A phase II study of ramelteon for the prevention of postoperative delirium in elderly patients undergoing gastrectomy.

PURPOSE: The growing number of cases of gastric cancer being diagnosed in elderly patients highlights the importance of preventing postoperative delirium. This phase II study aimed to evaluate the efficacy of perioperative treatment with ramelteon for preventing postoperative delirium in elderly patients undergoing gastrectomy. METHODS: This study was designed as a single-institute prospective phase II study. Patients ≥ 75 years old were eligible. Ramelteon 8 mg/day was administered from 8 days before the operation until discharge. Postoperative delirium was evaluated using the Confusion Assessment Method-Intensive Care Unit flow sheet. RESULTS: Between September 2015 and July 2017, a total of 83 patients were enrolled, 76 of whom were eligible and included in the analysis. Postoperative delirium was observed in four patients (5%) (60% confidence interval: 3.0-8.7). The upper margin of the confidence interval was lower than the prespecified threshold of 13%; therefore, the null hypothesis was rejected. CONCLUSION: This phase II study suggested that the perioperative administration of ramelteon is safe and feasible for preventing postoperative delirium in elderly patients undergoing gastrectomy. Trial registration This study was registered at UMIN (UMIN 000018697).

Metabolomic profiling of gastric cancer tissues identified potential biomarkers for predicting peritoneal recurrence.

BACKGROUND: Metabolomics is useful for analyzing the nutrients necessary for cancer progression, as the proliferation is regulated by available nutrients. We studied the metabolomic profile of gastric cancer (GC) tissue to elucidate the associations between metabolism and recurrence. METHODS: Cancer and adjacent non-cancerous tissues were obtained in a pair-wise manner from 140 patients with GC who underwent gastrectomy. Frozen tissues were homogenized and analyzed by capillary electrophoresis time-of-flight mass spectrometry (CE-TOFMS). Metabolites were further assessed based on the presence or absence of recurrence. RESULTS: Ninety-three metabolites were quantified. In cancer tissues, the lactate level was significantly higher and the adenylate energy charge was lower than in non-cancerous tissues. The Asp, ß-Ala, GDP, and Gly levels were significantly lower in patients with recurrence than in those without. Based on ROC analyses to determine the cut-off values of the four metabolites, patients were categorized into groups at high risk and low risk of peritoneal recurrence. Logistic regression and Cox proportional hazard analyses identified ß-Ala as an independent predictor of peritoneal recurrence (hazard ratio [HR] 5.21 [95% confidence interval 1.07-35.89], p = 0.029) and an independent prognostic factor for the overall survival (HR 3.44 [95% CI 1.65-7.14], p < 0.001). CONCLUSIONS: The metabolomic profiles of cancer tissues differed from those of non-cancerous tissues. In addition, four metabolites were significantly associated with recurrence in GC. ß-Ala was both a significant predictor of peritoneal recurrence and a prognostic factor.

Preventive effect on delayed gastric emptying of preserving the infra-pyloric vein in laparoscopic pylorus-preserving gastrectomy for early gastric cancer.

BACKGROUND: Pylorus-preserving gastrectomy (PPG) has the postoperative advantages of a better quality of life and less weight loss than distal gastrectomy. However, postoperative delayed gastric emptying (DGE) due to antral hypomotility can be a problem. Although preserving the infra-pyloric vein (IPV) is reported to improve congestion of the antrum and prevent DGE, the benefits of this procedure have not been confirmed. The present study aimed to clarify the preventive effect on DGE of preserving the IPV. METHODS: A total of 148 patients [IPV-preserved (IPVP): 78 patients and IPV-non-preserved (IPVN): 70 patients] who underwent laparoscopic and robotic PPG (LRPPG) for early gastric cancer were enrolled in this study. The clinicopathologic characteristics and incidence of DGE were compared between the groups. The nutritional risk index (NRI) at 1, 2, and 3 years after the operation and the relapse-free survival (RFS) were also compared. RESULTS: There were no significant differences in the clinicopathological characteristics between the two groups. DGE was observed in 15 of 148 patients (10.1%). The incidence of DGE did not differ markedly between the 2 groups (IPVP vs. IPVN; 11.5% vs. 8.6% p = 0.596). There were no significant differences in other complications between the groups either (IPVP vs. IPVN; 19.2% vs. 21.4%; p = 0.838). The NRI and 3-year RFS were not significantly different between the two groups. CONCLUSION: Regarding LRPPG, preserving the IPV did not help prevent DGE and resulted in no significant difference in the outcomes.

Impact of Preoperative Skeletal Muscle Quality Measurement on Long-Term Survival After Curative Gastrectomy for Locally Advanced Gastric Cancer.

BACKGROUND: Skeletal muscle quality is a prognostic factor in various cancers. However, similar studies on curatively resected gastric cancer are lacking. We evaluated skeletal muscle quality using intramuscular adipose tissue content (IMAC) to clarify its impact on survival in patients with locally advanced gastric cancer. METHODS: We reviewed 370 patients who underwent curative resection for stage II/III gastric cancer. IMAC was calculated using preoperative computed tomography images. IMAC cutoff values were determined for each sex and were set at the 75th percentile. The patients were classified into normal and high IMAC groups according to the cutoff values. Clinicopathological factors and survival outcomes were compared between the two groups. Multivariate Cox regression analysis was used to identify independent prognostic factors for overall survival (OS) and cancer-specific survival (CSS). RESULTS: In all, 277 patients were classified into the normal IMAC group and 93 were classified into the high IMAC group. The patients in the high IMAC group were older, more obese, and had more comorbidities and poor Eastern Cooperative Oncology Group performance status than those in the normal IMAC group. Although no significant differences were observed in the pathological findings between the two groups, a high IMAC was significantly associated with poor OS and CSS. Multivariate analysis identified high IMAC as an independent prognostic factor for both OS and CSS (p = 0.046 and p = 0.035, respectively). CONCLUSIONS: High IMAC was significantly associated with poor survival, suggesting that skeletal muscle quality has oncological implications in patients with locally advanced gastric cancer.

Changes in body weight, skeletal muscle and adipose tissue after gastrectomy: a comparison between proximal gastrectomy and total gastrectomy.

BACKGROUND: Proximal gastrectomy (PG) offers a well-preserved digestive function after surgery, which may result in a better nutritional outcome in comparison to total gastrectomy (TG). The aim of this study was to clarify the advantage of PG over TG by evaluating the longitudinal changes in body weight (BW) and body composition after surgery. METHODS: A total of 112 patients undergoing PG with a reconstruction preserving food passage through the duodenum (n = 39) or TG with a reconstruction bypassing the duodenum (n = 73) for clinical stage IA gastric cancer were included. Changes in BW, psoas muscle and subcutaneous (SAT) and visceral adipose tissue were assessed before surgery, and at 1 and 3 years after surgery and were compared between the two groups. RESULTS: BW and SAT decreased significantly in both groups, but the rate of reduction was significantly lower in the PG group (P < 0.001 and P < 0.001, respectively). There were no significant differences between the groups with regard to skeletal muscle or visceral adipose tissue (P = 0.110 and 0.710, respectively), although they both significantly decreased throughout the course of the study. CONCLUSIONS: The losses of BW and SAT were significantly smaller in the PG group. PG may be superior to TG in preserving BW and SAT in patients with clinical stage IA gastric cancer.

Validation of the prognostic impact of the new tumor-node-metastasis clinical staging in patients with gastric cancer.

BACKGROUND: In the 8th edition of the tumor-node-metastasis (TNM) classification, the gastric cancer staging system includes two classifications: the clinical stage (cStage) and the postoperative pathologic stage. However, the correlation between the new cStage and overall survival has not been studied. Moreover, clinical N (cN) grade analysis is not included in the new clinical staging system. This study validated the prognostic value of cStage in the 8th edition of the TNM classification and the significance of N classification for pretreatment staging in gastric cancer. METHODS: A total of 4374 patients with primary gastric cancer who underwent surgery at the Shizuoka Cancer Center were included. Survival analysis was conducted based on the newly proposed cStage criteria of the TNM 8th edition. Prognostic accuracy was evaluated using Harrell's concordance index (C-index). RESULTS: The five-year survival rates according to cStage were as follows: cStageI, 91.2%, cStageIIA: 75.1%, cStageIIB: 57.7%, cStageIII: 43.2%, cStageIVA: 31.6%, and cStageIVB: 7.7%. Significant differences were observed among all stages (P < 0.001). The cStage C-index was 0.802. Meanwhile, the five-year survival rates based on cN were as follows: cN0: 83.7%, cN1: 57.2%, cN2: 42.4%, cN3a: 22.1%, and cN3b: 0.0%. Significant differences were also observed among all cN grades (P < 0.001). CONCLUSIONS: The cStage of the 8th edition of the TNM classification has a good capability to predict prognosis; thus, it may be a useful indicator for selecting appropriate gastric cancer treatment modalities. In addition, cN can be included in developing a more precise clinical staging of gastric cancer.

Risk factors for 30-day hospital readmission after radical gastrectomy: a single-center retrospective study.

BACKGROUND: Hospital readmission is gathering greater attention as a measure of health care quality. The introduction of fast-track surgery has led to shorter lengths of hospitalization without increasing the risk of postoperative complications and readmission. The collection of comprehensive readmission data is essential for the further improvement of patient care. The aim of the present study is to evaluate the risk factors for readmission within 30 days of discharge after gastrectomy. METHODS: A total of 1929 patients who underwent radical gastrectomy at Shizuoka Cancer Center were included in this study. A risk analysis with a stepwise logistic regression model was conducted to identify the risk factors for 30-day hospital readmission. RESULTS: The 30-day readmission rate was 2.70%. Common causes of readmission were an intolerance of oral intake and the presence of an intra-abdominal abscess. The C reactive protein (CRP) level on postoperative day (POD) 3 was significantly higher in the readmitted group; however, the other surgical outcomes, including the incidence of postoperative complications, did not differ to a statistically significant extent. The stepwise logistic regression analysis revealed that CRP on POD3 ≥ 12 mg/dl [odds ratio (OR) 2.08, 95% confidence interval (CI) 1.09-3.95, p = 0.025], laparoscopic surgery (OR 2.25, 95% CI 1.17-4.31, p = 0.015), and TG (OR 2.23, 95% CI 1.17-4.78, p = 0.023) were found to be independent risk factors for readmission. CONCLUSIONS: CRP on POD3 ≥ 12 mg/dl, laparoscopic surgery, and TG were identified as independent risk factors for readmission.

Role of Palliative Resection in Patients with Incurable Advanced Gastric Cancer Who are Unfit for Chemotherapy.

BACKGROUND: The REGATTA trial showed that gastrectomy followed by chemotherapy for advanced gastric cancer with a single non-curable factor did not improve survival outcomes in comparison with chemotherapy alone. Chemotherapy is therefore the mainstay treatment for incurable gastric cancer. However, for patients who are unfit for chemotherapy, the role of palliative gastrectomy remains controversial. METHODS: We retrospectively identified 207 patients with in curable gastric cancer who underwent palliative gastrectomy or bypass surgery because of urgent symptoms who were treated from 2002 to 2014. Fifty-nine of these patients who did not receive chemotherapy following surgery were enrolled in the present study. The patients were divided into the palliative gastrectomy group (n = 40) and the bypass surgery group (n = 19). The survival outcomes of the two groups were compared. Independent prognostic factors were identified using multivariate analysis. RESULTS: The rate of patients who underwent gastrectomy was significantly higher among patients whose tumors were located in the upper third (n = 19/20, 95%) than in patients whose tumors were located in the lower or middle third (n = 21/39, 54%, p = 0.001). The median survival time (MST) in the gastrectomy group (145 days) was significantly longer than that in the bypass group (86 days) (p = 0.008). Bypass surgery was identified as an independent prognostic factor in the multivariate analysis (HR = 2.3; 95%CI = 1.3-4.2 p = 0.007). CONCLUSIONS: Palliative gastrectomy may improve survival in patients with incurable gastric cancer who show emergent symptoms and who are unfit for chemotherapy.

Esophagojejunal anastomotic leakage following gastrectomy for gastric cancer.

Esophagojejunal anastomotic leakage (EJAL) is a serious complication of total or proximal gastrectomy for gastric cancer, with a reported incidence of 2.1-14.6% and mortality of up to 50%. EJAL is an independent prognostic factor for the poor survival of gastric cancer patients. Meticulous surgical techniques, experience with anastomotic devices, and a thorough understanding of various risk factors and preventive measures are essential and early diagnosis is critical for preventing EJAL-related death. Patients with suspected EJAL must be evaluated promptly, but contrast swallow is not recommended. There is no standard treatment strategy for EJAL, although conservative treatment with drainage and nutritional support is the most common approach. Effective endoscopic treatments have been reported but need further validation. Surgical treatment is associated with high mortality but should be considered to prevent death from suboptimal EJAL management, for patients with severe sepsis or when conservative treatment has failed.

Impact of preoperative wait time on survival in patients with clinical stage II/III gastric cancer.

BACKGROUND: Preoperative wait time is affected by various factors, and a certain time is needed before surgery. There is a concern that cancer treatment delay can lead to poor survival. The present study aimed to evaluate the impact of preoperative wait time on survival in patients with clinical stage (cStage) II/III gastric cancer. METHODS: The study included patients with cStage II/III primary gastric cancer undergoing surgery between 2002 and 2012. Preoperative wait time was defined as the time from endoscopy for initial diagnosis to surgery. Patients were divided into the following three groups according to wait time: short wait group (≤ 30 days), intermediate wait group (> 30 and ≤ 60 days), and long wait group (> 60 and ≤ 90 days). Patient characteristics and survival were compared among the groups. RESULTS: This study included 467 male (67%) and 229 female (33%) patients, and the median patient age was 67 years. The numbers of cStage II and III patients were 332 (48%) and 364 (52%), respectively. The median wait time was 45 days. The body mass index was lower in the short wait group than in the other groups. A shorter wait time tended to be associated with a more advanced cStage. Although survival was significantly worse in the short wait group than in the long wait group, wait time was not identified as an independent prognostic factor in multivariate analysis. CONCLUSION: Preoperative wait time up to 90 days does not affect survival in patients with cStage II/III gastric cancer.

[The Current Status and Future Perspective about Robotic Surgery for Gastric Cancer].

Robotic surgery using da Vinci®Surgical System which has the high resolution 3-dimensional images, the forceps with 7 degrees freedom, the function for prevention of tremors and motion scaling enables to perform meticulous operation circumventing the action of forceps movement which is the major problem in conventional laparoscopic surgery. In 2003, initial robotic gastrectomy for gastric cancer has been reported. Since then robotic gastrectomy has been developed mainly in Japan, Korea and Italy. From January 2012, we launched robotic gastrectomy at our institute as prospective clinical phase II trials to clarify the safety of robotic gastrectomy. The results of these trials have already been published and the safety of robotic gastrectomy was confirmed. In the several retrospective analyses, robotic gastrectomy has been reported to show longer operation time, less blood loss and lower morbidity compared with conventional laparoscopic surgery. However, the superiority of robotic gastrectomy to laparoscopic gastrectomy has not yet been demonstrated in terms of short- and long-term outcomes in a randomized controlled trial. Since robotic gastrectomy has been approved in Japanese health insurance system at April 2018, it is expected to rapidly expand throughout the country in the near future. Therefore, it is urgent matter to establish an evidence and educational program. In this article, the current status and future perspective about robotic surgery for gastric cancer are presented.

Risk Factors for Postoperative Delirium After Gastrectomy in Gastric Cancer Patients.

PURPOSE: The incidence of postoperative delirium is reported to range from 9 to 87%; however, no report has focused on cases of postoperative delirium in gastric cancer surgery alone. Therefore, we investigated the incidence of and risk factors for postoperative delirium after gastrectomy in patients with gastric cancer. METHODS: A total of 1037 patients who underwent surgery were included in the study. Patients were divided into two groups-those with (delirium group) or without (non-delirium group) postoperative delirium-and their backgrounds were compared. The short-term outcomes and the overall survival were also investigated. RESULTS: Postoperative delirium was observed in 47 of 1037 patients (4.5%). A multivariate analysis revealed that male gender, age ≥ 75 years, a history of cerebrovascular disease, and the habitual use of sleeping pills were independent predictive factors for postoperative delirium. The postoperative hospital stay was significantly longer in the postoperative delirium group than in the non-delirium group. Postoperative delirium was significantly associated with postoperative complications. The 3-year overall survival was 74.3% in the delirium group and 85.5% in the non-delirium group (log-rank p = 0.006). A multivariate analysis revealed that postoperative delirium was an independent prognostic factor, along with the age and cancer stage. CONCLUSION: The incidence of postoperative delirium was 4.5% in gastric cancer patients. Male gender, age ≥ 75 years, a history of cerebrovascular disease, and the habitual use of narcoleptic agents were risk factors for postoperative delirium after gastrectomy in gastric cancer patients. Postoperative delirium was strongly associated with other postoperative complications and a poor survival after surgery.

Feasibility of Laparoscopic Distal Gastrectomy for Stage I Gastric Cancer in Patients Outside of Clinical Trials.

BACKGROUND: Randomized controlled trials, including the Japan Clinical Oncology Group (JCOG) 0912 trial, have shown the safety of laparoscopy-assisted distal gastrectomy (LADG) for select healthy patients. It is unclear whether LADG is feasible in patients who do not meet trial eligibility criteria. METHODS: The present study retrospectively reviewed 547 patients with clinical stage I gastric cancer who underwent distal or pylorus-preserving gastrectomy. Of these, 185 were identified as not fulfilling the eligibility criteria of JCOG 0912; the short-term surgical outcomes between LADG and open distal gastrectomy (ODG) were compared in this group before and after propensity score matching. RESULTS: Patients who were not eligible for inclusion in the trial comprised 33.8% of the total. After matching, there were 59 patients each in the LADG and ODG groups, with an improved balance of confounding factors between the two groups. LADG was associated with significantly longer operation time, less blood loss, and shorter postoperative hospital stay than ODG. The rate of overall postoperative complications of Clavien-Dindo Grade II or higher did not differ significantly between the LADG and ODG groups (23.7 vs. 18.6%, respectively; p = 0.653). The incidence of pneumonia (6.8 vs. 5.1%), intra-abdominal infectious complications (5.1 vs. 3.4%), and stasis syndrome (5.1 vs. 3.4%) was also comparable between the two groups. CONCLUSION: LADG was as safe as ODG in patients who did not meet the eligibility criteria of JCOG 0912. LADG could be a standard treatment option for patients with stage I gastric cancer, regardless of their general condition.

Long-Term Outcomes of Gastric Cancer Patients with Preoperative Sarcopenia.

BACKGROUND: There are few reports of long-term outcomes of gastric cancer patients with sarcopenia. The purpose of this study was to assess the impact of sarcopenia on long-term outcomes in gastric cancer patients who underwent curative resection. METHODS: A total of 951 patients aged 65 years or older who underwent R0 resection for gastric cancer were investigated. Sarcopenia was defined as a decreased arm muscle area < 38.05 cm2 in men and < 27.87 cm2 in women combined with a decline in grip strength to < 26 kgf in men and < 18 kgf in women. RESULTS: Of 951 patients, 111 (11.7%) were diagnosed with sarcopenia. Reduced surgery was performed significantly more frequently in patients with sarcopenia (p = 0.006). The incidence of eligible patients who received adjuvant chemotherapy was significantly lower in patients with sarcopenia than in those without sarcopenia (p = 0.030). Mortality due to gastric cancer and aging-associated multiple organ failure rates without obvious diseases were higher in patients with sarcopenia (p = 0.036 and p < 0.001, respectively). Overall survival (OS) and cause-specific survival (CSS) were significantly worse in patients with sarcopenia (p < 0.001 and p = 0.005, respectively). Multivariate analysis for OS and CSS revealed that sarcopenia was an independent prognostic factor in gastric cancer patients (p < 0.001 and p = 0.043, respectively). CONCLUSIONS: Sarcopenia is related to poor survival in gastric cancer patients and appears to be a significant negative prognostic factor in patients with gastric cancer who underwent curative resection.

Surgical outcomes after gastrectomy in very elderly patients with gastric cancer.

PURPOSE: Whether or not gastrectomy is feasible for very elderly gastric cancer patients is unclear. This study aimed to clarify the feasibility and safety of surgical treatment for patients in this age group. METHOD: The study included 55 very elderly patients with resectable gastric cancer who underwent gastrectomy (≥ 85 years of age; very-E group). The surgical outcomes were compared with those of 611 elderly patients (75-84 years old; E group). RESULTS: Female sex, a poor physical and performance status, and a low serum albumin level patients were more frequent in the very-E group than in the E group. Lymphadenectomy was less aggressive in the very-E group than in the E group (P < 0.001). The overall postoperative complication rate was not significantly different between the groups (46 vs 33%; P = 0.073). A multivariate analysis to predict the overall survival identified male sex (hazard ratio 1.75, 95% confidence interval 1.30-2.36), low body mass index (2.19, 1.52-3.16), poor performance status (2.14, 1.60-2.86), low serum albumin level (1.84, 1.37-2.48), and advanced tumor stage (1.71, 1.29-2.27) but not age (1.31, 0.84-2.03) as independent prognostic factors. CONCLUSION: Chronological age alone is not a contraindicative factor for gastrectomy in very elderly patients.

Impact of Malnutrition After Gastrectomy for Gastric Cancer on Long-Term Survival.

BACKGROUND: Preoperative malnutrition can worsen morbidity and mortality; however, the role of postgastrectomy nutritional status remains unclear. Our purpose was to clarify whether malnutrition after gastrectomy could predict long-term survival. METHODS: Patients with pathological stage I, II, and III gastric cancer who underwent gastrectomy between 2002 and 2013 were included. The nutrition risk index (NRI) was evaluated before and at 1, 3, 6 and 12 months after gastrectomy. The patients were divided into normal (NRI > 97.5) or malnutrition (NRI ≤ 97.5) groups, and we compared the correlations of clinicopathological characteristics, surgical treatment, and overall survival between the two groups. RESULTS: Among the 760 participants, patients in the malnutrition group were significantly older and had higher incidences of comorbidity and advanced cancer than the patients in the normal group. Multivariate analysis showed that overall survival was poorer in the malnutrition group before gastrectomy [hazard ratio (HR) 1.68] and at 1 month (HR 1.77), 3 months (HR 2.18), 6 months (HR 1.81) and 12 months (HR 2.17) after gastrectomy (all p < 0.01). Malnutrition at 1 and 3 months after gastrectomy was significantly associated with poor cause-specific survival. Total gastrectomy, preoperative malnutrition, older age, and adjuvant chemotherapy were independent risk factors of postoperative malnutrition at 12 months postgastrectomy. CONCLUSIONS: Malnutrition before gastrectomy and at 1, 3, 6 and 12 months after gastrectomy significantly and adversely affects overall survival. Nutritional interventions to lessen the impact of postoperative malnutrition offer hope for prolonged survival.

The value of diagnostic endoscopic submucosal dissection for patients with clinical submucosal invasive early gastric cancer.

BACKGROUND: The standard treatment for clinical submucosal invasive (cT1b) early gastric cancer is gastrectomy. However, Japanese gastric cancer treatment guidelines list endoscopic submucosal dissection (ESD) as an option for treating limited early gastric cancer cases. ESD can be curative depending on the pathological characteristics of resected specimens. Thus, we aimed to clarify the benefits and disadvantages of preceding ESD for early gastric cancer. METHODS: We retrospectively analyzed patients who underwent ESD or curative gastrectomy for cT1b gastric cancer with differentiated adenocarcinoma 30 mm or less in diameter. Patients who underwent ESD irrespective of undergoing gastrectomy were assigned to the ESD group (n = 107), and those who underwent gastrectomy without undergoing ESD were assigned to the non-ESD group (n = 181). Clinicopathological characteristics were assessed, and the short-term and long-term outcomes of patients were compared. RESULTS: The criteria for curative resection were satisfied by 83 patients (28.8%), and preceding ESD did not affect the surgical outcomes of gastrectomy. Two patients (1.9%) who underwent ESD had an unscheduled total gastrectomy. The en bloc and complete resection rates of ESD were 99.0% and 84.1% respectively. Nine patients (8.4%) experienced intraprocedure perforation and postprocedure bleeding caused by ESD. Overall survival (hazard ratio 1.38; P = 0.302) and cause-specific survival (hazard ratio 0.96; P = 0.944) were comparable between groups. CONCLUSIONS: The stomach was preserved in 28.8% of patients, and preceding ESD did not show obvious disadvantages. Therefore, diagnostic ESD should be considered as an initial treatment for limited cT1b gastric cancer cases.

Prospective phase II study evaluating the efficacy of swallow ability screening tests and pneumonia prevention using a team approach for elderly patients with gastric cancer.

BACKGROUND: Aging partly impairs swallowing function, which is considered a risk factor for postoperative pneumonia (PP). We evaluated the efficacy of a new team-based strategy to reduce the incidence of PP in elderly patients with gastric cancer. METHODS: This single-center, prospective phase II study included elderly patients (≥75 years old) with gastric cancer undergoing gastric surgery. The primary endpoint was the incidence of Clavien-Dindo grade II or higher PP. Patients were initially screened using three swallowing function screening tests: a symptom questionnaire, the modified water swallow test (MSWT), and the repetitive saliva swallowing test (RSST). All patients were provided standard preoperative oral checks and care and simple neck muscle training. For patients who screened positive, a videofluorographic swallowing study was performed; if an abnormality was found, the patient was given intensive swallowing rehabilitation both pre- and postoperatively. RESULTS: Of 86 eligible patients enrolled, PP developed in 3 (3.5%). The 60% confidence interval of 1.8-6.3% had an upper limit below the prespecified threshold of 7.8%. Positive screening results were found for 19 patients (22.1%) on the symptom questionnaire, 3 (3.5%) on the MSWT, and 1 (1.2%) on the RSST. PP was not observed in any patients who screened positive. CONCLUSION: In conclusion, although the screening tests we adopted here were not sufficient to identify patients at high risk of aspiration pneumonia, perioperative interventions using a team approach might be effective in reducing the incidence of PP in elderly patients with gastric cancer.

Comparison of Surgical Outcomes Between Robotic and Laparoscopic Distal Gastrectomy for cT1 Gastric Cancer.

BACKGROUND: Increasing numbers of patients are treated by robotic distal gastrectomy (RDG); however, it remains unclear whether RDG is clinically comparable with conventional laparoscopic distal gastrectomy (LDG). This study aimed to clarify the feasibility of RDG from safety aspects. METHODS: The study included 109 cT1 gastric cancer patients who underwent RDG at Shizuoka Cancer Center from January 2012 to April 2015. Short-term outcomes were compared with 160 cT1 gastric cancer patients who underwent LDG during the same period. RESULTS: Patient characteristics were well matched. The RDG patients experienced longer operative times (323 min) than LDG patients (285 min; P < 0.001), although all other surgical outcomes were comparable between the groups. Drain amylase levels on POD 1 were significantly lower in the RDG group compared to LDG cases (median 452 U/L and 892 U/L; P < 0.001). The incidence of all complications was similar across the study patients, although intra-abdominal infectious complications tended to be lower in the RDG group than in the LDG group (2.8 and 8.1%; P = 0.112). CONCLUSIONS: RDG was comparable to LDG in terms of feasibility for cT1 gastric cancer. RDG has the potential to reduce pancreas damage and thus to decrease intra-abdominal infectious complications.