Modified stomach-partitioning gastrojejunostomy for initially unresectable advanced gastric cancer with outlet obstruction: A case report.

BACKGROUND: Chemotherapy followed by gastrojejunostomy remains the main treatment for unresectable gastric cancer (GC) in the middle- or lower-third regions with gastric outlet obstruction (GOO). Radical surgery is performed as part of a multimodal treatment strategy for selected patients who respond well to chemotherapy. This study describes a case of successful radical resection with completely laparoscopic subtotal gastrectomy after a modified stomach-partitioning gastrojejunostomy (SPGJ) for obstruction relief, in a patient with GOO. CASE SUMMARY: During the initial esophagogastroduodenoscopy, an advanced growth was detected in the lower part of the stomach, which caused an obstruction in the pyloric ring. Following this, a computed tomography (CT) scan revealed the presence of lymph node metastases and tumor invasion in the duodenum, but no evidence of distant metastasis was found. Consequently, we performed a modified SPGJ, a complete laparoscopic SPGJ combined with No. 4sb lymph node dissection, for obstruction relief. Seven courses of adjuvant capecitabine plus oxaliplatin combined with Toripalimab (programmed death ligand-1 inhibitor) were administered thereafter. A preoperative CT showed partial response; therefore, completely laparoscopic radical subtotal gastrectomy with D2 lymphadenectomy was performed after conversion therapy, and pathological complete remission was achieved. CONCLUSION: Laparoscopic SPGJ combined with No. 4sb lymph node dissection was an effective surgical technique for initially unresectable GC with GOO.

Optimal postoperative surveillance strategies for cancer survivors with gastric neuroendocrine carcinoma based on individual risk: a multicenter real-world cohort study.

BACKGROUND: The best follow-up strategy for cancer survivors after treatment should balance the effectiveness and cost of disease detection while detecting recurrence as early as possible. Due to the low incidence of gastric neuroendocrine carcinoma and mixed adenoneuroendocrine carcinoma [G-(MA)NEC], high-level evidence-based follow-up strategies is limited. Currently, there is a lack of consensus among clinical practice guidelines regarding the appropriate follow-up strategies for patients with resectable G-(MA)NEC. MATERIALS AND METHODS: The study included patients diagnosed with G-(MA)NEC from 21 centers in China. The random forest survival model simulated the monthly probability of recurrence to establish an optimal surveillance schedule maximizing the power of detecting recurrence at each follow-up. The power and cost-effectiveness were compared with the National Comprehensive Cancer Network, European Neuroendocrine Tumor Society, and European Society for Medical Oncology Guidelines. RESULTS: A total of 801 patients with G-(MA)NEC were included. The patients were stratified into four distinct risk groups utilizing the modified TNM staging system. The study cohort comprised 106 (13.2%), 120 (15.0%), 379 (47.3%), and 196 cases (24.5%) for modified groups IIA, IIB, IIIA, and IIIB, respectively. Based on the monthly probability of disease recurrence, the authors established four distinct follow-up strategies for each risk group. The total number of follow-ups 5 years after surgery in the four groups was 12, 12, 13, and 13 times, respectively. The risk-based follow-up strategies demonstrated improved detection efficiency compared to existing clinical guidelines. Further Markov decision-analytic models verified that the risk-based follow-up strategies were better and more cost-effective than the control strategy recommended by the guidelines. CONCLUSIONS: This study developed four different monitoring strategies based on individualized risks for patients with G-(MA)NEC, which may improve the detection power at each visit and were more economical, effective. Even though our results are limited by the biases related to the retrospective study design, we believe that, in the absence of a randomized clinical trial, our findings should be considered when recommending follow-up strategies for G-(MA)NEC.

Perioperative treatment and biomarker analysis of LP002, an anti-PD-L1 antibody, plus chemotherapy in resectable gastric and gastroesophageal junction cancer.

BACKGROUND: The addition of immune checkpoint inhibitors to perioperative chemotherapy in operable gastric or gastroesophageal junction (GEJ) cancer has become one of the research hotspots, while reliable biomarkers for efficacy are lacking. We conducted a phase 1 trial to assess the safety and efficacy of LP002, an anti-PD-L1 antibody, plus chemotherapy as perioperative treatment in patients with gastric or GEJ cancer. METHODS: We enrolled patients with resectable and PD-L1 positive gastric or GEJ cancers. Eligible patients received three preoperative and six postoperative cycles of intravenous LP002 with cisplatin and 5-fluorouracil, repeated every 2 weeks. The primary endpoint was safety. Secondary endpoints included rate of margin-free (R0) resection and pathological complete response (pCR). We also characterized changes in the tumor immune microenvironment using multiplex immunofluorescence (MIF) staining and next-generation sequencing (NGS) with pre- and post-treatment tumor samples. RESULTS: Thirty patients were enrolled, of whom 28 had GEJ cancer. With a median follow-up of 7.9 months, all patients completed preoperative treatment, and 27 patients underwent surgery. Twenty-four patients underwent R0 resection. Six patients (20.0%) had Mandard tumor regression grade (TRG) 1-3, including one achieving pCR. Twenty-seven patients had treatment-related adverse events (TRAEs), while grade 3-4 TRAEs were observed in 11 patients. No treatment-related deaths occurred. MIF staining revealed that TRG 1-3 group was associated with a higher density of PD-L1+/CD68+ cells in the pre-treatment tumor parenchyma than TRG 4-5 group (p = 0.048). NGS studies with paired pre- and post-treatment tumor samples revealed the disappearance of pre-existing mutations, the emergence of new mutations, and variations in the abundance of mutations after preoperative LP002 and chemotherapy. Meanwhile, tumor mutational burden decreased in patients with TRG 1-3 (p = 0.0313). CONCLUSIONS: LP002 plus cisplatin and 5-fluorouracil are safe in patients with gastric or GEJ cancer, and patient selection via appropriate biomarkers is needed in the future.

A new scoring system to evaluate adjuvant chemotherapy for patients with T2N0M0 gastric cancer after D2 gastrectomy.

BACKGROUND: At present, there is insufficient medical evidence to determine whether adjuvant chemotherapy is necessary for T2N0M0 gastric cancer. AIM: To obtain a risk score to assess the need for adjuvant chemotherapy in patients with T2N0M0 gastric cancer. METHODS: We identified 325 patients with pathological T2N0M0 stage primary gastric cancer at the National Cancer Center between 2011 and 2018. Univariate and multivariate Cox regression analyses were performed to predict factors affecting prognosis. Vascular invasion, tumor site, and body mass index were assessed, and a scoring system was established. We compared the survival outcomes and benefits of adjuvant chemotherapy between the different subgroups. RESULTS: Five-year survival rates of the score 0, 1, 2, and 3 groups were 92%, 95%, 80%, and 50%, respectively (P < 0.001). In the score 2-3 group, five-year survival rates for patients in the adjuvant chemotherapy group and postoperative observation group were 95% and 61%, respectively (P = 0.021). CONCLUSION: For patients with T2N0M0 stage gastric cancer and two or more risk factors, adjuvant chemotherapy after D2 gastrectomy may have a survival benefit.

No long-term survival benefit with sustained-release 5-fluorouracil implants in patients with stages II and III gastric cancer.

BACKGROUND: The prognosis of gastric cancer in an advanced stage remains poor. The exact efficacy of the use of intraoperative sustained-release chemotherapy with 5-fluorouracil (5-FU) in advanced-stage gastric cancer is still unelucidated. AIM: To explore the long-term survival benefit of using sustained-release 5-FU implants in stage II and stage III gastric cancer patients. METHODS: Patients with gastric cancer in a locally advanced stage and who underwent an R0 radical resection between Jan 2014, to Dec 2016, in this single institution were included. Patients with pathological diagnoses other than adenocarcinoma were excluded. All included patients were grouped according to whether intraoperative sustained-release (SR) chemotherapy with 5-FU was used or not (NSR). The primary end-point was 5-year overall survival. Kaplan-Meier method with log-rank test was used to analyze the overall survival of patients and Cox analysis was used to analyze prognosis factors of these patients. RESULTS: In total, there were 563 patients with gastric cancer with locally advanced stage, who underwent an R0 radical resection. 309 patients were included in the final analysis. 219 (70.9%) were men, with an average age of 58.25 years. Furthermore, 56 (18.1%) received neoadjuvant chemotherapy, and 191 (61.8%) were in TNM stage III. In addition, 158 patients received intraoperative sustained-release chemotherapy with 5-FU and were included in the SR group, while the other 161 patients were included in the NSR group. The overall complication rate was 12.94% in the whole group and 10.81%, 16.46% in SR and NSR groups, respectively. There were no significant differences between the two groups in overall survival and complication rate (P > 0.05). The multivariate cox analysis indicated that only N Stage and neoadjuvant therapy were independent influencing factors of survival. CONCLUSION: Intraoperative sustained-release chemotherapy usage with 5-FU, did not improve the survival of patients who underwent an R0 radical resection in locally advanced stage of gastric cancer.

Adjuvant chemoradiotherapy vs adjuvant chemotherapy in locally advanced Siewert type II/III adenocarcinoma of gastroesophageal junction after D2/R0 resection.

BACKGROUND: For Siewert type II/III adenocarcinoma of gastroesophageal junction (AGE), the efficacy of adjuvant chemoradiotherapy (CRT) after D2/R0 resection remains uncertain. AIM: To determine whether CRT was superior to chemotherapy (CT) alone after D2/R0 resection for locally advanced Siewert type II/III AGE. METHODS: We identified 316 locally advanced Siewert type II/III AGE patients who were treated with D2/R0 resection at National Cancer Center from 2011 to 2018. 57 patients received adjuvant CRT and 259 patients received adjuvant CT. We followed patients for overall survival (OS), relapse-free survival, and recurrence pattern. RESULTS: Five-year OS rates of the CRT group and the CT group for all patients were 66.7% and 41.9% (P = 0.010). Five-year OS rates of the CRT group and the CT group for Siewert type III AGE patients were 65.7% and 43.9% (P = 0.006). Among the 195 patients whose recurrence information could be obtained, 18 cases (34.6%) and 61 cases (42.7%) were diagnosed as recurrence in the CRT group and CT group, respectively. The local and regional recurrence rates in the CRT group were lower than that in the CT group (22.2% vs 24.6%, 27.8% vs 39.3%). Multivariable cox regression analysis showed that vascular invasion, nerve invasion, and adjuvant CRT were important prognostic factors for Siewert type III AGE. CONCLUSION: For locally advanced Siewert type III AGE, adjuvant CRT may prolong OS and reduce the regional recurrence rate.

Protective effects of female reproductive factors on gastric signet-ring cell carcinoma.

BACKGROUND: The overall incidence of gastric cancer is higher in men than women worldwide. However, gastric signet-ring cell carcinoma (GSRC) is more frequently observed in younger female patients. AIM: To analyze clinicopathological differences between sexes in GSRC, because of the limited evidence regarding association between sex-specific differences and survival. METHODS: We reviewed medical records for 1431 patients who received treatment for GSRC at the Cancer Hospital, Chinese Academy of Medical Sciences between January 2011 and December 2018 and surveyed reproductive factors. Clinicopathological characteristics were compared between female and male patients. Cox multivariable model was used to compare the mortality risks of GSRC among men, menstrual women, and menopausal women. RESULTS: Of 1431 patients, 935 patients were male and 496 were female (181 menstrual and 315 menopausal). The 5-year overall survival in male, menstrual female and menopausal female groups was 65.6%, 76.5% and 65%, respectively (P < 0.01). Menstruation was found to be a protective factor (hazard ratio = 0.58, 95% confidence interval: 0.42-0.82). CONCLUSION: The mortality risk of GSRC in menstrual women was lower than that in men. This study identified the protective effects of female reproductive factors in GSRC.

Preoperative Concurrent Chemoradiotherapy Versus Neoadjuvant Chemotherapy for Locally Advanced Gastric Cancer: Phase II Randomized Study.

Objective: We evaluated and compared the efficacy and safety of neoadjuvant chemoradiotherapy (NACRT) versus neoadjuvant chemotherapy (NACT) for locally advanced gastric cancer (LAGC) in a single-center randomized phase II trial. Methods: Patients with LAGC were enrolled and received either NACT or NACRT, followed by gastrectomy and adjuvant chemotherapy. The primary endpoint was an R0 resection rate. Results: We enrolled 75 patients: 75.7% (NACT, 28/37 patients) and 76.3% (NACRT, 29/38 patients) underwent surgery; R0 resection rates were 73.0% (27/37) and 73.7% (28/38), respectively. The NACRT group had significantly better major pathological response than the NACT group (37.9% vs 17.9%, p = 0.019). Between-group postoperative complications were not significantly different. The median follow-up was 59.6 months; 5-year overall survival (OS) rate was 50.1% (NACT) and 61.9% (NACRT); neither group reached the median OS; median progression-free survival was 37.3 and 63.4 months, respectively. Conclusions: S-1-based NACRT did not improve the R0 resection rate, although it presented better tumor regression with similar safety to NACT. Trial registration: ClinicalTrial.gov NCT02301481.

Can Gastric Cancer Patients with High Mandard Score Benefit from Neoadjuvant Chemotherapy?

A high Mandard score may indicate the tumor is insensitive to chemotherapy. We analyzed tumor regression and lymph node response under different Mandard scores to assess the impact of Mandard score on prognosis. Methods. Mandard scores and ypN stage of postoperative pathological reports were recorded. The results were reviewed by a professional pathologist. The radiologist compared the tumor regression before and after chemotherapy by computed tomography (CT). The survival of all patients was obtained by telephone follow-up. Multivariate Cox regression was used to assess the relationship between overall risk of death and Mandard score, imaging evaluation, and ypN stage. Results. In the Mandard score (4-5) group, the median survival time for PR and ypN0 patients was 68.5 and 76.7 months. While in the Mandard score (1-2) group, the median survival time for PD and ypN3a patients was 15.6 and 14.5 months. Imaging evaluation of tumor regression (PR 68.5 months, SD 27.8 months, and PD 10.2 months) and lymph node remission (ypN0 76.7 months, ypN1 61.6 months, ypN2 18.0 months, ypN3a 18.7 months, and ypN3b 18.3 months) showed improved survival. Mandard score, imaging evaluation, and ypN stage are important prognostic factors affecting prognosis. Conclusion. A high Mandard score does not mean neoadjuvant chemotherapy is ineffective in gastric cancer. Patients with imaging evaluation of tumor regression and ypN stage reduction may benefit from neoadjuvant chemotherapy.

Laparoscopic vs open total gastrectomy for advanced gastric cancer following neoadjuvant therapy: A propensity score matching analysis.

BACKGROUND: Laparoscopic total gastrectomy (LTG) has drawn increasing attention over the years. Although LTG has shown surgical benefits compared to open TG (OTG) in early stage gastric cancer (GC), little is known about the surgical and oncological outcomes of LTG for advanced GC following neoadjuvant therapy (NAT). AIM: To compare the long- and short-term outcomes of advanced GC patients who underwent LTG vs OTG following NAT. METHODS: Advanced GC patients who underwent TG following NAT between April 2011 and May 2018 at the Cancer Hospital of the Chinese Academy of Medical Sciences were enrolled and stratified into two groups: LTG and OTG. Propensity score matching analysis was performed at a 1:1 ratio to overcome possible bias. RESULTS: In total, 185 patients were enrolled (LTG: 78; OTG: 109). Of these, 138 were paired after propensity score matching. After adjustment for propensity score matching, baseline parameters were similar between the two groups. Compared to OTG, LTG was associated with a significantly shorter length of hospital stay (P = 0.012). The rates of R0 resection, lymph node harvest, and postoperative morbidity did not significantly differ between the two groups. Overall survival (OS) outcomes were comparable between the two groups. Pathological T and N stages were found to be independent risk factors for OS. CONCLUSION: LTG can be a feasible method for advanced GC patients following NAT, as it appears to be associated with better short- and comparable long-term outcomes compared to OTG.

A New Scoring System to Predict Lymph Node Metastasis and Prognosis After Surgery for Gastric Cancer.

BACKGROUND: Lymph node metastasis is one of the most important factors affecting the prognosis of gastric cancer patients. The purpose of this study is to develop a new scoring system to predict lymph node metastasis in gastric cancer using preoperative tests in various combinations of inflammatory factors and to assess the predictive prognosis value of the new scoring system for the postoperative gastric cancer patients. METHOD: This study includes 380 gastric cancer patients, 307 in the training set and 73 in the validation set. We obtain three inflammatory markers, CRA (C-reactive protein/albumin), SIRI (systemic inflammatory response index), and PLR (platelets/lymphocytes), by calculating and comparing the results of preoperative laboratory tests. By using these three indicators, a new scoring system is developed to predict lymph node metastases, assess patients' prognoses, and compare clinicopathological characteristics in different patient subgroups. A nomogram is constructed to show and assess the predictive efficacy of every index for lymph node metastasis and survival. RESULTS: In the new scoring system, higher scores are associated with more advanced pathological stage (p < 0.001), perineural invasion (p < 0.001), and vascular invasion (p = 0.001). Univariate and multivariable Cox regression analyses show that perineural invasion, vascular invasion, smoking history, and high scores on the new scoring system are significant risk factors for OS and RFS. High-scoring subgroups as an independent prognostic factor could predict overall survival (OS) and relapse-free survival (RFS). High scores on the new scoring system are significantly associated with the degree of lymph node metastasis (p < 0.001). CAR and PLR play very important roles in predicting lymph node metastasis in gastric cancer. CAR is a vital major marker in the prediction of patient survival. CONCLUSIONS: The new scoring system can effectively predict the patients' lymph node metastasis with gastric cancer and can independently predict the prognosis of patients.

Retrospective analysis of surgically treated pT4b gastric cancer with pancreatic head invasion.

BACKGROUND: For advanced gastric cancer patients with pancreatic head invasion, some studies have suggested that extended multiorgan resections (EMR) improves survival. However, other reports have shown high rates of morbidity and mortality after EMR. EMR for T4b gastric cancer remains controversial. AIM: To evaluate the surgical approach for pT4b gastric cancer with pancreatic head invasion. METHODS: A total of 144 consecutive patients with gastric cancer with pancreatic head invasion were surgically treated between 2006 and 2016 at the China National Cancer Center. Gastric cancer was confirmed in 76 patients by postoperative pathology and retrospectively analyzed. The patients were divided into the gastrectomy plus en bloc pancreaticoduodenectomy group (GP group) and gastrectomy alone group (GA group) by comparing the clinicopathological features, surgical outcomes, and prognostic factors of these patients. RESULTS: There were 24 patients (16.8%) in the GP group who had significantly larger lesions (P < 0.001), a higher incidence of advanced N stage (P = 0.030), and less neoadjuvant chemotherapy (P < 0.001) than the GA group had. Postoperative morbidity (33.3% vs 15.3%, P = 0.128) and mortality (4.2% vs 4.8%, P = 1.000) were not significantly different in the GP and GA groups. The overall 3-year survival rate of the patients in the GP group was significantly longer than that in the GA group (47.6%, median 30.3 mo vs 20.4%, median 22.8 mo, P = 0.010). Multivariate analysis identified neoadjuvant chemotherapy [hazard ratio (HR) 0.290, 95% confidence interval (CI): 0.103-0.821, P = 0.020], linitis plastic (HR 2.614, 95% CI: 1.024-6.675, P = 0.033), surgical margin (HR 0.274, 95% CI: 0.102-0.738, P = 0.010), N stage (HR 3.489, 95% CI: 1.334-9.120, P = 0.011), and postoperative chemoradiotherapy (HR 0.369, 95% CI: 0.163-0.836, P = 0.017) as independent predictors of survival in patients with pT4b gastric cancer and pancreatic head invasion. CONCLUSION: Curative resection of the invaded pancreas should be performed to improve survival in selected patients. Invasion of the pancreatic head is not a contraindication for surgery.

Contrast-enhanced ultrasound imaging for intestinal lymphoma.

BACKGROUND: Intestinal lymphoma is a rare tumor. Contrast-enhanced ultrasound (CEUS) findings of intestinal lymphoma have not been reported previously, and the relationship between CEUS and clinicopathological features and prognostic factors is still unknown. AIM: To describe the B-mode US and CEUS features of intestinal lymphoma and investigate the correlation of CEUS and histopathological features. METHODS: This was a single-center retrospective study. Eighteen patients with histologically confirmed intestinal lymphoma underwent B-mode US and CEUS examinations between October 2016 and November 2019. We summarized the features of B-mode US and CUES imaging of intestinal lymphoma and compared the frequency of tumor necrosis in intestinal lymphomas with reference to different pathological subtypes (aggressive or indolent) and clinical stage (early or advanced). The time-intensity curve parameters of CEUS were also compared between patients with normal and elevated serum lactate dehydrogenase. RESULTS: In B-mode imaging, four patterns were observed in intestinal lymphoma: Mass type (12/18, 66.7%), infiltration type (1/18, 5.6%), mesentery type (4/18, 22.2%) and mixed type (1/18, 5.6%). All cases were hypoechoic and no cystic areas were detected. On CEUS, most cases (17/18, 94.4%) showed arterial hyperechoic enhancement. All cases showed arterial enhancement followed by venous wash out. A relatively high rate of tumor necrosis (11/18, 61.1%) was observed in this study. Tumor necrosis on CEUS was more frequent in aggressive subtypes (10/13, 76.9%) than in indolent subtypes (1/5, 20.0%) (P = 0.047). There were no correlations between tumor necrosis and lesion size and Ann Arbor stage. There was no significant difference in time-intensity curve parameters between normal and elevated lactate dehydrogenase groups. CONCLUSION: B-mode US and CEUS findings of intestinal lymphoma are characteristic. We observed a high rate of tumor necrosis, which appeared more frequently in aggressive pathological subtypes of intestinal lymphoma.

Investigation of the factors influencing surgical treatment of duodenal gastrointestinal stromal tumors.

BACKGROUND: Duodenal gastrointestinal stromal tumor (DGIST) is a rare tumor with a specific anatomic site and biological characteristics. As the incidence of lymph node metastasis is very low, the main treatment method is surgery. Two main surgical techniques (local resection and Whipple) are performed in patients with DGISTs. The critical question is which surgical technique to choose. AIM: To identify factors influencing the choice of surgery for DGISTs. METHODS: The clinicopathological data of patients with DGISTs who underwent surgery between January 1999 and January 2021 were analyzed. We used the Student's t-test or Mann-Whitney U-test and the χ 2 test or Fisher's exact test to determine the differences between the two groups of patients. Furthermore, we used logistic analysis to identify the relevant factors and independent factors related to the type of surgery. The Kaplan-Meier method was used to analyze the patient's survival information and Cox regression analysis was performed to determine prognostic risk factors. RESULTS: Overall, 86 patients were analyzed, including 43 men (50%) and 43 women (50%). We divided the patients into two groups based on surgical technique (local resection or Whipple surgery). There were no differences in the age, mitotic figures, and complications between the two groups; however, the tumor size, tumor location, risk grade, postoperative hospital stay, and abdominal drainage time were significantly different. Based on univariate logistic analysis, the Whipple procedure was chosen if the tumor size was ≥ 5.0 cm, the tumor was located in the descending part of the duodenum, or the risk grade was medium or high. In our research, the five-year overall survival rate of patients was more than 90%. We also describe two DGIST patients with liver metastases at first diagnosis and analyzed their management in order to provide advice on complicated cases. CONCLUSION: The Whipple procedure was performed if the primary tumor was in the descending part of the duodenum, tumor size was ≥ 5.0 cm, or the tumor risk grade was medium or high.

Feasibility of totally laparoscopic gastrectomy without prophylactic drains in gastric cancer patients.

BACKGROUND: Prophylactic drains have been used to remove intraperitoneal collections and detect complications early in open surgery. In the last decades, minimally invasive gastric cancer surgery has been performed worldwide. However, reports on routine prophylactic abdominal drainage after totally laparoscopic distal gastrectomy are few. AIM: To evaluate the feasibility performing totally laparoscopic distal gastrectomy without prophylactic drains in selected patients. METHODS: Data of patients with distal gastric cancer who underwent totally laparoscopic distal gastrectomy with and without prophylactic drainage at China National Cancer Center/Cancer Hospital from February 2018 to August 2019 were reviewed. The outcomes between patients with and without prophylactic drainage were compared. RESULTS: A total of 457 patients who underwent surgery for gastric cancer were identified. Of these, 125 patients who underwent totally laparoscopic distal gastrectomy were included. After propensity score matching, data of 42 pairs were extracted. The incidence of concurrent illness was higher in the drain group (42.9% vs 31.0%, P = 0.258). The overall postoperative complication rates were 19.5% and 10.6% in the drain (n = 76) and no-drain groups (n = 49), respectively; there were no significant differences between the two groups (P > 0.05). The difference between the two groups based on the need for percutaneous catheter drainage was also not significant (9.8% vs 6.4%, P = 0.700). However, patients with a larger body mass index (≥ 29 kg/m2) were prone to postoperative complications (P = 0.042). In addition, the number of days from surgery until the first flatus (4.33 ± 1.24 d vs 3.57 ± 1.85 d, P = 0.029) was greater in the drain group. CONCLUSION: Omitting prophylactic drainage may reduce surgery time and result in faster recovery. Routine prophylactic drains are not necessary in selected patients. A prophylactic drain may be useful in high-risk patients.

Low body mass index is an independent predictor of poor long-term prognosis among patients with resectable gastric cancer.

BACKGROUND: The association between body mass index (BMI) and clinical outcomes remains unclear among patients with resectable gastric cancer. AIM: To investigate the relationship between BMI and long-term survival of gastric cancer patients. METHODS: This retrospective study included 2526 patients who underwent radical gastrectomy for gastric cancer between September 2013 and June 2018. The patients were divided into four groups: Group A (low BMI, < 18.5 kg/m2), group B (normal BMI, 18.5-24.9 kg/m2), group C (overweight, 25-29.9 kg/m2), and group D (obese, ≥ 30 kg/m2). Clinicopathological findings and survival outcomes were recorded and analyzed. RESULTS: Preoperative weight loss was more common in the low-BMI group, while diabetes was more common in the obese group. Upper-third gastric cancer accounted for a large proportion of cases in the higher BMI groups. Major perioperative complications tended to increase with BMI. The 5-year overall survival rates were 66.4% for group A, 75.0% for group B, 77.1% for group C, and 78.6% for group D. The 5-year overall survival rate was significantly lower in group A than in group C (P = 0.008) or group D (P = 0.031). Relative to a normal BMI value, a BMI of < 18.5 kg/m2 was associated with poor survival (hazard ratio: 1.558, 95% confidence interval: 1.125-2.158, P = 0.008). CONCLUSION: Low BMI, but not high BMI, independently predicted poor survival in patients with resectable gastric cancer.

Survival outcomes and prognostic indicators for gastric cancer patients with positive peritoneal wash cytology but no peritoneal metastasis after radical gastrectomy.

BACKGROUND: Positive peritoneal wash cytology with no peritoneal metastasis (CY1P0) is a special type of distant gastric cancer metastasis, which describes a patient with positive peritoneal lavage cytology, but no definitive peritoneal metastasis, and there are no widely accepted treatment guidelines. We enrolled 48 primary CY1P0 gastric cancer patients treated by radical gastrectomy in this study. Our study illustrated the efficacy of radical gastrectomy for CY1P0 gastric cancer patients, and suggested that the pathological N factor and vascular invasion were significant independent risk factors for overall survival (OS). AIM: To assess the survival of CY1P0 gastric cancer patient post-radical gastrectomy, and to identify factors associated with long-term prognosis. METHODS: Our study included 48 patients with primary CY1P0 gastric cancer who had radical gastrectomies at the Cancer Hospital, Chinese Academy of Medical Sciences, Beijing, China between 2013 and 2018. R0 resection was achieved in all 48 patients. Twelve patients received neoadjuvant chemotherapy. Thirty patients received adjuvant chemotherapy and four received adjuvant chemoradiotherapy. OS statistics were available for 48 patients. Follow-up continued through March 2020. Univariate and multivariate analyses were performed using a Cox proportional hazards model to identify prognostic factors. RESULTS: Median OS was 22.0 mo (95% confidence interval: 13.366-30.634 mo) post-surgery. Univariate analyses demonstrated that tumor site (P = 0.021), pathological N factor (P = 0.001), pathological T factor (P = 0.028), vascular invasion (P = 0.046), and the level of CA199 prior to initiating therapy (P = 0.002) were significant risk factors for OS. Multivariate analyses demonstrated that pathological N factor (P = 0.001) and vascular invasion (P = 0.031) were significant independent risk factors for OS. CONCLUSION: This study suggested that radical gastrectomy may be efficient for CY1P0 gastric cancer patient post-radical gastrectomy and the pathological N factor and vascular invasion are significant independent risk factors for OS.

Feasibility and nutritional impact of laparoscopic assisted tailored subtotal gastrectomy for middle-third gastric cancer.

BACKGROUND: Laparoscopic assisted total gastrectomy (LaTG) is associated with reduced nutritional status, and the procedure is not easily carried out without extensive expertise. A small remnant stomach after near-total gastrectomy confers no significant nutritional benefits over total gastrectomy. In this study, we developed a modified laparoscopic subtotal gastrectomy procedure, termed laparoscopic-assisted tailored subtotal gastrectomy (LaTSG). AIM: To evaluate the feasibility and nutritional impact of LaTSG compared to those of LaTG in patients with advanced middle-third gastric cancer (GC). METHODS: We retrospectively analyzed surgical and oncological outcomes and postoperative nutritional status in 92 consecutive patients with middle-third GC who underwent radical laparoscopic gastrectomy at Department of Pancreatic Stomach Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences, and Peking Union Medical College between 2013 and 2017. Of these 92 patients, 47 underwent LaTSG (LaTSG group), and the remaining underwent LaTG (LaTG group). RESULTS: Operation time (210 ± 49.8 min vs 208 ± 50.0 min, P > 0.05) and intraoperative blood loss (152.3 ± 166.1 mL vs 188.9 ± 167.8 mL, P > 0.05) were similar between the groups. The incidence of postoperative morbidities was lower in the LaTSG group than in the LaTG group (4.2% vs 17.8%, P < 0.05). Postoperatively, nutritional indices did not significantly differ, until postoperative 12 mo. Albumin, prealbumin, total protein, hemoglobin levels, and red blood cell counts were significantly higher in the LaTSG group than in the LaTG group (P < 0.05). No significant differences in Fe or C-reaction protein levels were found between the two groups. Endoscopic examination demonstrated that reflux oesophagitis was more common in the LaTG group (0% vs 11.1%, P < 0.05). Kaplan-Meier analysis showed a significant improvement in the overall survival (OS) and disease free survival (DFS) in the LaTSG group. Multivariate analysis showed that LaTSG was an independent prognostic factor for OS (P = 0.048) but not for DFS (P = 0.054). Subgroup analysis showed that compared to LaTG, LaTSG improved the survival of patients with stage III cancers, but not for other stages. CONCLUSION: For advanced GC involving the middle third stomach, LaTSG can be a good option with reduced morbidity and favorable nutritional status and oncological outcomes.

Treatment strategies for gastric cancer during the COVID-19 pandemic.

The coronavirus disease 2019 pandemic has become a major global public health problem. Governments are taking the necessary steps to reduce the movement of people to contain the spread of the virus. However, these measures have caused considerable distress to patients with gastric cancer who are newly diagnosed or are undergoing treatment. In addition to the cancer, they must deal with longer waiting times for surgery and poor communication with doctors. Furthermore, gastric cancer patients generally have low immunity and a poor nutritional status, so they are a high-risk group for infection with the novel coronavirus. Therefore, it is necessary to formulate reasonable outpatient management strategies to reduce the adverse effects of the pandemic on their treatment. We summarize the management strategies for patients with gastric cancer during the pandemic.

Treatment of afferent loop syndrome using fluoroscopic-guided nasointestinal tube placement: Two case reports.

BACKGROUND: Afferent loop syndrome (ALS) is a rare mechanical complication that occurs after reconstruction of the stomach or esophagus to the jejunum, such as Billroth II gastrojejunostomy, Roux-en-Y gastrojejunostomy, or Roux-en-Y esophagoje-junostomy. Traditionally, an operation is the first choice for benign causes. However, for patients in poor physical condition who experience ALS soon after R0 resection, the type of treatment remains controversial. Here, we present an efficient conservative method to treat ALS. CASE SUMMARY: Case 1 was a 69-year-old male patient who underwent total gastrectomy with Roux-en-Y jejunojejunostomy. On postoperative day (POD) 10 he developed symptoms of ALS that persisted and increased over 1 wk. Case 2 was a 59-year-old male patient who underwent distal gastrectomy with Billroth II gastrojejunostomy. On postoperative day POD 9 he developed symptoms of ALS that persisted for 2 wk. Both patients underwent fluoroscopic-guided nasointestinal tube placement with maintenance of continuous negative pressure suction. Approximately 20 d after the procedure, both patients had recovered well and were discharged from hospital after removal of the tube. At 3-mo follow-up, there were no signs of ALS in these two patients. CONCLUSION: This is the first report of treating postoperative ALS by fluoroscopic-guided nasointestinal tube placement. Our cases demonstrate that this procedure is an effective and safe method to treat ALS that relieves patients' symptoms and avoids complications caused by other invasive procedures.