Reduced Port Laparoscopic Distal Gastrectomy with D2 Lymphadenectomy.

BACKGROUND: Reduced port laparoscopic surgery (RPLS), as a more minimally invasive treatment alternative to conventional laparoscopic surgery (CLS), has been increasing in recent years. 1 With the accumulation of surgical experience and improvements in surgical techniques, the indication of RPLS has been gradually extended from benign diseases to malignant tumors, including gastric cancer. 2-4 However, due to the lack of counteraction and triangulation, lymphadenectomy during reduced port laparoscopic gastrectomy (RPLG) for gastric cancer was considered challenging. In this study, we report our experience performing RPLG with D2 lymphadenectomy for distal gastric cancer. METHODS: A disposable, single-incision, multiport, laparoscopic surgery trocar was used through a 3-cm incision at the umbilicus for the laparoscopist and surgeon's right hand. One 12-mm trocar was inserted at the upper-right quadrant for the surgeon's left hand. Distal gastrectomy with D2 lymphadenectomy was performed in the same manner with CLS. 5 After extracting the resected specimen through the umbilicus incision, intracorporeal Roux-en-Y or B-II gastrojejunostomy was used for reconstruction. RESULTS: RPLG with D2 lymphadenectomy was performed on five patients from April 2017 to June 2017. No intraoperative event requiring conversion to CLS or open surgery occurred. No postoperative complication was observed. The median operating time and blood loss was 166 min and 50 ml. The mean number of retrieved lymph nodes was 32.7. Postoperatively, the mean time to first flatus, soft intake, and hospital stay was 2.6, 3.5, and 6.7 days respectively. CONCLUSIONS: RPLG with D2 lymphadenectomy might be safe and feasible in selected patients.

An automatically contamination-avoiding technique for intracorporeal esophagojejunostomy using a transorally inserted anvil during laparoscopic total gastrectomy for gastric cancer.

BACKGROUND: Intracorporeal Roux-en-Y esophagojejunostomy during laparoscopic total gastrectomy for gastric cancer remains a challenging manipulation due to the uncontrolled direction of the jejunal side or unintended embedded tissues, although several methods have been introduced. In this study, we simplified the procedure based on a surgical string fixing technique using a transorally inserted anvil (OrVil™; Covidien Ltd., Mansfield, MA, USA). METHODS: From March 2012 to September 2013, 14 consecutive patients underwent simplified intracorporeal Roux-en-Y esophagojejunostomy using OrVil™ during laparoscopic total gastrectomy for gastric cancer at our hospital. Clinicopathologic characteristics and surgical outcomes of these patients were retrospectively analyzed. RESULTS: All of the procedures were successful completed with no complication or conversion to open surgery. The mean overall operative time was 193.8 ± 41.8 min, whereas the mean reconstruction time was 32.6 ± 4.6 min. The mean estimated blood loss was 105.7 ± 65.4 ml. The mean diameter of anastomosis measured by upper gastrointestinal contrast X-ray test at 1 month after operation was 2.3 cm. During a median follow-up period of 12 months, neither local recurrence nor anastomosis-related morbidity was observed. CONCLUSIONS: Our preliminary results suggested that this automatically contamination-avoiding technique based on a surgical-string-fixing strategy using OrVil™ during laparoscopic total gastrectomy for gastric cancer might be feasible and safe and provide a simple solution for intracorporeal Roux-en-Y esophagojejunostomy.

[The safety and long-term survival after laparoscopic surgery versus open surgery for colon cancer].

OBJECTIVE: To evaluate the short-term outcomes and 5-year recurrence, overall survival, and disease-free survival of laparoscopic assisted surgery for colon cancer. METHODS: The clinical and pathologic data were compared between the patients who underwent colectomy during March 2003 to July 2008 and assigned in laparoscopic group (n = 92) and open group (n = 285) according the surgical approach. The 5-year overall survival, disease-free survival, and recurrence rate were analyzed for all patients who were followed-up for more than 36 months in either of the groups. RESULTS: The laparoscopic colectomy was associated with manifested less blood loss (50(50) ml) (Z = -8.292, P < 0.01), early return of bowel function (the evacuation time was (3.0 ± 1.0) days, and the meal time after operation was (4.0 ± 1.3) days) (t = -6.475 and -4.871, P < 0.01), and longer length (cm) of distal resection margin ((10 ± 4) cm vs. (9 ± 4) cm, t = 3.527, P = 0.000). The 5-year overall survival of the laparoscopic group and the open group were 63.6% and 61.8% respectively. The 5-year disease-free survival of the I-III stage patients in the laparoscopic group and the open group were 69.5% and 65.5% respectively, and the local recurrence were 8.7% and 13.6% (all P > 0.05). CONCLUSION: The laparoscopic colectomy for colon cancer is safe in short-term clinical results and non-inferior to the open colectomy in long-term oncological outcomes.

Perirectal fascia and spaces: annular distribution pattern around the mesorectum.

PURPOSE: In view of debate on the optimal surgical planes for total mesorectal excision, this study was designed to explore the regional anatomy of the perirectal fascia and spaces. METHODS: Twenty-one cadavers (15 male and 6 female) were embalmed and their vessels visualized by injection with color dye. From the cadavers, 30 hemipelves and 6 three-quarter pelves were harvested. The perirectal fascia and spaces and the pelvic autonomic nerves were dissected and examined. RESULTS: Three tissue layers were dissected from the inside to the periphery: the proper rectal fascia enveloping the mesorectum, the presacral fascia, and the piriformis fascia fused with the sacral periosteum. The mesorectum comprised 2 parts: posterior, with the classical posterolateral fat covered by the proper rectal fascia; and anterior, with the anterior fat covered by the posterior layer of Denonvilliers fascia. Extending anteriorly to the anterior layer of Denonvilliers fascia, the presacral fascia bisected the space between the mesorectum and the piriformis fascia into the retrorectal space and the presacral space. The retrorectal space extended cranially to the left Toldt's space, anterior to the space between the 2 layers of Denonvilliers fascia. CONCLUSIONS: From the inside to the periphery, the proper rectal fascia, the presacral fascia, and the muscular fascia are distributed in an annular pattern around the mesorectum. The presacral fascia divides the perirectal space into 2 annular parts: the central retrorectal space and the peripheral presacral space. The retrorectal space is the ideal surgical plane for the total mesorectal excision.

A new order of D2 lymphadenectomy in laparoscopic gastrectomy for cancer: live anatomy-based dissection.

It was the aim of this study to develop a methodology for dissection in laparoscopic distal gastrectomy with D2 lymphadenectomy (D2 LDG) for gastric cancer. One-hundred and thirty-two patients with distal gastric cancer underwent D2 LDG with a novel sequence of lymph node dissection between August 2004 and June 2008. Live anatomy in each step was observed simultaneously to ensure and confirm the newly developed methodology. Dissections in LDG were standardized as sequential steps: Dividing the gastrocolic ligament and getting access to the prepancreatic space--lymph node dissection in the lower left area--lymph node dissection in the lower right area--lymph node dissection in the upper right area--lymph nodes dissection centrally--lymph node dissection between liver and stomach. All dissections were successfully performed in peripancreatic spaces and their extensions. Gastric vessels were located by special landmarks, traced along vascular trunks and bifurcations, and identified by fine dissection technique in vaginavasorum. Sequential dissection around the pancreas was an effective method for D2 LDG. It was ensured by anatomical knowledge in each step: Vessels and fascial spaces around a central landmark, the pancreas.

Using Materialise's interactive medical image control system to reconstruct a model of a patient with rectal cancer and situs inversus totalis: A case report.

BACKGROUND: Situs inversus totalis (SIT) is a rare congenital anomaly that refers to a completely reversed location of abdominal and thoracic organs. An extremely small number of patients with this condition, especially those with rectal neoplasms, have been reported. Surgery in these patients is technically challenging. Therefore, we reconstructed a three-dimensional (3D) digital model with the Materialise's interactive medical image control system (Mimics) as a guide for laparoscopic resection. CASE SUMMARY: We report the case of a 68-year-old woman with rectal neoplasms and SIT diagnosed by electronic colonoscopy biopsy and enhanced computed tomography (CT), which showed that there was a soft tissue mass protruding into the lumen in the lower rectal segment, a lesion that involved the serosal layer, multiple enlarged peripheral lymph nodes, and visceral situs abnormalities. Based on the CT images, we reconstructed a 3D model with Mimics to assist with our surgical planning. Then, we performed laparoscopy-assisted radical resection of the rectal neoplasms and total excision of the lesion. Adjuvant chemotherapy with the XELOX regimen (oxaliplatin 150 mg, D1 + Xeloda 1.0 g, Bid, D1-14) was initiated 1 mo after the operation. The patient recovered well after surgery, and her physical condition remained stable. CONCLUSION: Preoperative 3D reconstruction of the imaging results could help reduce the unknown risks during surgery caused by anatomical abnormalities and improve the perioperative safety for patients.

The safety of esophagojejunostomy via a transorally inserted-anvil method vs extracorporeal anastomosis using a circular stapler during total gastrectomy for Siewert type 2 adenocarcinoma of the esophagogastric junction.

BACKGROUND: Intracorporeal esophagojejunostomy via a transorally inserted-anvil method during laparoscopic total gastrectomy (LTG) for upper gastric cancer has been demonstrated to be feasible, but the use of this assessment exclusively for Siewert type 2 adenocarcinoma of the esophagogastric junction (AEG) has not been reported. METHODS: A total of 428 consecutive gastric-cancer patients who underwent LTG in Nanfang Hospital from January 2008 to December 2016 were reviewed. Among these patients, 98 were classified as Siewert type 2 AEG. The patients underwent intracorporeal esophagojejunostomy through either a transorally inserted-anvil method (n = 27) or extracorporeal anastomosis usinga circular stapler (n = 71). After generating propensity scores with covariates that were associated with developing anastomotic leakage, 26 patients who underwent esophagojejunostomy via the transorally inserted-anvil method (transoral group) were 1:1 matched with 26 patients who underwent the procedure via extracorporeal anastomosis using a circular stapler (extracorporeal group). The safety after 30 days post-operatively was compared between the two groups. RESULTS: The transoral group and extracorporeal group were balanced regarding the baseline variables. The operative time, reconstruction duration, number of dissected lymph nodes, length of the proximal resection margins, estimated blood loss, intra-operative complication rate, and post-operative recovery course were not significantly different between the two groups. The mean anvil-insertion completion time (9.7 ± 3.0 vs 13.4 ± 2.0 minutes, P < 0.001) and the median incision length (5.5 vs 7.0 cm, P < 0.001) in the transoral group were shorter than those in the extracorporeal group. The incidence of post-operative complications (26.9% vs 23.1%, P = 0.749) and the classification of complication severity (P = 0.939) were similar between the two groups. CONCLUSIONS: Intracorporeal esophagojejunostomy through a transorally inserted-anvil method may be a potentially safe approach to simplify and optimize the procedure during LTG for Siewert type 2 AEG.

Long-Term Outcomes in Laparoscopic D2 Gastrectomy for Gastric Cancer: a Large Comprehensive Study Proposing Novel Hypotheses.

BACKGROUND: The long-term outcomes of laparoscopic gastrectomy (LG) versus open gastrectomy (OG) for gastric cancer (GC) remain obscure, especially for advanced cancer and disease affecting the upper stomach and in older patients. This study aimed to comprehensively assess the long-term efficacy of LG for GC using a large prospective database. METHODS: Totally, 1877 consecutive patients (1186 receiving LG and 691 OG) operated in 2004-2016 were analyzed, with a median follow-up of 63 months. Association of LG versus OG with disease-specific survival (DSS) and disease-free survival (DFS) overall and in various subgroups were investigated using multivariable Cox regression. Propensity score matching (PSM) was performed for sensitivity analysis. RESULTS: Before PSM, overall, there was no significant association of LG versus OG with survival after multivariable adjustment; however, in subgroup analyses, LG was associated with superior DSS in patients aged ≥ 70 years and those with upper GC. No significant associations regarding DFS were observed overall or in stratifications. PSM analyses revealed that LG was associated with better DSS also in patients aged ≥ 70 years (hazard ratio (HR) = 0.33, 95% confidence interval (CI) = 0.15-0.72) and in those with upper GC (HR = 0.51, 95% CI = 0.29-0.91), and with better DFS in those with upper GC (HR = 0.60, 95% CI = 0.37-0.99). Multivariable analysis showed that age, hepatitis B, performance status, tumor histology, stage, and vascular invasion were significantly associated with post-LG survival. LG-specific nomograms were then constructed with concordance indexes of 0.814 (DSS) and 0.809 (DFS) and excellent calibration. CONCLUSIONS: In this large institutional analysis, while LG for GC was associated with DSS and DFS similar to those for OG overall, non-inferior LG-associated survival especially DSS was observed in some subgroups rarely investigated in prospective or randomized settings. There could still be biases even after PSM due to confounders not accounted for in this observational study. However, these findings offer novel hypotheses for further validation.

Initial Experience of Dual-Port Laparoscopic Distal Gastrectomy for Gastric Cancer: A Single-Arm Study.

INTRODUCTION: Dual-port laparoscopic gastrectomy (DPLG) has been widely performed in recent years for treating gastric cancers. The present study reports our initial experience of dual-port laparoscopic distal gastrectomy (DPLDG). METHODS: From November 2016 to August 2018, 38 consecutive patients underwent DPLDG in our center. The observational outcomes included 30-day morbidity and mortality rates, time to first flatus, time to first oral liquid diet, time to first oral semiliquid diet, time to drainage tube removal, visual analogue scale (VAS) score, postoperative 4-day recovery rate, additional analgesic use, hospital stay and cosmetic benefits. RESULTS: Mean operative time was 191.6 ± 44.4 min, mean intra-operative blood loss was 39.8 ± 48.7 ml, and the mean number of dissected lymph nodes was 38.3 ± 13.7 nodes. One case was converted to five-port laparoscopic surgery, and no intraoperative complications occurred in any of the cases. The mean time to postoperative first flatus was 45.3 ± 18.0 h. The mean time to intake of an oral liquid diet was 56.7 ± 30.4 h. The mean time to drainage tube removal was 97.9 ± 52.3 h. The mean VAS scores for the 3 days after surgery were 2.3 ± 0.7, 2.0 ± 0.6 and 1.6 ± 0.5, respectively. A total of 81.6% of the enrolled patients met the postoperative 4-day recovery standard, and 15.8% of patients received additional analgesics. The mean postoperative hospital stay was 6.0 ± 2.0 days. No deaths were observed, and the 30-day morbidity rate was 13.2%. CONCLUSION: DPLDG is a feasible and safe procedure for experienced surgeons with acceptable short-term outcomes, reduced invasiveness and good cosmetic effects.

Tumor Immune Microenvironment and Chemosensitivity Signature for Predicting Response to Chemotherapy in Gastric Cancer.

Current gastric cancer staging alone cannot predict prognosis and adjuvant chemotherapy benefits in stage II and III gastric cancer. Tumor immune microenvironment biomarkers and tumor-cell chemosensitivity might add predictive value to staging. This study aimed to construct a predictive signature integrating tumor immune microenvironment and chemosensitivity-related features to improve the prediction of survival and adjuvant chemotherapy benefits in patients with stage II to III gastric cancer. We used IHC to assess 26 features related to tumor, stroma, and chemosensitivity in tumors from 223 patients and evaluated the association of the features with disease-free survival (DFS) and overall survival (OS). Support vector machine (SVM)-based methods were used to develop the predictive signature, which we call the SVM signature. Validation of the signature was performed in two independent cohorts of 445 patients. The diagnostic signature integrated seven features: CD3+ cells at the invasive margin (CD3 IM), CD8+ cells at the IM (CD8 IM), CD45RO+ cells in the center of tumors (CD45RO CT), CD66b+ cells at the IM (CD66b IM), CD34+ cells, periostin, and cyclooxygenase-2. Patients fell into low- and high-SVM groups with significant differences in 5-year DFS and OS in the training and validation cohorts (all P < 0.001). The signature was an independent prognosis indicator in multivariate analysis in each cohort. The signature had better prognostic value than various clinicopathologic risk factors and single features. High-SVM patients exhibited a favorable response to adjuvant chemotherapy. Thus, this SVM signature predicted survival and has the potential for identifying patients with stage II and III gastric cancer who could benefit from adjuvant chemotherapy.

Performance of risk stratification systems for gastrointestinal stromal tumors: A multicenter study.

BACKGROUND: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumor type in the gastrointestinal system. Presently, various classification systems to prognosticate GISTs have been proposed. AIM: To evaluate the application value of four different risk stratification systems for GISTs. METHODS: Patients who were diagnosed with GISTs and underwent surgical resection at four hospitals from 1998 to 2015 were identified from a database. Risk of recurrence was stratified by the modified National Institute of Health (NIH) criteria, the Armed Forces Institute of Pathology (AFIP) criteria, the Memorial Sloan Kettering Cancer Center (MSKCC) prognostic nomogram, and the contour maps. Receiver operating characteristic (ROC) curves were established to compare the four abovementioned risk stratification systems based on the area under the curve (AUC). RESULTS: A total of 1303 patients were included in the study. The mean age of the patients was 55.77 ± 13.70 yr; 52.3% of the patients were male. The mean follow-up period was 64.91 ± 35.79 mo. Approximately 67.0% the tumors were located in the stomach, and 59.5% were smaller than 5 cm; 67.3% of the patients had a mitotic count ≤ 5/50 high-power fields (HPFs). Thirty-four tumors ruptured before and during surgery. Univariate analysis demonstrated that tumor size > 5 cm (P < 0.05), mitotic count > 5/50 HPFs (P < 0.05), non-gastric location (P < 0.05), and tumor rupture (P < 0.05) were significantly associated with increased recurrence rates. According to the ROC curve, the AFIP criteria showed the largest AUC (0.754). CONCLUSION: According to our data, the AFIP criteria were associated with a larger AUC than the NIH modified criteria, the MSKCC nomogram, and the contour maps, which might indicate that the AFIP criteria have better accuracy to support therapeutic decision-making for patients with GISTs.

Morbidity and mortality of elderly patients with advanced gastric cancer after laparoscopy-assisted or open distal gastrectomy: a randomized-controlled trial.

Laparoscopy-assisted distal gastrectomy (LDG) combined with D2 lymphadenectomy may be safely performed in patients with advanced gastric cancer (AGC) by experienced surgeons at specialized high-volume institutions as shown in the Chinese Laparoscopic Gastrointestinal Surgery Study (CLASS)-01. However, studies focusing on the use of LDG in patients with gastric cancer older than 65 years are rare. This study was designed to investigate the morbidity and mortality of elderly patients with gastric cancer who underwent laparoscopic-assisted or open distal gastrectomy (ODG). In this prospective, randomized, open, parallel controlled trial, patients older than 65 years with tumor located at the middle or lower part of the stomach will be enrolled in this study. Patients will be randomly divided into a laparoscopic group and an open surgery group. The early post-operative complications, intra-operative complications and post-operative recovery will be compared between the two groups. This trial will provide valuable clinical evidence for the objective assessment of the feasibility, short-term safety, and potential benefits of LDG compared with ODG for gastric cancer in the elderly patients. This trial has been registered on ClinicalTrials.gov. (Identifier: NCT02246153.) in September 22, 2014.

[Sericin regulates proliferation of human gastric cancer MKN45 cells through autophagic pathway].

OBJECTIVE: To investigate the effect of sericin on the proliferation of human gastric cancer MKN45 cells and explore the underlying molecular mechanism. METHODS: MKN45 cells were transfected by LC3 double fluorescent autophagic virus, and the positive cells screened by puromycin were divided into blank group, sericin group and sericin∓3-MA group. After incubation with sericin for 48 h, the cells were examined for proliferation, apoptosis and cell cycle using CCK-8 assay and flow cytometry. Cell autophagy was detected by transmission electron microscopy (TEM) and fluorescent inverted microscope, and the autophagy-related markers including LC3, p62 and Beclin proteins were detected with Western blotting. Nude mice bearing gastric cancer xenograft were treated with normal saline or sericin injections (n=5) and the changes in the tumor volume and weight were measured. RESULTS: Compared with the blank group, MKN45 cells with sericin treatment showed significantly inhibited proliferation both in vitro and in nude mice. Autophagosomes were observed in sericin-treated cells under TEM and fluorescent inverted microscope. Sericin treatment of the cells significantly increased the cell apoptosis (P<0.01), caused obvious cell cycle arrest in G2/M phase (P<0.01), up-regulated the expressions of both LC3-2 and Beclin, and down-regulated the expression of p62. The autophagy inhibitor 3-MA obviously antagonized the effects of sericin on cell apoptosis, cell cycle and autophagic protein expressions. CONCLUSION: Sericin can inhibit the proliferation of human gastric cancer MKN45 cells by regulating cell autophagy to serve as potential anti-tumor agent.

Laparoscopic management of gastric gastrointestinal stromal tumors: A retrospective 10-year single-center experience.

AIM: To determine the feasibility, safety, and oncological outcome of laparoscopic resection of gastric gastrointestinal stromal tumors (GISTs) based on favorable or unfavorable location. METHODS: Our hospital database included 207 patients who underwent laparoscopic removal of gastric GISTs from January 2004 to September 2015. Patient demographics, clinical presentation, surgery, histopathology, postoperative course, and oncological outcomes were reviewed and analyzed. RESULTS: Gastric GIST in favorable locations was present in 81/207 (39.1%) cases, and in unfavorable locations in 126/207 (60.9%) cases. Overall mean tumor size was 3.28 ± 1.82 cm. No conversions occurred, and complete R0 resection was achieved in 207 (100%) cases. There were three incidences of iatrogenic tumor rupture. The feasibility and safety of laparoscopic surgery were comparable in both groups with no statistical difference between unfavorable and favorable location groups, respectively: for operative time: 83.86 ± 44.41 vs 80.77 ± 36.46 min, P = 0.627; conversion rate: 0% vs 0%; estimated blood loss: 27.74 ± 45.2 vs 29.59 ± 41.18 mL, P = 0.780; tumor rupture during surgery: 0.90% vs 2.82%, P = 0.322; or postoperative complications: 3.74% vs 7.04%, P = 0.325. The follow-up period recurrence rate was 1.89% with no significant differences between the two groups (3.03% vs 0%, P = 0.447). Overall 5-year survival rate was 98.76% and survival rates were similar between the two groups: 98.99% vs 98.39%, P = 0.623 (unfavorable vs favorable, respectively). CONCLUSION: The laparoscopic approach for gastric GISTs is safe and feasible with well-accepted oncological surgical outcomes. Strategies for laparoscopic resection should be selected according to the location and size of the tumor. Laparoscopic treatment of gastric GISTs in unfavorable locations should not be restricted in gastrointestinal centers.

Interleukin-17-Producing Neutrophils Link Inflammatory Stimuli to Disease Progression by Promoting Angiogenesis in Gastric Cancer.

Purpose: Elevated levels of neutrophils have been associated with poor survival in various cancers, but direct evidence supporting a role for neutrophils in the immunopathogenesis of human cancers is lacking.Experimental Design: A total of 573 patients with gastric cancer were enrolled in this study. Immunohistochemistry and real-time PCR were performed to analyze the distribution and clinical relevance of neutrophils in different microanatomic regions. The regulation and function of neutrophils were assessed both in vitro and in vivoResults: Increased neutrophil counts in the peripheral blood were associated with poor prognosis in gastric cancer patients. In gastric cancer tissues, neutrophils were enriched predominantly in the invasive margin, and neutrophil levels were a powerful predictor of poor survival in patients with gastric cancer. IL17+ neutrophils constitute a large portion of IL17-producing cells in human gastric cancer. Proinflammatory IL17 is a critical mediator of the recruitment of neutrophils into the invasive margin by CXC chemokines. Moreover, neutrophils at the invasive margin were a major source of matrix metalloproteinase-9, a secreted protein that stimulates proangiogenic activity in gastric cancer cells. Accordingly, high levels of infiltrated neutrophils at the invasive margin were positively correlated with angiogenesis progression in patients with gastric cancer.Conclusions: These data provide direct evidence supporting the pivotal role of neutrophils in gastric cancer progression and reveal a novel immune escape mechanism involving fine-tuned collaborative action between cancer cells and immune cells in the distinct tumor microenvironment. Clin Cancer Res; 23(6); 1575-85. ©2016 AACR.

Staging laparoscopy improves treatment decision-making for advanced gastric cancer.

AIM: To evaluate the clinical value of staging laparoscopy in treatment decision-making for advanced gastric cancer (GC). METHODS: Clinical data of 582 patients with advanced GC were retrospectively analyzed. All patients underwent staging laparoscopy. The strength of agreement between computed tomography (CT) stage, endoscopic ultrasound (EUS) stage, laparoscopic stage, and final stage were determined by weighted Kappa statistic (Kw). The number of patients with treatment decision-changes was counted. A χ(2) test was used to analyze the correlation between peritoneal metastasis or positive cytology and clinical characteristics. RESULTS: Among the 582 patients, the distributions of pathological T classifications were T2/3 (153, 26.3%), T4a (262, 45.0%), and T4b (167, 28.7%). Treatment plans for 211 (36.3%) patients were changed after staging laparoscopy was performed. Two (10.5%) of 19 patients in M1 regained the opportunity for potential radical resection by staging laparoscopy. Unnecessary laparotomy was avoided in 71 (12.2%) patients. The strength of agreement between preoperative T stage and final T stage was in almost perfect agreement (Kw = 0.838; 95% confidence interval (CI): 0.803-0.872; P < 0.05) for staging laparoscopy; compared with CT and EUS, which was in fair agreement. The strength of agreement between preoperative M stage and final M stage was in almost perfect agreement (Kw = 0.990; 95% CI: 0.977-1.000; P < 0.05) for staging laparoscopy; compared with CT, which was in slight agreement. Multivariate analysis revealed that tumor size (≥ 40 mm), depth of tumor invasion (T4b), and Borrmann type (III or IV) were significantly correlated with either peritoneal metastasis or positive cytology. The best performance in diagnosing P-positive was obtained when two or three risk factors existed. CONCLUSION: Staging laparoscopy can improve treatment decision-making for advanced GC and decrease unnecessary exploratory laparotomy.

Risk factors for pulmonary complications following laparoscopic gastrectomy: A single-center study.

The risk factors associated with postoperative pulmonary complications (PPCs) following laparoscopic gastrectomy have not been well studied. We sought to identify the risk factors for PPCs following gastric cancer surgery.A retrospective analysis was performed on all gastric cancer patients in a prospective database who underwent a laparoscopic gastrectomy from 2004 to 2014. The potential risk factors for PPCs were evaluated.PPCs occurred in 6.8% (83/1205) of patients and included pneumonia in 56 (67.5%) patients, pleural effusion in 26 (31.3%) patients, and pulmonary embolism in 1 (1.2%) patient. The multivariate analysis identified the following significant risk factors for PPCs: advanced age (odds ratio [OR] = 1.043, 95% confidence interval [CI] = 1.021%, 1.066%), chronic obstructive pulmonary disease (COPD) (OR = 17.788, 95% CI = 2.618%, 120.838%), total gastrectomy (OR = 2.781, 95% CI = 1.726%, 4.480%), time to first diet (OR = 1.175, 95% CI = 1.060%, 1.302%), and postoperative hospital stay (OR = 1.015, 95% CI = 1.002%, 1.028%). The risk factors for pneumonia included advanced age (OR = 1.036, 95% CI = 1.010%, 1.063%), total gastrectomy (OR = 3.420, 95% CI = 1.960%, 5.969%), and time to first diet (OR = 1.207, 95% CI = 1.703%, 1.358%). Only pancreatectomy was a risk factor for pleural effusion (OR = 9.082, 95% CI = 2.412%, 34.206%).The frequency of PPCs in patients with gastric cancer who underwent laparoscopic surgery was relatively high. Patients with cardiac and pulmonary comorbidities and those who undergo total gastrectomy and combined resection should be considered at high risk.

Evaluation of epithelial-mesenchymal transitioned circulating tumor cells in patients with resectable gastric cancer: Relevance to therapy response.

AIM: To evaluate the epithelial-to-mesenchymal transition (EMT) of circulating tumor cells (CTCs) in gastric cancer patients. METHODS: We detected tumor cells for expression of four epithelial (E(+)) transcripts (keratins 8, 18, and 19 and epithelial cell adhesion molecule) and two mesenchymal (M(+)) transcripts (Vimentin and Twist) by a quantifiable, dual-colorimetric RNA-in situ hybridization assay. Between July 2014 and October 2014, 44 patients with gastric cancer were recruited for CTC evaluation. Blood samples were obtained from selected patients during the treatment course [before surgery, after surgery and at the 6(th) cycle of XELOX based chemotherapy (about 6 mo postoperatively)]. RESULTS: We found the EMT phenomenon in which there were a few biphenotypic E(+)/M(+) cells in primary human gastric cancer specimens. Of the 44 patients, the presence of CTCs was reported in 35 (79.5%) patients at baseline. Five types of cells including from exclusively E(+) CTCs to intermediate CTCs and exclusively M(+) CTCs were identified (4 patients with M(+) CTCs and 10 patients with M(+) or M(+) > E(+) CTCs). Further, a chemotherapy patient having progressive disease showed a proportional increase of mesenchymal CTCs in the post-treatment blood specimens. We used NCI-N87 cells to analyze the linearity and sensitivity of CanPatrol(TM) system and the correlation coefficient (R(2)) was 0.999. CONCLUSION: The findings suggest that the EMT phenomenon was both in a few cells of primary tumors and abundantly in CTCs from the blood of gastric cancer patients, which might be used to monitor therapy response.

Crebanine N-oxide, a natural aporphine alkaloid isolated from Stephania hainanensis, induces apoptosis and autophagy in human gastric cancer SGC-7901 cells

Objective: To investigate the cytotoxic effects and the potential mechanisms of crebanine N-oxide in SGC-7901 gastric adenocarcinoma cells. Methods: The cytotoxicity of crebanine N-oxide was evaluated by 3-(4,5-dimethyl-2-thiazolyl)-2,5-diphenyl-2-H-tetrazolium bromide assay and cellular morphology was observed under a microscope. Cell apoptosis was determined by flow cytometry using propidium iodide staining. The expression levels of apoptotic-related proteins, cleaved caspase-3, cytochrome C, p53 and Bax, and autophagyrelated proteins p62, beclin1 and LC3 were detected by Western blotting assays. Results: Crebanine N-oxide treatment significantly inhibited the proliferation of SGC-7901 cells in a dose-dependent and timedependent manner via induction of G2-phase cell cycle arrest, apoptosis, and autophagy in SGC-7901 cells. Conclusions: Crebanine N-oxide could inhibit the growth of gastric cancer cells by promoting apoptosis and autophagy and could be used as a potential agent for treating gastric cancer.