Long-term Comparison of Robotic and Laparoscopic Gastrectomy for Gastric Cancer: A Propensity Score-weighted Analysis of 2084 Consecutive Patients.

OBJECTIVE: To compare long-term outcomes between robotic and LG approaches using propensity score weighting based on a generalized boosted method to control for selection bias. SUMMARY OF BACKGROUND DATA: Minimally invasive surgical approaches for GC are increasing, yet limited evidence exists for long-term outcomes of robotic gastrectomy (RG). METHODS: Patients (n = 2084) with GC stages I-III who underwent LG or RG between 2009 and 2017 were analyzed. Generalized boosted method was used to estimate a propensity score derived from all available preoperative characteristics. Long-term outcomes were compared using the adjusted Kaplan-Meier method and the weighted Cox proportional hazards regression model. RESULTS: After propensity score weighting, the population was balanced. Patients who underwent RG showed reduced blood loss (16 mL less, P = 0.025), sufficient lymph node harvest from the initial period, and no changes in surgical outcomes over time. With 52-month median follow-up, no difference was noted in 5-year overall survival in unweighted [91.5% in LG vs 94% in RG; hazard ratio (HR), 0.71; 95% confidence interval (CI), 0.46-1.1; P = 0.126] and weighted populations (94.2% in LG vs 93.2% in RG; HR, 0.88; 95% CI, 0.52-1.48; P = 0.636). There were no differences in 5-year recurrence-free survival (RFS), with unweighted 5-year RFS of 95.4% for LG and 95.2% for RG (HR, 0.95; 95% CI, 0.55-1.64; P = 0.845) and weighted 5-year RFS of 96.3% for LG and 95.3% for RG (HR, 1.24; 95% CI, 0.66-2.33; P = 0.498). CONCLUSIONS: After balancing covariates, RG demonstrated reliable surgical outcomes from the beginning. Long-term survival after RG and LG for GC was similar.

Prediction of Survival Outcomes Based on Preoperative Clinical Parameters in Gastric Cancer.

BACKGROUND: Few current preoperative risk assessment tools provide essential, optimized treatment for gastric cancer. The purpose of this study was to develop and validate a nomogram that uses preoperative data to predict survival and risk assessments. METHODS: A survival prediction model was constructed using data from a developmental cohort of 1251 patients with stage I to III gastric cancer who underwent curative resection between January 2005 and December 2008 at Ajou University Hospital, Korea. The model was internally validated for discrimination and calibrated using bootstrap resampling. To externally validate the model, data from a validation cohort of 2012 patients with stage I to III gastric cancer who underwent surgery at multiple centers in Korea between January 2001 and June 2006 were analyzed. Analyses included the model's discrimination index (C-index), calibration plots, and decision curve that predict overall survival. RESULTS: Eight independent predictors, including age, sex, clinical tumor size, macroscopic features, body mass index, histology, clinical stages, and tumor location, were considered for developing the nomogram. The discrimination index was 0.816 (adjusted C-index) in the developmental cohort and 0.781 (adjusted C-index) in the external validation cohort. Additionally, in both the developmental and validation datasets, age and tumor size were significantly correlated with each other and were independent indicators for survival (P < 0.05). CONCLUSIONS: We developed a new nomogram by using the most common and significant preoperative parameters that can help to identify high-risk patients before treatment and help clinicians to make appropriate decisions for patients with stage I to III gastric cancer.

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.

Clinical pathway for enhanced recovery after surgery for gastric cancer: A prospective single-center phase II clinical trial for safety and efficacy.

BACKGROUND: We aimed to evaluate the safety and efficacy of a clinical pathway (CP) for enhanced recovery after surgery (ERAS) in gastric cancer patients, including early oral feeding and discharge on postoperative day 4. METHODS: We performed a prospective, single-center, phase II clinical trial. Based on proposed indications for an ERAS CP in our retrospective study, we enrolled 133 patients younger than 65 years who were undergoing minimally invasive subtotal gastrectomy. The primary endpoint was the ERAS CP completion rate. Secondary endpoints included complication, mortality, hospital stay, and readmission. RESULTS: Among 133 patients, six patients were dropped out from this study. The ERAS CP completion rate (77.2%, 98 of 127) was comparable to the historical control group that completed a conventional CP (85.4%, P = .085). The postoperative complication incidence (13.4%, 15 of 127) was also similar to that of the conventional CP group (9.5%, P = .174). We identified reduced hospital stays (4.7 ± 1.3 vs 7.2±2.3 days; P < .001) and lower hospital costs ($7771 vs 8539; P < .001) in the ERAS CP group compared with the conventional CP group. CONCLUSIONS: An ERAS CP can be safely and effectively adopted for patients with gastric cancer without increasing the complication rate and could shorten hospital stays. TRIAL REGISTRATION: ClinicalTrials.gov (NCT01642953).

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.

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.

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.

Parasitic leiomyoma in the trocar site after laparoscopic myomectomy: A case report.

BACKGROUND: Laparoscopic myomectomy is increasingly used for resecting gynecological tumors. Leiomyomas require morcellation for retrieval from the peritoneal cavity. However, morcellated fragments may implant on the peritoneal cavity during retrieval. These fragments may receive a new blood supply from an adjacent structure and develop into parasitic leiomyomas. Parasitic leiomyomas can occur spontaneously or iatrogenically; however, trocar-site implantation is an iatrogenic complication of laparoscopic uterine surgery. We describe a parasitic leiomyoma in the trocar-site after laparoscopic myomectomy with power morcellation. CASE SUMMARY: A 50-year-old woman presented with a palpable abdominal mass without significant medical history. The patient had no related symptoms, such as abdominal pain. Computed tomography findings revealed a well-defined contrast-enhancing mass measuring 2.2 cm, and located on the trocar site of the left abdominal wall. She had undergone laparoscopic removal of uterine fibroids with power morcellation six years ago. The differential diagnosis included endometriosis and neurogenic tumors, such as neurofibroma. The radiologic diagnosis was a desmoid tumor, and surgical excision of the mass on the abdominal wall was successfully performed. The patient recovered from the surgery without complications. Histopathological examination revealed that the specimen resected from the trocar site was a uterine leiomyoma. CONCLUSION: Clinicians should consider the risks and benefits of laparoscopic vs laparotomic myomectomy for gynecological tumors. Considerable caution must be exercised for morcellation to avoid excessive tissue fragmentation.

Laparoscopic excision for ectopic peritoneal paragonimiasis mimicking a gastric duplication cyst: A case report.

INTRODUCTION: Paragonimiasis, lung fluke disease caused by infection with Paragonimus species, is a food-borne parasitic zoonosis. The overriding symptoms of Paragonimus westermani infection include chronic cough, shortness of breath, and pleuritic pain. Extrapulmonary paragonimiasis caused by aberrant parasitic migration is known to occur in a variety of sites such as the brain, abdominal wall, and intraperitoneal cavity. Ectopic paragonimiasis is an uncommon disease that presents with a few clinical manifestations, which makes it difficult to diagnose and treat. CASE PRESENTATION: A 47-year-old man with an unremarkable medical and surgical history presented with a peritoneal lesion that was discovered incidentally on abdominal computed tomography during routine health screening. The patient did not exhibit any associated symptoms such as abdominal pain. The radiologic diagnosis was a gastric duplication cyst and we performed laparoscopic excision of the peritoneal mass. Histopathological examination revealed paragonimiasis, and the result of the skin test for paragonimiasis was positive. The patient was treated with praziquantel. CLINICAL DISCUSSION: The diagnosis of ectopic peritoneal paragonimiasis remains challenging due to inexperience, misdiagnosis, and its rarity. Clinicians should bear in mind that an intra-abdominal mass may be related to a parasitic infection. The detection of the ova of Paragonimus parasites in sputum and biopsy specimens may be difficult due to an insufficient amount. CONCLUSION: Clinicians need to thoroughly take the patient's history and clinically suspect parasitic infections. Laparoscopic resection of this rare mass is safe, feasible, and allows for rapid recovery.

Prognostic value of hypocholesterolemia in patients with gastric cancer.

BACKGROUND: According to previous studies, low serum total cholesterol (TC) is associated with higher cancer incidence and mortality. However, the prognostic implications of preoperative TC in patients with gastric cancer (GC) remain to be determined. METHODS: A total of 1251 patients with GC, who underwent radical gastrectomy between 2005 and 2008, were recruited. Propensity score weighting (PSW) based on a generalized boosted method (GBM) was used to control for selection bias. RESULTS: After balancing the preoperative and operative covariates, low TC was associated with high incidence of complications (severe complication rate: 15.2% (Low TC) vs. 4.7% (Normal TC) vs 5.5% (High TC); p = 0.004). In multivariable analysis, lowering TC was associated with poor OS and RFS in weighted population. [OS: hazard ratio (HR) = 0.92; 95% CI = 0.867-0.980; P = 0.009 and RFS: HR = 0.93; 95% CI = 0.873-0.988; P = 0.02]. CONCLUSIONS: Preoperative TC is a useful predictor of postoperative survival and postoperative complications in patients with stage I-III GC and may help to identify high-risk patients for rational therapy, including nutritional support, and timely follow-up.

Risk Factors for the Severity of Complications in Minimally Invasive Total Gastrectomy for Gastric Cancer: a Retrospective Cohort Study.

PURPOSE: Minimally invasive gastrectomy is a promising surgical method with well-known benefits, including reduced postoperative complications. However, for total gastrectomy of gastric cancers, this approach does not significantly reduce the risk of complications. Therefore, we aimed to evaluate the incidence and risk factors for the severity of complications associated with minimally invasive total gastrectomy for gastric cancer. MATERIALS AND METHODS: The study included 392 consecutive patients with gastric cancer who underwent either laparoscopic or robotic total gastrectomy between 2011 and 2019. Clinicopathological and operative characteristics were assessed to determine the features related to postoperative complications after minimally invasive total gastrectomy. Binomial and multinomial logistic regression models were used to identify the risk factors for overall complications and mild and severe complications, respectively. RESULTS: Of 103 (26.3%) patients experiencing complications, 66 (16.8%) and 37 (9.4%) developed mild and severe complications, respectively. On multivariate multinomial regression analysis, independent predictors of severe complications included obesity (OR, 2.56; 95% CI, 1.02-6.43; P=0.046), advanced stage (OR, 2.90; 95% CI, 1.13-7.43; P=0.026), and more intraoperative bleeding (OR, 1.04; 95% CI, 1.02-1.06; P=0.001). Operation time was the only independent risk factor for mild complications (OR, 1.06; 95% CI, 1.001-1.13; P=0.047). CONCLUSIONS: The risk factors for mild and severe complications were associated with surgery, indicating surgical difficulty. Surgeons should be aware of these potential risks that are related to the severity of complications so as to reduce surgery-related complications after minimally invasive total gastrectomy for gastric cancer.

Textbook outcome and survival of robotic versus laparoscopic total gastrectomy for gastric cancer: a propensity score matched cohort study.

Textbook outcome is a composite quality measurement of short-term outcomes for evaluating complex surgical procedures. We compared textbook outcome and survival of robotic total gastrectomy (RTG) with those of laparoscopic total gastrectomy (LTG). We retrospectively reviewed 395 patients (RTG, n = 74; LTG, n = 321) who underwent curative total gastrectomy for gastric cancer via minimally invasive approaches from 2009 to 2018. We performed propensity score matched analysis to adjust for potential selection bias. Textbook outcome included a negative resection margin, no intraoperative complication, retrieved lymph nodes > 15, no severe complication, no reintervention, no unplanned intensive care unit admission, hospitalization ≤ 21 days, no readmission after discharge, and no postoperative mortality. Survival outcomes included 3-year overall and relapse-free survival rates. After matching, 74 patients in each group were selected. Textbook outcome was similar in the RTG and LTG groups (70.3% and 75.7%, respectively), although RTG required a longer operative time. The quality metric least often achieved was the presence of severe complications in both groups (77.0% in both groups). There were no differences in the 3-year overall survival rate (98.6% and 89.7%, respectively; log-rank P = 0.144) and relapse-free survival rate between the RTG and LTG groups (97.3% and 87.0%, respectively; log-rank P = 0.167). Textbook outcome and survival outcome of RTG were similar to those of LTG for gastric cancer.

Omentum preservation as an oncologically comparable and surgically superior alternative to total omentectomy during radical gastrectomy for T3-T4 gastric cancer.

BACKGROUND: Total omentectomy has conventionally been performed and has been regarded as standard procedure in radical gastrectomy for cancer. However, omentum preservation is the preferred procedure during minimally invasive surgery, without sufficient evidence of oncological safety, especially for T3-T4 gastric cancer. METHOD: A total of 3,510 patients who underwent radical gastrectomy for T3-T4 gastric cancer between January 2003 and December 2015 were reviewed, retrospectively. After propensity score matching, 225 patients in the omentum preservation group were compared with 225 patients in the total omentectomy group. The primary outcome was 5-year overall survival. RESULTS: The omentum preservation group showed significantly shorter operation time (P = .001) and less blood loss (P = .004) than the total omentectomy group. Shorter operation time was also observed with both open and minimally invasive approaches (P < .001 and P = .007, respectively). The 5-year overall survival rates were 75.4% for the omentum preservation group and 72.6% for the total omentectomy group (log-rank P = .06; hazard ratio 0.7 [95% confidence interval, 0.48-1.01]). The 5-year relapse-free survival was higher in the omentum preservation group (73.8%) than in the total omentectomy group (66.1%), without statistical significance (log-rank P = .09; hazard ratio 0.74 [95% confidence interval, 0.52-1.06]). CONCLUSION: Regardless of the surgical approach, omentum preservation provided comparable oncologic outcomes with better surgical outcomes, suggesting that this could be an acceptable alternative to total omentectomy for T3-T4 gastric cancer. These findings warrant further investigation in randomized clinical trials.

Incidence and treatment outcomes of leakage after gastrectomy for gastric cancer: Experience of 14,075 patients from a large volume centre.

INTRODUCTION: Leakage is a serious and potentially fatal complication of gastrectomy for gastric cancer. However, comprehensive reports regarding leakage after gastrectomy remain limited. We aimed to evaluate the incidence and treatment outcomes of leakage after gastrectomy for cancer. METHODS: We reviewed the prospectively collected data of 14,075 Patients who underwent gastrectomy for gastric cancer between 2005 and 2017. Outcomes included incidence, risk factors of leakage, and leakage treatment outcomes. RESULTS: The median day of leakage detection was postoperative day 7 (range 1-29days). The overall leakage incidence was 1.51% (213/14,075), and the most frequent location was the oesophagojejunostomy (2.07%). Leakage after total gastrectomy was more frequent with minimally invasive surgery (open:1.64%, laparoscopic:3.56%, robotic:5.83%; P < 0.001). Leakage incidence was higher in the surgeon's initial 100 cases than in later cases (2.4 vs. 1.3%; P < 0.001), especially with minimally invasive surgery. Early leakage (within 4 days of surgery) occurred more often after minimally invasive surgery (open:12.7%, laparoscopic:35.4%, robotic:29.0%; P = 0.006). The success rate for initial treatment of leakage was 70.4% (150/213). Surgery after initial treatment failure demonstrated a higher success rate for early leakage than for late leakage (80.0 vs. 22.2%). Among 213 patients who experienced leakage, fifteen patients (7.0%) died, and leakage-related mortality accounted for 38.5% (15/39) of all surgery-related mortality after gastrectomy. CONCLUSIONS: Leakage after gastric cancer surgery is associated with high mortality. Improved surgeon experience using minimally invasive techniques is required to reduce the risk of leakage. Surgery is an effective treatment for early leakage, although further studies are needed to establish the most appropriate treatment strategies.

Omental Free-Shaped Flap Reinforcement on the Anastomosis and Dissected Area (OFFROAD) Following Reconstruction after Gastrectomy: A Retrospective Case-Control Study.

The recent advancements in surgical techniques and perioperative care have improved postoperative morbidity and survival after gastric cancer surgeries. However, anastomotic leakage, the most serious complication post-gastrectomy, continues to occur. In esophageal and colorectal cancer surgeries, the omentum is used as a physical barrier and increases blood perfusion to prevent leakage to the anastomotic site. However, the use of the omentum as an anastomotic barrier after gastrectomy has not been reported yet. The authors aimed to evaluate the efficacy and safety of omental free-shaped flap reinforcement on the anastomosis and dissected area following reconstruction after gastrectomy for preventing and treating anastomotic leakage. They reported that omental free-shaped flap reinforcement on the anastomosis might prevent anastomotic leakage post-gastrectomy. The omental flap also prevented further deterioration when leakage occurred. However, anastomosis-related complications, such as anastomotic stenosis and delayed gastric emptying, after an omental patch technique need to be evaluated further.

Spontaneous rupture of immature gastric teratoma with hemoperitoneum in a newborn with 3-year follow-up.

Among the subtypes of germ cell tumors, teratomas are the most frequent in the pediatric population and commonly occur in the sacrococcygeal region and the gonads. Less than 1% of all teratoma are found in abdominal organs including the stomach, liver, and kidney. Gastric teratomas are very rare tumors predominantly found in infants. Moreover, an immature gastric teratoma is exceptionally rare. Here, we present a case of immature gastric teratoma with spontaneous rupture in a newborn who was preoperatively diagnosed with neuroblastoma. On the first day after birth, the neonate presented with progressive abdominal distension accompanying respiratory distress. A firm mass was detected during a physical examination of the abdomen. An emergency exploratory laparotomy revealed hemoperitoneum resulting from a rupture of the tumor located in the posterior wall of the gastric antrum. Complete resection of the tumor and gastroduodenostomy were performed. The pathology evaluation revealed a grade 3 immature gastric teratoma with no malignant components. The patient was treated with adjuvant chemotherapy to prevent recurrence, since the tumor was ruptured in the abdominal cavity and the level of alpha-fetoprotein was decreased but still remained high above the normal range after surgery. In conclusion, physicians should be aware of the existence of gastric teratoma as the differential diagnosis of a huge abdominal mass in infants, especially neonates. Complete surgical removal of the tumor and long-term follow-up has been adopted as the standard management for immature gastric teratoma, although there has been controversy with adjuvant chemotherapy.