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Purpose: This study investigated the prognostic value of the geriatric nutritional risk index (GNRI) in patients undergoing curative gastrectomy for remnant gastric cancer (RGC)., Methods: This multicenter retrospective study included 105 patients with RGC of ≥ 65 years of age who underwent curative gastrectomy at 10 institutions in Japan between January 2000 and December 2016. Postoperative complications, overall survival (OS), and disease-specific survival (DSS) were analyzed., Results: Receiver operating curve analyses indicated that the optimal cutoff value of the GNRI for OS was 95.4. Patients were categorized into high and low GNRI groups based on the optimal GNRI cutoff value. The GNRI was significantly correlated with body mass index (p < 0.001), amount of bleeding (p = 0.021), Clavien-Dindo grade 5 postoperative complications (p = 0.040), death caused by primary disease (p = 0.010), and death caused by other diseases (p = 0.002). The OS and DSS were significantly worse in the low GNRI group. A low GNRI and T3 or deeper tumor invasion were independent prognostic factors for OS and DSS., Conclusions: The GNRI is a promising predictor of both short- and long-term outcomes in older patients with RGC., (© 2024. The Author(s) under exclusive licence to Springer Nature Singapore Pte Ltd.)

Introduction: Radiomics offers the potential to predict oncological outcomes from pre-operative imaging in order to identify 'high risk' patients at increased risk of recurrence. The application of radiomics in predicting disease recurrence provides tailoring of therapeutic strategies. We aim to comprehensively assess the existing literature regarding the current role of radiomics as a predictor of disease recurrence in gastric cancer., Methods: A systematic search was conducted in Medline, EMBASE, and Web of Science databases. Inclusion criteria encompassed retrospective and prospective studies investigating the use of radiomics to predict post-operative recurrence in ovarian cancer. Study quality was assessed using the QUADAS-2 and Radiomics Quality Score tools., Results: Nine studies met the inclusion criteria, involving a total of 6,662 participants. Radiomic-based nomograms demonstrated consistent performance in predicting disease recurrence, as evidenced by satisfactory area under the receiver operating characteristic curve values (AUC range 0.72 - 1). The pooled AUCs calculated using the inverse-variance method for both the training and validation datasets were 0.819 and 0.789 respectively CONCLUSION: Our review provides good evidence supporting the role of radiomics as a predictor of post-operative disease recurrence in gastric cancer. Included studies noted good performance in predicting their primary outcome. Radiomics may enhance personalised medicine by tailoring treatment decision based on predicted prognosis., Competing Interests: Declaration of competing interest This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors report no conflict of interest., (Copyright © 2024. Published by Elsevier Inc.)

Purpose: In Japan, gastrectomy with D2 lymph node dissection and postoperative adjuvant chemotherapy are the standard treatments for locally advanced gastric cancer. Neoadjuvant chemotherapy (NAC) is not affected by postgastrectomy syndromes or postoperative complications. This multicenter retrospective study investigated the prognostic factors and significance of postoperative adjuvant chemotherapy in patients with advanced gastric cancer who underwent NAC followed by gastrectomy., Methods: Consecutive patients (n = 221) with advanced gastric cancer who underwent NAC followed by curative surgery were enrolled in this study. Prognostic factors including postoperative adjuvant chemotherapy were investigated using univariate and multivariate analyses., Results: A multivariate analysis revealed that pathological lymph node metastasis (ypN) status and postoperative adjuvant chemotherapy were independent prognostic factors for the overall and relapse-free survival. Forty-five patients (20.4%) did not receive postoperative adjuvant chemotherapy. There were no significant differences between patients with and without adjuvant chemotherapy for all factors, except age. The most common reason for not undergoing postoperative adjuvant chemotherapy was a poor condition (n = 23)., Conclusions: ypN status and postoperative adjuvant chemotherapy were independent prognostic factors in gastric cancer patients who underwent NAC followed by curative gastrectomy. It is important to maintain the patient's condition during NAC and the perioperative period so that they can receive postoperative adjuvant chemotherapy., (© 2024. The Author(s) under exclusive licence to Springer Nature Singapore Pte Ltd.)

Background: A single metric does not sufficiently capture the multidimensional and complex perioperative nature of treatment for patients with gastric cancer. There is a newly developed composite indicator, called textbook outcome, that reflects the "ideal" surgical outcome. However, limited evidence exists for the long-term prognosis of textbook outcome in patients with gastric cancer. Thus, this study was aimed at assessing the association between textbook outcome and long-term oncologic prognosis after gastrectomy., Methods: In total, 2,658 consecutive patients who underwent gastrectomy between January 2004 and December 2017 were included. The primary endpoint was 5-year conditional survival (if the patient survived the first 30 days after surgery). Textbook outcome was defined as retrieved ≥15 lymph nodes, pR0 resection, complete-potentially curative resection during operation, hospitalization ≤21 days, no reinterventions, no severe postoperative complications, no hospital readmission ≤30 days after discharge, no unplanned intensive care unit treatment, and no 30-day postoperative mortality. Multivariable analysis was performed to evaluate the adjusted predictors of textbook outcome. A Cox regression analysis was used to analyze the relationship between achieving textbook outcome parameters and long-term oncologic prognosis., Results: A total of 1,770 (66.6%) of the 2,658 patients achieved all textbook outcome metrics in this study. The textbook outcome group displayed a greater 5-year conditional overall survival than the nontextbook outcome group (64.7% vs 40.2%, P < .001). The 5-year conditional disease-free survival of the patients with textbook outcomes was strongly superior to that of the patients without textbook outcomes (63.1% vs 37.6%, P < .001). Textbook outcome was independently associated with longer 5-year conditional overall survival and disease-free survival (hazard ratio 0.494 [0.439-0.557] and hazard ratio 0.487 [0.433-0.547], respectively)., Conclusions: Attaining textbook outcome is strongly related to an improved long-term oncologic prognosis for patients with gastric cancer, underscoring the need for continued efforts to enhance surgical care quality., Competing Interests: Conflicts of Interest/Disclosure The authors have no relevant financial disclosures., (Copyright © 2024 Elsevier Inc. All rights reserved.)

We report two cases of total gastrectomy and Roux-en-Y reconstruction that required future endoscopic surveillance of the duodenum. As such, an additional proximal duodenojejunostomy was fashioned to facilitate endoscopic surveillance., (© 2024 The Authors. ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.)

Purpose: Accurately locating and analysing surgical instruments in laparoscopic surgical videos can assist doctors in postoperative quality assessment. This can provide patients with more scientific and rational solutions for healing surgical complications. Therefore, we propose an end-to-end algorithm for the detection of surgical instruments., Methods: Dual-Branched Head (DBH) and Overall Intersection over Union Loss (OIoU Loss) are introduced to solve the problem of inaccurate surgical instrument detection, both in terms of localization and classification. An effective method (DBHYOLO) for the detection for laparoscopic surgery in complex scenarios is proposed. This study manually annotates a new laparoscopic gastric cancer resection surgical instrument location dataset LGIL, which provides a better validation platform for surgical instrument detection methods., Results: The proposed method's performance was tested using the m2cai16-tool-locations, LGIL, and Onyeogulu datasets. The mean Average Precision (mAP) values obtained were 96.8%, 95.6%, and 98.4%, respectively, which were higher than the other classical models compared. The improved model is more effective than the benchmark network in distinguishing between surgical instrument classes with high similarity and avoiding too many missed detection cases., Conclusions: In this paper, the problem of inaccurate detection of surgical instruments is addressed from two different perspectives: classification and localization. And the experimental results on three representative datasets verify the performance of DBH-YOLO. It is shown that this method has a good generalization capability., (© 2024. CARS.)

The article discusses long-term safety of drug-eluting stents in emergent coronary revascularization.

The article presents a clinical case of perioperative non-ST-segment elevation myocardial infarction in a patient with primary metasynchronous cancer of the rectum, stomach and bladder, which developed during simultaneous surgical intervention in the volume of proximal gastrectomy and abdominoperineal extirpation of the rectum. Fluctuations in blood pressure and imbalance in the hemostasis system at the stages of anesthesia and surgery in a patient with severe systemic atherosclerosis caused the development of myocardial ischemia in the area of significant coronary stenosis. Emergency coronary angiography detected subtotal stenosis of the anterior descending artery; stenting of the affected area of the coronary artery was performed. Monitoring of hemodynamic parameters and changes in the hemostasis system during the optimal antianginal therapy allowed to bring the patient out of critical condition and discharge him from the hospital on the 18th day.

Background: The study aimed to assess postoperative complication rates of different oesophagojejunostomy (EJ) techniques used in laparoscopic total gastrectomy for gastric cancer., Methods: A total of 1155 patients who underwent laparoscopic total gastrectomy were retrospectively selected from the data obtained from the Korean Nationwide Survey for gastric cancer in 2019. Morbidity rate was compared between patients who received intracorporeal or extracorporeal EJ using linear or circular staplers during laparoscopic total gastrectomy. The variables of the groups were balanced using the inverse probability of treatment weighting., Results: Seven hundred and seventy-three patients received intracorporeal EJ using a linear stapler (IL), 137 received intracorporeal EJ using a circular stapler (IC), 134 received extracorporeal EJ using a linear stapler (EL) and 111 received extracorporeal EJ using a circular stapler (EC). The overall complication rates were lower in the extracorporeal group (EL: 13.4% versus EC: 12.6%) compared to the intracorporeal group (IL: 22.6% versus IC: 17.5%) (P = 0.006). Fewer major complications were observed in the extracorporeal group (EL: 1.4% versus EC: 1.8%) compared to the intracorporeal group (IL: 9.4% versus IC: 7.3%) (P = 0.004). There was no significant difference in EJ-related complications between the groups (P = 0.418 in EJ leakage and P = 0.474 in EJ stricture). Multivariable analysis showed that the IL method correlated with more overall and major complications than the extracorporeal method., Conclusion: The results of this study suggest that despite its widespread use, the IL method is a challenging procedure with higher complication rates than the extracorporeal method. Further high-quality studies are required to confirm the results., (© The Author(s) 2024. Published by Oxford University Press on behalf of BJS Foundation Ltd.)

Background: There is no optimal reconstruction technique after proximal gastrectomy. The esophagogastrostomy (EG) is a rather simple procedure technically, but the incidences of reflux esophagitis and anastomotic stricture are higher. While the double-tract reconstruction (DTR) can lessen postoperative reflux esophagitis, it is technically complex with a long operation time. The purpose of this study was to evaluate the quality of life (QoL) and short-term outcomes of the two reconstruction techniques., Methods: We retrospectively collected consecutive patients with upper-third gastric adenocarcinoma and adenocarcinoma of the esophagogastric junction (AEG) at our center between 2019 June and 2023 May. Patients who underwent laparoscopic proximal gastrectomy (LPG) with EG or DTR were included in this study. A comparison was made between the clinical and pathological characteristics of patients and their surgical parameters, postoperative complications, and its 1-year QoL in two groups. The QoL of the two groups was assessed by Visick grading, the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and EORTC QLQ-STO22 scales at 1 year after operation. The nutritional status of the two groups was evaluated by BMI, hemoglobin and serum albumin., Results: AII the qualified patients were divided EG group (n = 63) and DTR group (n = 93). Compared to the DTR group, the blood loss volume of EG group was more (p = 0.001). There were no significant differences in operation duration, number of lymph nodes dissected, and postoperative length of stay between the two groups(p > 0.05). No statistical differences were observed in terms of the incidence of early complications and Clavien-Dindo classification as well(p > 0.05). After one year, the Visick grade of the DTR group was better than EG group (p = 0.040). The multivariable logistic regression analysis showed the only independent risk factor for reflux esophagitis was the reconstruction method. According to the EORTC QLQ-C30 questionnaire, patients in the DTR group had a better global health status(p = 0.001) and complained less about nausea and vomiting(p = 0.033), and appetite loss (p = 0.022). Patients in the DTR group complained less about reflux (p = 0.030) based on the EORTC QLQ-STO22 questionnaire. The multiple linear regression analysis revealed that the reconstruction method, reflux esophagitis and age had a linear relationship with the global health status score. Regarding nutritional status, BMI of the two groups both decreased 1 year after operation, and BMI decline value of the DTR group was lower than EG group (p = 0.001). There is no statistically significant difference between the two groups as for postoperative change in hemoglobin and serum albumin., Conclusion: Our findings suggest that it is possible for skilled surgeons to achieve minimal blood loss volume without significantly increasing operation duration when performing DRT, which does not raise risk. In terms of anti-reflux, postoperative QoL and BMI maintenance, 1-year postoperative follow-up outcomes reveal the DTR is superior to EG, which deserve further research and promotion., (© 2024. The Author(s).)

Due to insufficient dietary intake and altered digestion and absorption of nutrients, patients after gastroesophageal cancer surgery are at risk of becoming malnourished and consequently develop micronutrient deficiencies. The aim of this study was to determine the prevalence of micronutrient deficiencies and anemia during follow-up after gastroesophageal cancer surgery. This single-center cross-sectional study included patients after resection for esophageal or gastric cancer visiting the outpatient clinic in 2016 and 2017. Only patients without signs of recurrent disease were included. All patients were guided by a dietician in the pre- and postoperative phase. Dietary supplements or enteral tube feeding was prescribed in case of inadequate dietary intake. Blood samples were examined for possible deficiencies or abnormalities in hemoglobin, prothrombin time, iron, ferritin, folic acid, calcium, zinc, vitamin A, vitamin B1, vitamin B6, vitamin B12, vitamin D and vitamin E. The percentage of patients with micronutrient deficiencies were scored. Of the 335 patients visiting the outpatient clinic, measurements were performed in 263 patients (221 after esophagectomy and 42 after gastrectomy), resulting in an inclusion rate of 79%. In the esophagectomy group, deficiencies in iron (36%), vitamin D (33%) and zinc (20%) were most prevalent. After gastric resection, deficiencies were most frequently observed in vitamin D (52%), iron (33%), zinc (28%) and ferritin (17%). Low levels of hemoglobin were found in 21% of patients after esophagectomy and 24% after gastrectomy. Despite active nutritional guidance, deficiencies in vitamin D, iron, zinc and ferritin, as well as low levels of hemoglobin, are frequently observed following gastroesophageal resection for cancer. These micronutrients should be periodically checked during follow-up and supplemented if needed., (© The Author(s) 2024. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus.)

The application of proximal gastrectomy for suitable upper gastric cancer and AEG patients is increasing along with the promotion of the concept and technology for function-preserving partial gastrectomy. The following problems such as postoperative reflux esophagitis and anastomotic stenosis naturally become the focus of academic field. Based on the understanding of the anti-reflux structure and function of the esophagogastric junction, scholars have successfully established some representative esophagogastric anastomosis methods with additional mechanical anti-reflux barrier, including gastric tube reconstruction, side overlap esophagogastrostomy, and double flap technique. Subsequently, a series of improved esophagogastric reconstruction methods have been derived. At present, the recognized ideal reconstruction method has not yet been established, and there are also misunderstandings in related concepts and cognition. Based on the literatures and the authors' own practical experience, this paper draws on the research results in the field of surgical treatment for reflux esophagitis, and discusses the theoretical basis, key details and anti-reflux effect of the above-mentioned digestive tract reconstruction methods after proximal gastrectomy, as well as the possible problems in the exploration of innovative surgical methods at home and abroad.

Digestive tract reconstruction for gastric cancer has gone through a century and gradually formed a mature and complete system. Reasonable digestive tract reconstruction is one of the key factors in minimizing functional disorders after gastrectomy and enhancing quality of life. Therefore, this article summarizes the history and current situation of digestive tract reconstruction both domestically and internationally, including distal gastrectomy, total gastrectomy, proximal gastrectomy, and pylorus preserving gastrectomy, in order to seek the future development direction of digestive tract reconstruction and benefit gastric cancer patients.

Objective: To share the results of laparoscopic assisted proximal gastrectomy λ- shaped modified double tract reconstruction. Method: This study retrospectively included 3 patients during January 2024 from the Department of Gastric Surgery at the First Affiliated Hospital of Nanjing Medical University using the λ-shaped modified double tract reconstruction. The procedure of the λ-shaped modified double tract reconstruction is as follows. After completing proximal gastrectomy, the jejunum is transected 15 cm from the Treitz ligament. A suture is made 18-20 cm from the distal jejunum to mark the esophagojejunal anastomosis site. A circular stapler anvil is inserted through the distal jejunum, and the remaining end of the jejunum is turned to the right. The circular stapler is pierced through the marked site for an esophagojejunal end-to-end anastomosis, which is reinforced with a barbed suture continuously. A 60mm linear stapler is used to close the remaining end of the jejunum. We then mark the gastric side of the gastrojejunal anastomosis with suture in the middle of the anterior wall of the residual stomach, and mark the jejunal side of the gastrojejunal anastomosis at a distance of about 2 cm and 8 cm from the residual end of the distal jejunum. We make an opening of about 0.5 cm and use a 60 mm linear stapler to perform anastomosis on the jejunal side of the anterior wall of the residual stomach according to the markings, so that the distance between the esophagojejunal anastomosis and the gastrojejunal anastomosis is 10-12 cm. The common opening is closed with barbed wire. About 50 cm below the esophagojejunal anastomosis, the small intestine opening is anastomosed side to side using a circular stapler and the common opening is closed. Return the jejunum into the abdominal cavity to complete the reconstruction of the λ-shaped double tract reconstruction. We analyzed the surgery and postoperative conditions, including surgery time, anastomosis time, intraoperative bleeding, tumor size and pathology, postoperative mobilization, passage of gas and water intake time, discharge time, postoperative complications, and postoperative gastrointestinal imaging to observe the passage of food through the gastric and intestinal loops. Results: Three patients successfully received laparoscopic assisted proximal gastrectomy with λ-shaped modified double tract reconstruction. The surgical time was 155 minutes, 240 minutes, and 160 minutes, respectively; The postoperative time for first ambulation was 20 hours, 18 hours, and 26 hours, respectively. The time for passage of gas was 59 hours, 83 hours, and 75 hours, respectively. The drinking time was 66 hours, 87 hours, and 90 hours, respectively. The postoperative discharge days were all 7 days. No surgical related complications occurred. On the 6th day and 3 months after surgery, gastrointestinal angiography was performed. The contrast agent passed smoothly through the jejunal loop and residual stomach jejunal loop, and both sides were unobstructed. No contrast agent was found to retrograde to the esophagojejunal anastomosis. Conclusion: Laparoscopic assisted proximal gastrectomy with λ-shaped modified double tract reconstruction is safe and feasible, as it improves the diversion of food through the residual stomach while ensuring anti-reflux effects.

With features such as high-definition magnification of the surgical field, filtering of hand tremor, and robotic arm with multi-degree-of-freedom rotatable wrist, surgical robot has unique advantages in various aspects of digestive tract reconstruction (DTR) after robotic gastrectomy (RG). Currently, there is still controversy about the selection and standardized application of DTR after RG for gastric cancer. To standardize the selection and implementation of DTR, we describe various aspects of quality control before DTR, selection of indications, principles of DTR, and prevention and management of postoperative complications of DTR. We also comment on the operation details of robotic-assisted and total robotic DTR, including manual suture, linear anastomosis with linear stapler, and circular anastomosis with circular stapler. Meanwhile, we propose our prospects on the potential application of new technology in robotic DTR for gastric cancer.

Objective: To analyze the efficacy and feasibility of performing a new surgical procedure, tunnel esophagogastrostomy, to perform proximal gastrectomy. Methods: The study cohort comprised 10 consecutive patients who had undergone esophagogastrostomy by the tunnel technique in Jiangsu Cancer Hospital between October 2019 and July 2022. All patients were male. Their average age was (64.2±8.1) years and body mass index (25.5±3.2) kg/m2. Nine had upper gastric body adenocarcinoma, the remaining one having signet ring cell carcinoma. TNM staging of the tumors showed that seven were Stage IA, one Stage IB, one Stage IIA, and one Stage IIIA. Briefly, tunnel esophagogastrostomy is performed as follows: After performing a proximal gastrectomy, a rectangular seromuscular flap (3.0 cm × 3.5 cm) is created. The posterior esophageal wall is sutured to the gastric wall at the orad end of the seromuscular flap 5 cm from the stump with three to four stitches. Next, the stump of the esophagus is opened, the posterior esophageal wall is sutured to the gastric mucosa and submucosa, and the anterior esophageal wall is sutured to the full layer of the stomach. Finally, the caudad end of the seromuscular flap is closed. Data on surgical safety, postoperative morbidity, and postoperative reflux esophagitis were analyzed. All enrolled patients completed endoscopic follow-up 1 year and 2 years after surgery. Results: All procedures were completed. They comprised four cases of laparoscopic assisted surgery, four of DaVinci robotic surgery, and two of open surgery. The mean operation time was 212.7±33.2 mins, mean anastomosis time (51.6±5.3) minutes, mean tunnel preparation time (20.0±3.5) minutes, and mean operative blood loss (90.0±51.6) mL. The time to first postoperative passage of flatus was (64.8±11.5) hours. The mean hospital stay after surgery was (9.2±1.7) days. There were no postoperative complications above Clavien-Dindo Grade II. The mean preoperative Reflux Disease Questionnaire score was (3.3± 0.4) before the surgery, (3.8±1.0) 1 month postoperatively, and (3.3±0.4) 12 months postoperatively. All patients underwent endoscopic follow-up; no anastomotic stenoses were found. However, one patient had Grade A reflux esophagitis 1 year after surgery and another Grade B reflux esophagitis 2 years after surgery. Conclusion: Esophagogastrostomy by the tunnel technique is a safe and feasible means of performing proximal gastrectomy.

Objective: This study aimed to share preliminary experiences of single-incision plus two ports laparoscopic proximal gastrectomy with right-sided overlap and single-flap valvuloplasty (ROSF). Methods: Following the 6th edition of the Japanese Gastric Cancer Treatment Guidelines, proximal gastrectomy with lymphadenectomy was performed. Using a single-port approach, the esophagus was transected at least 2 cm above the tumor's upper margin with linear staplers. The stomach was then extracted through a periumbilical incision, and the proximal stomach was subsequently transected extracorporeally, while ensuring appropriate resection margins on both the greater and lesser curvatures. A single flap was created before returning the remnant stomach to the abdominal cavity and re-establishing pneumoperitoneum. The No.2 clip was used to grasp and elevate the esophageal stump. An incision was made at the right lower edge of the esophageal stump to guarantee that the esophageal lumen was open. The linear stapler was then inserted into the openings of the stomach and esophagus to perform a side overlap anastomosis with a length of 3 cm. Another barbed suture was used to close the common opening of the esophagus and the stomach, and the same barbed suture were used to suture the gastric wall to the lower edge of the muscle flap. The first barbed suture was then used to sequentially suture the proximal brim of the flap to the esophagus and the right brim of the flap to the right brim of the mucosal window. After completion of anastomosis, a drainage tube was inserted through the right upper port. This procedure was employed from November 2023 to March 2024 on five patients diagnosed with adenocarcinoma of the esophagogastric junction and upper stomach. The cohort consisted of three males and two females, with an age range of 62 to 75 years and a body mass index (BMI) of 13.7 to 24.2 kg/m². All cases were preoperatively staged as T1-2N0M0, confirmed by endoscopic biopsy and enhanced CT scans of the chest, abdomen, and pelvis. Results: All five patients successfully underwent the surgery. The median surgery time was 180-325 minutes, with the intraoperative blood loss of 30-50 ml. The number of lymph nodes harvested ranged from 18 to 27. The time to first flatus, and restore liquid diet and was 2.0-5.0 and 1.0-3.0 days, respectively. The postoperative length of stay was 9.0-11.0 days. The pain scores on the Numeric Rating Scale (NRS). On the first day, the pain scores were 3.0 in two cases, 2.0 in two cases, and 1.0 in one case. On the second day, the pain scores were 2.0 in two cases and 1.0 in three cases. On the third day, the pain scores were 1.0 in four cases and 2.0 in one case. No short-term postoperative complications were observed, and there were no perioperative deaths. Conclusion: Single-incision plus two ports laparoscopic proximal gastrectomy with ROSF is safe and feasible.

The incidence of adenocarcinoma of the esophagogastric junction has been gradually increasing in recent years. Due to the smaller resection range, partial preservation of the function of stomach, high safety, better postoperative nutritional status, and lesser negative psychological impact on patients, the application of proximal gastrectomy has increased significantly. Proximal gastrectomy disrupts the normal anatomical structure of the esophagogastric junction, resulting in permanent loss of the anti-reflux function of the cardia. At the same time, the retained pylorus may lead to delayed gastric emptying, making it prone to the complications such as reflux esophagitis and anastomotic stenosis. In recent years, various anti-reflux digestive tract reconstruction methods have emerged, allowing proximal gastrectomy to partially preserve stomach function while avoiding severe postoperative reflux esophagitis. This consensus, based on the "Chinese consensus on digestive tract reconstruction after proximal gastrectomy (Version 2020)", updates the research findings of multiple anti-reflux surgical techniques. It aims to promote the technical points of various proximal gastrectomy digestive tract reconstruction techniques, evaluate their anti-reflux efficacy, and provide guidance for the clinical application of digestive tract reconstruction after proximal gastrectomy.

Objective: To explore the application of anterior esophageal wall full layer fixation and gastric tube guidance in total laparoscopic overlap method for intracorporeal esophagojejunostomy. Methods: Overlap esophagojejunostomy with anterior esophageal wall full layer fixation and gastric tube guidance is suitable for patients with advanced gastric cancer (clinical stage: cT1b~4aN0~3M0) and esophageal invasion <3 cm, who underwent radical total gastrectomy+ overlap esophagojejunostomy. The main operation procedure was performed as follows: A titanium clip was used for fixation of the full anterior wall of esophagus before overlap esophagojejunostomy, and the side-to-side esophagojejunostomy was performed with the linear stapler under the guidance of gastric tube. Then the titanium clip was removed after confirming that the correct cavity was entered. Finally, the common outlet was closed by two barbed sutures. A descriptive case series study was conducted. The clinical data of patients who underwent laparoscopic radical gastrectomy and overlap esophagojejunostomy with anterior esophageal wall full layer fixation and gastric tube guidance in Guangdong Provincial Hospital of Chinese medicine and the First Affiliated Hospital of Guangzhou University of Chinese medicine from May 2021 to June 2023 were retrospectively analyzed. Results: A total of 42 patients were collected, and all of them were successfully completed laparoscopic total radical gastrectomy without conversion to laparotomy or perioperative death. The esophagojejunostomy time, operative time, intraoperative blood loss was 17(5-25) minutes, (258.8±38.0) minutes and 50(20-200) ml, respectively. The incidence of esophageal false lumen was 0%, and there were no intraoperative complications. The time of gastric tube removal, initial fluid diet intake and the duration of postoperative hospital were 2(1-5) , 4(1-8) and 8(4-21) days, respectively. There were no postoperative anastomotic hemorrhage, anastomotic stenosis and other related complications. One patient (2.38%) developed a Clavien-Dindo IIIb complication, which was abdominal hemorrhage after operation. The second surgical exploration confirmed that the patient was bleeding due to gastroduodenal artery rupture. After intraoperative suture hemostasis, fluid expansion, blood transfusion and other treatments, the patient was discharged on the 15th day after the operation. Three patients (7.14%) developed Clavien-Dindo grade II complications, including anastomotic leakage, chylous leakage and pulmonary infection, and were discharged after conservative treatment such as anti-infection and prolonged retention of drainage tube. Conclusions: Laparoscopic overlap method for intracorporeal esophagojejunostomy with anterior esophageal wall fixation and gastric tube guidance can shorten the time of esophagojejunostomy and prevent the occurrence of false lumen, and do not increase anastomose-related complications.

Purpose: Retraction of the hepatic left lateral segment (HLLS) is a crucial maneuver for surgical field exposure during laparoscopic gastrectomy with systematic lymphadenectomy. Though various methods of retraction are available, there is no perfect solution. Here, we report the results of our initial 42 cases with HLLS inversion method and discuss the feasibility, safety, effectiveness and technical aspects of this method., Methods: The intraoperative and postoperative short-term outcomes of 42 patients who underwent HLLS inversion during laparoscopic total gastrectomy and proximal gastrectomy in our department September, 2023 to January, 2024 were reviewed. HLLS inversion was performed by mobilizing the HLLS and inverting it to the right supra-hepatic space through an incision at the falciform ligament., Results: 42 patients underwent HLLS inversion successfully with an average time of 13.9 min. 7 patients needed re-inversion due to slipping back of the HLLS during operation. Optimal exposure of the surgical field was achieved in all patients. No intra-operative complications occurred, except for 1 patient presented with mild intraoperative hepatic hemorrhage requiring electrocoagulation for hemostasis. Alanine aminotransferase and glutamine aminotransferase elevated in some patients on postoperative day 1(POD1), but declined to preoperative levels on the 7th postoperative day. There were no Clavien-Dindo II grade or higher digestive complications after surgery. In 5 patients with preservation the hepatic branch of the vagus nerve, the contractile function of the gall bladder was intact or slightly impaired 2 weeks after operation., Conclusion: For laparoscopic proximal gastrectomy (LPG) and laparoscopic total gastrectomy (LTG), HLLS inversion is a feasible method for optimizing visualization of the surgical field with preservation of the function of the hepatic branch of the vagus nerve. It is safe and acceptable as to the manipulation time. Re-inversion is easy and effective even in case of failure of inversion. HLLS inversion seems to be a promising technique for retraction of the liver during laparoscopic gastrectomy., (© 2024. The Author(s).)

Background: •Gastrointestinal stromal tumors (GIST) are rare mesenchymal tumors that most commonly occur in the stomach, small intestine and colon., Background: •Surgical R0 resection is the primary approach for localized GIST, but tumors larger than 10 cm are usually treated by open surgery., Background: •This case demonstrates the safety and feasibility of robotic resection of a giant gastric GIST., Background: •The use of the robotic platform resulted in minimal blood loss and favorable postoperative outcomes with maximum organ preservation.

A low Prognostic Nutritional Index (PNI) value, lymphovascular invasion (LVI), and perineural invasion (PeNI) have been identified as indicators of poor prognosis for many malignancies. We aimed to evaluate the relationship between PNI and LVI/PeNI, their prognostic significance, and their effect on overall survival in gastric cancer patients who underwent curative gastrectomy. A cutoff value of 39.8 was taken for the PNI, and PNI < 39.8 was defined as moderate to severe malnutrition. Patients were grouped as PNI-low (PNI < 39.8) and PNI-high (PNI ≥ 39.8). Paraffin-embedded tissue sections of surgical specimens were used to evaluate PeNI as defined by previously reported criteria. The study included 270 patients with ages ranging from 23 to 90 years. The mean PNI was calculated as 39.8 ± 6.35. PeNI was detected in 232 patients (85.93%), and LVI was identified in 248 patients (91.85%). It was observed that the PNI value of patients with an expired status in the PNI < 39.8 group was lower compared to those who survived, and in patients with PNI > 39.8, those without PeNI had better survival. The presence of PeNI in patients with PNI > 39.8 increased the mortality risk by 2.088 units, while in patients with PNI > 39.8, it was found that those without LVI had better survival, and the presence of LVI increased the mortality risk by 3.171 units. Mortality developed in 166 patients (61.48%) during the five-year follow-up period. The five-year overall survival was found to be 31.02 ± 21.73 months. In patients with gastric cancer, the PNI, LVI, and PeNI are independent prognostic factors for overall survival in postoperative patients. A low PNI score is an inherently poor prognostic factor. In patients with a high PNI score, the presence of positive LVI and PeNI negatively impacts survival. We found that in patients with a low PNI, the rates of PeNI and LVI are higher compared to those with a high PNI, and this significantly affects mortality., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose: Proximal gastrectomy (PG) offers advantages over total gastrectomy (TG) in enhancing the postoperative nutritional status of patients with proximal gastric cancer (PGC), yet its effect on long-term quality of life is still debated. This study aims to thoroughly compare postoperative health condition outcomes between PG and TG., Methods: We conducted a systematic search of English-language articles from the PubMed, Web of Science, and Cochrane Library databases, covering studies published up to February 2023. Key evaluation endpoints included surgical outcomes and postoperative health condition, assessed using the Post-Gastrectomy Syndrome Assessment Scale-45 (PGSAS-45)., Results: Six retrospective cohort studies were included in the analysis. The PG group demonstrated no significant negative impact on surgical outcomes compared to the TG group. Notably, patients who underwent PG experienced a superior postoperative health condition, characterized by fewer gastroesophageal reflux symptoms (WMD = -0.106, 95% CI -0.183 to -0.029, P < 0.01), less weight loss (WMD = 4.440, 95% CI 3.900 to 4.979, P < 0.01), and reduced dietary dissatisfaction (WMD = -0.205, 95% CI -0.385 to -0.025, P = 0.03)., Conclusion: This study provides compelling evidence that PG is superior to TG in enhancing postoperative health condition for patients with proximal gastric cancer, without compromising surgical outcomes. However, further rigorous randomized controlled trials are necessary to inform surgical decision-making more effectively., (© 2024. The Author(s).)

Background: Although surgery remains the primary treatment for gastric cancer (GC), the identification of effective alternative treatments for individuals for whom surgery is unsuitable holds significance. HER2 overexpression occurs in approximately 15%-20% of advanced GC cases, directly affecting treatment-related decisions. Spectral-computed tomography (sCT) enables the quantification of material compositions, and sCT iodine concentration parameters have been demonstrated to be useful for the diagnosis of GC and prediction of its invasion depth, angiogenesis, and response to systemic chemotherapy. No existing report describes the prediction of GC HER2 status through histogram analysis based on sCT iodine maps (IMs)., Aim: To investigate whether whole-volume histogram analysis of sCT IMs enables the prediction of the GC HER2 status., Methods: This study was performed with data from 101 patients with pathologically confirmed GC who underwent preoperative sCT examinations. Nineteen parameters were extracted via sCT IM histogram analysis: The minimum, maximum, mean, standard deviation, variance, coefficient of variation, skewness, kurtosis, entropy, percentiles (1 st , 5 th , 10 th , 25 th , 50 th , 75 th , 90 th , 95 th , and 99 th ), and lesion volume. Spearman correlations of the parameters with the HER2 status and clinicopathological parameters were assessed. Receiver operating characteristic curves were used to evaluate the parameters' diagnostic performance., Results: Values for the histogram parameters of the maximum, mean, standard deviation, variance, entropy, and percentiles were significantly lower in the HER2+ group than in the HER2- group (all P < 0.05). The GC differentiation and Lauren classification correlated significantly with the HER2 status of tumor tissue ( P = 0.001 and 0.023, respectively). The 99 th percentile had the largest area under the curve for GC HER2 status identification (0.740), with 76.2%, sensitivity, 65.0% specificity, and 67.3% accuracy. All sCT IM histogram parameters correlated positively with the GC HER2 status ( r = 0.237-0.337, P = 0.001-0.017)., Conclusion: Whole-lesion histogram parameters derived from sCT IM analysis, and especially the 99 th percentile, can serve as imaging biomarkers of HER2 overexpression in GC., Competing Interests: Conflict-of-interest statement: The authors declare that there is no conflict of interest regarding the publication of this paper., (©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background: Composite tumors are neoplasms comprising two distinct, yet intermingling, cell populations. This paper reports a rare phenomenon where early gastric signet-ring cell carcinoma (SRCC) and gastric mucosa-associated lymphoid tissue (MALT) lymphoma coexist within the same lesion., Case Summary: A 40-year-old woman presented to the West China Hospital for examination, which revealed a whitish, shallow, and uneven mucosal lesion in the stomach. The lesion was diagnosed as a poorly differentiated adenocarcinoma, including SRCC with atypical lymphoid hyperplasia associated with Helicobacter pylori infection, based on histopathological examination of the biopsy specimen. The lesion was excised using segmental gastrectomy. However, histological examination of the surgical specimen confirmed that it was a poorly differentiated gastric adenocarcinoma with features of SRCC and MALT lymphoma. These two entities were stage I and coexisted in the same lesion., Conclusion: It is uncommon for gastric SRCC and MALT lymphoma to coexist without distinct borders. Surgical resection is effective for these lesions., Competing Interests: Conflict-of-interest statement: The authors declare that they have no conflict of interest to disclose., (©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.)

Purpose: Serum fibrinogen and albumin play important roles in systemic inflammation and are implicated in tumor progression. The fibrinogen-to-albumin ratio (FAR) has shown a prognostic impact in several malignancies. This study aims to assess the prognostic value of the pretherapeutic FAR in patients with adenocarcinoma of the gastroesophageal junction (AEG) who underwent upfront resection., Methods: Consecutive patients who underwent surgical resection at the Department of Surgery at the Medical University of Vienna between 1992 and 2014 were included into this study. Optimal cut-off values were determined with the receiver-operating characteristic (ROC) curve, uni- and multivariate analyzes were calculated by the Cox proportional hazard regression model for overall survival (OS)., Results: Among 135 included patients, the majority were male (79.26%), with a mean age of 66.53 years. Elevated FAR correlated significantly (p = 0.002) with shorter OS in univariate analysis, also confirmed as independent prognostic factor (p = 0.005) in multivariable analysis. The ROC curve of FAR (AUC = 0.744) outperformed fibrinogen (AUC = 0.738) and albumin (AUC = 0.378) in predicting OS for AEG patients., Conclusion: The FAR serves as an independent prognostic factor for OS in patients undergoing primarily resection for AEG. Given its routine availability and ease of calculation, FAR could help in diagnosis and treatment selection for AEG patients. Further validation studies are warranted to confirm these findings conclusively., (© 2024. The Author(s).)

This study aimed to analyze the complications and long-term survival outcomes in patients who underwent radical gastrectomy for gastric cancer, as well as to identify the risk factors associated with postoperative complications. After conducting a comprehensive search within the medical records system, a total of 2508 patients who underwent radical gastrectomy and met the inclusion criteria were enrolled. Of the 2508 patients, 301 were diagnosed with postoperative complications. The pathological data, postoperative recovery, and survival outcome were compared between complication and control group. Subsequently, univariate and multivariate logistic regression analyses were conducted to identified the risk factors. According to the Clavien-Dindo grading criteria for postoperative complications, the proportions of grade I, II, III, IV, and V complications following radical gastrectomy were observed to be 28.2%, 42.9%, 19.6%, 8.0%, and 1.3%, respectively. The presence of postoperative complications significantly prolonged the duration of gastrointestinal decompression (P < 0.001), catheter retention (P < 0.001), fasting (P < 0.001), and hospitalization (P < 0.001). Additionally, it had a detrimental impact on survival outcomes. Age > 65years [odds ratio (OR) = 1.378, P = 0.020], presence of diabetes (OR = 2.042, P < 0.001), operative duration > 215 min (OR = 1.450, P = 0.006), intraoperative blood loss > 275 ml (OR = 1.474, P = 0.004), and Roux-en-Y anastomosis for both whole stomach (OR = 1.567, P = 0.021) and distal gastric cancer (OR = 2.083, P = 0.003) were identified as independent risk factors for postoperative complications. This study analyzed the complications and survival outcomes following radical gastrectomy, and investigated the predictors for postoperative complications, thereby providing valuable guidance on the prevention and management of surgical complications in gastric cancer., (© 2024. The Author(s).)

Endoscopic submucosal dissection (ESD) plays a pivotal role in treating early gastric cancer (EGC). Some patients require additional gastrectomy because of non-curative ESD. This study aimed to analyze the clinical factors associated with non-curative ESD and to re-evaluate the role of ESD according to its indication criteria. Altogether, 134 patients who had undergone additional gastrectomy with lymphadenectomy for non-curative ESD based on the pathological results of ESD specimens were included. Their data including pre-ESD diagnosis, reasons for requesting additional gastrectomy, and surgical outcomes were analyzed retrospectively. Of the 134 patients with EGC in the final pathology of ESD specimens, 56 underwent staging ESD for a diagnostic approach, of whom 28 were diagnosed with atypical glands and 28 with high-grade dysplasia (HGD) prior to ESD. The remaining 78 patients of the 134 were identified to have EGC and received ESD for therapy. Based on the pathological results of ESD specimens, additional gastrectomy was commissioned with non-curative ESD because of one or more causes such as deep submucosal invasion, lymphatic invasion, positive vertical margin, undifferentiated histology, positive lateral margin, and venous invasion. Regarding surgical specimens, 13 patients had lymph node metastasis (LNM) and 9 had local residual tumor; one of them had both LNM and a local residual tumor. In patients with atypical glands, 4 had LNM and 3 had a local residual tumor; one of them had both LNM and a local residual tumor, and then died of multiple organ metastasis. In patients with HGD, 4 had LNM and 1 had a local residual tumor. Additionally, 4 patients who were absolutely indicated for ESD had LNM, of whom 2 had atypical glands, and the other 2 had HGD. Similarly, in 6 patients with a local residual tumor absolutely indicated for ESD, 2 had atypical glands and 1 had HGD. Positive vertical margin, lymphatic invasion, and deep submucosal invasion were identified as independent risk factors for LNM. ESD may play diagnostic and therapeutic roles in determining the optimal treatment of EGC when the diagnosis is equivocal or insufficient in endoscopic assessments for gastric cancer screening., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: The value of prognostic nutritional index (PNI) in gastrectomy remains controversial. This meta-analysis aimed to evaluate the predictive value of PNI in patients undergoing gastrectomy for malignancy., Methods: We retrieved studies from medical literature databases to analyze the endpoints of overall survival, cancer-specific survival, recurrence-free survival, and clinicopathologic features. The hazard ratio (HR) and 95% confidence interval (CI) were used to access the survival prognostic value of PNI in patients after gastrectomy. Odds ratio and mean difference were used to evaluate the relationship between the low PNI and clinicopathologic features., Results: In total, we included 38 articles (39 trial comparisons) which contained 23,756 gastrectomy patients. The results showed that low PNI was associated with shorter overall survival (HR: 1.82, 95% CI 1.62-2.03), shorter cancer-specific survival (HR: 1.44, 95% CI 1.24-1.67), and shorter recurrence-free survival (HR: 2.52, 95% CI 1.41-4.47). Besides, patients with low PNI had a higher risk of postoperative complications compared with high PNI (HR: 1.65, 95% CI 1.30-2.09). And low PNI group was found to be related to older, lower BMI, larger tumor size, deeper tumor invasion, poorer differentiation, more advanced tumor stage, total gastrectomy, and the presence of lymph node metastasis, lymphatic invasion, and vessel invasion., Conclusion: PNI was significantly associated with survival and postoperative complications of gastric cancer patients undergoing gastrectomy. Therefore PNI has the potential to be a prognostic predictor for gastrectomy., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: To investigate the safety and efficacy of endoscopic subserosal dissection for patients with submucosal tumors in the upper gastrointestinal tract., Methods: This retrospective single-center study included 16 patients who underwent ESSD. All patients were enrolled from July 2018 to Dec 2021. Parameters such as demographics, size, resection margin, complications, pathological features, procedure time and follow-up were investigated and analyzed., Results: Our study achieved 100% en bloc resection and 100% R0 resection. The most common location was the corpus with a mean tumor size of 2.78 ± 1.56 cm. The mean age, procedure time, were 53.4 ± 10.3 years, 85.31 ± 46.64 min respectively. Acocording to National Institutes of Health classification, 7 (13, 53.85%), 5 (13, 38.46%) ,and 1 (13, 7.69%) objects belonged to the very low, low, and intermediate classification, respectively. Immunohistochemistry results showed a 100% positive rate of CD34, DOG-1, CD117, and Ki67. A mean follow-up of 9.3 ± 2.5 months showed no recurrence or metastasis., Conclusions: ESSD is effective and safe surgical procedure for curative removal of gastrointestinal submucosal tumors in the upper gastrointestinal tract, and it can be preferred for patients with no metastasis., (© 2024. The Author(s).)

Background: With the improvement of anastomotic techniques and the iteration of anastomotic instruments, robotic intracorporeal suturing has become increasingly proficient. The era of fully intracorporeal anastomosis in robotic gastric cancer resection is emerging. This study aims to explore the impact of totally robotic distal gastrectomy (TRDG) and robotic-assisted distal gastrectomy (RADG) on patients' quality of life., Patients and Methods: This study is a comparative retrospective study of propensity score matching. This study included 306 patients who underwent robotic distal gastrectomy for gastric cancer between June 2016 and December 2023 at our center. Covariates used in the propensity score included sex, age, BMI, ASA score, maximum tumour diameter, degree of histological differentiation, Pathological TNM stage, Pathological T stage, Pathological N stage, and Lauren classification. Outcome measures included operative time, intraoperative bleeding, time to first venting, time to first fluid intake, postoperative hospital stay, total hospitalization cost, total length of abdominal incision, postoperative complications, inflammatory response, body image, and quality of life., Results: According to the results of the study, compared with the RADG group, the TRDG group had a faster recovery time for gastrointestinal function (P = 0.025), shorter length of abdominal incision (P < 0.001), fewer days in the hospital (P = 0.006) less pain (P < 0.001), less need for additional analgesia (P = 0.013), and a postoperative white blood cell count (P < 0.001) and C-reactive protein content indexes were lower (P<0.001). In addition, the TRDG group had significantly better body imagery and cosmetic scores (P = 0.015), physical function (P = 0.039), role function (P = 0.046), and global function (P = 0.021) than the RARS group. Meanwhile, the TRDG group had milder symptoms of fatigue (P = 0.037) and pain (P < 0.001). The PASQ Total Subscale Score (P < 0.001) and Global Subscale Score (P < 0.001) were significantly lower in the TRDG group than in the RADG group at postoperative 3 months., Conclusion: Totally robotic distal gastrectomy has a smaller incision, faster gastrointestinal recovery time, fewer days of postoperative hospitalization, and lower inflammatory markers than robotic-assisted distal gastrectomy. At the same time, postoperative cosmetic and quality of life outcomes were satisfactory. Clinically, these benefits translate to enhanced patient recovery, reduced surgical trauma, and better postoperative outcomes. These findings could guide surgeons in selecting more effective surgical approaches for patients undergoing gastrectomy, leading to better overall patient satisfaction and outcomes., (© 2024. The Author(s).)

Background: Despite recent reports, the effectiveness of postoperative oral nutritional supplementation (ONS) on body weight loss and malnutrition after gastrectomy remains controversial. We aimed to elucidate the effectiveness of ONS especially in octogenarian patients undergoing oncological gastrectomy., Methods: A total of 286 consecutive patients who underwent gastrectomy for gastric cancer were eligible. Postoperative body weight loss, malnutrition, and sarcopenia were compared between patients with and without postoperative ONS among octogenarian patients aged ≥ 80 years and non-octogenarian patients aged < 80 years., Results: In this study, 36 (62.1%) octogenarian and 121 (53.1%) non-octogenarian patients continued postoperative ONS for three months. The clinicopathologic characteristics were not different between the ONS (-) and ONS (+) groups among the octogenarian and non-octogenarian patients. The changes in body weight and serum albumin levels at postoperative 1 year were different between the ONS (-) and ONS (+) groups (P = 0.03 and P = 0.04, respectively) among the octogenarian patients, but not between the two groups among the non-octogenarian patients (P = 0.99 and P = 0.29, respectively). Also, the decline in psoas muscle mass index at postoperative 6 months and 1 year was significantly lower in the ONS (+) group than in the ONS (-) group (P < 0.01 and P < 0.01, respectively). In addition, similar results were found in octogenarian patients who underwent distal gastrectomy., Conclusions: Postoperative ONS could prevent body weight loss, malnutrition, and sarcopenia especially in octogenarian patients who underwent gastrectomy for gastric cancer., (© 2024. The Author(s).)

Gastric Cancer (GC) is the fifth most common cancer worldwide. Early stages of GC began being detected, giving rise to a new concern, Quality of Life. This study aimed to systematically assess the effects of different GC reconstruction techniques on postoperative type 2 diabetes mellitus (T2DM), hypertension (HBP), and body mass index (BMI) reduction rate and to provide an overview of recent research on oncometabolic surgery (OS). We performed a systematic review and meta-analysis by searching three databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We performed a meta-analysis of risk ratios and mean differences to estimate the impact of duodenal bypass, Roux-en-Y reconstruction, and residual stomach on T2DM, HBP, and BMI reduction rate. Heterogeneity was assessed using the I 2 statistics. At the end of the follow-up, the duodenal bypass group compared to Billroth I had a significantly higher postoperative remission of T2DM and HBP, with a relative risk (RR) of 1.43 (95% confidence interval (95% CI) [1.27; 1.62]) and 1.3 (95% CI [1.00; 1.69]), respectively. Compared with the Billroth II group, Roux-en-Y reconstruction had significantly greater T2DM remission after gastrectomy (RR = 1.19; 95% CI [1.08; 1.31]), while HBP showed no significant differences. Regarding the improvement of HBP, total gastrectomy was significantly superior to subtotal gastrectomy (95% CI [1.01; 2.64]). A trend towards Roux-en-Y Esophagojejunostomy as the best option for T2DM remission was observed (95% CI [0.98; 2.77]; p = 0.06). Gastrectomy with Roux-en-Y reconstruction appears to be the most effective treatment for T2DM remission. Further research is needed to assess the impact of OS on metabolic diseases., (© 2024. The Author(s).)

Introduction: Evidence from Asian studies suggests that minimally-invasive gastrectomy achieves equivalent oncological but improved perioperative outcomes compared to open surgery. Oncological gastric resections are less frequent in European countries. Index procedures may play a role for the learning curve of minimally-invasive gastrectomy. The aim of our study was to evaluate if skills acquired in bariatric surgery allow a safe and oncologically adequate implementation of minimally-invasive gastrectomy in a cohort of european patients., Methods: In this single-center retrospective study, all patients who received primary bariatric surgery between January 2015 and December 2018 and minimally-invasive surgery for gastric cancer treated from June 2019 to January 2023 were evaluated. Primary endpoints were operation time, lymph node yield and lymph node fractions. Secondary endpoints included postoperative complications and oncological outcomes., Results: Learning curves for two surgeons with 350 bariatric procedures and 44 minimally-invasive gastrectomies were analyzed. For bariatric surgery, the mean operation time decreased from initially 82 ± 27 to 45 ± 21 min and 118 ± 28 to 81 ± 36 min for sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), while the complication rate remained within the international benchmark. For laparoscopic gastrectomy (n = 30), operation times decreased but then remained stable over time. Operation times for the robotic platform were longer (302 ± 60 vs. 390 ± 48 min; p < 0.001) with the learning curve remaining incomplete after 14 procedures. R0 status was achieved in 95.5% of patients; the mean number of lymph nodes retrieved was 37 ± 14 with no differences between the groups. Complete mesogastric excision was more frequently achieved during the later laparoscopic cases whereas it occurred earlier for the robotic group (p = 0.004). Perioperative morbidity was comparable to the European benchmark. Textbook outcome was achieved in 54.4% of the cases., Conclusion: In summary, we could demonstrate a successful skill transfer from bariatric surgery to minimally-invasive laparoscopic oncological gastric surgery enabling safe and oncologically adequate minimally-invasive D2 gastrectomy in a central European patient collective., (© 2024. The Author(s).)

This study aimed to assess the impact of surgeons' annual volume and insulin-like growth factor-like family member 2 (IGFL2) expression on gastric cancer prognosis. Clinicopathological data from 475 patients who underwent D2 lymph node dissection were analyzed. IGFL2 expression was evaluated using immunohistochemistry. Patients were divided into training (70%) and validation (30%) groups. Univariate and multivariate Cox regression identified risk factors for overall survival (OS) and disease-free survival (DFS), leading to a clinical prediction model. Model performance was evaluated using C-index. High IGFL2 expression and low surgical volume independently predicted poorer OS and DFS (hazard ratio = 2.13, 2.17, all P < .01). Surgeons performing >26 cases annually had higher OS and DFS (hazard ratio = 1.65, 1.58, all P < .01). Nomograms integrating surgical volume, IGFL2 expression, grade, TNM staging, and carcinoembryonic antigen showed superior predictive accuracy for OS and DFS compared to TNM alone, with robust C-indices and area under the curve values. Surgeons' annual volume and IGFL2 expression independently predict gastric cancer prognosis, emphasizing the need for specialized training and further research on IGFL2's molecular mechanisms to enhance patient outcomes., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Tumor microenvironment (TME) characteristics including tumor stroma ratio (TSR), tumor budding (TB), and tumor-infiltrating lymphocytes (TILs) were examined in resected gastric cancer. These TME features have been shown to indicate metastatic potential in colon cancer, and intestinal-type gastric cancer (IGC) has pathological similarities with that malignancy., Methods: TSR, TB, and TILs were quantified in routine histological sections from 493 patients with IGC who underwent radical resection at 2 university hospitals in China from 2010 to 2016. TME variables were dichotomized as follows: TSR (50%), TILs (median), TB per international guidelines (4 buds/0.785mm2), and platelet-lymphocyte ratio (PLR) per survival ROC. Association of TME features with patient clinicopathological characteristics, time-to-recurrence (TTR), and cancer-specific-survival (CSS) were examined using univariate and multivariate analysis, including a relative contribution analysis by Cox regression., Results: Patients whose tumors showed high TSR or high TB or low TILs were each significantly associated with increased T and N stage, higher histological grade, and poorer TTR and CSS at 5 years. Only TSR and N stage were independently associated with TTR and CSS after adjustment for covariates. PLR was only independently associated with TTR after adjustment for covariates. Among the variables examined, only TSR was significantly associated with both TTR (HR 1.72, 95% CI, 1.14-2.60, P = .01) and CSS (HR 1.62, 95% CI, 1.05-2.51, P = .03) multivariately. Relative contribution to TTR revealed that the top 3 contributors were N stage (45.1%), TSR (22.5%), and PLR (12.9%), while the top 3 contributors to CSS were N stage (59.9%), TSR (14.7%), and PLR (10.9%)., Conclusions: Among the examined TME features, TSR was the most robust for prognostication and was significantly associated with both TTR and CSS. Furthermore, the relative contribution of TSR to patient TTR and CSS was second only to nodal status., (© The Author(s) 2024. Published by Oxford University Press.)

Neoadjuvant cancer treatment (NCT) reduces both physical fitness and physical activity (PA) levels, which can increase the risk of adverse outcomes in cancer patients. This study aims to determine the effect of exercise prehabilitation on PA and sedentary behavior (SB) in patients undergoing NCT and surgery for esophagogastric malignancies. This study is a randomized pragmatic controlled multi-center trial conducted across three Irish hospitals. Participants were aged ≥18 years scheduled for esophagectomy or gastrectomy and were planned for NCT and surgery. Participants were randomized to an exercise prehabilitation group (EX) that commenced following cancer diagnosis, continued to the point of surgery, and resumed following recovery from surgery for 6 weeks or to usual care (UC) who received routine treatment. The primary outcome measures were PA and SB. Between March 2019 and December 2020, 71 participants were recruited: EX (n = 36) or UC (n = 35). No significant differences were found between the EX group and UC group on levels of PA or SBs across all measured timepoints. Significant decreases in moderate-vigorous physical activity levels (MVPAs) were found between baseline and post-surgery (P = 0.028), pre-surgery and post-surgery (P = 0.001) and pre-surgery and 6-week follow-up (P = 0.022) for all participants. Step count also significantly decreased between pre-surgery and post-surgery (P < 0.001). Baseline aerobic fitness was positively associated to PA levels and negatively associated with SB. Esophagogastric cancer patients have lower than recommended levels of PA at the time of diagnosis and this decreased further following completion of NCT. An optional home- or group-based exercise intervention was not effective in improving PA levels or behaviors across the cancer treatment journey., (© The Author(s) 2024. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus.)

Background: The best treatment option for patients with resectable gastric cancer is radical gastric cancer surgery. However, the postoperative overall survival rate is low. Lymphovascular invasion (LVI) is a risk factor for cancer recurrence and a stand-alone predictor of a poor post-operative prognosis for gastric cancer (GC) patients. Current evaluation of tumor LVI performed on histological specimens, which can only be assessed after surgery, is also limited by intra-tumoural heterogeneity via biopsy. This study explored the value of CT volume perfusion in assessing tumors' lymphovascular invasion of gastric cancer., Methods: 59 gastric cancer patients confirmed by pathology who underwent both computed tomography (CT) volume perfusion examinations and gastrectomy surgery were prospectively included. Tumour lymphovascular invasion (LVI, positive or negative) was evaluated. The relationship between clinicopathological variables associated with LVI and CT perfusion parameters was analyzed by univariate analysis, followed by multivariate logistic regression analysis and receiver operating characteristic (ROC) analysis., Results: The LVI-positive and LVI-negative groups differed significantly in terms of time to start (TTS), mean transit time (MTT), Tmax, and flow extraction product (FEP). Both FEP (odds ratio (OR), 1.048; 95% confidence interval (CI): 1.005-1.092) and MTT (OR, 0.549; 95% CI: 0.351-0.858) have the potential to be employed as independent predictors of LVI (both p < 0.05). There were different correlations between LVI, lower MTT and greater FEP. The specificity of MTT (87.88%) was higher than that of FEP (72.73%), while the sensitivity of MTT (53.85%) was lower than that of FEP (57.69%). Compared to MTT and FEP alone, the combination demonstrated a comparatively higher area under the curve (AUC) (0.797) and sensitivity (84.62%)., Conclusions: CT volume perfusion helps evaluate LVI in gastric cancer before surgery. MTT and FEP are independent predictors for LVI, and the combination variation has better diagnostic performance. Clinical Trial Register: Jiangmen Central Hospital, https://www.chictr.org.cn/showproj.html?proj=24375, ChiCTR1800014455.

Background: Prehabilitation is safe, feasible and may improve a range of outcomes in patients with oesophago-gastric cancer (OGC). Recent studies have suggested the potential of prehabilitation to improve body composition, sarcopenia and physical fitness, reduce surgical complications and improve quality of life. Despite this, prehabilitation services are not offered throughout all OGC centres in the UK. Where prehabilitation is offered, delivery and definitions vary significantly, as do funding sources and access., Methods: A professional association endorsed series of consensus meetings were conducted using a modified Delphi process developed by the Peri-Operative Quality Initiative (POQI) to identify and refine consensus statements relating to the development and delivery of prehabilitation services for OGC patients. Participants from a variety of disciplines were identified based on a track record of published studies in the field of prehabilitation and/or practice experience encompassing prehabilitation of OGC patients. Approval from the POQI board was obtained and independent supervision provided by POQI., Results: A total of 20 statements were developed and agreed by 26 participants over a preliminary meeting and 2 semi-structured formal POQI meetings. Ten research themes were identified. In the case of one statement, consensus was not reached and the statement was recorded and developed into a research theme. A strong recommendation was made for the majority of the consensus statements (17 of 20)., Discussion: Consensus statements encompassing the interventions and outcomes of prehabilitation services in oesophago-gastric cancer surgery have been developed to inform the implementation of programmes., (© The Author(s) 2024. Published by Oxford University Press on behalf of BJS Foundation Ltd. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Objective: We aimed to investigate the relationship between the visceral to subcutaneous fat area ratio (V/S ratio) and incidence of early postoperative small bowel obstruction (EPSBO) following total gastrectomy for cardia cancer., Methods: We conducted a retrospective analysis among patients with cardia cancer who underwent elective total gastrectomy with esophagojejunostomy Roux-en-Y anastomosis at Nanjing Yimin Hospital between November 2019 and April 2024. Preoperative, intraoperative, and postoperative factors were meticulously monitored. The V/S ratio was calculated using computed tomography scans at the umbilical level with Slice-O-Matic software (Tomovision, Montreal, Canada). Statistical analyses included logistic regression and receiver operating characteristic (ROC) curve analysis., Results: Among 175 patients, 27 (15.4%) developed EPSBO. The V/S ratio was significantly higher in the EPSBO group (1.76 ± 1.05 vs. 1.01 ± 0.54). Logistic regression identified the V/S ratio as a significant predictor of EPSBO (odds ratio [OR] = 1.612, 95% [CI]: 1.102-1.605). ROC curve analysis demonstrated high sensitivity (92%) and specificity (100%) for the V/S ratio in predicting EPSBO, with a 0.83 AUC., Conclusions: Our findings indicated a higher V/S ratio was a significant predictor of EPSBO following total gastrectomy for cardia cancer. Preoperative assessment of the V/S ratio can inform risk stratification and guide targeted interventions to improve postoperative outcomes., Competing Interests: Declaration of conflicting interestThe authors declare that there is no conflict of interest.

Purpose: We investigated the relationship between the resected stomach measurements, the incidence of delayed gastric emptying (DGE), and food residue 1 year after surgery in patients who underwent laparoscopic pylorus-preserving gastrectomy (PPG)., Materials and Methods: The DGE group included 10 patients fasting due to nausea, vomiting, abdominal distension, or remnant stomach distension on radiographs; the control group included 36 patients without these symptoms. We compared the size and length of lesser and greater curvatures of the resected stomach and endoscopic findings after 1 year., Results: No significant differences were observed between groups in terms of sex, body mass index, gross type, histology, tumor progression, number of dissected lymph nodes, operating time, or blood loss. The DGE group was older, had a longer postoperative stay, and showed a smaller size and shorter greater curvature of the resected stomach than the control group (p < 0.01 for all). No difference was observed in the length of the lesser curvature of the resected stomach. In addition, there were no disparities in residual food, degree and extent of gastritis, or bile reflux 1 year after gastrectomy., Conclusions: Measurements of the resected stomach suggest that preventing DGE may be achievable by removing a larger area of the greater curvature and/or stomach during laparoscopic PPG. This implies potential surgical strategy improvements for better outcomes. Further multicenter trials are needed to validate and refine techniques., (© 2024 Asia Endosurgery Task Force and Japan Society of Endoscopic Surgery and John Wiley & Sons Australia, Ltd.)

Purpose: Although laparoscopic distal gastrectomy has rapidly replaced open distal gastrectomy, laparoscopic total gastrectomy (LTG) is less frequently performed owing to technical difficulties. Robotic surgery could be an appropriate minimally invasive alternative to LTG because it alleviates the technical challenges posed by laparoscopic procedures. However, few studies have compared the oncological safety of robotic total gastrectomy (RTG) with that of LTG, especially for advanced gastric cancer (AGC). Herein, we aimed to assess the oncological outcomes of RTG for AGC and compare them with those of LTG., Materials and Methods: We retrospectively reviewed 147 and 204 patients who underwent RTG and LTG for AGC, respectively, between 2007 and 2020. Long-term outcomes were compared using inverse probability of treatment weighting (IPTW)., Results: After IPTW, the 2 groups exhibited similar clinicopathological features. The 5-year overall survival was comparable between the 2 groups (88.5% [95% confidence interval {CI}, 79.4%-93.7%] after RTG and 87.3% [95% CI, 80.1%-92.0%]) after LTG; log-rank P=0.544). The hazard ratio (HR) for death after RTG compared with that after LTG was 0.73 (95% CI, 0.40-1.33; P=0.304). The 5-year relapse-free survival was also similar between the 2 groups (75.7% [95% CI, 65.2%-83.4%] after RTG and 76.4% [95% CI, 67.9%-83.0%] after LTG; log-rank P=0.850). The HR for recurrence after RTG compared with that after LTG was 0.93 (95% CI, 0.60-1.46; P=0.753)., Conclusions: Our findings revealed that RTG and LTG for AGC had similar long-term outcomes. RTG is an oncologically safe alternative to LTG and has technical advantages., Competing Interests: H.W.J. reports receiving research grants from Medtronic and GC Pharma and is a stockholder and chief executive officer of Hutom. He provided consultancy services to Ethicon and SK Hynix (Wuxi) outside of the submitted work. The other authors have no disclosures to report., (Copyright © 2024. Korean Gastric Cancer Association.)

Purpose: Endoscopic submucosal dissection (ESD) is the standard treatment for early gastric cancer (EGC) with a low risk of lymph node metastasis. In Korea, ESD was included in the National Health Insurance (NHI) coverage in 2011, which was expanded in 2018. In the present study, we investigated the status and trends of ESD for EGC over the past decade since its incorporation into the NHI system., Materials and Methods: We analyzed the data from the National Health Insurance Service (NHIS) database from 2011 to 2021, focusing on patient characteristics, number of ESD procedures, in-hospital length of stay (LOS), and total medical cost (TMC) per admission. In addition, we conducted an interrupted time series analysis to assess the impact of changes in insurance coverage on these variables., Results: Overall, 95,348 cases of ESD for EGC were identified. A consistent annual increase in ESD procedures was observed, particularly in tertiary care hospitals and among patients aged >60 years. The overall median LOS and TMC were 4 days and 2,123,000 KRW, respectively. The 2018 insurance coverage expansion did not significantly affect the number of ESD procedures or LOS; however, the TMC increased significantly., Conclusions: Our study illustrates decade-long trends in the ESD for EGC in Korea. The policy needs to be revised continuously to optimize ESD use and improve resource allocation within healthcare systems., Competing Interests: No potential conflict of interest relevant to this article was reported., (Copyright © 2024. Korean Gastric Cancer Association.)

Purpose: This study aimed to develop and assess the feasibility and effectiveness of digital therapeutics for supportive care after gastrectomy., Materials and Method: The study included 39 patients with gastric cancer who underwent minimally invasive gastrectomy and were able to use a mobile application (app) on their smartphones. The developed research app automatically calculates and provides daily targets for calorie and protein intake based on the patient's body mass index (BMI). Patients recorded their daily diets, weights, and symptoms in the app and completed special questionnaires to assess the feasibility of the app in real-world clinical practice., Results: At the 10-week follow-up, the mean questionnaire scores for ease of learning, usability, and effectiveness of the app (primary endpoint) were 2.32±0.41, 2.35±0.43, and 2.4±0.39 (range: 0-3), respectively. Patients were classified as underweight (<18.5, n=4), normal (18.5-24.9, n=24), or overweight (≥25.0, n=11) according to predischarge BMI. Underweight patients showed higher compliance with app usage and a higher rate of achieving the target calorie and protein intake than normal weight and overweight patients (98% vs. 77% vs. 81%, p=0.0313; 102% vs. 75% vs. 61%, P=0.0111; 106% vs. 79% vs. 64%, P=0.0429). Two patients transitioned from underweight to normal weight (50.0%), one patient (4.3%) transitioned from normal weight to underweight, and two patients (22.2%) transitioned from overweight to normal weight., Conclusions: The mobile app is feasible and useful for postoperative supportive care in terms of ease of learning, usability, and effectiveness. Digital therapeutics may be an effective way to provide supportive care for postgastrectomy patients, particularly in terms of nutrition., Trial Registration: ClinicalTrials.gov Identifier: NCT04800991., Competing Interests: No potential conflict of interest relevant to this article was reported., (Copyright © 2024. Korean Gastric Cancer Association.)

Purpose: Oxyntic gland neoplasm (OGN) is a rare condition that can be classified as oxyntic gland adenoma (OGA) or gastric adenocarcinoma of fundic-gland type (GA-FG). GA-FG primarily presents as early gastric cancer, with only a few reported cases of advanced gastric cancer (AGC). We aimed to investigate the clinicopathological features of OGN and describe an aggressive variant., Materials and Methods: We investigated a total of 29 cases, including a patient with double primary cases, diagnosed with OGN or differentiated-type adenocarcinoma with GA-FG morphology, between November 2016 and April 2022. We analyzed 54 pathological specimens and reviewed their clinicopathological, endoscopic, and histological features. The lesions were reclassified as OGA or GA-FG, and immunohistochemical (IHC) staining for MUC-5AC and MUC-6 was performed on available resected GA-FG cases., Results: The median patient age was 65 years and males accounted for 58.6% of patients. Most cases occurred in the body horizontally (69.0%) and on the greater curvature side cross-sectionally (48.3%). Endoscopically, type 0-IIa (41.4%) and a subepithelial tumor-like appearance (24.1%) were the most common findings. Histologically, there were 8 cases of OGA (27.6%) and 21 cases of GA-FG (72.4%). In GA-FG, MUC-6 was positive in 13 cases (81.3%), whereas MUC-5AC was positive in 8 cases (50.0%). Three cases presented as AGCs., Conclusions: Although OGNs are generally considered low-grade, they can present as AGCs and may exhibit features of lymphovascular or perineural invasion. Recognizing the clinicopathological features and accurately diagnosing OGN are important for providing adequate treatment., Competing Interests: No potential conflict of interest relevant to this article was reported., (Copyright © 2024. Korean Gastric Cancer Association.)

Purpose: Foveolar-type adenocarcinoma of the stomach is a rare variant of gastric cancer. The clinicopathological features and outcomes of endoscopic submucosal dissection (ESD) for gastric foveolar-type adenocarcinoma remain unclear., Materials and Methods: This study included 1,161 patients who underwent ESD for single early gastric cancers (EGCs) (78 foveolar-type adenocarcinomas and 1,083 well-differentiated [WD] adenocarcinomas). The clinicopathological features and short- and long-term outcomes of ESD for gastric foveolar-type adenocarcinomas were reviewed and compared with those for WD EGCs., Results: Gastric foveolar-type adenocarcinomas were larger and more likely to exhibit an elevated macroscopic appearance than WD EGCs. Foveolar-type adenocarcinomas exhibited higher rates of lymphatic invasion, histological heterogeneity, and lateral margin involvement than WD EGCs. The en bloc R0 and curative resection rates of foveolar-type adenocarcinoma were 85.9% and 76.9%, respectively. Both foveolar-type adenocarcinoma rates were significantly lower than those of WD EGCs (95.8% and 91.3%, respectively). Lateral margin involvement accounted for 55.6% of the non-curative resection cases of foveolar-type adenocarcinoma. Among patients who underwent curative ESD for foveolar-type adenocarcinoma, no recurrence occurred during the median 62.3 months of follow-up. No lymph node metastases were detected in patients with foveolar-type adenocarcinoma who underwent additional surgery following ESD. The overall and disease-specific survival rates of patients with foveolar-type adenocarcinoma were comparable to those of patients with WD EGC., Conclusions: Gastric foveolar-type adenocarcinomas have distinct clinicopathological features among WD EGCs. Given favorable long-term outcomes after curative resection, ESD can be indicated for early gastric foveolar-type adenocarcinomas., Competing Interests: No potential conflict of interest relevant to this article was reported., (Copyright © 2024. Korean Gastric Cancer Association.)

Purpose: The usability of a new surgical navigation system that provides patient-specific vascular information for robotic gastrectomy in gastric cancer remains unexplored for laparoscopic gastrectomy owing to differences in surgical environments. This study aimed to evaluate the applicability and safety of this navigation system in laparoscopic gastrectomy and to compare the post-operative outcomes between procedures with and without its use., Materials and Methods: Between June 2022 and July 2023, 38 patients across 2 institutions underwent laparoscopic gastrectomy using a navigation system (navigation group). The technical feasibility, safety, and accuracy of detecting variations in vascular anatomy were measured. The perioperative outcomes were compared with 114 patients who underwent laparoscopic gastrectomy without a navigation system (non-navigation group) using 1:3 propensity score matching during the same study period., Results: In all patients in the navigation group, no adverse events associated with the navigation system occurred during surgery in any patient in the navigation group. No accidental vessel injuries necessitate auxiliary procedures. All vessels encountered during the gastrectomy were successfully reconstructed and visualized. Patient demographics and operative data were comparable between the 2 groups. The navigation group exhibited a significantly lower overall complication rate (10.5%) than the non-navigation group (26.3%, P=0.043). Notably, pancreas-related complications were absent in the navigation group but occurred in eight cases in the non-navigation group (7.0%, P=0.093), although the difference was not statistically significant., Conclusions: The patient-specific surgical navigation system demonstrated clinical feasibility and safety for laparoscopic gastrectomy for gastric cancer, potentially reducing complication rates compared with laparoscopic gastrectomy without its use., Competing Interests: Dr. Han and Dr. Kwon had full access to all study data and ensured the integrity and accuracy of data analysis. The authors declare no potential conflicts of interest., (Copyright © 2024. Korean Gastric Cancer Association.)

Background: Gastric cancer (GC) is the fourth leading cause of cancer mortality worldwide. Peritoneal metastasis (PM) is a significant cause of death in patients with GC, and presents a major challenge in clinical diagnosis and treatment. Predicting the occurrence of PM in high-risk patients, and diagnosing and treating PM in advance to improve patient survival, remains an unsolved problem in clinical practice. Given the low positive rate of cytology and difficulty in diagnosing occult PM, new molecular markers and detection technologies for early diagnosis require urgent validation. The primary objective of this study is to observe and evaluate the predictive effect of intraoperative peritoneal lavage fluid (PLF) circulating tumour cells (CTC) and circulating tumour DNA (ctDNA) levels in patients with pT4NxM0/pT1-3N+M0 GC on metachronous PM after R0 resection., Methods and Analysis: This prospective single-centre clinical study is conducted at Renji Hospital, Shanghai Jiao Tong University School of Medicine. In this study, 200 cases of patients with pT4NxM0/pT1-3N+M0 gastric adenocarcinoma older than 18 years will be screened. Participants will undergo intraoperative PLF CTC and ctDNA testing and will be followed up for 2 years, with imaging assessments performed every 3-6 months until PM occurrs. The primary outcome is the incidence of PM 1 year after surgery, which will be estimated using Clopper-Pearson method, with 95% CIs calculated and compared between groups. Secondary outcome include the incidence of PM 2 years after surgery, overall survival and disease progression. Data will be analysed using the Kaplan-Meier method and the log-rank test., Ethics and Communication: Informed consent has been obtained from all subjects. This protocol has been approved by the Ethics Committee of Renji Hospital, Shanghai Jiao Tong University School of Medicine (LY2023-142-B). The findings will be disseminated through peer-reviewed manuscripts, reports and presentations., Trial Registration Number: ChiCTR2300074910., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)