unfavorable risk factors for OS. Old age, advanced-stage cancer, high neutrophil count, and high BMI were unfavorable risk factors for RFS. CONCLUSIONS: Albumin level, BMI, and neutrophil count are the most useful parameters for predicting short- and long-term surgical outcomes. Compared with complex parameters, simple-to-measure parameters are better for predicting surgical outcomes for gastric cancer patients.

Reduced-port totally robotic distal subtotal gastrectomy with lymph node dissection for gastric cancer: a modified technique using Single-Site® and two additional ports.

BACKGROUND: Reduced-port laparoscopic gastrectomy further minimizes the invasiveness of laparoscopic gastrectomy, thereby improving patient quality of life. However, suboptimal ergonomics and visualization are challenges to performing reduced-port laparoscopy. As the application of a robotic surgical system may help overcome these challenges, the present study was performed to evaluate the short-term outcomes of reduced-port totally robotic distal subtotal gastrectomy. METHOD: An initial 40 consecutive gastric cancer patients treated with reduced-port totally robotic distal subtotal gastrectomy with lymph node dissection from February 2016 to February 2017 were retrospectively reviewed. An overturned infraumbilical Single-Site® port and two additional abdominal ports were utilized. Clinicopathological characteristics and short-term surgical outcomes were analyzed to evaluate the safety and feasibility of the procedure. RESULT: Patients comprised 23 (57.5%) males and 17 females. Mean age and body mass index were 54 years and 23.7 kg/m2, respectively. Preoperative clinical T stage was early in 22 patients and advanced (T2 or more) in 18 (45%) patients. No conversions to laparoscopic or open surgery and no additional port insertions were required. Eighteen patients (45%) underwent D2 lymph node dissection. All reconstructions after gastrectomy were made intracorporeally, including 34 (85%) Billroth I anastomoses. Mean operative time and blood loss were acceptable (210 min and 49.9 ml, respectively). The mean number of retrieved lymph nodes was 58.8. Postoperative clinical courses were acceptable for all patients, with no grade III or higher complications recorded. CONCLUSION: Reduced-port totally robotic distal subtotal gastrectomy with lymph node dissection was successfully applied and provided acceptable short-term postoperative results.

Intracorporeal delta-shaped gastroduodenostomy in reduced-port robotic distal subtotal gastrectomy: technical aspects and short-term outcomes.

BACKGROUND: Gastroduodenostomy is preferred as a method of reconstruction following distal subtotal gastrectomy. However, in initial reports on reduced-port gastrectomy, gastroduodenostomy has rarely been performed therein because of technical difficulties. The present study describes a novel intracorporeal gastroduodenostomy technique applicable during reduced-port robotic distal subtotal gastrectomy. METHODS: Data were retrospectively reviewed for cases of reduced-port (three-port) robotic distal subtotal gastrectomy with intracorporeal delta-shaped gastroduodenostomy performed from February 2016 to December 2016. The reduced-port approach used a Single-Site™ port via a 25-mm infraumbilical incision and two additional ports. We performed intracorporeal gastroduodenostomy using a 45-mm robotic or laparoscopic endolinear stapler. All staplers were inserted via a port on the left lower abdomen. RESULTS: In our initial experience with intracorporeal gastroduodenostomy, 28 consecutive patients underwent successful surgery with the technique without needing to convert to open, laparoscopic, or conventional five-port robotic surgery. Mean operation time was 201.1 min (110-282 min), and no major complications, including anastomosis-related problems, were recorded. CONCLUSIONS: Intracorporeal delta-shaped gastroduodenostomy was safely and feasibly applied during reduced-port robotic gastrectomy with acceptable operative outcomes and no major complications. Intracorporeal gastroduodenostomy should be considered during reduced-port distal subtotal gastrectomy.