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Objective: The aim of this study was to audit the 22 items and assessed each item's predictive value on surgical outcomes., Background: The KLASS-02 trial revealed that the oncologic outcomes of laparoscopic distal gastrectomy are not inferior to open distal gastrectomy in patients with advanced gastric cancer. The surgeons participating in this trial were chosen based on the assessment scores from the KLASS-02-QC trial, which used 22 items for standardization of D2 lymphadenectomy and quality control., Methods: We reviewed proficiency scores (PSs) for 22 items for 20 surgeons who participated in KLASS-02. The surgeons were divided into 2 groups according to PS, and the perioperative outcomes of 924 patients enrolled in KLASS-02 were compared between groups. Each item's predictive value for perioperative outcome was then assessed using multivariable regression models., Results: Of the total 924 patients, 529 were operated on by high-score surgeons (high PS) and 395 were operated on by low-score surgeons (low-PS). High-PS group had less intraoperative blood loss, longer operation times, and fewer complications, major complications, reoperations, and shorter first flatus and hospital stay than low-PS group ( P =0.006, P <0.001, P <0.001, P <0.001, P =0.042, P =0.013, and P <0.001, respectively). Some items used in KLASS-02-QC predicted perioperative outcomes, such as intraoperative blood loss, major complications, reoperation, and hospital stay., Conclusions: Although this study only analyzed data associated with qualified surgeons, the 22 items effectively assessed the surgeons based on PS. A high score was associated with longer operation times, but better perioperative outcomes., Competing Interests: W.J.H. reported receiving grants from Medtronic and GC pharma, stocks from Hutom, and personal fees from SK Hynix (Wuxi) outside the submitted work. S.-U.H. reported receiving grants from the National R&D Program for Cancer Control and Ethicon Endo-Surgery, a Johnson & Johnson Company, during the study period. S.-H.K. reported receiving grants from Medtronic and Stryker outside the submitted work. D.J.P. reported receiving grants from Daewoong Pharmaceuticals, JW Pharmaceuticals, and Medtronic outside the submitted work. J.W.K. reported receiving grants from the DN Company Co. Ltd research fund outside the submitted work. The remaining authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The benefit of regular follow-up after curative resection for gastric cancer is controversial as there is no evidence that it will improve survival. This study assessed whether regular follow-up leads to improved survival in patients after surgery for gastric cancer., Methods: A secondary analysis was undertaken of patients who participated in an RCT of laparoscopic versus open distal gastrectomy for advanced gastric cancer between November 2011 and April 2015. Depending on whether patients were compliant with the initial trial follow-up protocol or not, they were analysed as having had either regular or irregular follow-up. Clinicopathological characteristics, recurrence patterns, detection, treatments, and survival were compared between the groups., Results: The regular and irregular follow-up groups comprised 712 and 263 patients respectively. Disease recurrence within 36 months was more common in the regular group than in the irregular group (17.0 versus 11.4 per cent; P = 0.041). Recurrence patterns did not differ between the groups. The 3-year recurrence-free survival rate was worse in the regular than in the irregular group (81.2 versus 86.5 per cent; P = 0.031). However, the 5-year overall survival rate was comparable (84.5 versus 87.5 per cent respectively; P = 0.160). Multivariable analysis revealed that type of follow-up was not an independent factor affecting 5-year overall survival., Conclusion: Regular follow-up after radical gastrectomy was not associated with improved overall survival., (© The Author(s) 2023. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Importance: The long-term safety of laparoscopic distal gastrectomy for locally advanced gastric cancer (AGC) remains uncertain given the lack of 5-year follow-up results., Objective: To compare the 5-year follow-up results in patients with clinically AGC enrolled in the Korean Laparoendoscopic Gastrointestinal Surgery Study (KLASS)-02 randomized clinical trial who underwent laparoscopic or open distal gastrectomy., Design, Setting, and Participants: The KLASS-02, a multicenter randomized clinical trial, showed that laparoscopic surgery was noninferior to open surgery for patients with locally AGC. The present study assessed the 5-year follow-up results, including 5-year overall survival (OS) and relapse-free survival (RFS) rates and long-term complications, in patients enrolled in KLASS-02. From November 21, 2011, to April 29, 2015, patients aged 20 to 80 years diagnosed preoperatively with locally AGC were enrolled. Final follow-up was on June 15, 2021. Data were analyzed June 24 to September 9, 2021., Interventions: Patients were treated with R0 resection either by laparoscopic gastrectomy or open gastrectomy as the full analysis set of the KLASS-02 trial., Main Outcomes and Measures: Five-year OS and RFS rates, recurrence patterns, and long-term surgical complications were evaluated., Results: This study enrolled a total of 1050 patients. A total of 974 patients were treated with R0 resection; 492 (50.5%) in the laparoscopic gastrectomy group (mean [SD] age, 59.8 [11.0] years; 351 men [71.3%]) and 482 (49.5%) in the open gastrectomy group (mean [SD] age, 59.4 [11.5] years; 335 men [69.5%]). In patients who underwent laparoscopic and open distal gastrectomy, the 5-year OS (88.9% vs 88.7%) and RFS (79.5% vs 81.1%) rates did not differ significantly. The most common types of recurrence were peritoneal carcinomatosis (73 of 173 [42.1%]), hematogenous metastases (36 of 173 [20.8%]), and locoregional recurrence (23 of 173 [13.2%]), with no between-group differences in types of recurrence at each cancer stage. The correlation between 3-year RFS and 5-year OS at the individual level was highest in patients with stage III gastric cancer (ρ = 0.720). The late complication rate was significantly lower in the laparoscopic than in the open surgery group (32 of 492 [6.5%] vs 53 of 482 [11.0%]). The most common type of complication in both groups was intestinal obstruction (13 of 492 [2.6%] vs 24 of 482 [5.0%])., Conclusions and Relevance: The 5-year outcomes of the KLASS-02 trial support the 3-year results, which is the noninferiority of laparoscopic surgery compared with open gastrectomy for locally AGC. The laparoscopic approach can be recommended in patients with locally AGC to achieve the benefit of low incidence of late complications., Trial Registration: ClinicalTrials.gov Identifier: NCT01456598.

Objective: The aim of the study was to evaluate the short-term outcomes of KLASS-02-RCT, a multicenter randomized controlled trial comparing laparoscopic distal gastrectomy (LDG) with D2 lymphadenectomy with open distal gastrectomy (ODG)., Summary Background Data: Although several benefits of laparoscopic gastric cancer surgery have been reported, strong evidence is still limited, especially in locally advanced gastric cancer which requires extensive lymph node dissection., Methods: Enrollment criteria included histologically confirmed cT2-4a and N0-1 gastric adenocarcinoma. Thirty-day morbidity, 90-day mortality, postoperative pain, and recovery were compared between LDG and ODG groups., Results: A total of 1050 patients were randomly assigned to LDG (n = 526) or ODG group (n = 524) between November 2011 and April 2015. After excluding patients who received bypass or no surgery, 1011 patients were analyzed as actual treatment group. Mean number of totally retrieved lymph nodes was similar in both groups (LDG = 46.6 vs ODG = 47.4, P = 0.451). Early morbidity rate was significantly lower after LDG (16.6%) than after ODG (24.1%; P = 0.003). Postoperative analgesics use and patients' reported pain score were significantly lower after LDG. First day of flatus was earlier after LDG (3.5 vs 3.7 d, P = 0.025) and postoperative hospital stay was shorter in LDG group (8.1 vs 9.3 d, P = 0.005). Ninety days' mortality rate was similar in both groups (LDG = 0.4% vs ODG = 0.6%, P = 0.682)., Conclusions: Laparoscopic distal gastrectomy with D2 lymphadenectomy for locally advanced gastric cancer shows benefits in terms of lower complication rate, faster recovery, and less pain compared with open surgery.

Importance: Laparoscopic distal gastrectomy is gaining popularity over open distal gastrectomy for gastric cancer because of better early postoperative outcomes. However, to our knowledge, no studies have proved whether laparoscopic distal gastrectomy is oncologically equivalent to open distal gastrectomy., Objective: To examine whether the long-term survival among patients with stage I gastric cancer undergoing laparoscopic distal gastrectomy is noninferior to that among patients undergoing open distal gastrectomy., Design: The Korean Laparoendoscopic Gastrointestinal Surgery Study (KLASS) group, which includes 15 surgeons from 13 institutes, conducted a phase 3, multicenter, open-label, noninferiority, prospective randomized clinical trial (KLASS-01) of patients with histologically proven, preoperative clinical stage I gastric adenocarcinoma from January 5, 2006, to August 23, 2010. Survival and recurrence status of the patients was determined in December 2016., Interventions: Patients were randomly assigned (1:1) to laparoscopic distal gastrectomy (n = 705) or open distal gastrectomy (n = 711). Of these patients, 85 received a surgical approach opposite the one to which they were randomized (63 randomized to the open surgery group and 22 to the laparoscopic group)., Main Outcomes and Measures: Difference in 5-year overall survival between the laparoscopic and open distal gastrectomy groups. The noninferiority margin was prespecified as -5% (corresponding hazard ratio of 1.54), with an assumed survival of 90% after 5 years in the open surgery group., Results: Among the 1416 patients (mean [SD] age, 57.3 [11.1] years; 940 [66.4%] male) included in the study, the 5-year overall survival rates were 94.2% in the laparoscopic group and 93.3% in the open surgery group (log-rank P = .64). Intention-to-treat analysis confirmed the noninferiority of the laparoscopic approach compared with the open approach (difference, 0.9 percentage points; 1-sided 97.5% CI, -1.6 to infinity). The 5-year cancer-specific survival rates were similar between the 2 groups (97.1% in the laparoscopic group and 97.2% in the open surgery group, log-rank P = .91; difference, -0.03 percentage points; 1-sided 97.5% CI, -1.8 to infinity). Per-protocol analysis results were consistent with the intention-to-treat results for overall and cancer-specific survival rates., Conclusions and Relevance: The KLASS-01 trial revealed similar overall and cancer-specific survival rates between patients receiving laparoscopic and open distal gastrectomy. Laparoscopic distal gastrectomy is an oncologically safe alternative to open surgery for stage I gastric cancer., Trial Registration: ClinicalTrials.gov identifier: NCT00452751.

A survey to evaluate the current status of bariatric and metabolic operations in Korea was conducted. Data from 5467 cases (32 hospitals) were collected. The annual numbers of bariatric and metabolic operations increased each year, from 139 in 2003 to 1686 in 2013. Adjustable gastric band (AGB, 67.2 %) was the most common operation, followed by sleeve gastrectomy (SG, 14.2 %), and Roux-en-Y gastric bypass (RYGB, 12.7 %). Mean patient age and body mass index (BMI) were 35.4 years and 35.9 kg/m2, respectively. In-hospital morbidity and mortality rates were 6 % (114/2305) and 0.25 % (5/2176), respectively. In Korea, AGB was the most common operation because of the availability and activity of specialized bariatric clinics. These national survey results established a baseline for future data collection.

Objective: To determine the safety of laparoscopy-assisted distal gastrectomy (LADG) compared with open distal gastrectomy (ODG) in patients with clinical stage I gastric cancer in Korea., Background: There is still a lack of large-scale, multicenter randomized trials regarding the safety of LADG., Methods: A large-scale, phase 3, multicenter, prospective randomized controlled trial was conducted. The primary end point was 5-year overall survival. Morbidity within 30 postoperative days and surgical mortality were compared to evaluate the safety of LADG as a secondary end point, Results: : A total of 1416 patients were randomly assigned to the LADG group (n = 705) or the ODG group (n = 711) between February 1, 2006, and August 31, 2010, and 1384 patients were analyzed for modified intention-to-treat analysis (ITT) and 1256 were eligible for per protocol (PP) analysis (644 and 612, respectively). In the PP analysis, 6 patients (0.9%) needed open conversion in the LADG group. The overall complication rate was significantly lower in the LADG group (LADG vs ODG; 13.0% vs 19.9%, P = 0.001). In detail, the wound complication rate of the LADG group was significantly lower than that of the ODG group (3.1% vs 7.7%, P < 0.001). The major intra-abdominal complication (7.6% vs 10.3%, P = 0.095) and mortality rates (0.6% vs 0.3%, P = 0.687) were similar between the 2 groups. Modified ITT analysis showed similar results with PP analysis., Conclusions: LADG for patients with clinical stage I gastric cancer is safe and has a benefit of lower occurrence of wound complication compared with conventional ODG.

Background: Resection and anastomosis in laparoscopic distal gastrectomy can be performed extracorporeally or intracorporeally. Most surgeons have performed laparoscopy-assisted distal gastrectomy (LADG) because of technical difficulties of intracorporeal anastomosis. However, totally laparoscopic distal gastrectomy (TLDG) has recently been attempted and is expected to be feasible and less invasive compared with LADG. In this study, we tried to evaluate the clinical effect of the difference of invasiveness between TLDG and LADG, by way of a randomized prospective trial., Methods: From February 2011 to September 2013, a total of 110 patients with primary gastric cancer were randomly assigned to either TLDG or LADG. Clinicopathologic features, operative details, postoperative course, and quality of life (QoL) were compared between the two groups. QoL was assessed using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-C30 and gastric module STO22 at 2 weeks and 3 months after surgery., Results: The two groups were comparable in clinical and pathological characteristics. The proximal resection margin was significantly longer and the length of wound was shorter in the TLDG group. We could not find any significant difference in postoperative inflammatory parameters, postoperative pulmonary function, postoperative recovery, and QoL scores at 2 weeks and 3 months after surgery. There were no significant differences in complication rates., Conclusions: This study suggests that TLDG is as safe and feasible as LADG in gastric cancer. The parameters used routinely in the clinical field to evaluate early surgical outcomes could not reflect the delicate difference in surgical invasiveness between TLDG and LADG.

Background: Application of laparoscopy-assisted distal gastrectomy (LADG) for early gastric cancer (EGC) is still controversial because of scant evidence of long-term safety and feasibility. We evaluated the long-term outcome of LADG compared with conventional open distal gastrectomy (ODG) for EGC., Methods: Between March 1999 and July 2006, 106 patients underwent LADG and 105 patients underwent ODG for EGC. Clinicopathologic characteristics, postoperative outcomes, hospital course, postoperative morbidity, postoperative mortality, and long-term outcomes, including cancer recurrence and survival, were retrospectively compared between the two groups. Survival of all patients was confirmed with 55-month median follow-up., Results: Postoperative recovery was significantly faster in the LADG group; passing flatus occurred earlier, starting a liquid diet began sooner, and postoperative hospital stay was shorter (p < 0.05). Mean operation time was significantly longer in the LADG group. Postoperative complications in the LADG group occurred less frequently compared with in the ODG group (4.7% versus 13.3%, p = 0.046). Tumor recurrence occurred in two cases (0.9%) and death related to recurrence occurred in only one patient (0.5%). Overall 5-year survival rate (5-YSR) of all patients was 95.5%, while disease-specific 5-YSR was 98.8%. There was no significant difference in survival rates between the two groups; overall 5-YSR of the ODG and LADG groups was 94.9% and 95.9%, respectively., Conclusions: Our data suggest that LADG for EGC is feasible and safe. We expect the results of the present study to be confirmed by prospective randomized analysis.

Although laparoscopic surgery has become more popular, its technical difficulties have limited the applications of this technique to liver surgery. We report here on our experience with liver resection with using the laparoscopy-assisted (Lap-Assist) and total laparoscopic (Total-Lap) methods. From April 2001 to June 2003, a total of 20 laparoscopic anatomical resections of the liver were retrospectively reviewed. These were comprised of 10 cases in which the Lap-Assist method was used (these were performed during the early study period), and 10 cases in which the Total-Lap was used (these were done in the later study period). In the Lap-Assist group, the following resections were performed: 7 cases of left lateral sectionectomy, a case of left hemihepatectomy, a case of right hemihepatectomy and a case of open conversion. In the Total-Lap group, 6 cases of left hemihepatectomy and 4 cases of left lateral sectionectomy were performed. The sizes of the incisions were 8.7 cm and 4.6 cm, respectively, (p=0.000). There were no differences in the operation times, the transfusion amounts, the starting days of the patients' diets, the complication rates or the durations of the hospital stay between the two groups. Both the laparoscopy-assisted method and the total laparoscopic method are feasible to use for performing anatomical liver resection.

Nontraumatic perforation of the bile duct (NPB), which has also been reported as spontaneous perforation of the bile duct, is a disease in which spontaneous perforation occurs in the wall of the extrahepatic or intrahepatic duct without any traumatic or iatrogenic injury. Although NPB in adults is extremely rare, we have treated two such patients using a laparoscopic technique. Both cases presented with intra-abdominal abscesses associated with common bile duct stones, and laparoscopic surgery for those conditions was initially performed. During the procedure, NPB was identified in the right intrahepatic duct in one case and in the left intrahepatic duct in the other case. Laparoscopic surgery consisting of common bile duct exploration, T-tube placement, cholecystectomy, and abscess drainage was safely performed in both cases. Both patients eventually recovered without major complications. Although NBP is an uncommon disease, it can be treated successfully with a laparoscopic procedure.

Purpose: To evaluate the feasibility and efficacy of laparoscopic wedge resection with handsewn closure in gastroduodenal tumors., Methods: Laparoscopic wedge resection was performed in 16 patients with gastroduodenal tumor between May 2000 and December 2002. Every case, except one, was performed via an extragastric approach; a transgastric approach was adopted in a single case. Excision of the lesion was performed manually by means of electrocautery or ultrasonic coagulating shears and closed by manual intracorporeal running suture., Results: Among the 16 cases, two cases were treated using a laparoscope-assisted method, but there was no case of conversion to open surgery. Mean size of lesions was 27.9 mm in diameter and the mean operation time was 219 minutes. In all cases, a complete tumor excision with negative surgical margins was obtained. The final pathologic diagnoses were ectopic pancreas (4 cases), gastrointestinal stromal tumor (3 cases), leiomyoma (2 cases), adenomyoma (2 cases), tubular adenoma (1 case), Brunner's gland hyperplasia (1 case), carcinoid tumor (1 case), eosinophilic granuloma (1 case), and post-endoscopic mucosectomy state for early gastric cancer (1 case). The average numbers of days to first postoperative oral food intake and hospital stay were 3.1 days and 6.0 days, respectively. There were no postoperative complications., Conclusions: Laparoscopic wedge resection with handsewn closure should be considered as a valid treatment option for selected gastroduodenal tumors in terms of feasibility, safety, and cost. A more efficient surgical instrument and technique should be developed in future.