Systematic review of pancreaticoduodenectomy for locally advanced gastric cancer

Background

The purpose of this study was to identify and synthesize findings from all articles on surgical and long-term outcomes in patients with gastric cancer undergoing gastrectomy combined with pancreaticoduodenectomy (PD).

Methods

Electronic literature searches were conducted using Medline, EMBASE, and Cochrane databases from January 1, 1985, to December 31, 2009.

Results

Eight retrospective case series were included, with 132 patients having PD combined with gastrectomy. PD was combined with total gastrectomy in 27 patients, and subtotal gastrectomy in 81 patients; 24 patients had undocumented gastric resection type. Clinical stage was available for 92 patients (4 stage I, 7 stage II, 26 stage III, and 55 stage IV). Five studies (98 patients having PD combined with gastrectomy) compared PD and gastrectomy to gastrectomy alone. In the four studies reporting morbidity, PD had a higher morbidity. The pooled pancreatic anastomotic leak rate was 24.5% for the seven studies in which complications were reported; however, there were no peri-operative deaths. Long-term survival (37.3% at 5 years) in gastric cancer patients with PD combined with gastrectomy was described; however, survival was poor in the setting of incurable factors. Due to heterogeneity of patients and staging techniques in the case series no recommendations can be made on the appropriate selection criteria for patients undergoing PD and gastrectomy.

Conclusion

PD for gastric cancer invading the pancreas is associated with a higher morbidity; given the heterogeneous data, defining exact selection criteria is difficult.

     

Long-term outcomes of laparoscopy-assisted distal gastrectomy with suprapancreatic nodal dissection for clinical stage I gastric cancer: a multicenter phase II trial (JCOG0703)

Background

Laparoscopic gastrectomy has become a common surgical treatment for gastric cancer in eastern Asian countries. However, a large-scale prospective study to investigate the benefit of laparoscopy-assisted distal gastrectomy (LADG) regarding long-term outcomes has never been reported. We have already reported the short-term outcomes of this study. Here we report long-term outcomes as the secondary endpoints of this study after a 5-year follow-up period.

Methods

This study comprised patients with clinical stage I gastric cancer who were able to undergo a distal gastrectomy. LADG with D1 plus suprapancreatic lymph node dissection was performed by credentialed gastric surgeons who had each conducted at least 30 LADG and 30 open gastrectomy procedures. The primary endpoint was the proportion of patients who developed either anastomotic leakage or pancreatic fistula. The secondary endpoints included overall survival and relapse-free survival.

Results

From November 2007 to September 2008, 176 eligible patients were enrolled, comprising 140 patients with pathological stage IA disease, 23 patients with pathological stage IB disease, 9 patients with pathological stage II disease, and 4 patients with pathological stage IIIA disease. No patients had recurrent disease, and three of the patients died within the follow-up period. The 5-year overall survival was 98.2% (95% confidence interval 94.4–99.4%) and the 5-year relapse-free survival was 98.2% (95% confidence interval 94.4–99.4%).

Conclusions

The long-term outcomes of stage I gastric cancer patients undergoing LADG seem comparable to those of patients undergoing an open procedure, although this result should be confirmed by a randomized control trial. We have already completed accrual of 921 patients for a multicenter randomized phase III trial (JCOG0912) to confirm the noninferiority of LADG compared with open gastrectomy in terms of relapse-free survival.

     

A systematic review of surgery for non-curative gastric cancer

Background

Most gastric cancer patients present with advanced stage disease precluding curative surgical treatment. These patients may be considered for palliative resection or bypass in the presence of major symptoms; however, the utility of surgery for non-curative, asymptomatic advanced disease is debated and the appropriate treatment strategy unclear.

Purpose

To evaluate the non-curative surgical literature to better understand the limitations and benefits of non-curative surgery for advanced gastric cancer.

Methods

A literature search for non-curative surgical interventions in gastric cancer was conducted using MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials databases from 1 January 1985 to 1 December 2009. All abstracts were independently rated for relevance by a minimum of two reviewers. Outcomes of interest were procedure-related morbidity, mortality, and survival.

Results

Fifty-nine articles were included; the majority were retrospective, single institution case series. Definitions describing the treatment intent for gastrectomy were incomplete in most studies. Only five were truly performed with relief of symptoms as the primary indication for surgery, while the majority were considered non-curative or not otherwise specified. High rates of procedure-related morbidity and mortality were demonstrated for all surgeries across the majority of studies and treatment-intent categories. Median and 1-year survival were poor, and values ranged widely within surgical approaches and across studies.

Conclusions

A lack of transparent documentation of disease burden and symptoms limits the surgical literature in non-curative gastric cancer. Improved survival is not evident for all patients receiving non-curative gastrectomy. Further prospective research is required to determine the optimal intervention for palliative gastric cancer patients.

     

A systematic review of the indications for genetic testing and prophylactic gastrectomy among patients with hereditary diffuse gastric cancer

Background

Hereditary diffuse gastric cancer (HDGC) is a familial cancer syndrome specifically associated with germline mutations to the E-cadherin (CDH1) gene. HDGC is characterized by autosomal dominance and high penetrance and a high cumulative risk for advanced gastric cancer. Our purpose in this study was to identify and synthesize findings from all articles on: (1) current recommendations for CDH1 screening and prophylactic gastrectomy; (2) CDH1 testing results in HDGC patients; and (3) prophylactic gastrectomy results in HDGC patients.

Methods

Systematic electronic literature searches were conducted using Medline, Embase, and the Cochrane Central Register of Controlled Trials from 1985 to 2009.

Results

Seventy articles were included in this review. Among patients with a positive family history of gastric cancer, 1085 were screened from 454 families, and 38.4% tested positive. Mutation-positive families also had a considerable family history of breast and colon cancer. Of the 322 patients screened for CDH1 mutations by current HDGC screening criteria, 29.2% tested positive. Among the 76.8% of patients who underwent prophylactic gastrectomy following positive CDH1 test results, 87.0% had positive final histopathology results and 64.6% had signet ring cells identified. Some of the patients with negative final histopathology results had opted to undergo prophylactic gastrectomy prior to CDH1 testing, and were ultimately found to be negative for CDH1 mutations.

Conclusion

CDH1 mutation testing in families with a history of gastric cancer and prophylactic gastrectomy in mutation-positive patients are recommended for the management of HDGC.

     

The value of diagnostic endoscopic submucosal dissection for patients with clinical submucosal invasive early gastric cancer

Background

The standard treatment for clinical submucosal invasive (cT1b) early gastric cancer is gastrectomy. However, Japanese gastric cancer treatment guidelines list endoscopic submucosal dissection (ESD) as an option for treating limited early gastric cancer cases. ESD can be curative depending on the pathological characteristics of resected specimens. Thus, we aimed to clarify the benefits and disadvantages of preceding ESD for early gastric cancer.

Methods

We retrospectively analyzed patients who underwent ESD or curative gastrectomy for cT1b gastric cancer with differentiated adenocarcinoma 30 mm or less in diameter. Patients who underwent ESD irrespective of undergoing gastrectomy were assigned to the ESD group (n = 107), and those who underwent gastrectomy without undergoing ESD were assigned to the non-ESD group (n = 181). Clinicopathological characteristics were assessed, and the short-term and long-term outcomes of patients were compared.

Results

The criteria for curative resection were satisfied by 83 patients (28.8%), and preceding ESD did not affect the surgical outcomes of gastrectomy. Two patients (1.9%) who underwent ESD had an unscheduled total gastrectomy. The en bloc and complete resection rates of ESD were 99.0% and 84.1% respectively. Nine patients (8.4%) experienced intraprocedure perforation and postprocedure bleeding caused by ESD. Overall survival (hazard ratio 1.38; P = 0.302) and cause-specific survival (hazard ratio 0.96; P = 0.944) were comparable between groups.

Conclusions

The stomach was preserved in 28.8% of patients, and preceding ESD did not show obvious disadvantages. Therefore, diagnostic ESD should be considered as an initial treatment for limited cT1b gastric cancer cases.

     

Surgical management of gastric perforation in the setting of gastric cancer

Background

Gastric perforation is a rare presentation of gastric cancer and is thought to be a predictor of advanced disease and, thus, poor prognosis. Guidelines do not exist for the optimal management strategy. We aimed to identify, review, and summarize the literature pertaining to perforation in the setting of gastric cancer.

Methods

A qualitative, systematic review of the literature was performed from January 1, 1985, to January 1, 2010. Searches of MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were performed using search terms related to gastric cancer surgery. Abstracts were examined by two independent reviewers and a standardized data collection tool was used to extract relevant data points. Summary tables were created.

Results

Nine articles were included. Perforation was reported to occur in fewer than 5% of gastric cancer patients. Preoperative diagnosis of a gastric cancer was rated and occurred in 14–57% of patients in the papers reviewed. Mortality rates for emergency gastrectomy ranged from 0 to 50% and for simple closure procedures the rates ranged from 8 to 100%. Patients able to receive an R0 gastrectomy demonstrated better long-term survival (median 75 months, 50% 5-year) compared with patients who had simple closure procedures.

Conclusions

Gastric cancer patients presenting with a gastric perforation demonstrate improved overall survival with an R0 resection; however, implementation of this management technique is complicated by infrequent preoperative gastric cancer diagnosis, and inability to perform an oncologic resection due to patient instability and intra-abdominal contamination.

     

Clinical outcomes of early gastric cancer patients after noncurative endoscopic submucosal dissection in a large consecutive patient series

Background

Clinical outcomes of early gastric cancer (EGC) patients after noncurative endoscopic submucosal dissection (ESD) have not been fully elucidated; we therefore aimed to clarify these outcomes.

Methods

A total of 3058 consecutive patients with 3474 clinically diagnosed EGCs at initial onset underwent ESD with curative intent at our hospital between 1999 and 2010. We retrospectively assessed the following clinical outcomes of noncurative gastric ESD patients with a possible risk of lymph node (LN) metastasis by dividing patients into two groups with different treatment strategies (additional gastrectomy and simple follow-up): presence of LN metastasis at the time of gastrectomy, incidence of LN and distant metastases during the follow-up period, clinicopathological factors associated with metastasis, and 5-year disease-specific survival (DSS).

Results

After exclusion of 75 noncurative ESD patients with only a positive horizontal margin, 569 noncurative ESD patients with a possible risk of LN metastasis were identified. Among the 356 patients undergoing additional gastrectomy, LN metastasis was identified in 18 patients. A positive vertical margin with submucosal invasion (odds ratio 3.6) and lymphovascular invasion (odds ratio 3.5) were significantly associated with LN metastasis. The 5-year DSS rate was 98.8 %. Among the 212 patients who underwent simple follow-up, LN and/or distant metastases were found in eight patients. In this group, lymphovascular invasion (hazard ratio 6.6) was significantly associated with metastasis with a 5-year DSS rate of 96.8 %.

Conclusions

Additional gastrectomy should be performed particularly in noncurative gastric ESD patients with lymphovascular invasion or a positive vertical margin with submucosal invasion.

     

IL-6 serum levels predict postoperative morbidity in gastric cancer patients

Background

Despite progress in surgical techniques and perioperative care, gastrectomy remains a procedure of significant morbidity. Several scoring systems and clinical measures have been adopted to predict postoperative complications in gastric cancer patients. The aim of this study was to investigate whether high serum levels of interleukin 6 (IL-6) in the early postoperative period may be a prognostic factor of postoperative morbidity.

Methods

A group of 99 consecutive patients with resectable gastric cancer were enrolled. The mean age was 62.9 years and the male/female ratio was 72:27. Subtotal gastric resection was performed in 22 patients and total gastric resection in 77. The IL-6 serum level was measured on the 1st postoperative day (POD).

Results

Complications were recorded in 28 patients (28.3%). The observed case-fatality rate was 3.03%. An IL-6 serum level of >288.7 pg/ml on the 1st POD in univariate and multivariate Cox proportional hazard models was an independent prognostic factor for overall complications and infective complications.

Conclusion

Our study showed an association between perioperative IL-6 serum levels and postoperative morbidity in gastric cancer patients. The IL-6 serum level on the 1st POD was shown to be an independent prognostic factor for both overall complications and infective complications.

     

Risk of osteoporosis after gastrectomy in long-term gastric cancer survivors

Introduction

Although early detection and successful gastrectomy have improved the survival of patients with gastric cancer, long-term health problems remain troubling. We evaluated the prevalence of osteoporosis and its risk factors in long-term survivors of gastric cancer after gastrectomy.

Methods

We reviewed the medical records of a tertiary hospital between 2007 and 2014 to identify survivors of gastric cancer who had visited our center at around 5 years after gastrectomy. We evaluated their health status, including bone mineral density (BMD). Dual-energy X-ray absorptiometry was used to measure the BMD of the lumbar spine and femur (total and neck area). The prevalence of osteoporosis, defined by a BMD T score <?2.5, was investigated, and clinical variables associated with the presence of osteoporosis were identified.

Results

A total of 250 survivors were included. The mean age was 54.6 years old, and the median follow-up was 6.0 years. The prevalence of osteoporosis was 34.0% (27.4% for men and 43.6% for women). Older age [odds ratio (OR) 5.50, 95% CI 2.33–13.00], higher alkaline phosphatase levels before gastrectomy (OR 5.67, 95% CI 1.36–23.64), and marked weight loss (≥20%) after gastrectomy (OR 3.59, 95% CI 1.32–9.77) were independently associated with the presence of osteoporosis.

Conclusions

In our cohort, osteoporosis was commonly observed in long-term survivors of gastric cancer, and several risk factors for it were identified. To reduce the risk of osteoporosis after gastrectomy, maintaining adequate body weight may be necessary.

     

Modest overall survival improvements from 1998 to 2009 in metastatic gastric cancer patients: a population-based SEER analysis

Background

An increasing fraction of gastric cancer patients present with distant metastases at diagnosis. The objective of the present 11-year population-based trend analysis was to assess the survival rates in patients who underwent and in patients who did not undergo palliative gastrectomy.

Methods

Patients with metastatic gastric cancer were identified from the Surveillance, Epidemiology, and End Results (SEER) database between 1998 and 2009. Time trend and impact of palliative gastrectomy on survival were assessed by both a multivariate Cox proportional hazards model and propensity score matching.

Results

We identified 8249 patients with stage IV gastric cancer. The rate of metastatic disease increased from 31.0 % in 1998 to 37.5 % in 2009 (P < 0.001). The palliative gastrectomy rate dropped from 18.8 to 10.2 % (P = 0.004). The median survival for patients who underwent palliative gastrectomy (N = 1445, 17.4 %) and for patients who did not undergo palliative gastrectomy (N = 6804, 82.4 %) was 7 and 3 months, respectively. There was an increase in median overall survival from 2 months (1998) to 3 months (2009) in the no-gastrectomy group, and from 6.5 to 8 months in the gastrectomy group. The 3-year cancer-specific survival rates were 2.1 % (95 % confidence interval 1.7–2.5 %) for patients who did not undergo palliative gastrectomy and 9.4 % (95 % confidence interval 7.8–11.2 %) for patients who underwent palliative gastrectomy (P < 0.001). Palliative gastrectomy was associated with an increased cancer-specific survival in propensity-score-adjusted Cox regression analyses (hazard ratio 0.50, 95 % confidence interval 0.46–0.55, P < 0.001).

Conclusion

On a population-based level, only modest improvements in prognosis for metastatic gastric cancer were observed in patients who underwent and in patients who did not undergo palliative gastrectomy. Considering the low rate of midterm survivors in both groups, only a small subgroup of patients benefits from palliative gastrectomy.

     

Histopathological factors predicting response to neoadjuvant therapy in gastric carcinoma

Background

Neoadjuvant therapy (NAT) is a useful therapeutic option. However, some patients respond poorly to it and can even show tumor progression. It is important to define factors that can predict response to NAT.

Materials and methods

This is a retrospective cohort study to define histopathological factors predicting response to NAT in gastric tubular carcinoma. This study has enrolled 80 patients receiving chemotherapy for locally advanced gastric carcinoma.

Results

44.5% of the patients were men; mean age was 64.49 years. Only 5.7% of the patients showed a complete response to therapy, 10% had grade 1, 21.4% grade 2, and 62.9% grade 3 regression. On follow-up, 43.8% of the patients showed recurrence of disease (57.1% distant metastasis) and 33.8% eventually died of it. We found a statistically significant association between response and prognosis. We found a statistically significant association between regression and perineural, vascular, and lymph vessel invasion. Logistic regression model showed that only lymph vessel invasion had independent influence. Lymph vessel invasion not only indicated lack of response to therapy, but also higher incidence of lymph node involvement in the gastrectomy specimen.

Discussion

Our study indicates that the presence of vascular or perineural invasion in the endoscopic biopsies and high histopathological grade predict poor response to therapy. This seems peculiar, for undifferentiated tumors are supposed to have better response to therapy.

Conclusion

Our study indicates that undifferentiated tumors respond worse to therapy. Furthermore, studies are necessary to define lack of response, to help avoid neoadjuvant therapy in unfavorable cases.

     

Chirurgische Therapie des Magenkarzinoms

Background

Gastric cancer is one of the few tumor entities with a decreasing incidence but still constitutes a main cause of cancer-related deaths worldwide. The gold standard in therapy regimes with curative intent is surgery; however, palliative regimes should also include surgery in selected cases. Minimally invasive techniques are becoming established leading to improved perioperative outcomes.

Objective

Review of current oncological standards with a focus on the surgical approach in gastric cancer patients, discussion of current controversies regarding surgery with curative and palliative intent and outcomes of minimally invasive techniques.

Material and methods

Review of the literature on surgery of gastric cancer including conventional and minimally invasive tecnhniques.

Results

Surgery is the gold standard in regimes with curative intent for gastric cancer patients. The histological subtype is the basis for decision-making with respect to the extent of gastric resection. Radical D2 lymphadenectomy is the current standard in western countries. Multivisceral resection for locally advanced cancer is worthwhile in selected patients in terms of improved long-term survival despite potentially higher morbidity rates.. In palliative settings surgery can be a tool to improve the quality of life and to control tumor-related complications

Conclusion

Minimally invasive techniques are one of the main technical options to improve the perioperative outcome in gastric cancer patients. Multimodal therapy regimes may improve the quality of life and survival in curative and palliative settings.

     

Development and external validation of preoperative risk models for operative morbidities after total gastrectomy using a Japanese web-based nationwide registry

Background

Total gastrectomy is a relatively difficult and invasive procedure among gastrointestinal surgeries, and major morbidities following total gastrectomy can be serious and fatal. This study aimed to develop and validate preoperative risk models of morbidities associated with total gastrectomy using a Japanese web-based nationwide registry.

Methods

The national clinical database was used to retrieve the records of 39,253 patients who underwent total gastrectomy in 1,841 hospitals between January 1, 2011 and December 31, 2012.

Results

Mean patient age was 69.1 years, and 73.8% of the patients were male. The overall morbidity rate was 21.5%, which included 8.1% with surgical site infection (SSI), 4.5% with anastomotic leak, 5.0% with pancreatic fistula, 3.7% with pneumonia, 1.9% with prolonged ventilation, and 1.2% with renal failure. Sex, splenectomy, and Brinkman index were selected as common risk factors for SSI, anastomotic leak, and pancreatic fistula. Pancreatectomy was the most significant preoperative risk factor in the risk model of SSI and pancreatic fistula. Need of assistance with activities of daily living, chronic obstructive pulmonary disease, previous cerebrovascular disease, American Society of Anesthesiologists score class 3 and over, presence of esophageal cancer, and body mass index more than 25 were selected as common risk factors for pneumonia, prolonged ventilation over 48 h, and renal failure.

Conclusions

We have created the first reported risk models of morbidities associated with total gastrectomy, using a Japanese nationwide database. The risk models developed in this study may be useful to preoperatively predict operative morbidities in patients undergoing total gastrectomy.

     

Side overlap esophagogastrostomy to prevent reflux after proximal gastrectomy

Background

No optimal method of reconstruction for proximal gastrectomy has been established because of problems associated with postoperative reflux and anastomotic stenosis. It is also important that the reconstruction is easily performed laparoscopically because laparoscopic gastrectomy has become widely accepted in recent years.

Methods

We have developed a new method of esophagogastrostomy, side overlap with fundoplication by Yamashita (SOFY). The remnant stomach is fixated to the diaphragmatic crus on the dorsal side of the esophagus. The esophagus and the remnant stomach are overlapped by a length of 5 cm. A linear stapler is inserted in two holes on the left side of the esophageal stump and the anterior gastric wall. The stapler is rotated counterclockwise on its axis and fired. The entry hole is closed, and the right side of the esophagus is fixated to the stomach so that the esophagus sticks flat to the gastric wall. The surgical outcomes of the SOFY method were compared with those of esophagogastrectomy different from SOFY.

Results

Thirteen of the 14 patients in the SOFY group were asymptomatic without a proton pump inhibitor, but reflux esophagitis was observed in 5 of the 16 patients in the non-SOFY group and anastomotic stenosis was observed in 3 patients. Contrast enhancement findings in the SOFY group showed inflow of Gastrografin to the remnant stomach was extremely good, and no reflux into the esophagus was observed even with patients in the head-down tilt position.

Conclusions

SOFY can be easily performed laparoscopically and may overcome the problems of postoperative reflux and stenosis.

     

Systematic review of the predictors of positive margins in gastric cancer surgery and the effect on survival

Background

Complete resection is the only definitive treatment available for gastric cancer. Factors associated with positive margins and their survival effects have been the subject of many studies, but the appropriate management for these patients is still debated. The objective of this review is to examine positive margins after gastric cancer resections by exploring predictive factors, impact on survival, and optimal strategies for re-resection.

Methods

A systematic electronic literature search was conducted using Medline and EMBASE from January 1, 1998, to December 31, 2009. Studies on gastric or gastroesophageal junction adenocarcinoma that either investigated the predictors for positive margin or employed multivariate methods to analyze the survival effects of positive margins were selected.

Results

Twenty-two studies incorporating 19355 patients were included in this review. Positive margins were associated with larger tumor size, deeper wall penetration, more extensive gastric involvement, greater nodal involvement, higher stage, diffuse histology, higher Borrmann type, lymphatic vessel involvement, and total gastrectomy. Patient survival was independently associated with margin status, and this survival effect was more prominent in early cancers in most studies that performed subgroup analyses.

Conclusions

The probability of acquiring positive margins is highly dependent on the biology and the extent of the tumor. There is a significant negative effect on survival, which is more prominent in cancers at early stages, making re-resection or a second operation important. Patients with more advanced disease can be offered more extensive surgery to remove disease, but this should be balanced against the risks of more extensive resections.

     

Short-term outcomes and nutritional status after laparoscopic subtotal gastrectomy with a very small remnant stomach for cStage I proximal gastric carcinoma

Background

Total or proximal gastrectomy is usually performed for early proximal gastric carcinoma, but the optimal type of gastrectomy is still unknown. We evaluated short-term outcomes and nutritional status after laparoscopic subtotal gastrectomy (LsTG) in comparison with laparoscopic total gastrectomy (LTG) and laparoscopic proximal gastrectomy (LPG).

Methods

We analyzed 113 patients who underwent LsTG (n = 38), LTG (n = 48), or LPG (n = 27) for cStage I gastric cancer located in the upper third of the stomach. Postoperative morbidities, nutritional status including body weight, serum albumin, hemoglobin, the prognostic nutritional index (PNI), and endoscopic findings at 1 year after surgery were compared between LsTG and both LTG and LPG.

Results

Operation time and intraoperative blood loss were similar among the three groups. The incidence of postoperative morbidities was lower in LsTG than in LTG. The degree of body weight loss was significantly smaller in LsTG than in LTG at 6 and 12 months. At 12 months, LsTG resulted in better serum albumin and PNI than LPG, and better hemoglobin than LTG. Endoscopic examination demonstrated that one LsTG patient and two LPG patients had reflux esophagitis. Remnant gastritis was observed more frequently in LPG than in LsTG. No LsTG patient had bile reflux, although it was observed in four LPG patients.

Conclusions

LsTG with a very small remnant stomach had favorable short-term outcomes and nutritional status compared with LTG and LPG, so it may be a better treatment option for cStage I proximal gastric carcinoma.

     

Favorable long-term outcomes of one-year adjuvant S-1 monotherapy for pathological stage II or III gastric cancer treated at a high-volume center

Background

One-year adjuvant S-1 monotherapy following D2 gastrectomy has been the Japanese treatment standard for pathological stage II or III gastric cancer since the Adjuvant Chemotherapy Trial of S-1 for Gastric Cancer (ACTS-GC) was concluded in 2007. Trial patients were selected according to the 13th edition of the Japanese classification (JC-13). The JC-13 and the TNM classification underwent major revisions in 2010 (JC-14/TNM-7). However, neither the recent therapeutic results for patients with stage II/III disease defined by the current system nor comparisons with the ACTS-GC-results have been reported.

Methods

The 390 study patients had pathological stage II/III gastric cancer defined by the JC-14/TNM-7 and treated with S-1 following D2 gastrectomy between 2008 and 2012. The completion rate of 1-year S-1, first relapse site, and stage-specific survival according to the JC-14/TNM-7, JC-13, and TNM-6 were examined and the results compared with those of the ACTS-GC.

Results

The completion rate for 1-year S-1 (69.5%) was slightly higher than in the ACTS-GC. The recurrence pattern was almost identical. The 5-year overall survival rates of pathological IIA, IIB, IIIA, IIIB, and IIIC in the JC-14/TNM-7 were 96.0, 85.5, 81.8, 72.0, and 51.1%, respectively. Their 5-year overall and relapse-free survival rates by the JC-13 and TNM-6 systems were favorable as compared to those of ACTS-GC patients for all substages.

Conclusions

Survival outcome shown in this study of patients treated with 1-year adjuvant S-1 after D2 gastrectomy at a high-volume cancer hospital will provide a reference for future adjuvant trials targeting JC-14/TNM-7 stage II/III disease.

     

Robotic gastrectomy for elderly gastric cancer patients: comparisons with robotic gastrectomy in younger patients and laparoscopic gastrectomy in the elderly

Background

Robotic surgery for gastric cancer has been adopted to overcome technical difficulties in performing laparoscopic gastrectomy. This study aimed to investigate the feasibility and safety of robotic gastrectomy in elderly gastric cancer patients.

Methods

Patients who underwent laparoscopic or robotic gastrectomy from 2003 to 2010 in a single high-volume center were included in this study. We retrospectively compared preoperative characteristics, perioperative factors, and oncological parameters among an elderly (≥70 years old) robotic gastrectomy group (n = 49), a younger (<70 years old) robotic gastrectomy group (n = 321), and an elderly laparoscopic gastrectomy group (n = 132).

Results

The elderly robotic group presented with more comorbidities than the younger robotic group. Except for number of retrieved lymph nodes (36.5 vs. 41.5; P = 0.007), short-term operative outcomes including complications and pathological parameters were comparable between the two robotic groups. The elderly robotic group showed comparable disease-specific survival to the younger robotic group although overall survival was worse. Compared to their laparoscopic counterparts, the elderly robotic group showed longer mean operation time (227 vs. 174 min). Nevertheless, the incidence and severity of postoperative complications was not different between the two elderly groups. Overall and disease-specific survival were also comparable between the elderly groups. In multivariate analysis, age and surgical approach were not risk factors for overall and major complications.

Conclusions

The outcomes of robotic gastrectomy in the elderly did not differ from those in younger robotic gastrectomy patients and were comparable to those in elderly patients who underwent laparoscopic gastrectomy. Thus, robotic gastrectomy could be a safe and feasible approach in elderly patients.

     

Multivisceral resection for gastric cancer: a systematic review

Background

The overall prognosis and survival of patients with advanced gastric cancer is generally poor. One of the most powerful predictors of outcomes in gastric cancer surgery is an R0 resection. However, the extent of the required surgical resection and the additional benefit of multivisceral resection (MVR) are controversial.

Methods

Electronic literature searches were conducted using Medline, EMBASE, and the Cochrane Central Register of Controlled Trials from January 1, 1998 to December 31, 2009. All search titles and abstracts were independently rated for relevance by a minimum of two reviewers.

Results

Seventeen studies were included in this review. Among the 1343 patients who underwent MVR, overall complication rates ranged from 11.8 to 90.5%. Perioperative mortality was found to be 0–15%. Pathological T4 disease was confirmed in 28.8–89% of patients. R0 resection and extent of nodal involvement were important predictors of survival in patients undergoing MVR. Patient outcomes may also be affected by the number of organs resected.

Conclusions

Gastrectomy with MVR can be safely pursued in patients with locally advanced gastric cancer to achieve an R0 resection. MVR may not be beneficial in patients with extensive nodal disease.

     

Putative risk factors for postoperative pneumonia which affects poor prognosis in patients with gastric cancer

Background and objectives

Several recent studies identified that postoperative infectious complications contribute to recurrence and poor outcome in patients with gastric cancer. This study was designed to investigate the prognostic impact of postoperative pneumonia, and to identify the putative risk factors for its occurrence.

Methods

We retrospectively analyzed 1,415 consecutive patients who underwent curative gastrectomy for gastric cancer between 1997 and 2013.

Results

A total of 31 (2.2 %) patients developed postoperative pneumonia (Clavien–Dindo classification ≥II). Patients with postoperative pneumonia showed a significantly poorer prognosis than patients without (P < 0.001). Concerning the occurrence of postoperative pneumonia, univariate and multivariate analyses identified older age (≥65 years; P = 0.010; odds ratio [OR] 3.59), lower nutritious status (albumin <3 0; P = 0.029; OR 4.51), advanced stage (pStage ≥II; P = 0.045; OR 2.35), concurrent hypertension (P = 0.042; OR 2.21) and total gastrectomy (P = 0.026; OR 2.42) as independent risk factors.

Conclusions

Postoperative pneumonia was shown to be associated with long-term poor outcome in patients with gastric cancer. Care should be taken for patients with clinical factors such as older age, lower nutritional status, advanced stage, concurrent hypertension, and total gastrectomy.