Retracted: Long Non-Coding RNA (lncRNA) SNHG5 Participates in Vertical Sleeve Gastrectomy for Type II Diabetes Mellitus by Regulating TGR5.

The Editors of Medical Science Monitor wish to inform you that the above manuscript has been retracted from publication due to concerns with the credibility and originality of the study, the manuscript content, and the Figure images. Reference: Weiwei Wei, Hao Tian, Xiandong Fu, Rongrong Yao, Dewang Su. Long Non-Coding RNA (lncRNA) SNHG5 Participates in Vertical Sleeve Gastrectomy for Type II Diabetes Mellitus by Regulating TGR5. Med Sci Monit, 2020; 26: e920628. DOI: 10.12659/MSM.920628.

Surgical outcomes and prognosis of intracorporeal versus extracorporeal esophagojejunostomy after laparoscopic total gastrectomy for gastric cancer: a propensity score-matching study.

This study compared the surgical outcomes and long-term prognosis of intracorporeal and extracorporeal esophagojejunostomy after laparoscopic total gastrectomy (LTG) for gastric cancer patients. In total 228 clinical stage I gastric cancer patients undergoing LTG were enrolled from January 2012 and December 2022. Each case in the totally laparoscopic total gastrectomy (TLTG) group was 1:1 propensity score-matched to control cases in the laparoscopy-assisted total gastrectomy (LATG) group. In total, 95 and 93 LATG and TLTG patients were included after propensity score matching (PSM). Clinicopathological features, surgical outcomes, and survival variables were compared, and risk factors for postoperative complications were analyzed. Patient characteristics were well balanced between the LATG and TLTG groups after PSM. The TLTG group showed less blood loss, decreased frequency of analgesic use, and shorter duration of analgesic use. The TLTG group had significantly lower rates of intestinal obstruction and surgical site infection. Larger tumor size and advanced pTNM stage were independent risk factors for postoperative complications. There was no significant difference in overall survival (OS). Compared with LATG, TLTG was associated with better surgical outcomes and fewer postoperative surgical complications in gastric cancer patients although there was no significant difference in OS.

Laparoscopic right gastroepiploic artery-sparing distal gastric tube resection with lymph node dissection for gastric tube cancer after esophagectomy: A novel surgical approach (with video).

INTRODUCTION: Total resection of the gastric tube with lymphadenectomy for advanced gastric tube cancer is highly invasive and associated with severe complications. Other surgical option, partial gastrectomy or wedge resection, is insufficient if lymph node metastasis is suspected. Therefore, a technique balancing invasiveness and curability is required. MATERIALS AND SURGICAL TECHNIQUE: First, we laparoscopically peeled off adhesions of the gastric tube, gastric mesentery (including the right gastroepiploic artery/vein), pericardial membrane, and aorta, up to the planned resection line. Subsequently, we cut the infrapyloric and right gastric arteries at their roots and dissected No. 5 and No. 6 lymph nodes. We taped and spared the right gastroepiploic artery and vein and dissected the tissues including No. 4d lymph nodes. Finally, the gastric tube was cut using a linear stapler, and the remaining gastric tube was anastomosed to the jejunum with a circular stapler. The mean operative time for the three cases treated using this intervention was 729 min. The patients were discharged on postoperative day 8 or 9 without any complications. They all remained alive and recurrence-free. DISCUSSION: This novel approach balances invasiveness and curability by leveraging the advantages of laparoscopy. The procedure was performed safely and reproducibly in three consecutive cases, providing another viable option for the treatment of gastric tube cancer.

Long-Term Efficacy of Single-Incision Laparoscopic Intragastric Resection in Treating Gastrointestinal Stromal Tumors.

Gastrointestinal stromal tumors (GISTs), the most common mesenchymal tumors in the gastrointestinal tract, are increasingly treated with minimally invasive surgeries. Developed techniques include laparoscopic, endoscopic, and hybrid methods for gastric GIST resection. Our study, focusing on single-incision laparoscopic intragastric resection for gastric GISTs, aims to evaluate its safety, efficacy, and long-term outcomes. In a retrospective study of GIST surgery involving 14 patients who underwent single-incision laparoscopic intragastric resections, we analyzed and compared their preoperative demographics, American Society of Anesthesiologists (ASA) scores, tumor size, neoadjuvant treatment, operation duration, hospital stay, mitotic and Ki-67 indexes, and histological features with those of patients who underwent open and laparoscopic wedge resections, to assess the impact on both survival and disease-free survival. Average operation time was 93.07 minutes (range 81-120 minutes). Average blood loss: 67 ± 20 mL (range 40-110 mL). Postoperative hospital stay averaged 6.79 days (range 4-16 days). Strong correlations were observed between preoperative and pathological tumor sizes (P = .001, P < .001). Survival analysis indicated a significant association with ASA scores (P = .031), but not with mitotic index, Ki-67, or tumor size. Average survival was 80.57 months, with no recurrence or metastasis during follow-up. Based on our experience, the single-incision laparoscopic intragastric resection method emerges as a highly efficient, timesaving, and gentle oncological procedure, providing a safe and minimally invasive alternative resulting in shorter hospital stays and excellent long-term outcomes with minimal recurrence. For more definitive conclusions, larger, multicenter, and prospective studies are recommended.

Leaks after laparoscopic sleeve gastrectomy: 2024 update on risk factors.

PURPOSE: Leaks after sleeve gastrectomy remain a deadly complication significantly affecting outcomes and medical costs. The aim of the present review is to provide an updated decalogue on leak prevention. METHODS: Risk factors of leakage after LSG were examined based on an extensive review of literature (in period time 2016-2024) and summary of evidence was provided using Oxford levels of evidence scale. RESULTS: Pathogenesis of leakage after LSG still remain related to ischemic and mechanical factors and, therefore, no new evidence has been reported. Conversely, some technical aspect of the procedure has changed: bougie size, antrum resection, staple line reinforcement, and intraoperative leak testing. CONCLUSIONS: Bougie size 36 F is effective and safe achieving similar leakage rate compared to larger bougie sizes (EL:2) 2024 UPDATE; There is no significant difference in the leak rate between restrictive (< 6 cm) and conservative (6 cm) antrum resection (EL: 1) 2024 UPDATE; Surgical experience and case volume affect the leak rate more consistently than every kind of SLR (EL: 2) 2024 UPDATE; Intraoperative leak test after LSG represents a decision based on surgeon preference in absence of standardization (endoscopy, bubble test, methylene blue, indocyanine green.) and strong detection/prevention rate (EL: 3) 2024 UPDATE.

Major dietary patterns and their associations with total weight loss and weight loss composition 2-4 years after sleeve gastrectomy.

BACKGROUND: Food intakes 1-2 years following bariatric surgery depend more on patients than the surgery's gastrointestinal tract changes. This study aimed to determine the major dietary patterns of patients after the first two years of sleeve gastrectomy and to investigate their associations with total weight loss (TWL) and the proportion of TWL as fat mass (FM) and fat-free mass (FFM) loss. METHODS: This cross-sectional study included 146 patients undergoing sleeve gastrectomy 2-4 years after surgery. Dietary patterns were determined using principal component analysis based on the 19 food groups. The percentage of FM loss relative to TWL (%FML) and FFM loss relative to TWL (%FFML) were calculated. A suboptimal clinical response was defined as a TWL of less than 25%. High FM loss and excessive FFM loss were defined based on the highest tertiles. Linear and logistic regression models were used to derive unstandardized (B) coefficients and odds ratios (OR), with dietary pattern scores serving as both a continuous and a binary variable (higher vs. lower adherence groups based on median). RESULTS: Two predominant dietary patterns were retained. Each 1-unit increase in the first dietary pattern score characterized by high intakes of fast foods, soft drinks, processed meats, sugar confectionary, salty snacks, grains, and organ meats was associated with higher %FFML (B = 1.99; 95% confidence interval (CI) 0.34, 3.66), lower %FML (B = - 1.84; 95% CI - 3.49, - 0.20), and higher odds of excessive FFM loss (OR = 1.84; 95% CI 1.09, 3.11). Participants with higher adherence to the first dietary pattern had lower %TWL, and greater odds of suboptimal clinical response and excessive FFM loss than those with lower adherence. Each 1-unit increase in score for the second dietary pattern characterized by a high intake of fruits, dairy, vegetables, legumes, eggs, nuts, red meats, poultry, and fish was associated with lower odds of suboptimal clinical response (OR = 0.51; 95% CI 0.31, 0.86). CONCLUSION: Patients should be encouraged to modify their diet by reducing the consumption of ultra-processed foods and increasing their intake of high-quality protein sources, fruits, and vegetables to achieve the best postoperative outcome.

Complete Mesogastric Excision with D2 Lymphadenectomy for Gastric Cancer: Short-Term Results.

OBJECTIVE: To compare the short-term results of complete mesogastric excision with the conventional surgical technique. STUDY DESIGN: An experimental study. Place and Duration of the Study: Department of Gastroenterological Surgery, Health Sciences University, Basaksehir City Hospital, Istanbul, Turkiye, from April to December 2023. METHODOLOGY: Comparison of short-term results of open total gastrectomy + mesogastrectomy with standard total gastrectomy + D2 lymph node dissection at a tertiary centre in terms of peroperative results, histopathological findings, and postoperative short-term outcomes prospectively, with review of the literature. RESULTS: A total of 37 patients were included in the study. The groups involved 26 male and 11 female patients. The study group included 14 patients while the control group involved 23 patients. The mean blood loss (mL) was significantly lower and number of metastatic lymph nodes was significantly higher in the study group. CONCLUSION: Total mesogastric excision is a safe technique which has advantages over conventional D2 gastrectomy in terms of not only peroperative and short-term outcomes, but also disease-free survival. This is the first study from a different population of the world and initial results can contribute to the literature for universalisation. KEY WORDS: Complete mesogastrium excision, D2 lymphadenectomy, Gastric cancer, Gastrectomy, Mesogastrectomy.

A case of malignant gastric glomus tumor and literature review: A case report.

RATIONALE: Malignant gastric glomus tumor (GGT) is an extremely rare malignant tumor of mesenchymal origin, it affects the patient's health and even threatens life. Malignant GGT with vascular invasion is even more rarely reported in the available literature without a prognostic study. So, in this case, we report a malignant GGT with vascular invasion and performed a 5-year postoperative follow-up. To the best of our knowledge, we report the first case of malignant GGT with vascular invasion without recurrence 5 years after surgery. This provides examples and lessons for the treatment of malignant GGT with vascular invasion. PATIENT CONCERNS: A 49-year-old male was admitted to the hospital with gallbladder stones found on health check. After completing abdominal CT and ultrasound gastroscopy, a mass in the gastric antrum was found. DIAGNOSES: The diagnosis of malignant GGT was confirmed by combination of postoperative pathology with positive immunohistochemistry for SMA, vimentin, synaptophysin, H-caldesmon, and calponin, mitosis > 10/50 HPF and moderate-to-severe nuclear atypia. INTERVENTIONS: On the 6th day of hospitalization, the patient underwent laparoscopic distal gastrectomy and cholecystectomy. OUTCOMES: The patient was discharged successfully 1 week after surgery and was followed up for 5 years without recurrence. CONCLUSION: Malignant GGT can be asymptomatic. For malignant GGT without distant metastasis, despite the presence of vascular invasion, negative margin surgery can still be the standard surgical radical treatment.

Reply to Lee, S.Y. Comment on "Matsuo et al. Impact of Olfactory Change on Postoperative Body Weight Loss in Patients with Gastric Cancer after Gastrectomy. Nutrients 2024, 16, 851".

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Comment on Matsuo et al. Impact of Olfactory Change on Postoperative Body Weight Loss in Patients with Gastric Cancer after Gastrectomy. Nutrients 2024, 16, 851.

I read with interest the paper by Matsuo et al [...].

Gestational Weight Gain Following Metabolic Bariatric Surgery: A Scoping Review.

Metabolic bariatric surgery remains the most effective and durable treatment for severe obesity. Women of reproductive age represent the largest demographic group undergoing these procedures. Metabolic bariatric surgery can have both beneficial and adverse effects on pregnancy outcomes. One of the most common adverse effects is fetal growth restriction. To mitigate these adverse effects, it is crucial to explore lifestyle modifications aimed at promoting a healthy pregnancy. Modifiable factors during pregnancy after metabolic bariatric surgery include the amount of gestational weight gain. The aim of this comprehensive review is to provide an overview of what is known about gestational weight gain in pregnancy after bariatric metabolic surgery. This review is focused on the two most performed procedures: sleeve gastrectomy and Roux-en-Y gastric bypass.

Gastric cystica profunda: Another indication for minimally invasive endoscopic resection techniques?

Gastric cancer presents a significant global health burden, as it is the fifth most common malignancy and fourth leading cause of cancer mortality worldwide. Variations in incidence rates across regions underscores the multifactorial etiology of this disease. The overall 5-year survival rate remains low despite advances in its diagnosis and treatment. Although surgical gastrectomy was previously standard-of-care, endoscopic resection techniques, including endoscopic mucosal resection and endoscopic submucosal dissection (ESD) have emerged as effective alternatives for early lesions. Compared to surgical resection, endoscopic resection techniques have comparable 5-year survival rates, reduced treatment-related adverse events, shorter hospital stays and lower costs. ESD also enables en bloc resection, thus affording organ-sparing curative endoscopic resection for early cancers. In this editorial, we comment on the recent publication by Geng et al regarding gastric cystica profunda (GCP). GCP is a rare gastric pseudotumour with the potential for malignant progression. GCP presents a diagnostic challenge due to its nonspecific clinical manifestations and varied endoscopic appearance. There are several gaps in the literature regarding the diagnosis and management of GCP which warrants further research to standardize patient management. Advances in endoscopic resection techniques offer promising avenues for GCP and early gastric cancers.

Comparing the antireflux effect of laparoscopic proximal gastrectomy with double-flap technique reconstruction versus laparoscopic total gastrectomy with Roux-en-Y reconstruction for proximal early gastric cancer: study protocol for a multicentre, prospective, open-label, randomised controlled trial.

INTRODUCTION: Laparoscopic proximal gastrectomy with double flap technique (LPG-DFT) reconstruction has been used for proximal early gastric cancer in recent years. However, its feasibility and safety remain uncertain, as only a few retrospective studies have contained postoperative complications and long-term survival data. LPG-DFT for proximal early gastric cancer is still in the early stages of research. Large-scale, prospective randomised controlled trials (RCTs) are necessary to assess the value of LPG-DFT for proximal early gastric cancer. METHODS AND ANALYSIS: This study is a multicentre, prospective, open-label, RCT that investigates the antireflux effect of LPG-DFT compared with laparoscopic total gastrectomy with Roux-en-Y (LTG-RY) reconstruction for proximal early gastric cancer. A total of 216 eligible patients will be randomly assigned to the LPG-DFT group or the LTG-RY group at a 1:1 ratio using a central, dynamic and stratified block randomisation method, if inclusion criteria are met. General and clinical data will be collected when the patient is enrolled in the study and keep pace with the patient at each stage of his medical and follow-up pathway. The primary endpoint is the proportion of patients with reflux esophagitis (Los Angeles Grade B or more) within 12 months postoperatively. The secondary endpoints included intraoperative outcomes, postoperative recovery, postoperative pain assessment, pathological outcomes, postoperative quality of life, postoperative nutrition status, morbidity and mortality rate, and oncological outcomes (3-year overall survival (OS), 3-year disease-free survival (DFS), 5-year DFS and 5-year OS). ETHICS AND DISSEMINATION: The protocol is approved by the Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University ethics committee (registration number: SYSKY-2022-276-02) on 28 September 2022.We will report the positive as well as negative findings in international peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT05890339.

Timing Considerations for Sleeve Gastrectomy in Kidney Transplant Patients: A Single Center Evaluation.

Current scientific literature is deficient in detailing the optimal timing for conducting bariatric surgery in relation to kidney transplantation. In this study, we performed a retrospective evaluation of kidney transplant recipients with BMI >35 kg/m2. It aimed to provide data on those who received both sleeve gastrectomy (SG) and kidney transplantation (KT) simultaneously, as well as on patients who underwent SG and KT at different times, either before or after. In addition, the acceptance levels of the bariatric surgery among different scenarios were assessed. Our findings demonstrated that combined KT and SG led to successful weight loss, in contrast to undergoing kidney transplant alone, while maintaining comparable rates of graft and patient survival. Weight loss was similar between recipients who had a combined operation and those who underwent SG following the transplant. Additionally, over a median time frame of 1.7 years, patients who underwent SG before KT exhibited a statistically significant reduction in BMI at the time of the transplant. Notably, our study highlights that patients offered the combined procedure were significantly more likely to undergo SG compared to those for whom SG was presented at a different operative time than the transplant.

30-day morbidity and mortality of revisional bariatric surgery - An international multi-centre collaborative (BROAD) study.

INTRODUCTION: Revisional bariatric surgery (RBS) for insufficient weight loss/weight regain or metabolic relapse is increasing worldwide. There is currently no large multinational, prospective data on 30-day morbidity and mortality of RBS. In this study, we aimed to evaluate the 30-day morbidity and mortality of RBS at participating centres. METHODS: An international steering group was formed to oversee the study. The steering group members invited bariatric surgeons worldwide to participate in this study. Ethical approval was obtained at the lead centre. Data were collected prospectively on all consecutive RBS patients operated between 15th May 2021 to 31st December 2021. Revisions for complications were excluded. RESULTS: A total of 65 global centres submitted data on 750 patients. Sleeve gastrectomy (n = 369, 49.2 %) was the most common primary surgery for which revision was performed. Revisional procedures performed included Roux-en-Y gastric bypass (RYGB) in 41.1 % (n = 308) patients, One anastomosis gastric bypass (OAGB) in 19.3 % (n = 145), Sleeve Gastrectomy (SG) in 16.7 % (n = 125) and other procedures in 22.9 % (n = 172) patients. Indications for revision included weight regain in 615(81.8 %) patients, inadequate weight loss in 127(16.9 %), inadequate diabetes control in 47(6.3 %) and diabetes relapse in 27(3.6 %). 30-day complications were seen in 80(10.7 %) patients. Forty-nine (6.5 %) complications were Clavien Dindo grade 3 or higher. Two patients (0.3 %) died within 30 days of RBS. CONCLUSION: RBS for insufficient weight loss/weight regain or metabolic relapse is associated with 10.7 % morbidity and 0.3 % mortality. Sleeve gastrectomy is the most common primary procedure to undergo revisional bariatric surgery, while Roux-en-Y gastric bypass is the most commonly performed revision.

Ex-situ Open Approach Spleen Preserving Splenic Hilum Lymphadenectomy.

Background: multiple studies showed important benefices arising from splenic preservation in patients with digestive cancer in general and gastric cancer in particular. The minimally invasive approach remains controversial in locally advanced gastric cancer cases whilst the open approach still has an important role. This paper's aim is to describe and present the feasibility of an open surgical technique that allows removing stations 10 together with 11p and 11d with spleen and splenic vessels preservation in pacients operated upon by open surgery. Material and Methods: We present an open "Ex-situ" spleen and pancreas preserving surgical technique that removes the anterior and posterior ganglia from the splenic hilum, the splenic vessels and the distal pancreas in locally advanced gastric cancer cases of the upper two thirds of the stomach. Forty-three consecutive patients since 2003 were operated upon by the author in multiple centers. during upper two thirds gastric cancer resections requiring no. 10 lymphadenectomy. Results: no splenectomy was needed . All the spleens were viable at postoperative Doppler echography and CT scans. No spleen migrated nor caused mechanical complications. No clinically significant pancreatic leaks were noticed. Two patients died during hospital stay, one of miocardial infarction and one of massive stroke. Pertinent follow up data and survival were not available. Conclusions: The method enables the surgeon to remove the lymph nodes no. 10 along with 11p and 11d without needing to sacrifice the spleen. All spleens were reattached sucessfully using the preserved spleno-renal ligament fold, no wandering spleen was noticed.

MRI versus Dual-Energy CT in Local-Regional Staging of Gastric Cancer.

Background Preoperative local-regional tumor staging of gastric cancer (GC) is critical for appropriate treatment planning. The comparative accuracy of multiparametric MRI (mpMRI) versus dual-energy CT (DECT) for staging of GC is not known. Purpose To compare the diagnostic accuracy of personalized mpMRI with that of DECT for local-regional T and N staging in patients with GC receiving curative surgical intervention. Materials and Methods Patients with GC who underwent gastric mpMRI and DECT before gastrectomy with lymphadenectomy were eligible for this single-center prospective noninferiority study between November 2021 and September 2022. mpMRI comprised T2-weighted imaging, multiorientational zoomed diffusion-weighted imaging, and extradimensional volumetric interpolated breath-hold examination dynamic contrast-enhanced imaging. Dual-phase DECT images were reconstructed at 40 keV and standard 120 kVp-like images. Using gastrectomy specimens as the reference standard, the diagnostic accuracy of mpMRI and DECT for T and N staging was compared by six radiologists in a pairwise blinded manner. Interreader agreement was assessed using the weighted κ and Kendall W statistics. The McNemar test was used for head-to-head accuracy comparisons between DECT and mpMRI. Results This study included 202 participants (mean age, 62 years ± 11 [SD]; 145 male). The interreader agreement of the six readers for T and N staging of GC was excellent for both mpMRI (κ = 0.89 and 0.85, respectively) and DECT (κ = 0.86 and 0.84, respectively). Regardless of reader experience, higher accuracy was achieved with mpMRI than with DECT for both T (61%-77% vs 50%-64%; all P < .05) and N (54%-68% vs 51%-58%; P = .497-.005) staging, specifically T1 (83% vs 65%) and T4a (78% vs 68%) tumors and N1 (41% vs 24%) and N3 (64% vs 45%) nodules (all P < .05). Conclusion Personalized mpMRI was superior in T staging and noninferior or superior in N staging compared with DECT for patients with GC. Clinical trial registration no. NCT05508126 © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Méndez and Martín-Garre in this issue.

Efficiency and safety of single anastomosis sleeve ileal (SASI) bypass in the treatment of obesity and associated comorbidities: a systematic review and meta-analysis.

INTRODUCTION: The Single Anastomosis Sleeve Ileal (SASI) bypass is a new bariatric surgery corresponding to an adaptation of the Santoro approach, consisting of a sleeve gastrectomy (SG) followed by loop gastroileostomy. Therefore, we aimed to systematically assess all the current literature on SASI bypass in terms of safety, weight loss, improvement in associated comorbidities, and complications. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) recommendations, we conducted a systematic review and meta-analysis by searching three databases (PubMed, Scopus, and Web of Science). We performed a meta-analysis of risk ratios and mean differences to compare surgical approaches for excessive weight loss, improvement/remission in type 2 diabetes mellitus (T2DM), hypertension (HT), dyslipidemia (DL), obstructive sleep apnea (OSA), and complications. Heterogeneity was assessed using the I2 statistic. RESULTS: Eighteen studies were included in the qualitative analysis and four in the quantitative analysis, comparing SASI bypass with SG and One-Anastomosis Gastric Bypass (OAGB). A comparison between Roux-en-Y Gastric Bypass (RYGB) and SASI bypass could not be performed. Compared to SG, the SASI bypass was associated with improved weight loss (MD = 11.32; 95% confidence interval (95%CI) [7.89;14.76]; p < 0.0001), and improvement or remission in T2DM (RR = 1.35; 95%CI [1.07;1.69]; p = 0.011), DL (RR = 1.41; 95%CI [1.00;1.99]; p = 0.048) and OSA (RR = 1.50; 95%CI [1.01;2.22]; p = 0.042). No statistically significant differences in any of the assessed outcomes were observed when compared with OAGB. When compared to both SG and OAGB, the complication rate of SASI was similar. CONCLUSION: Although studies with longer follow-up periods are needed, this systematic review and meta-analysis showed that SASI bypass has a significant effect on weight loss and metabolic variables. Variations in outcomes between studies reinforce the need for standardization.

Textbook Outcome of Delta-Shaped Anastomosis in Minimally Invasive Distal Gastrectomy for Gastric Cancer in 4,505 Consecutive Patients.

PURPOSE: Textbook outcome is a comprehensive measure used to assess surgical quality and is increasingly being recognized as a valuable evaluation tool. Delta-shaped anastomosis (DA), an intracorporeal gastroduodenostomy, is a viable option for minimally invasive distal gastrectomy in patients with gastric cancer. This study aims to evaluate the surgical outcomes and calculate the textbook outcome of DA. MATERIALS AND METHODS: In this retrospective study, the records of 4,902 patients who underwent minimally invasive distal gastrectomy for DA between 2009 and 2020 were reviewed. The data were categorized into three phases to analyze the trends over time. Surgical outcomes, including the operation time, length of post-operative hospital stay, and complication rates, were assessed, and the textbook outcome was calculated. RESULTS: Among 4,505 patients, the textbook outcome is achieved in 3,736 (82.9%). Post-operative complications affect the textbook outcome the most significantly (91.9%). The highest textbook outcome is achieved in phase 2 (85.0%), which surpasses the rates of in phase 1 (81.7%) and phase 3 (82.3%). The post-operative complication rate within 30 d after surgery is 8.7%, and the rate of major complications exceeding the Clavien-Dindo classification grade 3 is 2.4%. CONCLUSIONS: Based on the outcomes of a large dataset, DA can be considered safe and feasible for gastric cancer.