Enhancing surgical outcomes in elderly gastric cancer patients: the role of comprehensive preoperative assessment and support.

BACKGROUND: As the prevalence of gastric cancer rises in aging populations, managing surgical risks and comorbidities in elderly patients presents a unique challenge. The Comprehensive Preoperative Assessment and Support (CPAS) program, through comprehensive preoperative assessments, aims to mitigate surgical stress and improve outcomes by enhancing patient awareness and preparation. This study investigates the efficacy of a CPAS program, incorporating frailty and sarcopenia evaluations, to improve short-term outcomes in elderly gastric cancer patients. METHODS: A retrospective analysis was conducted on 127 patients aged 75 or older who underwent surgery with CPAS between 2018 and August 2023, compared to 170 historical controls from 2012 to 2017. Propensity score matching balanced both groups based on age-adjusted Charlson Comorbidity Index and surgical details. The primary focus was on the impact of CPAS elements such as rehabilitation, nutrition, psychological support, oral frailty, and social support on short-term surgical outcomes. RESULTS: Among 83 matched pairs, the CPAS group, despite 40.4% of patients in the CPAS group and 21.2% in the control group had an ASA-PS score of 3 or higher (P < 0.001), demonstrated significantly reduced blood loss (100 ml vs. 190 ml, P = 0.026) and lower incidence of serious complications (19.3% vs. 33.7%, P = 0.034), especially in infections and respiratory issues. Sarcopenia was identified in 38.6% of CPAS patients who received tailored support. Additionally, the median postoperative hospital stay was notably shorter in the CPAS group (10 days vs. 15 days, P < 0.001), with no in-hospital deaths. These results suggest that personalized preoperative care effectively mitigates operative stress and postoperative complications. CONCLUSION: Implementing CPAS significantly enhances surgical safety and reduces complication rates in elderly gastric cancer patients, emphasizing the critical role of personalized preoperative care in surgical oncology for this demographic.

A comprehensive study on non-cancer-related mortality risk factors in elderly gastric cancer patients post-curative surgery.

BACKGROUND: The increasing incidence of gastric cancer in the elderly underscores the need for an in-depth understanding of the challenges and risks associated with surgical interventions in this demographic. This study aims to investigate the risk factors and prognostic indicators for non-cancer-related mortality following curative surgery in elderly gastric cancer patients. METHODS: This retrospective analysis examined 684 patients with pathological Stage I-III gastric cancer who underwent curative resection between January 2012 and December 2021. The study focused on patients aged 70 years and above, evaluating various clinical and pathological variables. Univariate analysis was utilized to identify potential risk factors with to non-cancer-related mortality and to access prognostic outcomes. RESULTS: Out of the initial 684 patients, 244 elderly patients were included in the analysis, with 33 succumbing to non-cancer-related causes. Univariate analysis identified advanced age (≥ 80 years), low body mass index (BMI) (< 18.5), high Charlson Comorbidity Index (CCI), and the presence of overall surgical complications as significant potential risk factors for non-cancer related mortality. These factors also correlated with poorer overall survival and prognosis. The most common cause of non-cancer-related deaths were respiratory issues and heart failure. CONCLUSION: In elderly gastric cancer patients, managing advanced age, low BMI, high CCI, and minimizing postoperative complications are essential for reducing non-cancer-related mortality following curative surgery.

Minimizing invasiveness and simplifying the surgical procedure for upper and middle early gastric cancer with near-infrared light and organ traction.

BACKGROUND: Surgeons are often faced with optimal resection extent and reconstructive method problems in laparoscopic gastrectomy for gastric cancer in the upper and middle body of the stomach. Indocyanine green (ICG) marking and Billroth I (B-I) reconstruction were used to solve these problems with the organ retraction technique. CASE PRESENTATION: A 51-year-old man with upper gastrointestinal endoscopy revealed a 0-IIc lesion in the posterior wall of the upper and middle gastric body 4 cm from the esophagogastric junction. Clinical T1bN0M0 (clinical stage IA) was the preoperative diagnosis. Laparoscopic distal gastrectomy (LDG) and D1 + lymphadenectomy was decided to be performed considering postoperative gastric function preservation. The ICG fluorescence method was used to determine the accurate tumor location since the determination was expected to be difficult to the extent of optimal resection with intraoperative findings. By mobilizing and rotating the stomach, the tumor in the posterior wall was fixed in the lesser curvature, and as large a residual stomach as possible was secured in gastrectomy. Finally, delta anastomosis was performed after increasing gastric and duodenal mobility sufficiently. Operation time was 234 min and intraoperative blood loss was 5 ml. The patient was allowed to be discharged on postoperative day 6 without complications. CONCLUSION: The indication for LDG and B-I reconstruction can be expanded to cases where laparoscopic total gastrectomy or LDG and Roux-en-Y reconstruction has been selected for early-stage gastric cancer in the upper gastric body by combining preoperative ICG markings and gastric rotation method dissection.

[Analysis of Chemotherapy-Induced Nausea and Vomiting during Chemotherapy for Gastric Cancer].

BACKGROUND: Chemotherapy-induced nausea and vomiting(CINV)are typical side effects caused by chemotherapy. We analyzed CINV during first-line chemotherapy for gastric cancer. MATERIALS AND METHOD: Thirty-one patients who received first-line chemotherapy for gastric cancer were retrospectively assessed for CINV. RESULTS: The median age was 70 years, and the gender(male/female)was 23/8 cases. NK1 receptor antagonist, 5-HT3 receptor antagonist, and dexamethasone were used as antiemetic agents in 29 patients(94%). Sixteen patients(52%)had Grade 1 or higher nausea, and 6 patients (19%)had Grade 1 or higher vomiting, and complete control of nausea and vomiting was achieved in 21 patients(68%). Nausea was significantly more frequent in patients with liver metastasis(p=0.0008), but there was no significant difference in vomiting(p=1.0000). There was no significant difference in the occurrence of CINV between chemotherapy regimens or combination of olanzapine. CONCLUSION: During first-line chemotherapy for gastric cancer, 3 antiemetic agents were used in 94% of cases, and the complete control rate of CINV was 67.8%.

[A Case of Early Gastric Cancer with Adachi Type â ¥ Vascular Anomaly Treated by Laparoscopic Distal Gastrectomy].

We report a case of early gastric cancer with Adachi Type Ⅵ vascular anomaly treated by laparoscopic distal gastrectomy. An 81-year-old woman was admitted because of anorexia, and was diagnosed with early gastric cancer. Preoperative MDCT revealed Adachi Type Ⅵ vascular anomaly, where the hepatic artery does not appear at the superior border of the pancreas. The patient was treated successfully with laparoscopic distal gastrectomy with D1+lymph node dissection. At surgery, we identified the portal vein, then, dissection of No. 8a lymph nodes was performed. The postoperative course was uneventful and the patient was discharged 10 days after surgery. The final pathology result showed gastric cancer, M, Less, Type 0-Ⅱc+Ⅲ, 58×50 mm, tub1>pap, pT1a(M), Ly0, V0, pN0(0/40), H0, P0, M0, pStage ⅠA. We understand the arterial running pattern before surgery by using MDCT, and performed laparoscopic surgery safely.

[A Case of Laparoscopic Resection Using the ICG Fluorescence for Peritoneal Disseminations of Hepatocellular Carcinoma].

A 71-year-old male had repeated resection and transcatheter arterial chemo-embolization(TACE)for hepatocellular carcinoma(HCC). Treatment with lenvatinib was started due to multiple liver recurrences and peritoneal disseminations. Since only the disseminated lesion had increased, it was decided to perform laparoscopic resection. Indocyanine green(ICG) was intravenously injected the day before surgery. Disseminated lesions could be easily detected with intraoperative fluorescence imaging, and we could completely resect disseminated lesions. The ICG fluorescence could be considered to be useful in laparoscopic resection for peritoneal dissemination of HCC.

[A Case of Stage â £ Gastric Cancer Completely Resected after Successful Second-Line Chemotherapy].

A 60s man was diagnosed with advanced gastric cancer(cT4b[PAN], cN+, cM0, cStage ⅣA). He started first-line chemotherapy consisting of S-1 and cisplatin, but tumor markers remained elevated and CT showed cancer progression. He then started second-line chemotherapy consisting of ramucirumab and paclitaxel. The tumor markers decreased, and CT revealed tumor regression. A distal gastrectomy with D2 lymph node dissection was performed as conversion surgery. The patient had an uncomplicated postoperative course and was discharged early from the hospital. A histological analysis confirmed complete resection of the Grade 1a tumor. The RAM plus PTX regimen was restarted on postoperative day 57. At 15 months postoperative, the patient remained alive and relapse-free.

[A Case of Recurrent Sigmoid Colon Cancer with Peritoneal Metastasis and Liver Metastasis Successfully Treated with Capecitabine plus Bevacizumab].

A 78-year-old man had undergone a laparoscopic sigmoid colon resection; left ureteral resection; and a ureteral reconstruction for sigmoid colon cancer with left ureteral invasion. The patient did not wish to undergo postoperative adjuvant chemotherapy, and he was followed up at fixed intervals. Six months after surgery, CT revealed peritoneal metastasis and liver metastasis(S6). Considering his advanced age and adverse events, the patient was started on capecitabine plus bevacizumab therapy. The patient was able to continue the treatment, even though he had to suspend and reduce the dose due to adverse events of hand-foot syndrome, and achieved CR by CT after 21 courses of treatment. Chemotherapy was discontinued after 24 courses, CR was maintained for 5 years, and the patient is still alive with no evidence of recurrence.

[A Case of Advanced Gastric Cancer Successfully Treated with mFOLFOX6 Therapy].

We report a case of advanced gastric cancer that was successfully treated with mFOLFOX6 therapy. A 78-year-old man presented to our hospital with a chief complaint of weight loss. Esophagogastroduodenoscopy(EGD)and computed tomography( CT)revealed the presence of type 3 advanced gastric cancer with distant lymph node metastasis and peritoneal dissemination. Biopsy specimen examination revealed moderately differentiated adenocarcinoma with a HER2 score of 1. Chemotherapy comprising 5-fluorouracil, Leucovorin, and oxaliplatin(mFOLFOX6)was administered because of renal failure. Subsequently, the gastric lesion, distant lymph node metastasis, and peritoneal dissemination were seen to be reduced on EGD and CT. After 7 courses, the regimen was changed to 5-fluorouracil and Leucovorin(5-FU/l -LV)chemotherapy because of thrombocytopenia. For more than 10 months, he has continued to receive chemotherapy without the recurrence of metastasis.

[A Case of Gastrointestinal Submucosal Tumor with an Intraluminal Growth Pattern Resected by Laparoscopic Wedge Resection].

We report a case of gastrointestinal submucosal tumor with an intraluminal growth pattern resected by laparoscopic wedge resection. A 62-year-old man was admitted because of melena. Upper gastrointestinal endoscopy revealed gastrointestinal submucosal tumor with an intraluminal growth pattern just below the gastric junction, and the pathological diagnosis was GIST. A laparoscopic wedge resections(percutaneous endoscopic intragastric surgery)was performed by a single access port. After laparotomy 5 cm above the umbilicus, the anterior wall of the middle part of the stomach was incised and fixed to the skin, and the tumor was dissected with a linear stapler. The final pathology result showed a high risk GIST of 70×40 mm with 110 mitotic images/50 HPF, and the patient was treated with imatinib mesylate adjuvant chemotherapy. There were no complications, including postoperative transit disturbances, and there were no local or distant metastatic recurrences.

[Postoperative Gastric Metastasis from Needle Tract Seeding after Using of EUS-FNA for Pancreatic Body Cancer-A Case Report].

A 67-year-old woman with a pancreatic cancer diagnosed by endoscopic ultrasound with fine needle aspiration(EUS- FNA)was underwent distal pancreatectomy. Two years and 10 months after the operation, a computed tomography scan revealed a tumor in the posterior wall of the lower body of the stomach. Upper gastrointestinal endoscopy showed a 15 mm-sized submucosal tumor on the posterior wall of the angular region, and its biopsy showed tubular adenocarcinoma that it was resembling the resected pancreatic cancer. Needle tract seeding(NTS)of the pancreatic cancer to the gastric wall was suspected. After 5 courses of chemotherapy with gemcitabine and nab-paclitaxel, the tumor shrank and there were no other signs of metastasis, we performed distal gastrectomy. The pathological findings of the resected specimen showed a tubular adenocarcinoma, consistent with the primary pancreatic tumor. We finally diagnosed as the NTS of the pancreatic cancer to the gastric wall. In the case of EUS-FNA for the body or tail tumor of pancreas, it should be paid attention to the recurrence due to NTS because the surgical resection does not include the needle tract site.

Laparoscopic resection of a large nonadrenal ganglioneuroma adhered to the aorta and inferior mesenteric artery: A case report and literature review.

INTRODUCTION: Ganglioneuromas are well-differentiated benign tumors that arise from sympathetic ganglion cells. In ganglioneuromas of the retroperitoneum, nonadrenal cases are resected by laparotomy due to the proximity to major vessels. There have been few reports of laparoscopic resection for retroperitoneal paraaortic ganglioneuromas. We experienced a case in which laparoscopic resection was required for a 90-mm ganglioneuroma adhered to the aorta and inferior mesenteric artery. PRESENTATION OF CASE: A 49-year-old female patient presented with epigastric pain. Computed tomography showed a 90 mm retroperitoneal tumor, partially located between the aorta and inferior mesenteric artery. A definitive diagnosis was not obtained, and laparoscopic excision of the retroperitoneal tumor was performed transabdominally. The patient recovered without postoperative complications and left the hospital on postoperative day 8. Postoperative pathological findings revealed a ganglioneuroma from the abdominal periaortic plexus. DISCUSSION: We searched the literature for nonadrenal ganglioneuromas resected laparoscopically using a transabdominal approach and summarized the tumor locations. The median age was 33 years, and the median tumor size was 50 mm. Regarding the surgical results, the median operative time was 170.5 min, median blood loss was 21.5 mL, and median postoperative stay was 7 days. CONCLUSION: Laparoscopic resection of nonadrenal ganglioneuromas is feasible even when a tumor adheres to major blood vessels.

[Laparoscopic Repair of Incarcerated Diaphragmatic Hernia as a Complication of Left Hepatectomy for Liver Cancer].

We report a case of laparoscopic repair of a diaphragmatic hernia after left hepatectomy for liver cancer. A woman in her 70s had undergone left hepatectomy for liver cancer 9 months earlier, and she was admitted because of epigastric pain after vomiting immediately following contrast-enhanced CT. On the next day, contrast-enhanced CT revealed an incarcerated diaphragmatic hernia, for which laparoscopic diaphragmatic hernia repair was performed. The incarcerated stomach was pushed back into the abdominal cavity, and the diaphragm was closed with 2-0 proline sutures. Gastric resection was not performed because the blood flow gradually improved. The postoperative course was good; the patient was discharged on the 7th postoperative day and is under outpatient follow-up.

Preoperative imatinib and laparoscopic intersphincteric resection for large rectal gastrointestinal stromal tumor: A case report.

INTRODUCTION: Anus-preserving surgery for a large rectal gastrointestinal stromal tumor (GIST) may be difficult because of the location of the tumor in the pelvis. Therefore, rectal GIST might require extensive surgery, such as abdominoperineal resection. In recent years, preoperative imatinib therapy has been used to reduce tumor size and preserve the anus in some cases. However, there have been few reports of laparoscopic anal-preserving surgery for giant rectal GIST. PRESENTATION OF A CASE: We present the case of a 55-year-old man who was referred to our hospital for examination of a 10-cm pelvic mass in the lower rectum. Endoscopic ultrasound with fine needle aspiration was performed, and the pathological findings resulted in a diagnosis of GIST. The mass had spread to the prostate and left levator ani muscles, and as a result, surgery was deemed difficult to perform without damaging the pseudo-capsule. Therefore, preoperative chemotherapy with imatinib mesylate (IM) was performed for 8 months. The mass was reduced to 7.8 cm, and laparoscopic intersphincteric resection (ISR) was performed. DISCUSSION: We also review prior cases of rectal GIST where patients had undergone anal-preserving surgery following preoperative chemotherapy with IM. Our case represented the largest tumor size in a review of cases of patients who had successful anal-preserving laparoscopic surgery following preoperative chemotherapy with IM. CONCLUSION: Preoperative chemotherapy with imatinib mesylate was effective for reducing the rectal GIST, and laparoscopic ISR was useful for anal preservation, even when a tumor is large.

[Surgical Resection of the Lymph Node Metastasis after Liver Resection for Hepatocellular Carcinoma].

A 76-year-old man had undergone right lobectomy after transcatheter arterial chemoembolization(TACE)for hepatocellular carcinoma(HCC)in segment 5/6 of the liver. He had undergone TACE for intrahepatic recurrence in segment 1 eight months after the operation. Abdominal CT revealed intrahepatic recurrence in segment 2 and segment 3 and a hepatic portal lymph node swelling 13 months after the operation, he underwent TACE and radiofrequency ablation for intrahepatic lesions. There was neither intrahepatic recurrences nor new extrahepatic lesions, and the hepatic portal lymph node resection was performed. He was discharged on postoperative day 8, and there has been no subsequent recurrence over 42 months after initial treatment. The lymph node metastasis of HCC is rare and systemic chemotherapy such as molecular targeted argent is the standard treatment, but its prognosis is poor. When a patient has a resectable metastasis with controlled intrahepatic lesions, lymph node resection appears to be an effective option.