Study of the therapeutic strategy to improve survival outcomes from the perspective of perioperative conditions in elderly gastric cancer patients: a propensity score-matched analysis.

BACKGROUND: Elderly gastric cancer patients (EGCPs) require treatment according to not just the stage of their cancer, but also to their general condition and organ function, and rather than full treatment, the appropriate amount of treatment is necessary. METHODS: A total of 425 patients who underwent gastrectomy for primary gastric cancer in our institution between April 2013 and March 2020 were classified by age into two groups: elderly patients (EP, age ≥ 80 years, n = 89); and younger patients (YP, age < 80 years, n = 336). The preoperative, intraoperative, and postoperative conditions of the two groups were then compared. Propensity score matching (PSM) was performed, and factors affecting complications and survival outcomes were examined in detail. In addition, the necessary treatment strategy for EGCPs in the preoperative, intraoperative, and postoperative periods was investigated. RESULTS: Of the preoperative factors, American Society of Anesthesiologists physical status (ASA-PS) was significantly higher, and respiratory function was significantly lower in the EP group than in the YP group, and the prognostic nutritional index (PNI) also tended to be lower. Of the intraoperative factors, there was no difference in the level of lymph node dissection. However, the EP group had significantly higher rates of postoperative pneumonia and anastomotic leakage. Of the postoperative factors, on simple comparison, postoperative long-term outcomes of the EP group were significantly worse (63.8% vs. 85.4%, p < 0.001), but there was no significant difference in disease-specific survival (DSS), and the DSS survival curves after PSM were almost identical, indicating that the survival rate in the EP group was decreased by death from other disease. Though the survival rate of laparoscopic surgery was significantly better than that of open surgery in the YP group, there was a significantly lower rate of postoperative complications in the EP group after PSM. CONCLUSIONS: In EGCPs, one needs to be aware of short-term complications such as pneumonia and anastomotic leakage due to respiratory dysfunction and malnutrition that are present before surgery. Furthermore, to suppress deaths from other diseases that reduce postoperative survival rates, prevention of postoperative complications (particularly pneumonia) through minimally invasive surgery can be effective.

Functional evaluations comparing Billroth I with a large remnant stomach and Roux en Y with a small remnant stomach following laparoscopic distal gastrectomy for gastric cancer: An investigation including laparoscopic total gastrectomy.

PURPOSE: This study compared the pros and cons of two post-distal gastrectomy (DG) reconstruction methods by comparing the patient quality of life and functional dynamics at one year postoperatively. METHODS: We compared functional outcomes between Billroth I following laparoscopic 1/2 DG (L-B1; n = 27) and Roux en Y following laparoscopic 4/5 DG (L-RY; n = 24), including laparoscopic total gastrectomy (L-TG; n = 25), at one year postoperatively. Clinical investigations were performed in each patient, and functional evaluations by the acetaminophen (AAP) absorption test and plasma gastrointestinal hormone measurements were performed in consenting patients in each group (L-B1: n = 10, L-RY: n = 10, L-TG: n = 5). RESULTS: Postoperative/preoperative body weight ratios were significantly higher in the L-B1 and L-RY groups, in descending order than the L-TG group, although the meal intake ratio was not significantly different between the L-B1 and L-RY groups. The incidence of remnant gastritis was significantly higher in the B1 than in the RY group. AAP levels, glucose and glucagon-like peptide 1 were significantly lower in the L-B1 than in the L-RY group. Active ghrelin levels (AGL) were similar between the L-B1 and L-RY groups. CONCLUSIONS: L-B1 maintains gradual intestinal absorption and physiological meal passage and prevents postoperative weight loss. L-RY results in maintenance of the postoperative meal intake via high AGL, equivalent to that in the L-B1 group.

Preventive procedure for stenosis after esophagojejunostomy using a circular stapler and transorally inserted anvil (OrVil™) following laparoscopic proximal gastrectomy and total gastrectomy involving reduction of anastomotic tension.

BACKGROUND: Recently, due to increasing reports of stenosis after esophagojejunostomy created using circular staplers and a transorally inserted anvil (OrVil™) following laparoscopic proximal gastrectomy (LPG) and total gastrectomy (LTG), linear staplers are being used instead. We investigated our preventive procedure for esophagojejunostomy stenosis following use of circular staplers. METHODS: Since the anastomotic stenosis is considered to be mainly caused by tension in the esophageal and jejunal stumps at the anastomotic site, we have been performing procedures to relieve this tension, by cutting off the rubber band and pushing the shaft of the circular stapler toward the esophageal side, since July 2015. We retrospectively compared the incidence of anastomotic stenosis in cases of LPG and LTG performed before July 2015 (early phase, 30 cases) versus those performed after this period (later phase, 22 cases). RESULTS: Comparison of the incidence of anastomotic stenosis according to the type of surgery, LPG or LTG, and between the two time periods versus all cases, indicated a significantly lower incidence in the later phase than in the early phase (4.5 vs. 26.7%, p < 0.05), especially for LPG (0 vs. 38.5%, p < 0.05). CONCLUSIONS: It is possible to use a circular stapler during laparoscopic esophagojejunostomy, as with open surgery, if steps to reduce tension on the anastomotic site are undertaken. These procedures will contribute to the spread of safe and simple laparoscopic anastomotic techniques.