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Objective: Textbook outcome (TO) is widely recognized as a comprehensive prognostic indication for patients with gastric cancer (GC). This study aims to develop a modified TO (mTO) for elderly patients with GC. Methods: Data from the elderly patients (aged ≥ 65 years) in two Chinese tertiary referral hospitals were analyzed. 1389 patients from Fujian Medical University Union Hospital were assigned as the training cohort and 185 patients from Affiliated Hospital of Putian University as the validation cohort. Nomogram was developed by the independent prognostic factors of Overall Survival (OS) based on Cox regression. Results: In the training cohort, laparoscopic surgery was significantly correlated with higher TO rate (P < 0.05). Cox regression analysis revealed that surgical approach was also an independent factor of OS (P < 0.001), distinct from the traditional TO. In light of these findings, TO parameters were enhanced by the inclusion of surgical approach, rendering a modified TO (mTO). Further analysis showed that mTO, tumor size, pTNM staging, and adjuvant chemotherapy were independent prognostic factors associated with OS (all P < 0.05). Additionally, the nomogram incorporating these four indicators accurately predicted 1-, 3-, and 5-year OS in the training cohort, with AUC values of 0.793, 0.814, and 0.807, respectively, and exhibited outstanding predictive performance within the validation cohort. Conclusion: mTO holds a robust association with the prognosis of elderly patients with GC, meriting intensified attention in efforts aimed at enhancing surgical quality. Furthermore, the predictive model incorporating mTO demonstrates excellent predictive performance for elderly patients with GC. [ABSTRACT FROM AUTHOR]

Robotic surgery may be an alternative to laparoscopic surgery for gastric cancer (GC). However, randomized controlled trials (RCTs) reporting the differences in survival between these two approaches are currently lacking. From September 2017 to January 2020, 300 patients with cT1-4a and N0/+ were enrolled and randomized to either the robotic (RDG) or laparoscopic distal gastrectomy (LDG) group (NCT03313700). The primary endpoint was 3-year disease-free survival (DFS); secondary endpoints reported here are the 3-year overall survival (OS) and recurrence patterns. The remaining secondary outcomes include intraoperative outcomes, postoperative recovery, quality of lymphadenectomy, and cost differences, which have previously been reported. There were 283 patients in the modified intention-to-treat analysis (RDG group: n = 141; LDG group: n = 142). The trial has met pre-specified endpoints. The 3-year DFS rates were 85.8% and 73.2% in the RDG and LDG groups, respectively (p = 0.011). Multivariable Cox regression model including age, tumor size, sex, ECOG PS, lymphovascular invasion, histology, pT stage, and pN stage showed that RDG was associated with better 3-year DFS (HR: 0.541; 95% CI: 0.314-0.932). The RDG also improved the 3-year cumulative recurrence rate (RDG vs. LDG: 12.1% vs. 21.1%; HR: 0.546, 95% CI: 0.302-0.990). Compared to LDG, RDG demonstrated non-inferiority in 3-year DFS rate. Robotic surgery has been demonstrated to improve short-term outcomes for patients with gastric cancer who received a gastrectomy, but the long-term effects are less clear. Here, the authors report the survival outcomes of their phase 2 randomized controlled trial comparing robotic to laparoscopic distal gastrectomy in patients with resectable gastric cancer. [ABSTRACT FROM AUTHOR]

Background: Sarcopenic obesity may affect the health outcome of people with obesity after laparoscopic sleeve gastrectomy (LSG). To assess the impact of sarcopenic obesity (SO) on weight loss outcomes and improvement of quality of life after LSG. Materials and Methods: This observational study included patients who underwent LSG with SO (99 patients) or without SO (146 patients) from a single center. The primary endpoint was weight loss and disease-specific quality of life in patients with or without SO after the operation. Fat-free mass (FFM) and fat mass (FM) were calculated based on the L3-level images of preoperative CT scans. SO was diagnosed if FM/FFM ≥ 0.80. Results: Operative time and postoperative hospital stay days were longer in the SO group (p < 0.001). After LSG, weight, BMI, and EBMI were significantly lower in the NSO group than in the SO group (all P < 0.05), while %EWL and the number of patients with %EWL ≥ 100% were significantly lower in the SO group (both p < 0.05). The total BAROS scores of patients in the NSO group were higher than those in the SO group (p < 0.05). Additionally, the MA II questionnaire assessment showed a lower percentage of "very good" and "good" outcomes in the SO group (p < 0.05). Conclusions: Patients with SO take a slower rate, longer time to reach the ideal weight, and lower quality of life self-ratings than NSO patients after LSG. Thus, preoperative evaluation and tailoring rehabilitation guidance for people with SO should be accounted. [ABSTRACT FROM AUTHOR]

Background: Laparoscopy-assisted gastrectomy (LG) is rapidly gaining popularity owing to its minimal invasiveness. Previous studies have found that compared with two-dimensional (2D)-LG, three-dimensional (3D)-LG showed better short-term outcomes. However, the long-term oncological outcomes in patients with locally resectable gastric cancer (GC) remain controversial. Methods: In this noninferiority, open-label, randomized clinical trial, a total of 438 eligible GC participants were randomly assigned in a 1:1 ratio to either 3D-LG or 2D-LG from January 2015 to April 2016. The primary endpoint was operating time, while the secondary endpoints included 5-year overall survival (OS), disease-free survival (DFS), and recurrence pattern. Results: Data from 401 participants were included in the per-protocol analysis, with 204 patients in the 3D group and 197 patients in the 2D group. The 5-year OS and DFS rates were comparable between the 3D and 2D groups (5-year OS: 70.6% vs. 71.1%, Log-rank P = 0.743; 5-year DFS: 68.1% vs. 69.0%, log-rank P = 0.712). No significant differences were observed between the 3D and 2D groups in the 5-year recurrence rate (28.9% vs. 28.9%, P = 0.958) or recurrence time (mean time, 22.6 vs. 20.5 months, P = 0.412). Further stratified analysis based on the type of gastrectomy, postoperative pathological staging, and preoperative BMI showed that the 5-year OS, DFS, and recurrence rates of the 3D group in each subgroup were similar to those of the 2D group (all P > 0.05). Conclusions: For patients with locally resectable GC, 3D-LG performed by experienced surgeons in high-volume professional institutions can achieve long-term oncological outcomes comparable to those of 2D-LG. Registration number: NCT02327481 (http://clinicaltrials.gov). [ABSTRACT FROM AUTHOR]

Background: Textbook outcome (TO) has been widely employed as a comprehensive indicator to assess the short-term prognosis of patients with cancer. Preoperative malnutrition is a potential risk factor for adverse surgical outcomes in patients with gastric cancer (GC). This study aimed to compare the TO between robotic-assisted gastrectomy (RAG) and laparoscopic-assisted gastrectomy (LAG) in malnourished patients with GC. Methods: According to the diagnostic consensus of malnutrition proposed by Global Leadership Initiative on Malnutrition (GLIM) and Nutrition Risk Index (NRI), 895 malnourished patients with GC who underwent RAG (n = 115) or LAG (n = 780) at a tertiary referral hospital between January 2016 and May 2021 were included in the propensity score matching (PSM, 1:2) analysis. Results: After PSM, no significant differences in clinicopathological characteristics were observed between the RAG (n = 97) and LAG (n = 194) groups. The RAG group had significantly higher operative time and lymph nodes harvested, as well as significantly lower blood loss and hospital stay time compared to the LAG group. More patients in the RAG achieved TO. Logistic regression analysis revealed that RAG was an independent protective factor for achieving TO. There were more adjuvant chemotherapy (AC) cycles in the RAG group than in the LAG group. After one year of surgery, a higher percentage of patients (36.7% vs. 22.8%; P < 0.05) in the RAG group recovered from malnutrition compared to the LAG group. Conclusions: For malnourished patients with GC, RAG performed by experienced surgeons can achieved a higher rate of TO than those of LAG, which directly contributed to better AC compliance and a faster restoration of nutritional status. [ABSTRACT FROM AUTHOR]

Background: It remains inconclusive whether laparoscopic gastrectomy (LG) has better long-term outcomes when compared with open gastrectomy (OG) for elderly gastric cancer (EGC). We attempted to explore the influence of the immune prognostic index (IPI) on the prognosis of EGCs treated by LG or OG to identify a population among EGC who may benefit from LG. Methods: We included 1539 EGCs treated with radical gastrectomy from January 2007 to December 2016. Propensity score matching was applied at a ratio of 1:1 to compare the LG and OG groups. The IPI based on dNLR ≥ cut-off value (dNLR) and sLDH ≥ cut-off value (sLDH) was developed, characterizing two groups (IPI = 0, good, 0 factors; IPI = 1, poor, 1 or 2 factors). Results: Of the 528 EGCs (LG: 264 and OG: 264), 271 were in the IPI = 0 group, and 257 were in the IPI = 1 group. In the entire cohort, the IPI = 0 group was associated with good 5-year overall survival (OS) (p = 0.001) and progression-free survival (PFS) (p = 0.003) compared to the IPI = 1 group; no significant differences in 5-year OS and PFS between the LG and OG groups were observed. In the IPI = 1 cohort, there was no significant difference in OS or PFS between the LG and OG groups across all tumor stages. However, in the IPI = 0 cohort, LG was associated with longer OS (p = 0.015) and PFS (p = 0.018) than OG in stage II EGC, but not in stage I or III EGC. Multivariate analysis showed that IPI = 0 was an independent protective factor for stage II EGC receiving LG, but not for those receiving OG. Conclusion: The IPI is related to the long-term prognosis of EGC. Compared with OG, LG may improve the 5-year survival rate of stage II EGC with a good IPI score. This hypothesis needs to be further confirmed by prospective studies. [ABSTRACT FROM AUTHOR]

Background: The oncologic efficacy of laparoscopic versus open surgery for advanced distal gastric cancer (ADGC) beyond 3 years after surgery remain obscure. Methods: A total of 1256 patients with ADGC at two teaching institutions in China from April 2007 to December 2014 were enrolled. The general data of the two groups were identified to enable rigorous estimation of propensity scores. Restricted mean survival time (RMST) and Landmark analysis was used to compare survival. Results: After matching 461 patients each in the open distal gastrectomy (ODG) and laparoscopic distal gastrectomy (LDG) groups, they were included into analysis. The 3- and 5-year overall survival (OS) and disease-free survival were comparable in two groups. RMST-stratified analysis showed that the 3-year RMST of ODG group was similar to that of LDG group in patients with cT4a (− 1.38 years, p = 0.163) or with cT4a and tumor size > 5 cm, whereas the 5-year RMST had significant differences between groups in cT4a patients(− 8.36 years, P = 0.005) or cT4a and tumor size > 5 cm patients(4.67 years, P = 0.042). In patients with cT4a and tumors > 5 cm, the number of peritoneal recurrences was significantly fewer in the ODG group than in the LDG group (4 vs. 17, P = 0.033), and the peritoneal recurrence time and multiple-site recurrence time were both later in the ODG group. Conclusion: By reducing recurrence, ODG achieves a better survival for GC patients with serous infiltration and tumors larger than 5 cm beyond 3 years after surgery. The present findings can serve as a reference for surgical options and the setting of follow-up time point for clinical studies. [ABSTRACT FROM AUTHOR]

Background: Due to lacking evidence for confirming the efficacy of performing laparoscopic surgery for locally advanced gastric cancer (LAGC). Therefore, this study aimed to compare the static and dynamic failure patterns after laparoscopic gastrectomy (LG) and open gastrectomy (OG) in LAGC. Methods: A total of 1792 LAGC patients who underwent radical resection between January 2010 and January 2017 were divided into the LG group (n = 1557) and the OG group (n = 235). Propensity score matching was performed to balance the two groups. Dynamic hazard rates of failure were calculated using the hazard function. Early and late failure were defined as failure occurring before and after 2 years since surgery, respectively. Results: A total of 1175 patients with LAGC were included after matching (LG group, n = 940; OG, n = 235). The failure rate of the whole cohort was 43.2% (508/1175), accounting for 41.4% (389/940) and 50.6% (119/235) in the LG and OG groups, respectively. Although the two groups showed no significant differences in failure rate for any failure type, landmark analysis showed a lower early distant recurrence rate in the stage IIa–IIIb subgroup of the LG group (OG versus LG: 30.3% versus 21.1%, P = 0.004). The dynamic hazard rate peaked at 9.4 months (peak rate = 0.0186) before gradually declining. In stage IIa–IIIb patients, the hazard rate of the OG group remained significantly higher than that of the LG group within the first 2 years in terms of distant recurrence (peak rate: OG versus LG, 0.0091 versus 0.0055). Conclusion: Given the differences in early failure between LG and OG, more intensive surveillance for distant recurrence within the first 2 years should be considered for patients with stage IIa–IIIb after OG. [ABSTRACT FROM AUTHOR]

Background: This study evaluated the safety, effectiveness, and feasibility of indocyanine green (ICG) tracing in guiding lymph-node (LN) dissection during laparoscopic D2 radical gastrectomy in patients with advanced gastric cancer (AGC) after neoadjuvant chemotherapy (NAC). Method: We retrospectively analyzed data on 313 patients with clinical stage of cT1-4N0-3M0 who underwent laparoscopic radical gastrectomy after NAC between February 2010 and October 2020 from two hospitals in China. Grouped according to whether ICG was injected. For the ICG group (n = 102) and non-ICG group (n = 211), 1:1 propensity matching analysis was used. Results: After matching, there was no significant difference in the general clinical pathological data between the two groups (ICG vs. non-ICG: 94 vs. 94). The average number of total LN dissections was significantly higher in the ICG group and lower LN non-compliance rate than in the non-ICG group. Subgroup analysis showed that among patients with LN and tumor did not shrink after NAC, the number of LN dissections was significantly more and LN non-compliance rate was lower in the ICG group than in the non-ICG group. Intraoperative blood loss was significantly lesser in the ICG group than in the non-ICG group, while the recovery and complications of the two groups were similar. Conclusion: For patients with poor NAC outcomes, ICG tracing can increase the number of LN dissections during laparoscopic radical gastrectomy, reduce the rate of LN non-compliance, and reduce intraoperative bleeding. Patients with AGC should routinely undergo ICG-guided laparoscopic radical gastrectomy. [ABSTRACT FROM AUTHOR]

Background: Application of indocyanine green (ICG) fluorescence imaging is effective in guiding laparoscopic radical lymphadenectomy for gastric cancer. However, the optimal approach for indocyanine green injection is controversial. Therefore, the objective of this study was aimed to compare the efficacy and ICG injection between the preoperative submucosal and intraoperative subserosal approaches for lymph node (LN) tracing during laparoscopic gastrectomy.Method: This randomized controlled trial (ClinicalTrials.gov, NCT04219332) included 266 patients with potentially resectable gastric cancer (cT1-T4a, N0/+, M0) enrolled from a tertiary teaching center between December 2019 and October 2020. The primary endpoint was total number of retrieved LNs.Results: In total, 259 patients (n = 130 and n = 129 in the submucosal and subserosal groups, respectively) were included in the per-protocol analysis. There are no significant differences in total number of retrieved LNs between the two groups (49.8 vs. 49.2, P = 0.713). The rate of LN noncompliance in the submucosal group was comparable to that in the subserosal group (32.3% vs. 33.3%, P = 0.860). No significant difference was found between the submucosal and subserosal groups in terms of the incidence (17.7% vs. 16.3%; P = 0.762) or severity of postoperative complications. The mean fluorescence cost in the submucosal group was higher than that in the subserosal group ($335.3 vs. $182.4; P < 0.001). The overall treatment satisfaction score was lower in the submucosal group than in the subserosal group (70.5 vs. 76.1%, P = 0.048).Conclusion: ICG administered by subserosal injection was comparable to that administered by submucosal injection for lymph node tracing in gastric cancer. However, the former approach imposed a lower economic and mental burden on patients undergoing laparoscopic D2 lymphadenectomy.Trial Registration: ClinicalTrials.gov, NCT04219332 . [ABSTRACT FROM AUTHOR]

Background: Numerous studies have shown that the short-term efficacy of three-dimensional (3D) laparoscopic radical gastrectomy (LG) is comparable to that of two-dimensional (2D)-LG. Whether 3D-LG affects the recurrence patterns of gastric cancer (GC) patients has not been investigated. Methods: From January 2015 to April 2016, a total of 419 patients were recruited for a phase III clinical trial (NCT02327481), which compared the short-term outcomes between the 2D and 3D groups. The long-term efficacy including recurrence patterns was compared between the 2D and 3D groups in this retrospective study. Multivariate analyses were performed to determine whether 3D-LG affects the recurrence patterns. Results: Ultimately, 401 patients were analyzed (197 in the 2D-LG group and 204 in the 3D-LG group), and no differences were observed in the clinicopathological data between the two groups. There were no significant differences between the two groups in the recurrence types, first recurrence time or recurrence-free survival (RFS) (all p > 0.05). According to the 7th American Joint Committee on Cancer tumor-node-metastasis (TNM) staging system, both groups were stratified into pathological stages I, II, and III. The stratified analysis showed no significant differences in RFS or overall survival (OS) among patients in each subgroup (all p > 0.05). The multivariate analysis of RFS showed that tumor diameter, pTNM stage, lymphovascular invasion, and adjuvant chemotherapy were independent factors (all p < 0.05). The multivariate analysis of post-recurrence survival (PRS) showed that adjuvant chemotherapy was an independent protective factor (p = 0.043). Conclusions: 3D-LG for GC did not differ significantly from 2D-LG in the effects on 3-year recurrence patterns, RFS and OS, which provides more tumor-related evidence for 3D technology. And due to the technological similarity, it may have certain reference value for robotic-assisted gastrectomy. Further multicenter, large-scale clinical trials are warranted. [ABSTRACT FROM AUTHOR]

Background: To determine whether laparoscopic surgery can be used in high-risk patients with gastric cancer.Methods: The clinicopathological data of 3743 patients with primary gastric adenocarcinoma, collected from January 2007 to December 2014, were retrospectively analyzed. Patients who had ≥ 1 of the following conditions were defined as high-risk patients: (1) age ≥ 80 years; (2) BMI ≥ 30 kg/m2; (3) ASA (American Society of Anesthesiologists) grade ≥ 3; or (4) clinical T stage 4 (cT4). Propensity score matching (PSM) was used to reduce confounding bias; then, we compared the short-term and long-term efficacy of laparoscopic gastrectomy (LG) with open gastrectomy (OG) in high-risk patients with gastric cancer.Results: A total of 1296 patients were included in PSM. After PSM, no significant difference in clinicopathological data was observed between the LG group (n = 341) and the OG group (n = 341). The operative time (181.70 vs. 266.71 min, p < 0.001) and blood loss during the operation (68.11 vs. 225.54 ml, p < 0.001) in the LG group were significantly lower than those in the OG group. In the LG and OG groups, postoperative complications occurred in 39 (11.4%) and 63 (18.5%) patients, respectively, p = 0.010. Multivariate analysis showed that laparoscopic surgery was an independent protective factor against postoperative complications (p = 0.019). The number of risk factors was an independent risk factor for postoperative complications (p = 0.021). The 5-year overall survival rate in the LG group was comparable to that in the OG group (55.0 vs. 52.0%, p = 0.086). Hierarchical analysis further confirmed that the LG and OG groups exhibited comparable survival rates among patients with stages cI, pI, cII, pII, cIII, and pIII (all p > 0.05).Conclusions: For high-risk patients with gastric cancer, LG not only exhibits better short-term efficacy than OG but also has a comparable 5-year survival rate to OG. [ABSTRACT FROM AUTHOR]

Background: Robotic-assisted gastrectomy (RAG) has been rapidly adopted for gastric cancer (GC) treatment. However, whether RAG provides any significant outcome/cost advantages over laparoscopy-assisted gastrectomy (LAG) for the experienced laparoscopist remains unclear.Methods: A retrospective review of a prospectively collected database identified 768 consecutive patients who underwent either RAG (n = 103) or LAG (n = 667) for GC between July 2016 and June 2017 at a large center. A 1:3 matched propensity score analysis was performed. The short-term outcomes and hospital costs between the two groups were compared.Results: A well-balanced cohort of 404 patients was analyzed (RAG:LAG = 1:3 match). The mean operation times were 226.6 ± 36.2 min for the RAG group and 181.8 ± 49.8 min for the LAG group (p < 0.001). The total numbers of retrieved lymph nodes were similar in the RAG and LAG groups (means 38 and 40, respectively, p = 0.115). The overall and major complication rates (RAG, 13.9% vs. LAG, 12.5%, p = 0.732 and RAG, 3.0% vs. LAG, 1.3%, p = 0.373, respectively) were similar. RAG was much more costly than LAG (1.3 times, p < 0.001) mainly due to the amortization and consumables of the robotic system. According to cumulative sum (CUSUM), the learning phases were divided as follows: phase 1 (cases 1-21), phase 2 (cases 22-63), and phase 3 (cases 64-101), in the robotic group. The surgical stress (SS) was higher in the robotic group compared with the laparoscopic group in phase 1 (p < 0.05). However, the SS did not differ significantly between the two groups in phase 3.Conclusions: RAG is a feasible and safe surgical procedure for GC, especially in the post-learning curve period. However, further studies are warranted to evaluate the long-term oncological outcomes and to elucidate whether RAG is cost-effective when compared to LAG. [ABSTRACT FROM AUTHOR]

Background: The proportion of elderly patients who undergo surgery has rapidly increased. However, clinical indicators that predict outcomes are limited. Frailty is thought to estimate physiological reserves, although its use has not been evaluated in laparoscopic surgical patients. This study aimed to evaluate the significance of preoperative modified frailty index (PMFI) in octogenarians undergoing a laparoscopic gastrectomy.Methods: We reviewed prospectively collected data from 119 patients with gastric cancer (GC) aged 80 years or older who underwent a radical laparoscopic gastrectomy (RLG) between January 2007 and December 2012. Three baseline frailty traits were measured using routine preoperative laboratory data: albumin < 3.4 g/dL, haematocrit < 35%, and creatinine > 2 mg/dL. Patients were categorized by the number of positive traits as follows: low preoperative modified frailty index (LPMFI): 0-2 traits and high preoperative modified frailty index (HPMFI): 3 traits. We compared patient characteristics, operative outcomes, pathological results, morbidity, and survival.Results: A total of 43 (36.1%) patients were considered HPMFI, and 76 (63.9%) patients were considered LPMFI. HPMFI was associated with an increased risk of postoperative complications (HPMFI group: odds ratio 2.506; 95% CI, 1.113-5.643, P = 0.027). With a median follow-up of 39.0 months, the 3-year overall survival (OS), recurrence-free survival (RFS), and cancer-specific survival (CSS) rates for the entire cohort were 47.9, 34.3, and 51.7%, respectively. Significant differences were observed in OS (HPMFI group, 37.2%; LPMFI group, 53.9%; P = 0.038) and RFS (HPMFI group, 23.3%; LPMFI group, 40.5%; P = 0.012) between the groups, but no difference was found for CSS (HPMFI group, 43.5%; LPMFI group, 56.4%; P = 0.078).Conclusions: HPMFI based on an easily calculable preoperative measure may be useful for predicting postoperative complications and have a negative impact on 3-year OS and RFS after an RLG in octogenarians. Therefore, HPMFI can serve as a low-cost, simple screen for high-risk individuals who might suffer more than expected during the postoperative period after an RLG. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to compare the short- and long-term outcomes of malnourished gastric cancer patients who underwent laparoscopic or open radical gastrectomy. Background: Preoperative malnutrition is an independent risk factor for postoperative mortality and morbidity in major gastrointestinal surgery. However, whether laparoscopic surgery can improve the short- and long-term outcomes of malnourished gastric cancer patients has not been determined. Methods: We reviewed prospectively collected data from 2441 patients with gastric cancer between January 2009 and December 2014 and compared the short- and long-term outcomes in malnourished gastric cancer patients who underwent laparoscopic or open radical gastrectomy. Nutritional risk factors included weight loss >10% within 6 months, body mass index <18.5 kg/m, Subjective Global Assessment Grade C, and serum albumin <3.0 g/dL. Results: Overall, 501 patients (20.52%) were classified as malnourished. Patients with gastric stump carcinoma, neoadjuvant chemotherapy, distant metastases, palliative operation, or the presence of other malignancies were excluded. Finally, a total of 412 patients were analyzed; 304 in the laparoscopic group and 108 in the open group. There were no significant differences between the two groups regarding the clinicopathological characteristics. However, the operation time (181 ± 53 vs. 253 ± 81 min), intraoperative blood loss (80 ± 116 vs. 322 ± 502 mL), time to first ambulation (2.21 ± 1.04 vs. 2.55 ± 1.50 days), liquid diet (4.91 ± 1.61 vs. 5.72 ± 2.09 days) and semiliquid diet (7.67 ± 1.56 vs. 9.53 ± 2.09 days) as well as the postoperative hospital stay duration (13.00 ± 6.56 vs. 15.22 ± 6.87 days) were significantly lower in the laparoscopic group than those in the open group ( p < 0.05). The instances of overall complications (laparoscopic vs. open: 18.4 vs. 30.6%, p = 0.008) and pneumonia (laparoscopic vs. open: 10.9 vs. 19.4%, p = 0.023) were significantly lower in the laparoscopic group. With a median follow-up of 31.0 months (range 1.0-88.0), the 3-year overall survival (OS), recurrence-free survival (RFS), and cancer-specific survival (CSS) rates for the entire cohort were 58.9, 54.0 and 63.0%, respectively. Further analysis showed that the OS (57.5 vs. 59.4%, p = 0.560), RFS (51.8 vs. 54.8%, p = 0.441) and CSS (62.8 vs. 63.0%, p = 0.789) between the laparoscopic and open groups, respectively, were no significantly different. Further analysis showed no significant differences in the OS rates of the two groups of patients stratified by tumor stage ( p > 0.05). Conclusion: Compared with open radical gastrectomy, laparoscopy would reduce the postoperative complications especially pneumonia and shorten the postoperative hospital stay for patients with preoperative malnutrition without affecting their long-term survival. [ABSTRACT FROM AUTHOR]

Background D2 lymphadenectomy including No.10 lymph nodes (LNs) is the standard procedure for treating advanced gastric cancer (AGC) via total gastrectomy. However, there was no research focusing on the posterior LN dissection along the splenic vessels (No.10p LNs). This study is performed to assess the effect of dissecting No.10p LNs. Methods We analyzed 404 consecutive gastric cancer patients who underwent laparoscopic total gastrectomy (LTG) with D2 lymphadenectomy. There were 68 patients with No.10p LN dissection (No.10p group), and 336 patients without No.10p LN dissection (nNo.10p group). The surgical outcomes are compared. Results No.10p LN dissection was preferentially performed in patients who were younger and had a lower BMI, concentrated and single-branched type of splenic artery, and pancreatic tail near the lower pole of the spleen. The time for No.10 LN dissection and the number of No.10 LNs were greater in the No.10p group than in the nNo.10p group. There was no No.10p LNs metastasis, and the numbers of positive No.10 LNs were similar between the two groups. The morbidity and mortality rates of the No.10p group were comparable to those of the nNo.10p group. The overall survival (OS) rates of the two groups were not significantly different (P > 0.05). Conclusions Although No.10p LN dissection might retrieve more No.10 LNs, operation times were longer, and the number of positive No.10 LNs and the OS rate were not improved. It might be no necessary to dissect No.10p LNs during total gastrectomy with D2 lymphadenectomy for AGC. [ABSTRACT FROM AUTHOR]

Background: Few studies have evaluated the outcomes of laparoscopic-assisted total gastrectomy (LATG) for Siewert type II and III adenocarcinoma of the esophagogastric junction (AEG). Thus, aim of this study was to investigate the surgical outcomes of LATG for Siewert type II and III AEG.Methods: Clinical data for 700 Siewert type II and III AEG patients were analyzed retrospectively. The short- and long-term outcomes were compared between the matched groups using a propensity score matching method.Results: Before matching, the comorbidities, Siewert classifications and tumor invasion depths significantly differed between the LATG and open total gastrectomy (OTG) groups. After matching, the clinicopathologic characteristics were well balanced between the two groups. In addition, after matching, decreases in the operative time, amount of blood loss, time to resumption of a semifluid diet, and length of hospital stay and an increased number of lymph nodes (LNs) retrieved were observed in the LATG group compared with the OTG group. Further, a significantly higher 3-year overall survival rate (81.3 vs 66.4%; P = 0.011) and disease-free survival rate (77.5 vs 63.8%; P = 0.040) were observed for the Siewert type II AEG patients in the LATG group compared with those in the OTG group; however, the survival rates were similar for the Siewert type III AEG patients in the two groups (P = 0.853 and P = 0.844, respectively).Conclusions: LATG is associated with better short-term outcomes for Siewert type II and III AEG. In addition, it may result in an increased number of retrieved LNs and better long-term survival for Siewert type II AEG patients in particular. [ABSTRACT FROM AUTHOR]

Objective: In this study, we evaluated the short-term outcomes following three-dimensional (3D) or two-dimensional (2D) laparoscopic surgery for patients with gastric cancer.Background: There is a lack of prospective evidence regarding the safety and efficacy of 3D versus 2D laparoscopic surgery for patients with gastric cancer. Therefore, we conducted a phase III single-center, prospective, randomized, controlled trial to compare 3D and 2D laparoscopic surgery for patients with gastric cancer.Methods: We compared operation time, intraoperative blood loss, number of lymph node dissections, morbidity, and mortality between the 3D and 2D groups following laparoscopic surgery for gastric cancer. The study is registered at ClinicalTrials.gov with ID number NCT02327481.Results: A total of 228 patients were randomized (3D group 115 cases; 2D group 113 cases) between January 1, 2015 and September 1, 2015. Seven patients who underwent exploratory operations were excluded. Finally, a total of 221 patients were analyzed (3D group 109 cases, 2D group 112 cases). There were no significant differences between the two groups regarding the clinical pathological characteristics, operating time (3D vs. 2D, 184 ± 36 vs. 178 ± 37 min, P = 0.288), number of lymph node dissections (36 ± 14 vs. 37 ± 13, P = 0.698), time to first ambulation (2.27 ± 1.60 vs. 2.04 ± 0.84, P = 0.18), flatus (3.89 ± 1.49 vs. 3.69 ± 1.12, P = 0.255), liquid diet (4.88 ± 1.88 vs. 4.79 ± 1.57, P = 0.684), or duration of postoperative hospital stay (12.52 ± 4.83 vs. 12.63 ± 7.32, P = 0.903). The postoperative complication rates of the 3D and 2D groups were 18.3 and 16.1%, respectively, P = 0.723. No patients died during the postoperative hospital stay. However, the intraoperative blood loss in the 3D group was significantly lower than the 2D group (58 ± 75 vs. 78 ± 72 ml, P = 0.047).Conclusion: There was no significant difference in operation time and number of lymph node harvested between the 3D and 2D groups; however, 3D laparoscopic surgery may reduce the intraoperative blood loss compared to 2D procedure. Therefore, we conclude that this trial is safe and is thus ongoing. [ABSTRACT FROM AUTHOR]

Background: To investigate the incidence of and factors associated with postoperative complications and failure to rescue following laparoscopic and open gastrectomy for gastric cancer.Study Design: We analyzed the records of 4124 patients who underwent a laparoscopic or open gastrectomy for gastric cancer. One-to-one propensity score matching was performed to compare the difference between the two groups.Results: A total of 4124 patients were included in the study, 627 of whom (15.2 %) developed postoperative complications. Postoperative deaths occurred in 23 (0.6 %) patients with serious complications. In the propensity score matching analysis with 1361 pairs, no significant differences in the rates of overall complications (14.2 vs. 16.5 %, p = 0.093) were observed between laparoscopic and open gastrectomy group. In-hospital mortality decreased in patients who underwent laparoscopic gastrectomy compared to patients who underwent open gastrectomy (0.3 vs. 1.2 %, p = 0.004). Failure to rescue rates were lower in patients who underwent laparoscopic gastrectomy (2.1 vs. 7.6 %, p = 0.008). Multivariate analysis showed that older age, tumor location, TNM stage classification, extent of gastric resection, operative time and intra-operative blood loss were adverse risk factors for postoperative complications. Laparoscopic gastrectomy was found to be a protective factor for failure to rescue. Complications associated with failure to rescue included abdominal bleeding, anastomotic leakage and cardiac events. In-hospital mortality increased as the number of complications per patient increased.Conclusions: Assuming equal competence with open and laparoscopic approaches of a surgeon, the proportion of patients with postoperative complications were similar among those who underwent laparoscopic gastrectomy compared to patients who underwent open gastrectomy. However, when complications occurred, patients with open gastrectomy were more likely to die. [ABSTRACT FROM AUTHOR]

Background: The evidence regarding the long-term results of laparoscopic spleen-preserving splenic hilar lymphadenectomy (LSPL) has only been rarely reported. The aim of this study was to investigate the feasibility and oncologic efficacy of LSPL for locally advanced proximal gastric cancer.Methods: From May 2007 to December 2012, we prospectively collected and retrospectively analyzed the data of 548 patients who underwent laparoscopic radical total gastrectomy due to proximal gastric cancer. The patients were grouped according to spleen-preserving splenic hilar lymphadenectomy (200 in the D2 group and 348 in the D2-group). The short- and long-term outcomes were compared between the two groups after propensity score matching.Results: Before matching, TNM stages were significantly different between the D2 and D2-groups. After propensity score matching, the two groups were well balanced in clinicopathologic characteristics. After matching, the time for lymph node dissection was longer in the D2 group, but a greater number of lymph nodes were dissected; the estimated blood loss, time to first flatus and duration of hospital stay were similar in the two groups. Furthermore, no significant differences in morbidity and mortality were found. Before matching, the 3-year overall survival (OS) and disease-free survival (DFS) rates of the D2 group were comparable with those of the D2-group (62.4 vs. 57.7 %, p = 0.076). After matching, the 3-year OS remained comparable, but the D2 group showed significantly longer 3-year DFS (61.6 vs. 53.7 %, p = 0.034). Stratified analysis showed that, in stage III patients, the D2 group had better 3-year DFS. Multivariate Cox regression showed that age (p = 0.003), operation (p = 0.001) and pN stage (p < 0.001) were independent prognostic factors.Conclusions: LSPL is a safe and feasible procedure, and patients with stage III proximal gastric cancer might obtain higher 3-year DFS rates. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the safety, feasibility and clinical results of the modified delta-shaped gastroduodenostomy (MDSG) in totally laparoscopic distal gastrectomy (TLDG) for gastric cancer (GC).Methods: We performed a case-control and case-matched study enrolling 642 patients with GC undergoing laparoscopic distal gastrectomy with Billroth-I anastomosis from January 2011 to December 2014. TLDG with MDSG was performed in 158 patients (Group TL), and laparoscopy-assisted distal gastrectomy with circular anastomosis was performed in 484 patients (Group LA). One-to-one propensity score matching (PSM) was performed to compare the clinicopathological characteristics between the two groups.Results: Patients with smaller tumors or stage I cancer were more likely to receive TLDG (P < 0.05). In the propensity-matched analysis of 143 pairs, there were no differences in demographic and pathologic characteristics between groups (all P < 0.05). All patients successfully underwent laparoscopic radical distal gastrectomy. Before PSM, Group TL had more dissected lymph nodes (LNs), a longer time to first fluid diet and a longer postoperative length of stay than Group LA (all P < 0.05). After PSM, except for the fact that more dissected LNs were obtained in Group LA (P < 0.05), no difference was found in the intraoperative and postoperative outcomes between the groups (all P > 0.05). The postoperative complications were similar in both groups (all P > 0.05). Stratification analysis performed after PSM showed that in early GC, no difference was observed in intraoperative and postoperative outcomes between the groups (all P > 0.05). However, in locally advanced GC, Group TL had more dissected LNs and a higher rate of postoperative complications (both P < 0.05). Univariate analysis carried out in locally advanced cases after PSM showed that the body mass index (BMI), the method of digestive tract reconstruction and Charlson's score were significant factors that affected postoperative morbidity (all P < 0.05). Multivariate analysis indicated that BMI was an independent risk factor for postoperative morbidity (P < 0.05).Conclusions: The MDSG in TLDG is safe and feasible for early GC; however, it should be chosen with caution in advanced GC, particularly in patients with a high BMI. [ABSTRACT FROM AUTHOR]

Background: A scoring system allows risk stratification of morbidity might be helpful for selecting risk-adapted interventions to improve surgical safety. Few studies have been designed to develop scoring systems to predict SSIs after laparoscopic gastrectomy for gastric cancer.Methods: We analyzed the records of 2364 patients who underwent laparoscopic gastrectomy for gastric cancer. A logistic regression model was used to identify the determinant variables and develop a predictive score.Results: There were 2364 patients, of whom 131 (5.5 %) developed overall SSIs, 33 (1.4 %) developed incisional SSIs, and 98 (4.1 %) developed organ/space SSIs. No significant risk factor was associated with incisional SSIs. A multivariate analysis showed the following adverse risk factors for organ/space SSIs: BMI ≥ 25 kg/m(2), intraoperative blood loss ≥75 ml, operation time ≥240 min, and perioperative transfusion. Each of these factors contributed 1 point to the risk score. The organ/space SSIs rates were 1.8, 3.9, 9.9, and 39.0 % for the low-, intermediate-, high-, and extremely high-risk categories, respectively (p < 0.001). The area under the receiver operating characteristic curve for the score of organ/space SSIs was 0.734. There were no statistically significant differences between the observed and predicted incidence rates for organ/space SSIs in the validation set.Conclusions: This validated and simple scoring system could accurately predict the risk of organ/space SSIs after laparoscopic gastrectomy for gastric cancer. The score might be helpful in the selection of risk-adapted interventions to decrease the incidence rates of organ/space SSIs. [ABSTRACT FROM AUTHOR]

Objective: To validate the efficacy and safety of laparoscopic total gastrectomy (LTG) for advanced gastric cancer (AGC).Background: Laparoscopic distal gastrectomy (LDG) in the treatment of patients with local AGC is becoming increasingly popular, and there have been several multicenter randomized controlled trials focused on this treatment. However, few reports on the procedure of LTG for AGC exist.Methods: The data of 976 patients who underwent LTG for AGC were retrieved from a prospectively constructed database of 2170 patients who underwent laparoscopic gastrectomy between 2007 and 2013. Surgical outcomes of LTG were investigated and compared with those of patients who underwent LDG.Results: LTG was associated with significantly longer operation time, number of dissected lymph nodes, and time of resume soft diet compared with the LDG group. According to Clavien-Dindo classification, the morbidity and mortality rates of the LTG group were comparable to those of the LDG group. Multivariate analyses revealed that elderly patients, more comorbidities, and longer operation time were the significant independent risk factors for determining postoperative complications. The difference in overall survival rates between the two groups was statistically significant. However, a comparative analysis of overall survival showed no statistical significance for any of the stages of cancer between the LTG and LDG groups.Conclusions: The study findings suggest that LTG is an oncologically safe procedure for AGC yields comparable surgical outcomes. A well-designed phase III trial can be carried out to provide valuable evidence for the oncologic safety of LTG for the treatment of AGC. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic gastrectomy (LG) for gastric cancer has increased in popularity due to advances in surgical techniques. The aim of this study is to validate the efficacy and safety of laparoscopic gastrectomy for gastric cancer compared with open gastrectomy (OG). Methods: The study comprised 3,580 patients who were treated with curative intent either by laparoscopic gastrectomy (2,041 patients) or open gastrectomy (1,539 patents) between January 2005 and October 2013. The surgical outcomes were compared between the two groups. Results: Laparoscopic gastrectomy was associated with significantly less blood loss, transfused patient number, time to ground activities, and post-operative hospital stay, but with similar operation time, time to first flatus, and time to resumption of diet, compared with the open gastrectomy. No significant difference in the number of lymph nodes dissected was observed between these two groups. The morbidity and mortality rates of the LG group were comparable to those of the OG group (13.6% vs. 14.4%, P = 0.526, and 0.3% vs. 0.2%, P = 0.740). The 3-year disease-free and overall survival rates between the two groups were statistically significant (P<0.05). According to the UICC TNM classification of gastric cancer, the 3-year disease-free and overall survival rates were not statistically different at each stage. Conclusions: Our single-center study of a large patient series revealed that LG for gastric cancer yields comparable surgical outcomes. This result was also true of local advanced gastric cancer (AGC). A well-designed randomized controlled trial comparing surgical outcomes between LG and OG in a larger number of patients for AGC can be carried out. [ABSTRACT FROM AUTHOR]

Purpose: This study was designed to formulate a model that efficiently predicts splenic hilar lymph node metastasis (SHLNM) in patients with proximal gastric cancer and to assess indications for laparoscopic spleen-preserving no.10 lymph node dissection (LSPNo.10LND) based on this model. Methods: Patients (N = 346) with proximal gastric cancer who underwent LSPNo.10LND from January 2010 to October 2013 were prospectively enrolled and retrospectively evaluated. Groups of patients with and without SHLNM were compared, and independent risk factors for SHLNM determined. An optimal predictive model of SHLNM in patients with proximal gastric cancer was well established. Results: Of the 346 patients with proximal gastric cancer, only 35 (10.1%) were diagnosed with SHLNM. Depth of invasion, tumor location and metastases to No.7 and No.11 lymph nodes (LNs) were independent risk factors for SHLNM (p<0.0001 each). A model involving depth of invasion, tumor location and metastasis to No.7 and 11 LNs yielded a lowest Akaike’s information criterion (AIC) of −913.535 and a highest area under the ROC curve (AUC) of 0.897(95%CI:0.851–0.944). Stratification analysis showed no SHLNMs in the absence of serosal invasion of the lesser curvature and metastases at No.7 and No.11 LNs (T2-3∶0/87, 95% CI: 0.00–4.15). Conclusions: A model including depth of invasion, tumor location and metastases at No.7 and No.11 LNs was found optimal for predicting SHLNM for proximal gastric cancers. LSPNo.10LND may be avoided when tumors on the lesser curvature did not show serosal invasion or metastases at No.7 and No.11 LNs. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic spleen-preserving Splenic hilar lymphadenectomy (LSPL) is required in laparoscopy-assisted total gastrectomy for advanced proximal gastric cancer. However, it is considerably difficult and risk in clinical practice. Thus, we explore the application of LSPL performed by following the perigastric fascias and the intrafascial space in D2 radical gastrectomy for advanced upper-third gastric cancer. Methods: From July 2010 to December 2012, 109 patients with T2–3 upper-third gastric cancer underwent LSPL. Of these patients, 55 underwent classic LSPL (classic group), and the remaining 54 patients underwent LSPL performed by following the fascias and intrafascial space (fascia group). Clinicopathologic characteristics and intraoperative and postoperative variables were compared between the two groups. Results: There were no significant differences in clinicopathological characteristics between the two groups (P>0.05). All of the operations were successful without conversion to laparotomy. The operation time, mean splenic hilar lymph node (LN) dissection time, mean total blood loss and mean blood loss from splenic hilar LN dissection were significantly lower in the fascia group than in the classic group (P<0.05), whereas the times to first flatus, fluid diet and soft diet and the duration of hospital stay were similar in both groups. The mean number of harvested LNs (No. 10 and No. 11d) was slightly higher in the fascia group, but the difference was not significant. No significant difference in morbidity was found between the fascia group and the classic group (9.3% vs.10.9%, P>0.05). At a median follow-up of 12 months(range 5 to 35 months), none of the patients had died or experienced recurrent or metastatic disease. Conclusion: LSPL performed by following the fascias and intrafascial space is an optimal and safe technique based on anatomical logic, and it reduces the difficulties associated with LSPL, making it easier to master and allowing its widespread adoption. [ABSTRACT FROM AUTHOR]