Western body mass indices need not compromise outcomes after modified D2 gastrectomy for carcinoma

BACKGROUND: To determine the role of body mass index (BMI) in a Western population on outcomes after modified D2 gastrectomy (preserving pancreas and spleen where possible) for gastric cancer. METHODS: Eighty-four consecutive patients undergoing an R0 modified D2 gastrectomy for gastric cancer were studied prospectively. Male patients with a BMI of greater than 24.7 kgm(-2) and female patients with a BMI of greater than 22.6 kgm(-2) were classified as overweight and compared with control patients with BMIs below these reference values. RESULTS: Thirty-eight of the patients (45%) were classified as overweight. The median BMI of the overweight patients was 27.0 kgm(-2) (range, 22.7-34.7 kgm(-2); 27 males) compared with 21.2 kgm(-2) (range, 15.2-24.7 kgm(-2), 31 males) for control patients. Operative morbidity and mortality were 26% and 7.9% in overweight patients compared with 22% and 6.5% in control patients (morbidity, chi(2) = 0.240; df = 1; P = 0.624; mortality, chi(2) = 0.059; df = 1; P = 0.808). Cumulative survival at 5 years was 52% for overweight patients compared with 55% for control patients (chi(2) = 0.15; df = 1; P = 0.7002). In a multivariate analysis, the number of lymph node metastases (hazard ratio, 1.441; 95% confidence interval [CI], 1.159-1.723; P = 0.009) and splenectomy (hazard ratio, 12.111; 95% CI, 9.645-14.577; P = 0.043) were independently associated with the duration of survival. CONCLUSION: High BMIs were not associated with increased operative risk, and longterm outcomes were similar in the two groups after modified D2 gastrectomy.     

Changes in vitamin D after gastrectomy

Background We previously reported that the administration of 1α hydroxy vitamin D3 was effective for treating post-gastrectomy bone disorders. Accordingly, we performed the present study to obtain evidence supporting the effectiveness of 1α hydroxy vitamin D3 in post-gastrectomy patients. Methods The study involved 22 outpatients who had undergone gastrectomy for gastric cancer and had not been treated with 1α hydroxy vitamin D3 or calcium. They comprised 17 men and 5 women, with a mean age of 61.9 years. Laboratory tests were performed to examine the following parameters: 1,25(OH)₂ vitamin D3; 25(OH) vitamin D3; 24,25(OH)₂ vitamin D3; ionized calcium; calcium; phosphorus; alkaline phosphatase; N-parathyroid hormone; and osteocalcin. Results The level of 1,25(OH)₂ vitamin D3, the most active of the vitamin D metabolites, was found to be normal in all of the patients. In contrast, the level of 25(OH) vitamin D3, which shows weak activity, was below the normal range in 7 of the 22 patients (31.8%). The mean serum level of 25(OH) vitamin D3 was significantly lower in patients at 1 year or more postoperatively than the level in those at less than 1 year postoperatively (P = 0.041), as well as being significantly lower in patients who had received total gastrectomy than in patients who underwent other gastrectomy procedures. The level of 24,25(OH)₂ vitamin D3, a metabolite of 25(OH) vitamin D3 that shows weak activity, was below the normal range in 19 of the 22 patients (86.4%). On multivariate analyses, factors associated with the change in vitamin D metabolites did not remain. Conclusion The patients showed a decrease of 25(OH) vitamin D3 and 24,25(OH)₂ vitamin D3, which are metabolites that show weak activity. This suggests that a homeostatic response maintains the normal level of 1,25(OH)₂ vitamin D3, which is important for calcium regulation. Thus, it was suggested that gastrectomy had a moderate influence on the metabolism of vitamin D. However we could not detect any factor associated with the decrease of 25(OH) vitamin D3 and 24,25(OH)₂ vitamin D3.     

胰腺癌根治术与术后辅助外放疗的疗效比较

目的 探讨术后放疗对胰腺癌患者生存率的影响.方法 44例胰腺癌患者分为手术组(根治性外科切除)和手术+放疗组(根治性外科切除后接受外放疗),比较两组患者的治疗效果.结果 手术组平均生存期为453 d,中位生存期为379 d.手术+放疗组平均生存期789 d,中位生存期为665 d.手术组和手术+放疗组的1、3、5年生存率分别为46.3%、8.3%、4.2%和65.2%、20.2%、14.1%,手术+放疗组优于手术组(P=0.017).手术+放疗组局部复发率及区域淋巴结转移率低于手术组(P<0.05),且并发症发生率并不高于手术组(P>0.05).结论 胰腺癌根治术后结合放疗有助于改善患者生存期.     

D1和D2式胃癌切除术后并发症对比研究

目的分析实施D1和D2式胃癌切除术后患者的早期并发症发生率和死亡率,进一步提高胃癌手术治疗的效果。方法收集2006年1月至2007年12月连续收治的实施D1或D2式胃癌切除术患者的临床资料,分析肿瘤临床病理特征、淋巴结廓清程度和术后早期并发症以及死亡率之间的关系。结果130例患者实施了胃癌切除术,D1式34例,D2式96例。D2式术后早期并发症发生率明显高于D1式（20．6％比39．6％,P〈0．05）。进一步分析单个并发症的发生情况,两种术式差异无统计学意义。D2式术后死亡率为4．2％（4／96）,D1式为0（0／34）,但差异无统计学意义（P〉0．05）。死亡患者4例,均为D2式切除术。与吻合口瘘、胰瘘等相关的肺部并发症是术后患者死亡的重要原因。结论D2式胃癌切除术是治疗胃癌安全有效的方法。淋巴结清除程度是增加术后并发症发生率和死亡率的因素。提高手术廓清技能和标准化胃癌淋巴结廓清术可能是减少术后早期并发症和死亡率的关键途径。     

Experimental and clinical studies on pancreatic duct obstruction in preventing pancreatic fistula formation]

Even after prolonged use in clinical practice, obstruction of the pancreatic duct in preventing fistula formation still lacks solid proof. Sixteen dogs were randomized into an pancreatic duct obstruction group and a control group. Four to 8 ml of silicon gel was injected into the pancreatic duct in the former group while the latter group received exploratory laparotomy only. The pancreas was examined histopathologically 1, 3, 5, 7 and 9 months after operation. It was shown that the exocrine glands underwent marked atrophy but the endocrine glands showed only mild damage. Clinical studies on 27 patients who were operated for pancreatic cancers and diseases showed that pancreatic fistula developed in 7.7% of patients (1/13) in the obstruction group and 21% (3/14) in the control group.     

Postoperative outcomes after laparoscopic or open gastrectomy. A national cohort study of 10,343 patients

BackgroundLaparoscopy for gastric cancer has not been as popular compared with other digestive surgeries, with conflicting reports on outcomes. The aim of this study focuses on the surgical techniques comparing open and laparoscopy by assessing the morbi-mortality and long-term complications after gastrectomy.MethodsA retrospective study (2013–2018) was performed on a prospective national cohort (PMSI). All patients undergoing resection for gastric cancer with a partial gastrectomy (PG) or total gastrectomy (TG) were included. Overall morbidity at 90 post-operative days and long-term results were the main outcomes. The groups (open and laparoscopy) were compared using a propensity score and volume activity matching after stratification on resection type (TG or PG).ResultsA total of 10,343 patients were included. The overall 90-day mortality and morbidity were 7% and 45%, with reintervention required in 9.1%. High centre volume was associated with improved outcomes. There was no difference in population characteristics between groups after matching. An overall benefit for a laparoscopic approach after PG was found for morbidity (Open = 39.4% vs. Laparoscopy = 32.6%, p = 0.01), length of stay (Open = 14[10–21] vs. Laparoscopy = 11[8–17] days, p<0.0001). For TG, increased reintervention rate (Open = 10.8% vs. Laparoscopy = 14.5%, p = 0.04) and increased oesophageal stricture rate (HR = 2.54[1.67–3.85], p<0.001) were encountered after a laparoscopic approach. No benefit on mortality was found for laparoscopic approach in both type of resections after adjusted analysis.ConclusionsLaparoscopy is feasible for PG with a substantial benefit on morbidity and length of stay, however, laparoscopic TG should be performed with caution, with of higher rates of reintervention and oesophageal stricture.     

Adjuvant capecitabine plus oxaliplatin after D2 gastrectomy in Japanese patients with gastric cancer: a phase II study

Background

Adjuvant chemotherapy with XELOX (capecitabine plus oxaliplatin) has been shown to be beneficial following resection of gastric cancer in South Korean, Chinese, and Taiwanese patients. This phase II study (J-CLASSIC-PII) was undertaken to evaluate the feasibility of XELOX in Japanese patients with resected gastric cancer.

Methods

Patients with stage II or III gastric cancer who underwent curative D2 gastrectomy received adjuvant XELOX (eight 3-week cycles of oral capecitabine, 1000 mg/m² twice daily on days 1–14, plus intravenous oxaliplatin 130 mg/m² on day 1). The primary endpoint was dose intensity. Secondary endpoints were safety, proportion of patients completing treatment, and 1-year disease-free survival (DFS) rate.

Results

One hundred patients were enrolled, 76 of whom completed the study as planned. The mean dose intensity was 67.2 % (95 % CI, 61.9–72.5 %) for capecitabine and 73.4 % (95 % CI, 68.4–78.4 %) for oxaliplatin, which were higher than the predefined age-adjusted threshold values of 63.4 % and 69.4 %, respectively, and the study therefore met its primary endpoint. The 1-year DFS rate was 86 % (95 % CI, 77–91 %). No new safety signals were identified.

Conclusions

The feasibility of adjuvant XELOX in Japanese patients with resected gastric cancer is similar to that observed in South Korean, Chinese, and Taiwanese patients in the Capecitabine and Oxaliplatin Adjuvant Study in Stomach Cancer (CLASSIC) study. Based on findings from this study and the CLASSIC study, the XELOX regimen can be considered an adjuvant treatment option for Japanese gastric cancer patients who have undergone curative resection.

     

Modulation of GemOx chemotherapy according to CIRS in elderly patients with advanced pancreatic cancer

The present study evaluated activity and toxicity of modulated doses of gemcitabine associated to oxaliplatin in patients with secondary CIRS and with locally advanced pancreatic adenocarcinoma (LAPC) and metastatic pancreatic adenocarcinoma (MPC). Since January 2006, untreated LAPC and MPC patients have been assessed with ADL, IADL, CIRS to modulate chemotherapy dosages according to co-morbidity stage. Patiens aged<75 years, co-morbidity stage primary/intermediate, or ≥75 years and co-morbidity stage primary, received gemcitabine 1,000 mg/m2 as a 10 mg/m2/min infusion on day 1 and oxaliplatin 70 mg/m2 as a 2-h infusion on day 2 every 2 weeks. Patiens aged<75 years, co-morbidity stage secondary or ≥75 years and co-morbidity stage intermediate/secondary patients received gemcitabine 800 mg/m2. Primary endpoint was the overall response rate (ORR). Secondary endpoints were disease control rate (DCR), PFS, OS and toxicity. Thirty-one patients were recruited: 26% (8/31) LAPC and 74% (23/31) MPC; median age 69 years. Co-morbidity stage primary/intermediate, 19; secondary, 12. Twenty-seven valuable patients: ORR 30% (CI±0.14); disease control rate 85% (CI±0.18). Median follow-up 13 months: median PFS and OS were 6 and 15 months, respectively. Valuable cycles 140. Grade 3/4 toxicity per patient: leukopenia, 18.5%; neutropenia, 55,5%; thrombocytopenia, 7.4%; SGOT/SGPT, 7.4%; gamma-GT, 7.4%; fever without neutropenia, 3.7%. Median received dose intensity: gemcitabine 400 mg/m2/w; oxaliplatin 35 mg/m2/w. Modulation of GemOx chemotherapy according, to CIRS stage in advanced pancreatic cancer confirms reported efficacy and tolerability.     

Higher incidence of pancreatic fistula in laparoscopic gastrectomy. Real-world evidence from a nationwide prospective cohort study

Background

Laparoscopic distal gastrectomy (LDG) is becoming the standard procedure for gastric cancer. However, supporting evidence thus far has been derived primarily from randomized control trials conducted by centers of excellence. In the present study we used the National Clinical Database (NCD) in Japan to prospectively accumulate data from diverse types of hospitals and examine whether LDG is a safe and valid standard procedure.

Methods

From the NCD, 169 institutions were selected to form a cohort that was considered to be representative of Japan. From August 2014 to July 2015, 5288 patients who underwent LDG were registered prospectively, and clinical data were acquired through the NCD. To compare surgical outcomes between open distal gastrectomy (ODG) and LDG, we adjusted for confounding factors using propensity score matching, ultimately retrieving data from 1067 patients in each group.

Results

There were no significant differences in the number of in-hospital deaths in the ODG and LDG groups (3/1067 vs. 6/1067; P = 0.51) or in the number of reoperations (20/1067 vs. 29/1067; P = 0.19). However, the length of hospital stay was significantly shorter in the LDG. Although wound infection and dehiscence were more common in the ODG group, LDG was more often associated with grade B or higher pancreatic fistulas.

Conclusion

The safety and minimal invasiveness of LDG were confirmed in the present Japanese nationwide survey. However, care must be taken to prevent the formation of pancreatic fistulas with LDG, and further improvements in surgical quality are warranted in this regard.

     

胃癌D2根治术后大出血的临床分析

目的总结分析胃癌D2根治术后发生大出血的原因及治疗方法并探讨其对生存预后的影响。方法回顾性分析广东省中医院2012年1月至2016年3月258例行胃癌D2根治术患者的临床资料,根据术后是否发生大出血分为出血组和非出血组。结果14例患者(5.4%)术后发生大出血;吻合口出血、十二指肠残端瘘或破裂是出血的主要原因;二次手术和胃镜止血是主要治疗措施。两组的短期总生存期有统计学意义(1年:P=0.017,3年:P=0.011)。结论吻合口出血、十二指肠残端瘘或破裂是胃癌D2根治术后出血的主要原因,及时诊断和治疗能有效降低病死率。胃癌D2根治术后大出血会降低患者的短期总生存期。     

Postoperative pancreatic fistulas decrease the survival of pancreatic cancer patients treated with surgery after neoadjuvant chemoradiotherapy: A retrospective analysis

Background and objectivesA postoperative pancreatic fistula (POPF) is a critical complication after surgery for pancreatic cancer. Whether a POPF affects the long-term prognosis of pancreatic cancer cases remains controversial. This study aimed to clarify the effect of a POPF on the long-term prognosis of pancreatic cancer patients, especially after neoadjuvant chemoradiotherapy (NACRT).MethodsPatients who underwent curative pancreatectomy for pancreatic cancer between January 2012 and June 2019 at Kyoto University Hospital were retrospectively investigated. A fistula ≥ Grade B was considered a POPF.ResultsDuring the study period, 148 patients underwent upfront surgery (Upfront group), and 52 patients underwent surgery after NACRT (NACRT group). A POPF developed in 16% of patients in the Upfront group and 13% in the NACRT group (p = 0.824). In the Upfront group, development of a POPF did not have a significant effect on recurrence-free survival (p = 0.766) or overall survival (p = 0.863). However, in the NACRT group, development of a POPF significantly decreased recurrence-free survival (HR 5.856, p = 0.002) and overall survival (HR 7.097, p = 0.020) on multivariate analysis.ConclusionsThe development of a POPF decreases the survival of pancreatic cancer patients treated by surgery after NACRT.     

Outcome of patients with non-Hodgkin's lymphoma of the stomach after gastrectomy: clinicopathologic study and reclassification according to the revised European-American lymphoma classification

Background. The best treatment for patients with non-Hodgkin's lymphoma (NHL) of the stomach is still uncertain. The revised European-American lymphoma (REAL) classification has helped to define new, potentially more appropriate classification schemes for gastric lymphomas. Methods. Fifty-one resected gastric lymphomas were reclassified according to the REAL classification, and the efficacy of multimodal treatment was examined retrospectively. The principal treatment plan consisted of: (1) surgical resection of the stomach with lymph node dissection, followed by (2) systemic chemotherapy, mainly using the cyclophosphamide/doxorubicin/vincristine/prednisone (CHOP) regimen. Results. According to the Ann Arbor classification, 27 patients had stage IE, 19 had stage IIE, and 5 had stage IV NHL. Using the REAL classification, we diagnosed diffuse large B-cell lymphoma (DLBL) in 23 patients, marginal zone B-cell (low-grade mucosa-associated lymphoid tissue [MALT]-type) lymphoma in 22, follicle center lymphoma in 4, mantle cell lymphoma in 1, and peripheral T-cell lymphoma in 1 patient. Nine of the 51 patients relapsed, and 8 patients with DLBL died of cancer. Survival rates at 5 years after surgery were 96.0% for stage IE, 83.3% for stage IIE, and 87.0% for all patients. Univariate analysis indicated that the tumor histology (according to the REAL classification), depth of invasion, degree of nodal involvement, Ann Arbor staging, and chemotherapy had an impact on patient outcome (P = 0.0018; P = 0.0002; P = 0.0308; P = 0.0016, and P = 0.0118, respectively). Conclusions. These data reveal that gastric NHL, especially of the low-grade MALT-type, often remains localized and has a good prognosis after surgery. The REAL classification was useful for classifying new categories of NHL, including the MALT-type, in the clinical setting, and for determining the optimal treatment modality for gastric NHL. Received: December 11, 2000 / Accepted: July 18, 2001     

Delta-shaped anastomosis in totally laparoscopic D2 radical distal gastrectomy

With less injury and faster postoperative recovery, laparoscopic techniques have been widely applied in D2 radical gastrectomy for distal gastric cancer. Billroth I anastomosis is a common reconstruction procedure in D2 radical gastrectomy for distal gastric cancer. The delta-shaped anastomosis, an intra-abdominal Billroth I reconstruction, has been increasingly applied by gastrointestinal surgeons. This surgical video demonstrates the delta-shaped anastomosis in laparoscopic-assisted D2 radical gastrectomy for distal gastric cancer.Key Words: Gastric cancer, delta-shaped anastomosis, laparoscopyIn 2002, Professor Seiichiro Kanaya from Japan Himeji Medical Center first introduced the delta-shaped anastomosis (1), which was a Billroth I side-to-side anastomosis of the posterior walls of the remnant stomach and the duodenum using a laparoscopic linear stapler. During the anastomosis, the staple line was in a “V” shape, which would turn into a triangular shape after the anastomosis was closed, hence the name “delta-shaped anastomosis”. With increasing application of laparoscopic techniques in the D2 radical treatment of distal gastric cancer, the delta-shaped reconstruction has been gradually adopted in China.In April 2013, a 54-year-old woman presented with dull abdominal pain for three months was diagnosed with adenocarcinoma of the gastric angle by gastroscopic biopsy. The lesion had a diameter of about 3 cm. After routine preoperative preparation, total laparoscopic D2 distal gastrectomy was performed; the delta-shaped anastomosis was used to reconstruct the gastrointestinal tract during operation. An ultrasonic scalpel (Johnson & Johnson, U.S.) was used for anatomical separation, and the anastomosis was completed with a gastroscopic linear stapler (Tri-Staple).After general anesthesia, the patient was put in supine position with the head elevated and legs apart. During the surgery (Video 1), five trocars were inserted. CO₂ pneumoperitoneum of 12 mmHg was established. Standing on the left side of the patient, the surgeon divided the stomach and duodenum using an ultrasonic scalpel, and dissected the related lymph nodes according to the 2002 edition of the Gastric cancer treatment guidelines in Japan (2). A 60 mm gastroscopic linear stapler was inserted through the left upper trocar, which was used to transect the duedenum by rotating 90° from back to front. This would help to ensure the blood supply for anastomotic stoma. The stomach was then resected by successively transecting from the greater curvature to the lesser curvature with the stapler. A small incision was made to the remnant stomach and the edge of the duodenum respectively by the ultrasonic scalpel. The upper and lower anvils of a 60 mm linear stapler were inserted into one end respectively to close the posterior walls of the stomach and the duodenum. The stapling length was adjusted to 45 mm. Then the anastomosis of both ends was triggered. Upon confirmation of no leakage and bleeding of the anastomosis, the gastric tube was inserted into the distal anastomotic end of the duodenum. Finally, the common opening of the stomach and the duodenum was closed with the linear stapler.Open in a separate windowVideo 1Delta-shaped anastomosis in totally laparoscopic D2 radical distal gastrectomyThroughout the surgery, the delta-shaped anastomosis procedure lasted about more than 10 minutes. Both resected specimens had negative margins. A total of 30 lymph nodes were dissected. Pathological staging was T2N0M0. Flatus occurred three days after the surgery. Liquid diet was started on the fourth day, and the patient was discharged on the eighth day. Based on the follow-up so far, the patient has been free of postoperative complications.In short, the application of delta-shaped anastomosis with a linear stapler as part of the intraperitoneal Billroth I reconstruction is safe and feasible (3), allowing satisfying postoperative recovery and outcomes.     

Patterns of failure in gastric carcinoma after D2 gastrectomy and chemoradiotherapy: a radiation oncologist's view

The risk of locoregional recurrence in resected gastric adenocarcinoma is high, but the benefit of adjuvant treatment remains controversial. In particular, after extended lymph node dissection, the role of radiotherapy is questionable. Since 1995, we started a clinical protocol of adjuvant chemoradiotherapy after D2 gastrectomy and analysed the patterns of failure for 291 patients. Adjuvant chemotherapy consisted of five cycles of fluorouracil and leucovorin, and concurrent radiotherapy was given with 4500 cGy from the second cycle of chemotherapy. With a median follow-up of 48 months, 114 patients (39%) showed any type of failure, and the local and regional failures were seen in 7% (20 out of 291) and 12% (35 out of 291), respectively. When the recurrent site was analysed with respect to the radiation field, in-field recurrence was 16% and represented 35% of all recurrences. Our results suggest that adjuvant chemoradiotherapy has a potential effect on reducing locoregional recurrence. Moreover, low locoregional recurrence rates could give a clue as to which subset of patients could be helped by radiotherapy after D2 gastrectomy. However, in order to draw a conclusion on the role of adjuvant radiotherapy, a randomised study is needed.