Four Cases of Proximal Release-Type Colon Stents for Obstructive Rectal Cancer.

Malignant colonic obstruction can cause necrosis, bacterial translocation, electrolytic imbalance, and death; therefore, immediate decompression should be performed. Self-expandable metallic colonic stents are an established treatment for the decompression of malignant colonic obstructions. The use of stents that open from the distal side, which have been commonly used until now, requires caution because placing a stent on the dentate line can cause severe pain, and there is a possibility of cutting the stent during rectal resection of the distal side of the tumor. Therefore, we designed a new proximal-release-type colorectal stent for use in our hospital; it is 22 mm in diameter and 70 mm in length, which was placed using the over-the-wire method with a 16 Fr delivery system. We have encountered four cases in which it was appropriate as a bridge to surgical treatment. None of the patients experienced complications, such as bleeding, pain, or other incidents, after stent placement. Additionally, the stents were not affected by the surgical dissection of the rectum on the anorectal side of the tumor. Herein, we presented the four aforementioned cases and discussed the stenting techniques.

Two cases of laparoscopic deroofing of giant liver cysts using indocyanine green fluorescence imaging.

Laparoscopic deroofing (LD) for giant liver cysts using indocyanine green (ICG) fluorescence imaging was performed in two patients: a 53-year-old man with a 26-cm, symptomatic cyst and a 50-year-old woman with a 13-cm, symptomatic cyst. ICG fluorescence imaging can be used to easily identify the boundary between the liver parenchyma and the liver cyst. No postoperative bile leakage was observed in both patients. ICG fluorescence imaging is expected to become a desirable procedure in LD for giant liver cysts to reduce the occurrence of perioperative complications.

Validation of a surgical difficulty grading system in laparoscopic cholecystectomy for acute cholecystitis.

BACKGROUND: The surgical difficulty of laparoscopic cholecystectomy (LC) for acute cholecystitis varies from case to case, and appropriate intraoperative evaluation would help prevent bile duct injury (BDI). METHODS: We analyzed 178 patients who underwent LC for acute cholecystitis. Expert surgeons and trainees individually evaluated the surgical difficulty. The inter-rater agreement was analyzed using Conger's κ and Gwet's agreement coefficient (AC). Furthermore, we analyzed the predictive surgical difficulty item for performing subtotal cholecystectomy (STC). RESULTS: Regarding the inter-rater agreement between expert surgeons and trainees, 15 of the 17 surgical difficulty items had a Gwet's AC of 0.5 or higher, indicating "moderate" agreement or higher. Furthermore, the highest and total surgical difficulty scores were deemed "substantial" agreement. Scarring and dense fibrotic changes around the Calot's triangle area with easy bleeding with/without necrotic changes were predictive of whether STC should be performed. CONCLUSIONS: This surgical difficulty grading system is expected to be a tool that can be used by any surgeon with LC experience. STC should be performed to prevent BDI according to the changes around the Calot's triangle area.

Prognostic Relevance of Primary Tumor Sidedness in Early-stage Colorectal Cancer: An Integrated Analysis of 4 Randomized Controlled Trials (JCOG2003A).

OBJECTIVE: The aim of this study was to determine the genuine prognostic relevance of primary tumor sidedness (PTS) in patients with early-stage colorectal cancer (CRC). BACKGROUND: The prognostic relevance of PTS in early-stage CRC remains a topic of debate. Several large epidemiological studies investigated survival only and did not consider the risk of recurrence so far. METHODS: Patients with stage II/III adenocarcinoma of the colon and upper rectum from 4 randomized controlled trials were analyzed. Survival outcomes were compared according to the tumor location: right-sided (cecum to transverse colon) or left-sided (descending colon to upper rectum). RESULTS: A total of 4113 patients were divided into a right-sided group (N=1349) and a left-sided group (N=2764). Relapse-free survival after primary surgery was not associated with PTS in all patients and each stage [hazard ratio (HR) adjusted =1.024 (95% CI: 0.886-1.183) in all patients; 1.327 (0.852-2.067) in stage II; and 0.990 (0.850-1.154) in stage III]. Also, overall survival after primary surgery was not associated with PTS in all patients and each stage [HR adjusted =0.879 (95% CI: 0.726-1.064) in all patients; 1.517 (0.738-3.115) in stage II; and 0.840 (0.689-1.024) in stage III]. In total, 795 patients (right-sided, N=257; left-sided, N=538) developed recurrence after primary surgery. PTS was significantly associated with overall survival after recurrence (HR adjusted =0.773, 95% CI: 0.627-0.954). CONCLUSIONS: PTS had no impact on the risk of recurrence for stage II/III CRC. Treatment stratification based on PTS is unnecessary for early-stage CRC.

[Collision Tumor Involving Primary Ascending Colon Cancer and Malignant Lymphoma].

A 78-year-old male was diagnosed with a primary gastric B-cell malignant lymphoma and metastatic lung tumor 10 years ago. He underwent chemotherapy at another hospital, achieved complete remission, and was actively undergoing follow- up. He presented to our hospital with a 1-month history of a bulge in his right lower abdomen. CT revealed thickening of the ascending colon and dilatation of the oral intestine. He was diagnosed with ascending colon cancer and underwent right hemicolectomy. The subsequent pathological examination revealed a collision tumor involving diffuse, large B-cell lymphoma and well-differentiated adenocarcinoma. He was discharged from our hospital and received chemotherapy at another institution. Unfortunately, the patient died of interstitial pneumonia 31 months postoperatively. This report describes the resection of a collision tumor involving ascending colon cancer and malignant lymphoma. Surgical treatment combined with postoperative chemotherapy improved this patient's long-term survival.

A Japanese Prospective, Multicenter Study of Colonic Stenting for Palliation Using a High Axial Force Self-Expandable Metal Stent for Malignant Large Bowel Obstruction in 200 Patients.

Evidence of the efficacy and safety of colorectal stent placement for palliation remains insufficient. This single-arm, prospective, multicenter study with a WallFlex enteral colonic stent included 200 consecutive patients with malignant large bowl obstruction in the palliation cohort. The technical and clinical success, as well as stent patency and complications as short-term (≤7 days) and long-term (>7 days) outcomes, of high axial force self-expandable metal stent (SEMS) placement was evaluated. The technical and clinical success rates were 98.5% and 94.5%, respectively. Non-recurrent colorectal obstruction at 1 year was 63.9%, and 71.2% of the patients remained free of recurrent colorectal obstruction until death or the last follow-up. Fifty-six patients (28.0%) received chemotherapy, and five patients were administered bevacizumab after stent placement. The overall complication rate was 47%, including four (2.0%) early-onset and ten (5.0%) late-onset perforations, mostly due to stent-edge injury. Only the use of a long SEMS was a risk factor for perforation. In conclusion, endoscopic colorectal stenting using high axial force SEMS is an effective and safe procedure for palliation in patients with malignant colorectal obstruction. However, care should be taken to avoid perforation at the stent edge when using a long SEMS.

Rapid identification of bacteria using a multiplex polymerase chain reaction system for acute abdominal infections.

Purpose: Acute abdominal infections can be fatal if the causative organism (s) are misidentified. The spread of antimicrobial-resistant bacteria has become a serious problem worldwide, making antibiotic selection extremely difficult. Using quantitative metagenomic analysis, we evaluated a commercial multiplex polymerase chain reaction (PCR) system (FilmArray™, bioMérieux, Marcy-l'Étoile, France) for the rapid identification of causative bacteria. Methods: The cases of 10 patients with acute abdominal infections were enrolled in this retrospective study. There were six cases of perforated peritonitis and four cases of intraabdominal abscess. Fluid collected from the acute surgical abdominal infections were examined. Results: All specimens tested positive for microorganisms in culture, and six involved two or more microorganisms. Using the multiplex PCR system, nine of ten specimens were found to involve at least one microorganism. One specimen was not included in the multiplex PCR system panel. Nineteen of 21 microorganisms (90.5%) isolated by culture were detected by the multiplex PCR system. Microorganisms with very small numbers of reads (19 reads) were detectable. Conclusion: This multiplex PCR system showed a high detection rate for causative microorganisms in ascites and intraabdominal abscesses. This system may be suitable as an affordable rapid identification system for causative bacteria in these cases.

Definitive S-1/mitomycin-C chemoradiotherapy for stage II/III anal canal squamous cell carcinoma: a phase I/II dose-finding and single-arm confirmatory study (JCOG0903).

BACKGROUND: Definitive chemoradiotherapy (CRT) with 5-fluorouracil plus mitomycin-C is a standard treatment for stage II/III squamous cell carcinoma of the anal canal (SCCA). We performed this dose-finding and single-arm confirmatory trial of CRT with S-1 plus mitomycin-C to determine the recommended dose (RD) of S-1 and evaluate its efficacy and safety for locally advanced SCCA. METHODS: Patients with clinical stage II/III SCCA (UICC 6th) received CRT comprising mitomycin-C (10 mg/m2 on days 1 and 29) and S-1 (60 mg/m2/day at level 0 and 80 mg/m2/day at level 1 on days 1-14 and 29-42) with concurrent radiotherapy (59.4 Gy). Dose-finding used a 3 + 3 cohort design. The primary endpoint of the confirmatory trial was 3-year event-free survival. The sample size was 65, with one-sided alpha of 5%, power of 80%, and expected and threshold values of 75% and 60%, respectively. RESULTS: Sixty-nine patients (dose-finding, n = 10; confirmatory, n = 59) were enrolled. The RD of S-1 was determined as 80 mg/m2/day. Three-year event-free survival in 63 eligible patients who received the RD was 65.0% (90% confidence interval 54.1-73.9). Three-year overall, progression-free, and colostomy-free survival rates were 87.3%, 85.7%, and 76.2%, respectively; the complete response rate was 81% on central review. Common grade 3/4 acute toxicities were leukopenia (63.1%), neutropenia (40.0%), diarrhea (20.0%), radiation dermatitis (15.4%), and febrile neutropenia (3.1%). No treatment-related deaths occurred. CONCLUSIONS: Although the primary endpoint was not met, S-1/mitomycin-C chemoradiotherapy had an acceptable toxicity profile and favorable 3-year survival and could be a treatment option for locally advanced SCCA. CLINICAL TRIAL INFORMATION: jRCTs031180002.

Clinical Guidelines for Diagnosis and Management of Peutz-Jeghers Syndrome in Children and Adults.

BACKGROUND: Peutz-Jeghers syndrome (PJS) is a rare disease characterized by the presence of hamartomatous polyposis throughout the gastrointestinal tract, except for the esophagus, along with characteristic mucocutaneous pigmentation. It is caused by germline pathogenic variants of the STK11 gene, which exhibit an autosomal dominant mode of inheritance. Some patients with PJS develop gastrointestinal lesions in childhood and require continuous medical care until adulthood and sometimes have serious complications that significantly reduce their quality of life. Hamartomatous polyps in the small bowel may cause bleeding, intestinal obstruction, and intussusception. Novel diagnostic and therapeutic endoscopic procedures such as small-bowel capsule endoscopy and balloon-assisted enteroscopy have been developed in recent years. SUMMARY: Under these circumstances, there is growing concern about the management of PJS in Japan, and there are no practice guidelines available. To address this situation, the guideline committee was organized by the Research Group on Rare and Intractable Diseases granted by the Ministry of Health, Labour and Welfare with specialists from multiple academic societies. The present clinical guidelines explain the principles in the diagnosis and management of PJS together with four clinical questions and corresponding recommendations based on a careful review of the evidence and involved incorporating the concept of the Grading of Recommendations Assessment, Development and Evaluation system. KEY MESSAGES: Herein, we present the English version of the clinical practice guidelines of PJS to promote seamless implementation of accurate diagnosis and appropriate management of pediatric, adolescent, and adult patients with PJS.

Intensive endoscopic resection for downstaging of polyp burden in patients with familial adenomatous polyposis (J-FAPP Study III): a multicenter prospective interventional study.

BACKGROUND: Total colectomy is the standard treatment for familial adenomatous polyposis (FAP). Recently, an increasing number of young patients with FAP have requested the postponement of surgery or have refused to undergo surgery. We aimed to evaluate the effectiveness of intensive endoscopic removal for downstaging of polyp burden (IDP) in FAP. METHOD: A single-arm intervention study was conducted at 22 facilities. Participants were patients with FAP, aged ≥ 16 years, who had not undergone colectomy or who had undergone colectomy but had ≥ 10 cm of large intestine remaining. For IDP, colorectal polyps of ≥ 10 mm were removed, followed by polyps of ≥ 5 mm. The primary end point was the presence/absence of colectomy during a 5-year intervention period. RESULTS: 222 patients were eligible, of whom 166 had not undergone colectomy, 46 had undergone subtotal colectomy with ileorectal anastomosis, and 10 had undergone partial resection of the large intestine. During the intervention period, five patients (2.3 %, 95 % confidence interval [CI] 0.74 %-5.18 %) underwent colectomy, and three patients died. Completion of the 5-year intervention period without colectomy was confirmed in 150 /166 patients who had not undergone colectomy (90.4 %, 95 %CI 84.8 %-94.4 %) and in 47 /56 patients who had previously undergone colectomy (83.9 %, 95 %CI 71.7 %-92.4 %). CONCLUSION: IDP in patients with mild-to-moderate FAP could have the potential to be a useful means of preventing colorectal cancer without implementing colectomy. However, if the IDP protocol was proposed during a much longer term, it may not preclude the possibility that a large proportion of colectomies may still need to be performed.

[Malignant Melanoma of a Male Breast That Was Difficult to Differentiate from Breast Cancer-A Case Report].

INTRODUCTION: Malignant melanoma in the male breast is extremely rare. Here we report a case of malignant melanoma in which a small cystic lesion in the male breast gradually increased during follow-up and was difficult to distinguish from breast cancer. CASE: A 65-year-old male was diagnosed with a tumor in the right breast and was referred to our department for further examination. At 42 years of age, he underwent tumor resection of a malignant melanoma of the abdominal skin. Mammary ultrasonography showed a 0.6 cm cystic mass in his right breast. Eight months later, the right breast mass had increased to 1.4 cm, and a core needle biopsy suggested breast cancer. Total mastectomy with axillary lymph node dissection was performed. HE staining of the resected tumor showed intranuclear inclusion bodies and some large nucleoli. On the basis of various immunostaining methods, malignant melanoma was diagnosed instead of breast cancer. After surgery, adjuvant chemotherapy with molecularly targeted drugs was administered. DISCUSSION: This might have been a case of male breast metastasis of malignant melanoma with very late recurrence.

[Laparoscopic Tumor Resection for Asymptomatic Paraganglioma-A Case Study].

A 55-year-old man was referred for the close examination of an abdominal mass noted on abdominal ultrasonography during a physical examination. A contrast-enhanced computed tomography(CT)scan of his abdomen revealed a 36-mm heterogeneously contrast-enhanced mass on the left side of the aorta. He was referred for laparoscopic tumor resection without preoperative histological examination. The tumor was identified from the dorsal aspect of the mesentery of the transverse colon and was resected only because it was detachable from the duodenum. A temporary abnormal hypertension was observed intraoperatively. However, he exhibited a favorable postoperative course and was discharged on the 8th postoperative day. Grossly, it was a nodular tumor with a diameter of 38 mm. Histopathological examination revealed that the tumor cells having abundant cytoplasm formed large foci and were surrounded by sinusoidal vessels. Immunohistochemistry results were positive for chromogranin A, synaptophysin, and neural cell adhesion molecule; thus, paraganglioma was diagnosed. Herein, we report a case of laparoscopic resection of an asymptomatic paraganglioma.

Prognostic factors of patients with left-sided obstructive colorectal cancer: post hoc analysis of a retrospective multicenter study by the Japan Colonic Stent Safe Procedure Research Group.

BACKGROUND: There are many reports on the choice of treatment for and prognosis of left-sided obstructive colorectal cancer; however, few studies have focused on the prognostic factors of left-sided obstructive colorectal cancer. Therefore, we analyzed the prognostic factors using a post hoc analysis of a retrospective multicenter study in Japan. METHODS: A total of 301 patients were enrolled in this study to investigate the prognostic factors for relapse-free survival. The relationships between sex, age, decompression for bridge to surgery, depth of invasion, lymph node metastasis, postoperative complications, adjuvant chemotherapy, carcinoembryonic antigen, carbohydrate antigen 19-9, neutrophil-to-lymphocyte ratio, and relapse-free survival were examined. RESULTS: No change in the decompression method, T3 cancer, negative postoperative complications (grades 0-1 of Clavien-Dindo classification), and adjuvant chemotherapy during Stage III indicated a significantly better prognosis in a Cox univariate analysis. Lymph node metastasis was not selected as a prognostic factor. Excluding patients with <12 harvested lymph nodes (possible stage migration), lymph node metastasis was determined as a prognostic factor. In a Cox multivariate analysis, change in the decompression method, depth of invasion, lymph node metastasis (excluding N0 cases with <12 harvested lymph nodes), and adjuvant chemotherapy were prognostic factors. CONCLUSIONS: Similar to those in nonobstructive colorectal cancer, depth of invasion and lymph node metastasis were prognostic factors in left-sided obstructive colorectal cancer, and patients with <12 dissected lymph nodes experienced stage migration. Stage migration may result in disadvantages, such as not being able to receive adjuvant chemotherapy.

Long-term outcomes of standardized colonic stenting using WallFlex as a bridge to surgery: Multicenter prospective cohort study.

OBJECTIVES: The oncological outcomes, especially high recurrence rate, of bridge-to-surgery (BTS) self-expandable metallic stent (SEMS) placement remain concerning, emphasizing the necessity of standardized SEMS placement. However, its impact on long-term BTS outcomes is unknown. We investigated the long-term outcomes of BTS colonic stenting using standardized SEMS placement. METHODS: This prospective, multicenter cohort study conducted at 46 hospitals in Japan (March 2012 to October 2013) included consecutive patients with stage II and III obstructive colorectal cancer managed with BTS SEMS placement. The SEMS placement technique was standardized by information dissemination among the participating hospitals. The primary outcome was overall survival (OS) after SEMS placement, and the secondary outcomes were relapse-free survival (RFS), recurrence, and short-term outcomes of SEMS placement and surgery. RESULTS: The 1-, 3-, and 5-year OS rates were 94.1%, 77.4%, and 67.4% (Kaplan-Meier), respectively, with high technical success (99.0%, 206/208) and low perforation (1.9%, 4/208) rates. The 1-, 3-, and 5-year RFS rates were 81.6%, 65.6%, and 57.9% (Kaplan-Meier), respectively, and the overall recurrence rate was 31.0% (62/200). The RFS rate was significantly poorer in patients with perforation (n = 4) than in those without perforation (n = 196) (log-rank P = 0.017); moreover, perforation was identified as an independent factor affecting RFS (hazard ratio 3.31; 95% confidence interval 1.03-10.71, multivariate Cox regression). CONCLUSION: This large, prospective, multicenter study revealed satisfactory long-term outcomes of BTS colonic stenting using a standardized SEMS insertion method, which might be specifically due to the reduced perforation rate. (UMIN000007953).

Short-Term Outcomes of Colorectal Stenting Using a Low Axial Force Self-Expandable Metal Stent for Malignant Colorectal Obstruction: A Japanese Multicenter Prospective Study.

(1) Background: Endoscopic colorectal stenting with high technical success and safety is essential in discussing the oncological outcomes for the management of malignant colorectal obstruction. Mechanical properties of self-expandable metal stents are usually considered to affect clinical outcomes. (2) Methods: A multicenter, prospective study was conducted in Japan. A self-expandable metal stent with low axial force was inserted endoscopically. The primary endpoint was clinical success, defined as the resolution of symptoms and radiological findings within 24 h. Secondary endpoints were technical success and adverse events. Short-term outcomes of 7 days were evaluated in this study. (3) Results: Two hundred and five consecutive patients were enrolled. Three patients were excluded, and the remaining 202 patients were evaluated. The technical and clinical success rates were 97.5% and 96.0%, respectively. Major stent-related adverse events included stent migration (1.0%), insufficient stent expansion (0.5%), and stent occlusion (0.5%). No colonic perforation was observed. There were two fatal cases (1%) which were not related to stent placement. (4) Conclusions: The placement of self-expandable metal stents with low axial force is safe with no perforation and showed high technical and clinical success rates in short-term outcomes for the management of malignant colorectal obstruction.

Quick detection of causative bacteria in cases of acute cholangitis and cholecystitis using a multichannel gene autoanalyzer.

PURPOSES: Acute cholangitis and cholecystitis can become severe conditions as a result of inappropriate therapeutic administration and thereafter become increasingly resistant to antimicrobial treatment. The simultaneous detection of the bacterial nucleic acid and antimicrobial resistance gene is covered by the national health insurance program in Japan for sepsis. In this study, we evaluate the use of a multichannel gene autoanalyzer (Verigene system) for the quick detection of causative bacteria in cases of acute cholangitis and cholecystitis. METHODS: This study included 108 patients diagnosed with acute cholangitis or cholecystitis between June 2015 and November 2018. A bacterial culture test and Verigene assay were used to evaluate the bile samples. RESULTS: The most commonly isolated bacteria were Escherichia coli, which includes six extended-spectrum beta-lactamase (ESBL)-producing E. coli. Among the patients with positive bile cultures, bacteria were detected in 35.7% of cases via the Verigene system. The detection rates of the Verigene system significantly increased when the number of bacterial colonies was ≥ 106 colony-forming unit (CFU)/mL (58.1%). Cases with a maximum colony quantity of ≥ 106 CFU/mL exhibited higher inflammation, suggesting the presence of a bacterial infection. CONCLUSIONS: The Verigene system might be a new method for the quick detection of causative bacteria in patients with infectious acute cholangitis and cholecystitis.

[Two Cases of Hereditary Breast Cancer in Which Genetic Counseling Was Useful].

INTRODUCTION: The importance of genetic counseling has been noted for hereditary breast cancer. We report the cases of two 32-year-old woman, unmarried, BRCA mutation-positive patients. CASES: In Case 1, the chief complaint was awareness of a right breast mass. There was a family history of breast cancer(3 previous cases in the family). The BRCA2 mutation was positive during the BRACAnalysis test. Right breast mastectomy and axillary dissection were performed. Genetic counseling was performed postoperatively, and her eggs were cryopreserved. In Case 2, the chief complaint was calcification of the right breast. She also had a family history of breast cancer(3 previous cases in the family). The BRCA1 mutation was positive during the BRACAnalysis test. Nipple-sparing mastectomy and sentinel lymph node biopsy were performed, and the pathological diagnosis was DCIS. After genetic counseling, she did not desire the cryopreservation of her eggs. DISCUSSION: In these cases, the histological type, stage, subtype, BRCA mutation site, etc., were different from each other, and detailed support by genetic counseling was taken according to each medical condition such as surgery and postoperative adjuvant therapy.

Comparing the mechanical properties of a self-expandable metallic stent for colorectal obstruction: Proposed measurement method of axial force using a new measurement machine.

OBJECTIVES: Colorectal stenting is widely performed using self-expandable metallic stents (SEMSs), but the mechanical properties have not been evaluated. Therefore, we conducted an in vitro study to evaluate the mechanical properties of colorectal SEMSs. METHODS: Eighteen individual types and sizes of uncovered SEMSs were evaluated for their mechanical properties. Radial force was measured using a measurement machine. Axial force (AF) was measured by two methods: a conventional manual method and a new method using a measurement machine. The correlation of these two methods was evaluated. We also proposed an "AF zero border" that was defined as the angle at which the torque force disappeared. RESULTS: Radial force versus diameter curves and AF versus angle curves were influenced by the structure and the size of each stent. There was excellent correlation of AFs measured by the new and conventional manual method (y = 21.434x, R = 0.881, P < 0.0001). Colorectal SEMSs could be categorized into five subgroups according to the mechanical properties. Most hook-wired SEMSs had the AF of zero border. CONCLUSIONS: This is the first report to evaluate the mechanical properties of colorectal SEMSs, and these data may provide useful information for the clinical use and development of colorectal SEMS. Furthermore, the new measurement machine might standardize the measuring method of AF.

What are the important prognostic factors in gastric cancer with positive duodenal margins? A multi-institutional analysis.

PURPOSE: Positive margins are reported in from 4.8 to 9.5% of all gastric cancer surgeries and they have a negative impact on the overall survival. Few cases with positive duodenal margins have been included in previous studies regarding the prognosis. METHODS: This multi-institutional retrospective study included 115 gastric cancer patients with positive duodenal margins following gastrectomy between January 2002 and December 2017. The association between clinicopathological factors and the overall survival was evaluated by univariate and multivariate analyses. RESULTS: The three-year overall survival was 22% and the median survival was 13 months. A multivariate analysis found that distant metastasis, no postoperative chemotherapy, and non-Type 4 disease were significantly associated with a poor survival. Patients without distant metastasis who received postoperative chemotherapy had a 3-year overall survival of 56% and a median survival of 44 months. CONCLUSION: The patients who underwent post-operative chemotherapy showed a significantly better OS compared with those who did not undergo post-operative chemotherapy, regardless of the existence of distant metastasis. Postoperative chemotherapy may, therefore, improve the prognosis of surgically treated gastric cancer patients with positive duodenal margins.