How do we prevent severe intra-abdominal infectious complications following minimally invasive gastrectomy for cancer? The usefulness of a novel marker using computed tomography images (minimum umbilicus-vertebra diameter) and robotic surgery.

Background: Intra-abdominal infectious complications (IAICs) following minimally invasive gastrectomy (MIG) for cancer sometimes worsen short- and long-term outcomes. In this study, we focused on the minimum umbilicus-vertebra diameter (MUVD) in preoperative computed tomography (CT) images and robotic surgery to prevent severe IAIC occurrence. Patients and Methods: A total of 400 patients with gastric cancer who underwent 204 laparoscopic gastrectomy (LG) and 196 robotic gastrectomy (RG) procedures were enrolled in this study. We retrospectively investigated the significance of the MUVD and robotic surgery for preventing severe IAICs following MIG using multivariate and propensity score matching analysis. Results: The MUVD cutoff value was 84 mm by receiver operating characteristic (ROC) curve using severe IAICs as the end point. The MUVD and visceral fat area (VFA) had significantly higher area under the curve (AUC) than BMI (MUVD vs. BMI, p = 0.032; VFA vs. BMI, p < 0.01). In the multivariate analysis, high MUVD (HR, 9.46; p = 0.026) and laparoscopic surgery (HR, 3.35; p = 0.042) were independent risk factors for severe IAIC occurrence. In the propensity matching analysis between robotic and laparoscopic surgery in the high MUVD group, the RG group tended to have a lower severe IAIC rate than the LG group (0% vs. 9.8%, p = 0.056). Conclusion: The MUVD was a novel and easy-measuring predictor of severe IAICs following MIG. Robotic surgery should be considered first in patients with gastric cancer having an MUVD value of 84 mm or higher from the perspective of severe IAIC occurrence.

Study of Short-Term and Long-Term Outcomes Between Esophagogastrostomy and Double-Tract Reconstruction After Proximal Gastrectomy.

BACKGROUND: As the opportunities for proximal gastrectomy (PG) for early gastric cancer in the upper third stomach have been increasing, the safety and feasibility of PG have been a great concern in recent years. This study aimed to compare the short-term and long-term outcomes between patients who underwent esophagogastrostomy (EG) and those who underwent double-tract reconstruction (DTR) after PG. METHODS: We retrospectively reviewed the medical records of 34 patients who underwent EG and 39 who underwent DTR at our hospital between 2011 and 2022. We compared the procedure data and postoperative complications including anastomotic complications within 1 year after surgery as short-term outcomes and the rates of change in nutritional status, skeletal muscle mass, and 3-year survival as long-term outcomes. RESULTS: Although operation time of the DTR group was significantly longer than that of the EG group, there were no significant differences in postoperative complications between 2 groups. Regarding the endoscopic findings, the incidence of anastomotic stenosis and reflux esophagitis was significantly higher in the EG group than in the DTR group (26.5% vs 0%, p < 0.001; 15.2% vs 0%, p = 0.020). In long-term outcomes, there were no significant differences in body weight, BMI, laboratory data, and skeletal muscle mass index between 2 groups for 3 years. The 3-year overall survival rates of 2 groups were similar. CONCLUSION: DTR after PG could prevent the occurrence of anastomotic complications in comparison to EG. The long-term outcomes were similar between these 2 types of reconstruction.

The development of a risk assessment tool for patients with postoperative pneumonia after gastrectomy for gastric cancer.

BACKGROUND: Although frail patients are known to experience increased postoperative complications, this is unclear for postoperative pneumonia (POP). We investigated associations between frailty and POP in patients with gastric cancer (GC) undergoing gastrectomy. METHODS: In this prospective study conducted between August 2016 and December 2022, we preoperatively assessed frailty in 341 patients with GC undergoing gastrectomy using a frailty index (FI). Patients were divided into high FI vs low FI groups to examine frailty and pneumonia rates after gastrectomy for GC. RESULTS: Of 327 patients, 18 (5.5%) experienced POP after gastrectomy. Multivariate analyses showed that a high FI and total or proximal gastrectomy (TG/PG) were independent risk factors for POP (high FI: odds ratio [OR], 5.00; 95% CI, 1.77-15.54; TG/PG: OR, 3.07; 95% CI, 1.09-8.78). The proportion of patients with POP was 2.4% in those with nonhigh FI and non-TG/PG, 5.3% in those with nonhigh FI and TG/PG, 7.1% in those with high FI and non-TG/PG, and 28.0% in those with high FI and TG/PG (P < .001). The area under the receiver operating characteristic curve for this risk assessment for predicting POP was 0.740. CONCLUSION: In patients with GC undergoing gastrectomy, POP was independently associated with preoperatively high FI and TG/PG. Our simple POP risk assessment method, which combines these factors, may effectively predict and prepare patients for POP.

Impact of a robotic system on intra-abdominal infectious complications after minimally invasive gastrectomy in patients with gastric cancer: A propensity score matching analysis regarding visceral obesity.

Background: The efficacy of robotic gastrectomy (RG) on postoperative complications in patients with gastric cancer (GC) is unclear in terms of the volume of intra-abdominal fat tissue. Patients and Methods: We enrolled 403 patients with GC who had minimally invasive surgery between January 2015 and July 2022. During this time, 197 RG and 206 laparoscopic gastrectomies (LG) were performed on the study participants. According to the computed tomography scan, patients were defined as having or not having visceral obesity based on the visceral fatty area (VFA). In each high and low VFA group, we compared short-term outcomes between the RG group and LG group. Results: After PS matching for patients with high VFA, the two groups were well matched, with 71 cases in both the RG and LG groups. The median surgical time in the RG group was significantly longer (420 vs. 365 min, p < 0.001). However, the RG group had a significantly lower rate of severe intra-abdominal infectious complications (IAIC), such as anastomotic leakage, pancreatic fistula, and intra-abdominal abscess (1.4% vs. 15.4%, p = 0.004). However, among the 77 patients with low VFA values, we found no significant difference in the rate of severe IAIC between the two groups (1.1% in the RG group vs. 2.6% in the LG group, p = 1.00). Conclusion: RG may be a viable alternative to LG because of the lower postoperative IAIC for patients with visceral obesity and GC. However, RG may not benefit non-obese patients.

The Cancer Cachexia Index Can Be Used to Prognostically Predict Patients with Gastric Cancer Undergoing Gastrectomy.

INTRODUCTION: Cancer cachexia occurs in cancer patients more frequently as the cancer progresses, with a negative impact on treatment outcomes. In this study, we sought to clarify the clinical impact of a cancer cachexia index (CXI) in patients with gastric cancer (GC) undergoing gastrectomy. METHODS: Between January 2013 and December 2018, we reviewed data from 556 patients treated for GC at our hospital. CXI was calculated using skeletal muscle index (SMI), serum albumin, and neutrophil-lymphocyte ratios (NLR). Patients were divided into high (n = 414) or low CXI (n = 142) groups. We investigated the clinical impact of CXI in patients with GC undergoing gastrectomy. RESULTS: Multivariate analyses of 5-year overall survival (OS) and cancer-specific survival (CSS) rates indicated that a low CXI was independently associated with unfavorable outcomes for patients with GC. In multivariate analyses, SMI was independent predictor of OS but not CSS. NLR was not an independent predictor of either OS or CSS. Complication incidences (≥ Clavien Dindo 3) were non-significantly higher in the low (vs. high) CXI group. CONCLUSION: CXI was a more valuable prognostic biomarker when compared with SMI or NLR in GC patients undergoing gastrectomy. We suggest that patients with low CXI values should be given more comprehensive treatment, including exercise and nutritional therapy to improve clinical outcomes.

Risk factors of "loss of independence" in elderly patients who received gastrectomy for gastric cancer.

OBJECTIVE: The aim of this study was to clarify the risk of loss of independence (LOI) following gastrectomy in elderly patients with gastric cancer (GC). METHODS: In this prospective study, frailty was assessed preoperatively by a frailty index (FI) in 243 patients aged ≥ 65 years who underwent gastrectomy for GC between August 2016 and December 2020. Patients were assigned into two groups (high FI vs. low FI) to investigate frailty and the risk of LOI after gastrectomy for GC. RESULTS: Overall and minor (Clavien-Dindo classification [CD] 1, 2) complication rates were significantly higher in the high FI group, but the two groups had similar rates of major (CD ≥ 3) complications. The frequency of pneumonia was significantly higher in the high FI group. In univariate and multivariate analyses for LOI after surgery, high FI, older age (≥ 75 years), and major (CD ≥ 3) complications were independent risk factors. A risk score assigning 1 point for each of these variables was useful in predicting postoperative LOI (LOI: score 0, 7.4%; score 1, 18.2%; score 2, 43.9%; score 3, 100%; area under the curve [AUC] = 0.765.) CONCLUSIONS: LOI after gastrectomy was independently associated with high FI, older age (≥ 75 years), and major (CD ≥ 3) complications. A simple risk score assigning points for these factors was an accurate predictor of postoperative LOI. We propose that frailty screening should be applied for all elderly GC patients before surgery.

[Surgical Technique for Mesorectal Division in the Robotic Anterior Resection for Rectal Cancer].

Since April 2018, robot-assisted rectal resection has been approved as an insurance medical treatment, and robot- assisted rectal resection is rapidly becoming widespread. Even in robot-assisted laparoscopic surgery, mesorectal division is difficult in a narrow pelvic cavity. At the beginning of the operation, Vessel Sealer ExtendTM(price 89,250 yen)was used, but as the procedure became stable, the mesorectal division was started with bipolar forceps and monopolar scissors. The purpose of this study was to investigate the mesorectal division time and postoperative complications associated with changes in the procedure. 36 patients who underwent robot-assisted anterior resection for rectal cancer by the same surgeon from January 2019 to December 2021. We compared mesorectal division time and postoperative complication. Median operation time were 267 minutes, median console time were 132 minutes. There were no complications such as intestinal obstruction or anastomotic leakage. There was no difference in mesorectal division time time between Vessel Sealer groups and Scissors groups(14 min 55 sec vs 16 min 5 sec). The mesorectal division with bipolar forceps and monopolar scissors could be performed without extending the operation time, and could be performed with cost-benefit and safely.

Comparison of Short-Term Surgical Outcomes of Two Types of Robotic Gastrectomy for Gastric Cancer: Ultrasonic Shears Method Versus the Maryland Bipolar Forceps Method.

BACKGROUND: This study investigated the impact and short-term surgical outcomes of two different main energy devices for robotic gastrectomy for gastric cancer. The outcomes of robotic gastrectomy with ultrasonic shears and those of robotic gastrectomy with conventional forceps were compared. METHODS: We retrospectively evaluated 171 patients who underwent robotic distal gastrectomy or total gastrectomy for gastric cancer. We classified patients into the ultrasonic shears (US) and Maryland bipolar (MB) forceps groups according to the main energy device used for robotic gastrectomy. RESULTS: We extracted 58 patients from the US group and 58 patients from the MB forceps groups using propensity score matching. The total console time (310 min [interquartile range (IQR), 253-369 min] and 332 min, [IQR, 294-429 min]; p = 0.022) and the console time to gastrectomy (222 min [IQR, 177-266 min] and 247 min [IQR, 208-321 min]; p = 0.004) were significantly shorter in the US group than in the MB forceps group. Less blood loss occurred in the US group than in the MB forceps group (20 mL [IQR, 10-40 mL] and 30 mL [IQR, 16-80 mL]; p = 0.014). The postoperative complication rate and postoperative hospital stay length were similar between groups. A multivariate multiple linear regression analysis demonstrated that the use of an ultrasonically activated device was one an independent factor that reduced the operative time of robotic gastrectomy. CONCLUSION: Using ultrasonic shears as the main energy device may contribute to better surgical outcomes after robotic gastrectomy for gastric cancer.

Jejunal Mesentery Preservation Reduces Leakage at Esophagojejunostomy After Minimally Invasive Total Gastrectomy for Gastric Cancer: a Propensity Score-Matched Cohort Study.

PURPOSE: The mesentery of the jejunum (MJ) of the Roux limb is conventionally divided when Roux-en-Y reconstruction is performed after total gastrectomy for gastric cancer (GC). However, the impact of dividing or preserving the MJ on anastomotic leakage (AL) at the esophagojejunostomy (EJS) site after minimally invasive total gastrectomy for GC is unclear. METHODS: This retrospective cohort study enrolled 226 patients with GC who underwent EJS after laparoscopic or robotic total gastrectomy, including preservation of the MJ (n = 87) and division of the MJ (n = 137). The prevalence of anastomotic complications at the EJS and short-term outcomes were compared between groups using propensity score (PS) matching. RESULTS: After PS matching, 69 patients were selected for the preserving and dividing MJ groups. There were no significant intergroup differences in patient backgrounds, including oncological stage, body mass index, and gender ratio. After PS matching, overall and severe complications after surgery were compared between the preserving and dividing MJ groups (21.7% vs. 27.5%, p = 0.554 and 8.7% vs. 13.8%, p = 0.137, respectively). However, the rate of AL at the EJS was significantly lower in the preserving than that in the dividing MJ group (1.4% vs. 13.0%, p = 0.017). In addition, the median postoperative hospital stay was significantly shorter in the preserving than that in the dividing MJ group (13.0 days vs. 16.0 days, p = 0.005). CONCLUSIONS: Preserving the MJ significantly reduced AL at the EJS after minimally invasive total gastrectomy for GC.

[Locally Advanced Pancreatic Cancer Treated with Two-Staged Pancreaticoduodenectomy after Laparoscopic Median Arcuate Ligament Section-A Case Report].

A 76-year-old male was diagnosed as locally advanced pancreatic cancer because abdominal CT scan revealed a pancreatic head tumor with involvement of the proper hepatic artery. Gemcitabine plus nab-paclitaxel was initiated, but was discontinued because interstitial pneumonia was occurred. The treatment was switched to S-1 therapy and achieved stable disease for 22 months. Therefore, conversion surgery was scheduled. Because stenosis of the celiac artery origin due to median arcuate ligament(MAL)compression and dilatation of pancreatoduodenal artery arcade were observed, laparoscopic MAL section was performed. The patient was discharged on postoperative day 5 without complications. Postoperative CT scan revealed no stenosis of the celiac artery origin and disappearance of dilatation of pancreatoduodenal artery arcade. On postoperative day 14, subtotal stomach-preserving pancreaticoduodenectomy(PD)with portal vein resection was performed. The patient was discharged on postoperative day 19 without complications. Two-staged PD after MAL section make possible to evaluate blood flow accurately and select an appropriate operative method. Laparoscopic MAL section is minimally invasive and may be useful for two-staged PD in patients with celiac axis stenosis.

Less Severe Intra-Abdominal Infections in Robotic Surgery for Gastric Cancer Compared with Conventional Laparoscopic Surgery: A Propensity Score-matched Analysis.

BACKGROUND: The impact of robotic gastrectomy (RG) for gastric cancer (GC) on the incidence of postoperative complication is debatable and unclear. METHODS: This study enrolled 200 patients with GC who were surgically treated and consisted of 100 RG and 100 laparoscopic gastrectomy (LG) cases using an ultrasonic scalpel. The short-term outcomes were compared between the two groups. These outcomes were compared using a 1:1 propensity score (PS)-matching analysis. RESULTS: After PS matching, 76 cases in each group were well matched. Mean surgical time was significantly longer in the RG group than in the LG group (393 vs. 342 min, p < 0.005), whereas mean blood loss during surgery was significantly lower in the RG group than in the LG group (30.1 vs. 50.1 mL, p = 0.023). The median number of surgeons who attend the main part of the surgery was significantly less in the RG group than in the LG group (2.0 vs. 3.0, p = 0.01). The rate of severe intra-abdominal infectious complication was significantly lower in the RG group than in the LG group (0% vs. 9.2%, p = 0.014). The duration from surgery to adjuvant chemotherapy was significantly shorter in the RG group than in the LG group (29.6 ± 11.0 vs. 45.2 ± 27.8 days, p = 0.046). CONCLUSIONS: RG using an ultrasonic scalpel may be a viable alternative to LG because of the improvement in the rate of postoperative intra-abdominal infectious complications after curative surgery for GC.

[A Case of Recurrent Gastric Cancer of Multiple Organ Metastasis with Long-Term Survival Due to Multimodal Treatment].

A 67-year-old man was introduced to examine for abnormal findings in physical examination. Upper gastrointestinal endoscopy detected the 3 lesions and diagnosed multiple gastric cancers with biopsy. Laparoscopic total gastrectomy was performed and final pathological diagnosis was pT2N1M0, pStage ⅡA with HER2 positive(3+). Adjuvant chemotherapy was not administrated. CT findings 6 months after procedure showed 2 liver metastases(S6, S7)and laparoscopic partial liver resection was performed. Pathological findings proved the metastasis of previous gastric cancer. Although adjuvant chemotherapy of S-1 was started 2 months after hepatectomy, CT findings showed second recurrences in liver and right adrenal gland. Chemotherapy was changed to S-1 plus cisplatin(SP)plus trastuzumab. AS these recurrence sites and ascites could not be detected by CT after 6 courses, therapeutic effect was judged as clinical CR(cCR)and SP plus trastuzumab was stopped due to side effect. Since then, regular follow-up CT showed preservation of status of cCR without chemotherapy and he has been alive without recurrence for 8 years and 9 months after gastrectomy. We report a case of recurrent gastric cancer of multiple organ metastasis with long-term survival due to multimodal treatment.

[Impact of Sarcopenia on Patients with Advanced Gastric Cancer Who Underwent Surgery].

This study aimed to investigate the short- and long-term outcomes in patients with sarcopenia who underwent surgery for advanced gastric cancer. We included 76 patients with pStage Ⅱ or Ⅲ gastric cancer who underwent gastrectomy between January 2017 and June 2021. Patients with pT3N0 cancer were excluded. Using the Asian Working Group for Sarcopenia( AWGS)2019 criteria, the patients were divided into the sarcopenia group(S group)and the non-sarcopenia group (NS group). The surgical outcomes, effects on postoperative adjuvant chemotherapy, and prognosis of the 2 groups were evaluated and compared. No significant differences were observed in the operative time, blood loss, postoperative hospital stays, or incidence of postoperative complications with a grade higher than Clavien-Dindo Grade Ⅱ. The number of patients who received postoperative adjuvant chemotherapy was 5(26.3%)in the S group and 38(66.7%)in the NS group which was significantly lower in the S group(p=0.003). The 3-year overall survival rate was 45.7% in the S group and 71.0% in the NS group(p=0.302). There was no significant difference but survival rate was lower in the S group. The results suggest that postoperative adjuvant chemotherapy is not always available for patients with advanced gastric cancer, and that may worsen the prognosis.

[A Case of Robotic Surgery for Local and Peritoneal Recurrence of Colorectal Cancer].

A 35-year-old women with sigmoid cancer(pT4aN1aM0, pStage Ⅲb)underwent laparoscopic sigmoidectomy. She had 8 courses of CapeOX for adjuvant chemotherapy, but follow up CT scan 1 year after the operation detected intraabdominal nodules in anastomotic site and in left lower quadrant of abdomen. After 10 courses of IRIS plus bevacizumab, the both intraabdominal nodules decreased in size. Robot assisted laparoscopic lower anterior resection and laparoscopic disseminated nodule resection were performed. The patient had no postoperative complications and the postoperative course was good. She remains alive without recurrence at 6 months after the second operation.

[A Case of pStage IB Gastric Cancer Relapsed on Both Pleura and Peritoneum Eight Year after Radical Gastrectomy].

An 86-year-old man presented with upper abdominal pain and was diagnosed with type 0-Ⅲ gastric cancer located at the posterior wall of the upper stomach by upper gastrointestinal endoscopy. Laparoscopic total gastrectomy(D1+)was performed for gastric cancer of cStage Ⅰ. As final pathological diagnosis was pT2N0(0/27)M0H0P0CY0, pStage ⅠB, adjuvant chemotherapy was not administrated. The patient has been alive with no recurrence for 5 years after surgery. 8 years and 1 month after procedure, he visited our hospital with chief complaint of abdominal distention and anorexia. Chest and abdominal CT showed pleural fluid and ascites, but PET-CT could not detect any sites of recurrence. Cytopathology and cell blocks by immunohistochemical staining of ascites proved recurrence of previous gastric cancer. Any treatment was rejected, and the patient died 3 months after recurrence and 8 years and 4 months after gastrectomy. Late recurrence on both pleura and peritoneum of gastric cancer is very rare. We report a case of pStage ⅠB gastric cancer relapsed on both pleura and peritoneum 8 year after radical gastrectomy.

Depletion of skeletal muscle mass adversely affects long-term outcomes for men undergoing gastrectomy for gastric cancer.

BACKGROUND: Although low skeletal muscle mass has an adverse impact on the treatment outcomes of cancer patients, whether the relationship between preoperative skeletal muscle mass and gastrectomy outcomes in gastric cancer (GC) differs between men and women is unclear. The study aimed to clarify this relationship based on gender. METHODS: Between January 2007 and December 2015, 1054 patients who underwent gastrectomy for GC at Osaka City General Hospital were enrolled in this study. We evaluated sarcopenia by the skeletal muscle index (SMI), which was measured by computed tomography (CT) using areas of muscle in the third lumbar vertebral body (L3). Male and female patients were each divided into two groups (low skeletal muscle and high skeletal muscle). RESULTS: The SMI emerged as an independent predictor of 5-year overall survival (OS) in male GC patients (Hazard ratio 2.51; 95% confidence interval (CI) 1.73-3.63, p < 0.001) based on multivariate analysis. However, this index was not an independent predictive determinant of 5-year cancer-specific survival (CSS). The SMI was not an independent predictor of either OS or CSS in female GC patients. The incidence of leakage and major complication (Clavien Dindo grade ≧ 3) did not differ significantly across groups. CONCLUSIONS: Preoperative skeletal muscle mass is a valuable prognostic predictor of OS in male GC patients.

Multiple stage IV colorectal cancers in a patient who received multidisciplinary treatment, including chemotherapy and Japanese Kampo medicine: A case report.

FOLFOXIRI (fluorouracil, leucovorin, oxaliplatin, and irinotecan) plus bevacizumab is the preferred first-line treatment for right-sided metastatic colorectal cancer with RAS mutation. However, severe adverse events are common in Japanese patients. We report the successful management of multiple stage IV colorectal cancers in a patient who received multidisciplinary treatment, including chemotherapy and Japanese Kampo medicine. A 68-year-old man presented with epigastralgia and appetite loss and was diagnosed with multiple stage IV colorectal cancers. Colonoscopy identified type II tumors in the ascending colon, sigmoid colon, and upper rectum. Histopathological examination of a biopsy specimen revealed well- to moderately differentiated tubular adenocarcinoma. Enhanced computed tomography of the thorax and abdomen showed multiple pulmonary nodules and para-aortic lymph node swelling. Laparoscopic loop-ileostomy was performed to avoid bowel obstruction due to severe stenosis of ascending colon cancer. Intraoperative observation revealed two white nodules suggestive of metastasis in the lateral area of the liver. Therefore, we diagnosed multiple stage IV colorectal cancers with multiple metastases (lung, liver, and distant lymph nodes). His postoperative course was uneventful, and chemotherapy was started. Since the cancer cells harbored a RAS mutation, he received FOLFOXIRI plus bevacizumab. Japanese Kampo medicine consisting of Hangeshashinto and Juzen-taiho-to, to prevent diarrhea and fatigue, was administered daily. After 12 courses of chemotherapy, though circumferential stenosis still existed in the ascending colon, the tumors in the sigmoid colon and upper rectum were unclear. Enhanced computed tomography showed shrinkage of the pulmonary nodules and para-aortic lymph node; therefore, laparoscopic-assisted ileocecal resection was performed. The postoperative histopathological examination revealed moderately differentiated adenocarcinoma. The patient recovered uneventfully, and Kampo medicine consisting of Ninjin'yoeito was administered for postoperative weakness. Administration of adjuvant chemotherapy in this patient led to a near complete response that has been maintained without recurrence for 2 years and 8 months without reduced quality of life.

[A Case of Double Colorectal Cancer Diagnosed by Preoperative CT Colonography].

A 66‒year‒old man was admitted to our hospital because of anemia and a positive fecal occult blood test in the medical examination. Colonoscopy revealed a type 2 advanced sigmoid colon cancer with circular stenosis. Computed tomography (CT)colonography was performed to examine the oral colon. The apple core signs were found both in the sigmoid and transverse colon. We diagnosed a double colon cancer and performed a laparoscopic left hemicolectomy and sigmoidectomy. The tumor was histopathologically diagnosed as a multiple cancer including a transverse and a sigmoid colon cancer. Although evaluations of the intestine for colon cancer with stenosis are performed by enema examination or endoscopic examination after colon stent placement, both examinations are invasive. CT colonography is considered to be a minimally invasive and an effective preoperative examination for colorectal cancer with stenosis.

Impact of chronic kidney disease on the short- and long-term outcomes of laparoscopic gastrectomy for gastric cancer patients.

BACKGROUNDS: This study was undertaken to investigate the impact of coexisting chronic kidney disease (CKD) on short- and long-term outcomes of laparoscopic gastrectomy in patients with gastric cancer (GC). METHODS: We reviewed the data of 798 patients treated for GC by laparoscopic gastrectomy. All procedures took place between January 2010 and December 2017. Patients were divided into three groups according to their estimated glomerular filtration rate (eGFR): severe CKD group, 44 patients with eGFR < 45 mL/min/1.73 m2; moderate CKD group, 117 patients with 45 ≤ eGFR < 60; control group, 637 patients with eGFR ≥ 60. RESULTS: Based on multivariate analysis, severe CKD (eGFR < 45) emerged as an independent predictor of anastomotic leak (Hazard ratio 4.63, 95% confidence interval [CI] 1.62-11.54). The 5-year overall survival (OS) rates by group were 46.3% (severe CKD), 76.6% (moderate CKD), and 81.5% (control). Multivariate analysis likewise identified severe CKD (eGFR < 45) as an independent correlate of poor 5-year OS. The 5-year cancer-specific survival (CSS) rates did not differ significantly by group. CONCLUSIONS: An eGFR value less than 45 mL/min/1.73 m2 is a useful factor for predicting both anastomotic leak and 5-year OS in GC patients undergoing laparoscopic gastrectomy. Clinical care to improve eGFR should be reinforced before and after gastrectomy for GC patients with severe CKD.

[A Case of Advanced Gastric Cancer-Recurrence of Skin Metastasis Nine Years after Surgery and Rectal Stenosis Due to Peritoneal Dissemination Ten Years Later].

A 70-year-old man previously underwent laparoscopic total gastrectomy for gastric cancer in 2010 and pathological diagnoses were pT4a, pN3, M0, pStage ⅢC. The postoperative adjuvant chemotherapy was interrupted due to nausea, but the patient had no apparent recurrence within 5 years after gastrectomy. In 2019, a swelling appeared from the left inguinal region to the scrotum, and MRI scan showed subcutaneous edematous changes in the same region. Biopsy showed adenocarcinoma and we diagnosed a recurrence of gastric cancer with skin metastasis. In November 2020, the patient complained of defecation disorder, and CT scan showed a circumferential wall thickening with contrast effect in the rectum. Although colonoscopy revealed rectal stenosis, biopsy specimen showed no malignant findings. We suspected rectal stenosis due to peritoneal dissemination of gastric cancer and performed a colostomy. Intraoperative findings showed that the rectal wall was remarkably thickened with serosal erythema. Adenocarcinoma cells were found from the cytology of ascites. The patient was treated with nab-paclitaxel plus ramucirumab, then treated with nivolumab after failure of first-line therapy.