Effects of Reproductive Factors on Lauren Intestinal-Type Gastric Cancers in Females: A Multicenter Retrospective Study in South Korea.

Background/Aims: Gastric cancers (GCs), particularly the Lauren intestinal type, show a male predominance. The aim of this study was to investigate the effects of reproductive factors on GCs in females, according to Lauren classification. Methods: Medical records of 1,849 males and 424 females who underwent radical gastrectomy or endoscopic resection for GCs between 2010 and 2018 were reviewed. The incidences of intestinal-type GCs were compared between males and groups of females stratified according to postmenopausal period. Associations between reproductive factors in females and intestinaltype GCs were analyzed using multivariate models. Results: The proportions of intestinal-type GCs were significantly lower in premenopausal (19%), less than 10 years postmenopausal (30.4%), and 10 to 19 years postmenopausal females (44.1%) than in males (61.0%) (p<0.05 for all). Females ≥20 years postmenopause had a proportion of intestinal-type GCs similar to that in males (60.6% vs 61.0%; p=0.948). Multivariate analysis revealed that age (odds ratio [OR], 1.075; 95% confidence interval [CI], 1.039 to 1.113; p<0.001) and parity ≥3 (OR, 1.775; 95% CI, 1.012 to 3.114; p=0.045) were positively associated with an increased risk of intestinal-type GCs in postmenopausal females, while long fertility duration (OR, 1.147; 95% CI, 1.043 to 1.261; p=0.005) was positively associated with an increased risk of intestinal-type GCs in premenopausal females. Conclusions: There were no significant differences in the proportions of intestinal-type GCs between males and females ≥20 years postmenopause, suggesting that female reproductive factors play a role in the prevention of intestinal-type GC.

Advanced Diagnostic Technology of Volatile Organic Compounds Real Time analysis Analysis From Exhaled Breath of Gastric Cancer Patients Using Proton-Transfer-Reaction Time-of-Flight Mass Spectrometry.

BACKGROUND: Screening endoscopy is considered to be the most accurate tool for early detection of gastric cancer, but it is both invasive and costly. It is therefore essential to develop cost-effective and non-invasive diagnostic tools for gastric cancer. The aim of this study is to investigate the presence of certain volatile organic compounds (VOCs) associated with gastric cancer and to survey the usefulness of VOCs as screening tools of gastric cancer. METHODS: The present study was conducted prospectively to identify the relationship between gastric cancer and specific VOCs quantified by mass spectrometry. Exhaled breath samples from a total of 43 participants were analysed. This study was approved by the Institutional Review Board of the College of Medicine, Catholic University of Korea (KC16TISI0598), and registered to clinical research information service (KCT0004356). RESULTS: Nine VOCs differed significantly between the control and cancer patient groups. When participants were divided into control, early gastric cancer (EGC), and advanced gastric cancer (AGC) groups, seven VOCs remained significantly different. Of these, four (propanal, aceticamide, isoprene and 1,3 propanediol) showed gradual increases as cancer advanced, from normal control to EGC to AGC. In receiver operating characteristic curves for these four VOCs, the area under the curve for gastric cancer prediction was highest (0.842) when more than two VOCs were present. CONCLUSIONS: The present study offers potential directions for non-invasive gastric cancer screening, and may inspire advanced diagnostic technologies in the era of smart home healthcare. However, despite the high accuracy, cancer-specific VOCs from several studies on different populations, and analytic methods show inconsistency, it is necessary to establish standards for each analytical method, and to validate on each population.

Association between absolute lymphocyte count and overall mortality in patients with surgically resected gastric cancer.

BACKGROUND/AIMS: Lymphocytes are an important component of the cell-mediated immune system. As lymphopenia is reportedly associated with poor prognoses in patients with various cancers, we investigated this notion in patients who underwent curative gastrectomy. METHODS: We retrospectively analyzed the association between absolute lymphocyte count (ALC) and prognosis in patients with stage I-III gastric cancer who underwent curative surgical resection. Ever lymphopenic patients were defined as those with ALCs < 1,000/µL at any time post-diagnosis except within 30 days post-surgery. Adjusted multivariable regression models were used to evaluate the associations between lymphopenia and overall mortality, gastric cancer-specific mortality, and disease-free survival. RESULTS: We investigated 1,222 patients diagnosed between January 2011 and December 2015. Fifty-six patients (4.6%) were lymphopenic at diagnosis and nearly one-quarter (24.8%) were ever lymphopenic with a mean minimum ALC of 640/µL. Older age (odds ratio [OR], 1.02) and higher stage (stage III vs. I; OR, 3.01) were positively associated with ever lymphopenia. On multivariable analysis, ever lymphopenia predicted higher overall mortality (hazard ratio [HR], 1.83; p = 0.008), higher gastric cancer-specific mortality (HR, 1.58; p = 0.048), and shorter disease-free survival (HR, 1.83; p = 0.006). The 5-year gastric cancer-specific mortality rates for ever- and never lymphopenic patients were 10.9% and 3.7%, respectively; their 5-year cumulative recurrence rates were 15.1% and 4.6%, respectively. CONCLUSION: This study demonstrate that ever lymphopenia is independent prognostic factor for overall mortality and recurrence in patients with potentially curable gastric cancer; hence, ALCs may be a biomarker for predicting the prognoses of patients with stage I-III gastric cancer who had curative gastrectomy.

Modified controlling nutritional status score: A refined prognostic indicator depending on the stage of gastric cancer.

BACKGROUND: The role of controlling nutritional status (CONUT) score in predicting cancer survival remains uncertain. This study aimed to investigate the predictive value of the CONUT score and to develop a more appropriate scoring system beyond CONUT for gastric cancer. METHODS: We retrospectively reviewed 1307 patients who underwent curative gastrectomy between 2009 and 2015. The CONUT and three modified scores with modified lipid components (L-CONUT: albumin/total lymphocyte count [TLC]/low density lipoprotein, H-CONUT: albumin/TLC/high density lipoprotein, and T-CONUT: albumin/TLC/triglyceride) were calculated. The predictive value of each scoring system on long-term survival was assessed. RESULTS: The values of the four nutritional scores were categorized into four groups (normal, light, moderate, and severe). The CONUT (P < 0.001), L-CONUT (P < 0.001), H-CONUT (P < 0.001), and T-CONUT (P < 0.001) scores showed significant differences in overall survival in between groups. Survival analysis according to the pathological stage showed that advanced age, Eastern Cooperative Oncology Group performance status, male sex, and moderate H-CONUT score (HR, 3.970; 95% CI, 1.826-8.633; P = 0.001) were independent worse prognostic factors for overall survival in the stage I group. In the stage II group, light CONUT score (HR, 2.230; 95% CI, 1.067-4.664; P = 0.033) and moderate CONUT score (HR, 5.077; 95% CI, 1.647-15.650; P = 0.005) were significantly associated with poor prognosis. In the stage III group, no scoring system showed significant results. CONCLUSION: In advanced gastric cancer (beyond stage II), the prognostic impact of the nutritional scoring system was uncertain. However, the H-CONUT score is a promising indicator of prognosis in stage I, and the CONUT score is useful for predicting long-term survival in stage II gastric cancer.

Operative safety of curative gastrectomy after endoscopic submucosal dissection (ESD) for early gastric cancer - 1:2 propensity score matching analysis: A retrospective single-center study (cohort study).

BACKGROUND: This study aimed to evaluate the operative safety and long-term outcomes of additional curative gastrectomy (ACG) after non-curative endoscopic submucosal dissection (ESD), as compared with standard gastrectomy (SG) without ESD in patients with early gastric cancer. MATERIALS AND METHODS: Data from 101 patients receiving ACG after non-curative ESD (Post-ESD group) and 1080 patients after SG without ESD (Surgery-only group), between 2009 and 2016, were reviewed retrospectively. Clinicopathologic characteristics, overall survival (OS), disease-specific survival (DSS), and relapse-free survival (RFS) were compared between groups, using propensity score matching analysis. RESULTS: After propensity score matching, a total of 101 patients in the post-ESD group and 202 patients in the surgery-only group were analyzed. The post-ESD group had shorter operation times than did the surgery-only group (p = 0.005). Estimated blood loss and the incidence of postoperative morbidity did not differ between the two groups, and no differences were observed in pathologic outcomes, including N stage (p = 0.268). In addition, 5-year OS, DSS, and RFS rates were not significantly different between groups (OS; 95.1% vs. 98.2%, p = 0.535, DSS; 98.2% vs. 98.7%, p = 0.956, and RFS; 98.6% vs. 98.9%, p = 0.757, respectively). CONCLUSION: ACG can be performed safely after non-curative endoscopic submucosal dissection, with good operative outcomes.

Development and validation of a pretreatment nomogram to predict overall survival in gastric cancer.

BACKGROUND: Pretreatment clinical staging is essential to select therapy. However, there have been no published pretreatment gastric cancer nomograms constructed using pretreatment clinical prognostic factors, including in nonresection patients. We aimed to develop a new pretreatment gastric cancer nomogram for individualized prediction of overall survival (OS). METHODS: The nomogram was developed using data of 5231 Japanese gastric cancer patients, and it was created with a Cox regression model. Fifteen clinical variables, which were obtained at pretreatment, were collected and registered. Data of two independent cohorts of patients from Seoul St. Mary's Hospital (1001 patients), and the University of Verona (389 patients) formed the external validation cohorts. The model was validated internally and externally using measures of discrimination (Harrell's C-index), calibration, and decision curve analysis. RESULTS: The developed nomogram showed good discrimination, with a C-index of 0.855; that of the American Joint Committee on Cancer (AJCC) clinical stage was 0.819. In the external validation procedure, the C-indexes were 0.856 (AJCC, 0.795) in the Seoul St. Mary's cohort and 0.714 (AJCC, 0.648) in the University of Verona cohort. The nomogram performed well in the calibration and decision curve analyses when applied to both the internal and external validation cohorts. A stage-specific subset survival analysis of the three risk groups calculated using the nomogram also showed the superiority of nomogram-prediction when compared to AJCC. CONCLUSION: This new pretreatment model accurately predicts OS in gastric cancer and can be used for patient counseling in clinical practice and stratification in clinical trials.

Regional Lymph Node Dissection as an Additional Treatment Option to Endoscopic Resection for Expanded Indications in Gastric Cancer: a Prospective Cohort Study.

PURPOSE: Expanded indications for endoscopic submucosal dissection (ESD) in early gastric cancer (EGC) remain controversial due to the potential risk of undertreatment after adequate lymph node dissection (LND). Regional LND (RLND) is a novel technique used for limited lymphadenectomy to avoid gastrectomy. This study established the safety and effectiveness of RNLD as an additional treatment option after ESD for expanded indications. MATERIALS AND METHODS: A total of 69 patients who met the expanded indications for ESD were prospectively enrolled from 2014 to 2017. The tumors were localized using intraoperative esophagogastroduodenoscopy (EGD) before RLND. All patients underwent RLND first, followed by conventional radical gastrectomy with LND. The locations of the preoperative and intraoperative EGD were compared. Pathologic findings of the primary lesion and the RLND status were analyzed. RESULTS: The concordance rates of tumor location between the preoperative and intraoperative EGD were 79.7%, 76.8%, and 63.8% according to the longitudinal, circumferential, and regional locations, respectively. Of the 4 patients (5.7%) with metastatic LNs, 3 were pathologically classified as beyond the expanded indication for ESD and 1 had a single LN metastasis in the regional lymph node. CONCLUSIONS: RLND is a safe additional option for the treatment of EGC in patients meeting expanded indications after ESD.

Negative Impact of Endoscopic Submucosal Dissection on Short-Term Surgical Outcomes of Subsequent Laparoscopic Distal Gastrectomy for Gastric Cancer.

BACKGROUND: Endoscopic submucosal dissection (ESD) for gastric cancer produces an artificial ulcer, and negative effects on the surgical outcomes of additional gastrectomy after ESD are anticipated. The aim of this study is to analyze the effect of ESD on subsequent laparoscopic radical gastrectomy procedures and to compare the surgical results of post-ESD patients with the control group using propensity score (PS) methods. PATIENTS AND METHODS: From 2013 to 2018, 1446 patients underwent totally laparoscopic distal gastrectomy in our center. Among these patients, the clinicopathological factors and short-term surgical outcomes of 107 patients who underwent ESD before surgery (the ESD group) were evaluated. A 1:4 PS matching and inverse probability weighting method was utilized to compare the short-term surgical outcomes of the ESD group with those of a matched control group. RESULTS: A longer operation time was required for the patients who underwent gastrectomy earlier than 24 days after ESD than for the patients who did not. Patients whose ulcer size, due to previous ESD, exceeded 4.6 cm required longer operation times and exhibited more intraoperative blood loss than patients whose ulcer size was small. In the PS matching analysis, patients who underwent distal gastrectomy within 24 days after ESD showed more frequent postoperative morbidity than non-ESD patients. CONCLUSIONS: ESD after laparoscopic distal gastrectomy is largely safe in terms of short-term surgical outcomes, but a short interval between the two procedures and a large ESD scar can make subsequent operation difficult.

Efficacy of capecitabine and oxaliplatin versus S-1 as adjuvant chemotherapy in gastric cancer after D2 lymph node dissection according to lymph node ratio and N stage.

BACKGROUND: We sought to assess the prognostic significance of lymph node ratio (LNR) and N stage in patients undergoing D2 gastrectomy and adjuvant chemotherapy, S-1, and XELOX and to compare the efficacy of them according to LNRs and N stages to evaluate the clinical impact of using LNRs compared with using N staging. METHODS: Patients undergoing D2 gastrectomy with adequate lymph node dissection and adjuvant chemotherapy for stage II/III gastric cancer between Mar 2011 and Dec 2016 were analysed. Of the 477 patients enrolled, 331 received S-1 and 146 received XELOX. LNR groups were segregated as 0, 0-0.1, 0.1-0.25, and > 0.25 (LNR0, 1, 2, and 3, respectively). Propensity score matching (PSM) was used to minimise potential selection bias and compare DFS and OS stratified by LNRs and N stages in the two treatment groups. RESULTS: After PSM, the sample size of each group was 110 patients, and variables were well balanced. All patients had more than 15 examined lymph nodes (median 51, range 16~124). In multivariate analysis, LNR (> 0.25) and N stage (N3) showed independent prognostic value in OS and DFS, but LNR (> 0.25) showed better prognostic value. In subgroup analysis, the LNR3 group showed better 5-year DFS (20% vs 54%; HR 0.29; p = 0.004) and 5-year OS (26% vs 67%; HR 0.28; p = 0.020) in the XELOX group. The N3 group showed better 5-year DFS (38% vs 66%; HR 0.40; p = 0.004) and 5-year OS (47% vs 71%; HR 0.45; p = 0.019) in the XELOX group. Stage IIIC showed better 5-year DFS (22% vs 57%; HR 0.32; p = 0.004) and 5-year OS (27% vs 68%; HR 0.32; p = 0.009) in the XELOX group. The LNR3 group within N3 patients showed better 5-year DFS (21% vs 55%; HR 0.31; p = 0.004) and 5-year OS (27% vs 68%; HR 0.34; p = 0.018) in the XELOX group. CONCLUSIONS: LNR showed better prognostic value than N staging. LNR3, N3 and stage IIIC groups showed the superior efficacy of XELOX to that of S-1. And the LNR3 group within N3 patients showed more survival benefit from XELOX. LNR > 0.25, N3 stage and stage IIIC were the discriminant factors for selecting XELOX over S-1. TRIAL REGISTRATION: Not applicable (retrospective study).

The Effect of Metformin on Prognosis in Patients With Locally Advanced Gastric Cancer Associated With Type 2 Diabetes Mellitus.

OBJECTIVES: This study examined the effect of metformin use on the prognosis of gastric cancer patients. MATERIALS AND METHODS: The study population comprised 2187 patients who underwent curative gastrectomy for the treatment of gastric cancer. They were divided into 3 groups: metformin (n=103), non-metformin (n=139), and non-diabetes mellitus (DM) (n=1945) according to their history of type 2 DM and metformin use. Survival, disease recurrence, and the pathologic stage were analyzed. RESULTS: Overall survival was better in the metformin group than in the non-DM group (P=0.005). Metformin use was an independent prognostic factor of overall survival, cancer recurrence, and peritoneal recurrence. An effect of metformin use was especially notable in patients with T4 or N0 disease. CONCLUSIONS: Metformin improves the survival of patients with gastric cancer and type 2 DM.

Stage-specific difference in timing and pattern of initial recurrence after curative surgery for gastric cancer.

BACKGROUND: Gastric cancer (GC) follow-up schedule after curative surgery is universally recommended based on the pathologic stage, but their details, including intervals and modalities of surveillance have not yet been standardised. The aim of this study was to investigate the characteristics of GC recurrence by stage to establish optimal postoperative surveillance strategies. METHODS: Medical information on 5095 patients with GC who underwent curative intent gastrectomy in our institution between January 1989 and December 2013 was reviewed retrospectively. Moreover, 656 patients who had recurrences after radical surgery were identified. Clinicopathologic characteristics, timing and pattern of recurrence, and survival data of these patients were analysed. RESULTS: Among the 656 patients, 50 (7.6%), 123 (18.8%), and 483 (73.6%) had stages I, II, and III GC, respectively. The median times to initial recurrence in patients with stages I, II, and III GC were 23.5 months (interquartile range [IQR], 13.0-33.0 months), 13.0 months (IQR, 9.0-25.0 months), and 12.0 months (IQR, 7.0-21.0 months), respectively. In patients with stage I GC, more than half (58%) of them had distant organ metastasis; otherwise, peritoneal dissemination (39%) was the most common pattern in patients with stage III GC. CONCLUSIONS: Despite the low incidence, the time of initial recurrence in stage I GC was longer than those in stage II and III GC. Moreover, the pattern of initial recurrence was also different according to the pathologic stage. Therefore, clinicians should consider stage-specific differences of recurrence in setting up surveillance strategies after curative surgery for GC patients.

Efficacy of an antiadhesive agent for the prevention of intra-abdominal adhesions after radical gastrectomy: A prospective randomized, multicenter trial.

BACKGROUND: Guardix-SG is a poloxamer-based antiadhesive agent. The aim of this study was to investigate its efficacy in preventing abdominal adhesions in gastric cancer patients undergoing gastrectomy. Few clinical studies have reported that antiadhesive agent reduces the incidence of adhesion after gastrectomy. METHODS: We conducted a multicenter trial from June 2013 and August 2015 in patients with gastric adenocarcinoma undergoing radical gastrectomy. Patients were randomly assigned to the Guardix treatment or control group. Postoperative adhesions were diagnosed based on postoperative symptoms, plain x-ray films, and computed tomography. The primary endpoint of the study was the incidence of small bowel obstruction in the first postoperative year. The secondary end-point was the safety of Guardix-SG. RESULTS: The study included 109 patients in the Guardix group and 105 patients in the control group. The groups were similarly matched with pathological stage, operation type, anastomosis method, midline incision length, and the extent of lymph node dissection. Eight in the Guardix group and 21 in the control group experienced intestinal obstruction during the 1-year follow-up period. The cumulative incidence of small bowel obstruction was significantly lower in the Guardix group compared to that seen in the control group (4.7% vs 8.6% at 6 months and 7.3% vs 20% at 1 year; P = .007, log-rank test). There were no differences in postoperative complications and adverse events. CONCLUSION: Guardix-SG significantly decreased the incidence of intestinal obstruction without affecting the incidence of postoperative complications.

The Relevance of Serosal Exposure Without Nodal Metastasis in Resectional Gastric Cancer.

BACKGROUND: According to 8th AJCC/UICC TNM criteria, stage IIB includes pT1N3M0, pT2N2M0, pT3N1M0, and pT4aN0M0, which includes not only early gastric cancer but also locally advanced cancer. There are currently no data about whether there is any additional impact of serosal exposed cancer without nodal metastasis (pT4aN0) on patients' survival outcomes compared with other subgroups in IIB. METHODS: Patients who underwent radical gastrectomy for gastric cancer patients were enrolled, including 427 patients in stage IIB; 20 (4.68%), 104 (24.35%), 172 (40.28%), and 131 (30.67%) patients were classified as pT1N3a, pT2N2, pT3N1, and pT4aN0, respectively. Clinicopathological characteristics, recurrence pattern, and survival and recurrence rates were analyzed according to the TNM subgroups. RESULTS: Cancer-specific and relapse-free survival were significantly worse in serosal exposed cancer than in nonserosal exposed cancer in stage IIB (P = 0.019 and P = 0.015). Recurrence rate was highest in the pT4aN0 subgroup (29.0%) in stage IIB, and peritoneal metastasis was the most common pattern. Survival outcomes of the pT4aN0 subgroup were not significantly different from those of the stage IIIA or pT4aN1 subgroups. CONCLUSIONS: Patients with serosal exposed cancer without nodal metastasis shows worse cancer specific and disease-free survival with higher incidence of peritoneal metastasis than other subgroups in stage IIB. Further surveillance studies, including staging laparoscopy and active adjuvant therapy, are required in this subgroup of patients.

Discordancy and changes in the pattern of programmed death ligand 1 expression before and after platinum-based chemotherapy in metastatic gastric cancer.

BACKGROUND: Our goal was to evaluate changes in PD-L1 expression in primary tumours of metastatic gastric cancer before and after chemotherapy. METHODS: We evaluated the PD-L1 expression of 72 patients with primary gastric cancer, before and after palliative first-line platinum-based chemotherapy, between January 2015 and March 2017. The PD-L1 ratio was defined as pre-chemotherapy PD-L1 expression divided by the post-chemotherapy PD-L1 expression. RESULTS: In 30 patients with PD-L1 negative pre-chemotherapy, 12 (40%) were positive post-chemotherapy; among the 42 patients with PD-L1 positive pre-chemotherapy, 24 (57.1%) were negative post-chemotherapy. The degree of PD-L1 expression decreased from 58.3% before chemotherapy to 41.7% after chemotherapy (P = 0.046). Among patients with complete response/partial response (CR/PR), the degree of PD-L1 expression decreased (P = 0.002), as well as PD-L1 positivity with statistical significance (P = 0.013) after chemotherapy, but not among patients with stable disease/progressive disease (SD/PD). Higher disease control rates (CR/PR/SD) were observed in patients with an elevated PD-L1 ratio (P = 0.043). Patients with a high PD-L1 ratio (> 1) were found to be associated with a better progression-free survival (HR 0.34, 95% CI 0.17-0.67, P = 0.002). CONCLUSIONS: PD-L1 expression can change during chemotherapy. Moreover, changes in patterns of PD-L1 expression might be associated with patient prognosis and response to chemotherapy.

Nature versus nurture: the impact of nativity and site of treatment on survival for gastric cancer.

BACKGROUND: The prognosis of gastric cancer patients is better in Asia than in the West. Genetic, environmental, and treatment factors have all been implicated. We sought to explore the extent to which the place of birth and the place of treatment influences survival outcomes in Korean and US patients with localized gastric cancer. METHODS: Patients with localized gastric adenocarcinoma undergoing potentially curative gastrectomy from 1989 to 2010 were identified from the SEER registry and two single institution databases from the US and Korea. Patients were categorized into three groups: Koreans born/treated in Korea (KK), Koreans born in Korea/treated in the US (KUS), and White Americans born/treated in the US (W), and disease-specific survival rates compared. RESULTS: We identified 16,622 patients: 3,984 (24.0%) KK, 1,046 (6.3%) KUS, and 11,592 (69.7%) W patients. KK patients had longer unadjusted median (not reached) and 5-year disease-specific survival (81.6%) rates than KUS (87 months, 55.9%) and W (35 months, 39.2%; p < 0.001 for all comparisons) patients. This finding persisted on subset analyses of patients with stage IA tumors, without cardia/GEJ tumors, with > 15 examined lymph nodes, and treated at a US center of excellence. On multivariable analysis, KUS (HR 2.80, p < 0.001) and W (HR 5.79, p < 0.001) patients had an increased risk of mortality compared to KK patients. CONCLUSIONS: Both the place of birth and the place of treatment significantly contribute to the improved prognosis of patients with gastric cancer in Korea relative to those in the US, implicating both nature and nurture in this phenomenon.

Safety of Laparoscopic Radical Gastrectomy in Gastric Cancer Patients with End-Stage Renal Disease.

PURPOSE: The surgical outcomes of end-stage renal disease (ESRD) patients undergoing radical gastrectomy for gastric cancer were inferior compared with those of non-ESRD patients. This study aimed to evaluate the short- and long-term surgical outcomes of ESRD patients undergoing laparoscopic gastrectomy (LG) and open gastrectomy (OG) for gastric cancer. MATERIALS AND METHODS: Between 2004 and 2014, 38 patients (OG: 21 patients, LG: 17 patients) with ESRD underwent gastrectomy for gastric cancer. Comparisons were made based on the clinicopathological characteristics, surgical outcomes, and long-term survival rates. RESULTS: No significant differences were noted in the clinicopathological characteristics of either group. LG patients had lower estimated blood loss volumes than OG patients (LG vs. OG: 94 vs. 275 mL, P=0.005). The operation time and postoperative hospital stay were similar in both the groups. The postoperative morbidity for LG and OG patients was 41.1% and 33.3%, respectively (P=0.873). No significant difference was observed in the long-term overall survival rates between the 2 groups (5-year overall survival, LG vs. OG: 82.4% vs. 64.7%, P=0.947). CONCLUSIONS: In ESRD patients, LG yielded non-inferior short- and long-term surgical outcomes compared to OG. Laparoscopic procedures might be safely adopted for ESRD patients who can benefit from the advantages of minimally invasive surgery.

Three-Port Right-Side Approach-Duet Totally Laparoscopic Distal Gastrectomy for Uncut Roux-en-Y Reconstruction.

BACKGROUND: This study presents the initial feasibility of three-port right-side approach-duet totally laparoscopic distal gastrectomy (R-duet TLDG) with uncut Roux-en-Y (R-Y) reconstruction for the treatment of lower- or middle-third gastric cancer. METHODS: A total of 30 patients who underwent R-duet TLDG with uncut R-Y reconstruction for gastric cancer were enrolled. All patients were treated at the Catholic Medical Center. Reconstructions were performed intracorporeally without special instruments. The clinicopathological characteristics, operative details, postoperative short-term outcomes, and postoperative follow-up endoscopy results were analyzed retrospectively. RESULTS: All operations were performed by three-port R-duet TLDG. There were no conversions to an open approach, and no additional ports were placed. The mean operating time was 170 minutes, and the mean number of retrieved lymph nodes was 44. Three patients experienced mild postoperative complications, including small bowel ileus and pneumonia. Follow-up endoscopy was carried out at 3 months. No patients had experienced moderate-or-severe food stasis, alkaline gastritis, or bile reflux during the follow-up period. Recanalization of the biliopancreatic limb was not observed. CONCLUSIONS: R-duet TLDG with uncut R-Y reconstruction could be safely performed as a reduced port surgery without special instruments.

Long-Term Nutritional Outcomes of Near-Total Gastrectomy in Gastric Cancer Treatment: a Comparison with Total Gastrectomy Using Propensity Score Matching Analysis.

PURPOSE: This study sought to examine whether near total gastrectomy (nTG) confers a long-term nutritional benefit when compared with total gastrectomy (TG) for the treatment of gastric cancer. MATERIALS AND METHODS: Patients who underwent nTG or TG for gastric cancer were included (n=570). Using the 1:2 matched propensity score, 25 patients from the nTG group and 50 patients from the TG group were compared retrospectively for oncologic outcomes, including long-term survival and nutritional status. RESULTS: The length of the proximal resection margin, number of retrieved lymph nodes and tumor nodes, metastasis stage, short-term postoperative outcomes, and long-term survival were not significantly different between the groups. The body mass index values, and serum total protein and hemoglobin levels of the patients decreased significantly until postoperative 6 months, and then recovered slightly over time (P<0.05); however, there was no difference in the levels between the groups. The prognostic nutritional index values and serum albumin levels decreased significantly until postoperative 6 months and then recovered (P<0.05); the levels decreased more in the nTG group than in the TG group (P<0.05). The mean corpuscular volumes and serum transferrin levels increased significantly until postoperative 1 year and then recovered slightly over time (P<0.05); however, there was no difference between the groups. Serum vitamin B12, iron, and ferritin levels of the patients did not change significantly over time, and no difference existed between the groups. CONCLUSIONS: A small remnant stomach after nTG conferred no significant nutritional benefits over TG.

Venous Thromboembolism Incidence and Prophylaxis Use After Gastrectomy Among Korean Patients With Gastric Adenocarcinoma: The PROTECTOR Randomized Clinical Trial.

Importance: The guidelines by the National Comprehensive Cancer Network and the American Society for Clinical Oncology recommend the routine use of thromboprophylaxis for patients with gastric adenocarcinoma. However, many physicians in Asian countries use venous thromboembolism (VTE) prophylaxis much less often because of the perceived lower VTE incidence in this population. Objectives: To evaluate the incidence of postgastrectomy VTE in Korean patients with gastric adenocarcinoma, and to identify the complications and evaluate the efficacy and safety of VTE prevention methods. Design, Setting, and Participants: The Optimal Prophylactic Method for Venous Thromboembolism After Gastrectomy in Korean Patients (PROTECTOR) randomized clinical trial was conducted between August 1, 2011, and March 31, 2015. Patients with histologically confirmed gastric adenocarcinoma presenting to a single center (Seoul St Mary's Hospital in Seoul, South Korea) were enrolled. Patients were randomized to either an intermittent pneumatic compression (IPC)-only group or an IPC+low-molecular-weight (LMW) heparin sodium group. The data were analyzed on intention-to-treat and per protocol bases. Data analysis was performed from April 1, 2016, to October 30, 2017. Main Outcomes and Measures: Venous thromboembolism incidence was the primary outcome. Postoperative complications, particularly those associated with VTE prophylaxis methods, were the secondary end point. Results: Of the 682 patients enrolled and randomized, 447 (65.5%) were male and 245 (34.5%) were female, with a mean (SD) age of 57.67 (12.94) years. Among the 666 patients included in the analysis, the overall incidence of VTE was 2.1%. The incidence of VTE was statistically significantly higher in the IPC-only group compared with the IPC+LMW heparin group (3.6%; 95% CI, 2.05%-6.14% vs 0.6%; 95% CI, 0.17%-2.18%; P = .008). Among the 14 patients (2.1%) with VTE, 13 were asymptomatic and received a deep vein thrombosis diagnosis, whereas 1 patient received a symptomatic pulmonary thromboembolism diagnosis. The overall incidence of bleeding complications was 5.1%. The incidence of bleeding complications was significantly higher in the IPC+LMW heparin group compared with the IPC-only group (9.1% vs 1.2%; P < .001). No cases of VTE-associated mortality were noted. Conclusions and Relevance: Use of IPC alone is inferior to the use of IPC+LMW heparin in preventing postoperative VTE. Because LMW heparin is associated with a high bleeding risk, further study is needed to stratify the patients at high risk for perioperative development of VTE. Trial Registration: ClinicalTrials.gov Identifier: NCT01448746.

Borrmann Type 1 Cancer is Associated with a High Recurrence Rate in Locally Advanced Gastric Cancer.

BACKGROUND: This study aimed to investigate the clinicopathologic characteristics and outcomes of Borrmann type 1 gastric cancer and evaluate its clinical significance in advanced gastric cancer compared with Borrmann types 2 and 3 cancer. METHODS: Between January 1989 and December 2013, 1949 patients with advanced gastric cancer who underwent curative gastrectomy at our institution were enrolled in the study. RESULTS: Of the 1949 patients, 59 (3%) exhibited Borrmann type 1 cancer, characterized by a large size, rare serosal invasion, lower lymph node involvement, location in the upper third of the stomach, intestinal type, and differentiated histology. The recurrence rate was higher for Borrmann type 1 than for Borrmann types 2 and 3 cancer. In addition, more than half of the Borrmann type 1 recurrences showed a hematogenous pattern. However, overall survival did not differ significantly among the three cancer types. In the multivariate analysis, Borrmann type 1 cancer, with tumor depth, node metastasis, and vascular invasion, was an independent risk factor associated with recurrence. Particularly, Borrmann type 1 cancer showed a worse prognosis in both overall survival and recurrence-free survival than the other Borrmann types in the upper third of the stomach. CONCLUSIONS: Borrmann type 1 gastric cancer is associated with a higher recurrence rate than Borrmann types 2 and 3, but not with a difference in the overall survival rate.