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Backgrounds: Strong evidence is lacking as no confirmatory randomized controlled trials (RCTs) have compared the efficacy of totally laparoscopic distal gastrectomy (TLDG) with laparoscopy-assisted distal gastrectomy (LADG). The authors performed an RCT to confirm if TLDG is different from LADG., Methods: The KLASS-07 trial is a multi-centre, open-label, parallel-group, phase III, RCT of 442 patients with clinical stage I gastric cancer. Patients were enroled from 21 cancer care centres in South Korea between January 2018 and September 2020 and randomized to undergo TLDG or LADG using blocked randomization with a 1:1 allocation ratio, stratified by the participating investigators. Patients were treated through R0 resections by TLDG or LADG as the full analysis set of the KLASS-07 trial. The primary endpoint was morbidity within postoperative day 30, and the secondary endpoint was quality of life (QoL) for 1 year. This trial is registered at ClinicalTrials.gov (NCT03393182)., Results: Four hundred forty-two patients were randomized (222 to TLDG, 220 to LADG), and 422 patients were included in the pure analysis (213 and 209, respectively). The overall complication rate did not differ between the two groups (TLDG vs. LADG: 12.2% vs. 17.2%). However, TLDG provided less postoperative ileus and pulmonary complications than LADG (0.9% vs. 5.7%, P= 0.006; and 0.5% vs. 4.3%, P= 0.035, respectively). The QoL was better after TLDG than after LADG regarding emotional functioning at 6 months, pain at 3 months, anxiety at 3 and 6 months, and body image at 3 and 6 months (all P< 0.05). However, these QoL differences were resolved at 1 year., Conclusions: The KLASS-07 trial confirmed that TLDG is not different from LADG in terms of postoperative complications but has the advantages to reduce ileus and pulmonary complications. TLDG can be a good option to offer better QoL in terms of pain, body image, emotion, and anxiety at 3-6 months., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose: Adjuvant chemotherapy after D2 gastrectomy is standard for resectable locally advanced gastric cancer (LAGC) in Asia. Based on positive findings for perioperative chemotherapy in European phase III studies, the phase III PRODIGY study (ClinicalTrials.gov identifier: NCT01515748) investigated whether neoadjuvant docetaxel, oxaliplatin, and S-1 (DOS) followed by surgery and adjuvant S-1 could improve outcomes versus standard treatment in Korean patients with resectable LAGC., Patients and Methods: Patients 20-75 years of age, with Eastern Cooperative Oncology Group performance status 0-1, and with histologically confirmed primary gastric or gastroesophageal junction adenocarcinoma (clinical TNM staging: T2-3N+ or T4Nany) were randomly assigned to D2 surgery followed by adjuvant S-1 (40-60 mg orally twice a day, days 1-28 every 6 weeks for eight cycles; SC group) or neoadjuvant DOS (docetaxel 50 mg/m 2 , oxaliplatin 100 mg/m 2 intravenously day 1, S-1 40 mg/m 2 orally twice a day, days 1-14 every 3 weeks for three cycles) before D2 surgery, followed by adjuvant S-1 (CSC group). The primary objective was progression-free survival (PFS) with CSC versus SC. Two sensitivity analyses were performed: intent-to-treat and landmark PFS analysis., Results: Between January 18, 2012, and January 2, 2017, 266 patients were randomly assigned to CSC and 264 to SC at 18 Korean study sites; 238 and 246 patients, respectively, were treated (full analysis set). Follow-up was ongoing in 176 patients at data cutoff (January 21, 2019; median follow-up 38.6 months [interquartile range, 23.5-62.1]). CSC improved PFS versus SC (adjusted hazard ratio, 0.70; 95% CI, 0.52 to 0.95; stratified log-rank P = .023). Sensitivity analyses confirmed these findings. Treatments were well tolerated. Two grade 5 adverse events (febrile neutropenia and dyspnea) occurred during neoadjuvant treatment., Conclusion: PRODIGY showed that neoadjuvant DOS chemotherapy, as part of perioperative chemotherapy, is effective and tolerable in Korean patients with LAGC., Competing Interests: Yoon-Koo KangConsulting or Advisory Role: DAEHWA Pharmaceutical, Bristol-Myers Squibb, Zymeworks, ALX Oncology, Amgen, Novartis, MacroGenics, Surface Oncology Min-Hee RyuHonoraria: DAEHWA Pharmaceutical, Bristol-Myers Squibb, Lilly, Ono Pharmaceutical, MSD, Taiho Pharmaceutical, Novartis, Daiichi Sankyo, AstraZenecaConsulting or Advisory Role: DAEHWA Pharmaceutical, Bristol-Myers Squibb, Lilly, Ono Pharmaceutical, MSD, Taiho Pharmaceutical, Novartis, Daiichi Sankyo, AstraZeneca Sun Young RhaConsulting or Advisory Role: MSD Oncology, Ipsen, Daiichi Sankyo, Eisai, Amgen, IndivumedSpeakers' Bureau: Lilly, EisaiResearch Funding: MSD Oncology, Bristol-Myers Squibb, Eisai, Roche/Genentech, MedPacto, ASLAN Pharmaceuticals, SillaJen, Bayer, Immunomet Gyunji KimEmployment: Sanofi, NovartisStock and Other Ownership Interests: Sanofi YeonJu LeeEmployment: SanofiStock and Other Ownership Interests: Sanofi Jee Hyun LeeEmployment: SanofiNo other potential conflicts of interest were reported.

Background & Aims: The benefits of enhanced recovery after surgery (ERAS) in patients undergoing gastrectomy have been reported in several studies; however, there is limited evidence supporting the efficacy of ERAS in clinical settings. We aimed to identify the benefits of ERAS in the clinical setting by investigating short-term surgical outcomes before and after the implementation of ERAS in patients who underwent gastrectomy., Methods: We searched our gastric cancer database from 2008 to 2018 to identify patients who underwent gastrectomy before ERAS was implemented (2008-2009) and after the final version of ERAS was implemented (2016-2018). We enrolled 424 patients who were treated before ERAS was implemented and 565 patients who received our completed version of ERAS. After propensity score matching, each group included 219 patients, and short-term surgical outcomes were compared between the two groups., Results: The length of hospital stay was significantly shorter in the ERAS group (8.8 vs. 11.5 days, p = 0.001), but the readmission rates were similar in the two groups, at 2.3%. There were no significant differences in morbidity, mortality, and complications of ≥ grade III between the groups. Of the complications, intra-abdominal bleeding (0% vs. 4.1%, p = 0.002) and intra-abdominal abscess (0% vs. 2.7%, p = 0.038) were significantly lower, whereas postoperative ileus was significantly higher in the ERAS group (8.6% vs. 0.5%, p < 0.001). In subgroup analyses by age, operative approach, and the extent of gastric resection, the ERAS group experienced a shorter hospital stay without increased readmission in all subgroups., Conclusions: These results demonstrated that ERAS was associated with a 3-day reduction in hospital stay without increased readmission after gastrectomy. This study validated the benefits of ERAS in the clinical setting of gastrectomy., Competing Interests: Conflict of interest All authors declare no conflicts of interest., (Copyright © 2020 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Background: Lymph nodes (LNs) at the splenic hilum (no. 10) are treated as regional LNs in proximal gastric carcinoma. However, patients with no.10 LN metastasis show a poor prognosis after curative surgery. This study aimed to investigate the prognostic impact of no.10 LN metastasis in proximal gastric carcinoma., Methods: We retrospective reviewed 665 proximal gastric carcinoma patients who underwent total gastrectomy and D2 LN dissection. Clinicopathological features were compared between patients with and without no.10 LN metastasis. The prognostic value of no.10 LN metastasis was examined using Cox prognostic model., Results: There were 63 (9.5%) patients with no. 10 LN metastasis. No. 10 LN metastasis only existed in stage III/IV, and was significantly associated with greater curvature/circumferential tumor location, larger tumor size, B4 gross type, undifferentiated histology, lymphovascular invasion. The 5-year survival of no.10 LN metastasis group was 26%, which was significantly lower than those without no.10 LN metastasis (79%, p < 0.001). Patients with no. 10 LN metastasis also showed a significantly worse survival than those without in each tumor stage (stage III = 45% vs. 66%, p = 0.044, stage IV = 13% vs. 33%, p = 0.024). In the multivariate cox model, no.10 LN metastasis was an independent poor prognostic factor when adjusting for TNM stage and other prognostic factors., Conclusion: The prognosis of no.10 LN metastasis is as poor as that of distant metastasis. This suggests that no. 10 LN should rather be considered as non-regional LNs in the treatment of proximal gastric carcinoma., (Copyright © 2018 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Background/objectives: Nutritional risk screening (NRS) score has been reported as a predictor of postoperative outcomes in patients undergoing abdominal surgery, although the correlation between NRS and anastomotic leakage (AL) after rectal cancer surgery is uncertain. This study aimed to evaluate the association between NRS score and AL following rectal cancer surgery., Subject/methods: We retrospectively reviewed data of rectal cancer patients from a tertiary referral center in South Korea, and included 1063 patients with primary rectal cancer who underwent sphincter-preserving surgery between January 2011 and December 2015. We utilized the Chonnam National University Hwasun Hospital-Nutritional Risk Screening Tool (CNUHH-NRST), which was developed and cross-validated on the basis of the NRS 2002 and MST, as a screening tool of nutritional risk. Patients with NRS scores ≥4 were compared with those with NRS scores <4, and the risk factors for AL were analyzed., Results: One-hundred-nineteen (11.2%) patients had high nutritional risk (NRS score ≥4). The patients with a nutritional risk had more advanced tumor stages than those without nutritional risk. AL occurred in 69 (6.5%) patients. The multivariate logistic regression analysis showed high American Society of Anesthesiologists score (odds ratio (OR) = 2.435, 95% confidence interval (CI) = 1.085-5.469), long operative time (OR = 1.975, 95% CI = 1.177-3.313), and high NRS score (OR = 2.044, 95% CI = 1.085-3.851) as independent risk factors of AL., Conclusions: The NRS score was an independent predictive factor of AL after rectal cancer surgery. Patients with nutritional risks who require rectal cancer surgery should be carefully managed.

Background: Technical proficiency at laparoscopic D2 lymph node dissection (LND) is essential for extending the use of laparoscopic surgery beyond the treatment of early gastric cancer (EGC). The aim of this study was to evaluate the technical and oncological feasibility of laparoscopic distal gastrectomy (LDG) with D2 LND for distal gastric cancer., Methods: Of 922 patients who underwent open or LDG with D2 LND for gastric carcinoma, 133 treated by LDG and 133 treated by open distal gastrectomy (ODG) were selected using the propensity score matching method. The short-term surgical outcomes and long-term survivals of these matched groups were compared., Results: The two study groups were well matched with respect to age, sex, body mass index, comorbidity, ASA score, abdominal operation history, and tumor stage. The LDG group had a significantly longer mean operating time (227 vs. 161 min, p < 0.001) but showed significantly less intraoperative blood loss (149 vs. 189 ml, p = 0.007). Total numbers of collected lymph nodes were similar in the two groups. Postoperatively, no significant intergroup differences were found for hospital stay, morbidity, or mortality. Furthermore, overall survivals were similar in the two groups (p = 0.621). Multivariate analysis showed that male gender, age ≥70 years, and intraoperative blood loss of ≥200 ml were independent risk factors of postoperative morbidity., Conclusions: Laparoscopic D2 LND for distal gastric cancer is technically safe and feasible compared with ODG. A prospective randomized trial is warranted to evaluate long-term oncological outcomes in advanced gastric carcinoma.