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Studies have shown that traditional nutrition indicators and body composition indicators are closely related to prognosis after radical gastric cancer (GC) surgery. However, the effect of the combined muscle and adipose composite on the prognosis of GC has not been reported.The clinicopathological data of 514 patients with GC were retrospectively analyzed. The skeletal muscle adipose tissue were measured by preoperative CT images to obtain the muscle index and adipose index. X-tile software was used to determine the diagnostic threshold of muscle-adipose imbalance.The 5-year OS and RFS of the muscle-adipose imbalanced group were significantly worse than those of the balanced group. Multivariate analysis showed that muscle-adipose imbalance and the CONUT score were independent prognostic factors of OS and RFS (p0.05). The nuclear density curve showed that the recurrence risk of the muscle-adipose imbalanced group was higher than that of the balanced group, whereas the nuclear density curve of the CONUT score was confounded. Incorporating the muscle-adipose index into cTNM has the same prognostic performance as the pTNM staging system. Chemotherapy-benefit analysis showed that stage II/III patients in the muscle-adipose balanced group could benefit from adjuvant chemotherapy.The preoperative muscle-adipose index discovered for the first time is a new independent prognostic factor that affects the prognosis with GC. In addition, the preoperative muscle-adipose index is better than traditional nutrition and body composition indicators in terms of the prognostic evaluation of GC patients and the predictive value of recurrence risk.

The tumor immunosuppressive microenvironment can influence treatment response and outcomes. A previously validated immunosuppression scoring system (ISS) assesses multiple immune checkpoints in gastric cancer (GC) using tissue-based assays. We aimed to develop a radiological signature for non-invasive assessment of ISS and treatment outcomes.A total of 642 patients with resectable GC from three centers were divided into four cohorts. Radiomic features were extracted from portal venous-phase CT images of GC. A radiomic signature for predicting ISS (RISS) was constructed using the least absolute shrinkage and selection operator (LASSO) regression method. Moreover, we investigated the value of the RISS in predicting survival and chemotherapy response.The RISS, which consisted of 10 selected features, showed good discrimination of immunosuppressive status in three independent cohorts (area under the curve = 0.840, 0.809, and 0.843, respectively). Multivariate analysis revealed that the RISS was an independent prognostic factor for both disease-free survival (DFS) and overall survival (OS) in all cohorts (all p 0.05). Further analysis revealed that stage II and III GC patients with low RISS exhibited a favorable response to adjuvant chemotherapy (OS: hazard ratio [HR] 0.407, 95% confidence interval [CI] 0.284-0.584); DFS: HR 0.395, 95% CI 0.275-0.568). Furthermore, the RISS could predict prognosis and select stage II and III GC patients who could benefit from adjuvant chemotherapy independent of microsatellite instability status and Epstein-Barr virus status.The new, non-invasive radiomic signature could effectively predict the immunosuppressive status and prognosis of GC. Moreover, the RISS could help identify stage II and III GC patients most likely to benefit from adjuvant chemotherapy and avoid overtreatment.

An accurate recurrence risk assessment system and surveillance strategy for hepatoid adenocarcinoma of the stomach (HAS) remain poorly defined. This study aimed to develop a nomogram to predict postoperative recurrence of HAS and guide individually tailored surveillance strategies.The study enrolled all patients with primary HAS who had undergone curative-intent resection at 14 institutions from 2004 to 2019. Clinicopathologic variables with statistical significance in the multivariate Cox regression were incorporated into a nomogram to build a recurrence predictive model.The nomogram of recurrence-free survival (RFS) based on independent prognostic factors, including age, preoperative carcinoembryonic antigen, number of examined lymph nodes, perineural invasion, and lymph node ratio, achieved a C-index of 0.723 (95% confidence interval [CI], 0.674-0.772) in the whole cohort, which was significantly higher than those of the eighth American Joint Committed on Cancer (AJCC) staging system (C-index, 0.629; 95% CI, 0.573-0.685; P0.001). The nomogram accurately stratified patients into low-, middle-, and high-risk groups of postoperative recurrence. The postoperative recurrence risk rates for patients in the middle- and high-risk groups were respectively 3 and 10 times higher than for the low-risk group. The patients in the middle- and high-risk groups showed more recurrence and metastasis, particularly multiple site metastasis, within 36 months after the operation than those in the low-risk group (low, 2.2%; middle, 8.6%; high, 24.0%; P = 0.003).The nomogram achieved good prediction of postoperative recurrence for the patients with HAS after radical resection. For the middle- and high-risk patients, more active surveillance and targeted examination methods should be adopted within 36 months after the operation, particularly for liver and multiple metastases.

The systemic inflammatory response caused by host-tumor interactions is currently recognized as a hallmark feature of cancer. No study has confirmed which systemic inflammatory factors can accurately predict the progression and long-term prognosis of gastric cancer (GC). Through the analysis of receiver operating characteristic curve (ROC), in the discovery cohort, a variety of indicators composed of usual inflammatory factors were compared. Fibrinogen-albumin ratio (FAR), which can accurately predict the long-term survival of GC patients was selected and was further verified in the test cohort and the external validation cohort. The ROC curve analysis showed that the area under curve (AUC) value of FAR on the overall survival (OS) of GC patients was higher than that of other combined markers (P < 0.01). Patients in the high FAR group showed more advanced pathological stages, larger tumor diameters, and more poorly differentiated pathological type than those in the low FAR group (P < 0.05). Logistic regression analysis elucidated that, FAR was an independent risk factor for LN metastasis and tumor invasion of GC. High FAR was an independent risk factor for poor prognosis of GC patients. The relationship between FAR and pathological stage of GC and long-term prognosis of patients was verified in the test cohort and the external validation cohort with the same FAR cutoff value. The results are consistent with those of the discovery cohort. As a new developed inflammation-related marker, FAR can independently and effectively predict the tumor burden and long-term prognosis of patients with advanced GC.

The application of splenic hilar lymph node (no. 10 LN) dissection (no. 10 LND) for proximal gastric cancer (PGC) remains controversial. This study aimed to investigate the clinical relevance of no. 10 LND from the perspective of long-term survival. The main study population included 995 previously untreated patients who underwent laparoscopic radical total gastrectomy between January 2008 and December 2014. Of these 995 patients, 564 underwent no. 10 LND (no. 10D+ group) and the remaining 431 patients did not (no. 10D– group). Propensity score-matching was applied to reduce the effects of confounding factors. The study end points were overall survival (OS) and disease-free survival (DFS). Additionally, 39 patients who received neoadjuvant chemotherapy during the same period also were included as a separate population for analysis. The metastasis rate for no. 10 LN was 10.5 % (59/564). No significant differences were observed in intra- and postoperative complications nor in mortality between the no. 10D+ and no. 10D– groups (all P > 0.05). After 1:1 matching, the two groups were comparable in clinicopathologic characteristics. The no. 10D+ group had significantly better survival than the no. 10D– group (5-year OS: 63.3 % vs 52.2 %, P = 0.003; 5-year DFS: 60.4 % vs 48.1 %, P = 0.013). For the patients who received neoadjuvant chemotherapy, the 5-year OS rates in the no. 10D+ and no. 10D– groups were respectively 50.6 % and 31.3 % (P = 0.150) and the 5-year DFS rates were respectively 51.5 % and 31.3 % (P = 0.123). Patients with untreated PGC may achieve the benefit of long-term survival from no. 10 LND. For patients with PGC who undergo neoadjuvant chemotherapy, no. 10 LND may not bring survival benefits. However, further validation with a large-sample study is needed.

Totally laparoscopic total gastrectomy (TLTG) and laparoscopic-assisted total gastrectomy (LATG) are two types of minimally invasive radical gastrectomy procedures to treat gastric cancer (GC). This study compared the long-term prognosis and postoperative health-related quality of life (HRQoL) between TLTG and LATG.A total of 106 patients who underwent TLTG and 1,076 patients who underwent LATG at the Union Hospital of Fujian Medical University (Fuzhou, China) between January 2014 and April 2018 were included in the propensity score matching (PSM, 1:2). Patient-reported outcomes at 3, 6, and 12 months after gastrectomy were analyzed. The questionnaire referred to the European Organization for Research and Treatment of Cancer (EORTC) 30-item core QoL (QLQ-C30)and the GC module (QLQ-STO22) questionnaire.After PSM, there were no significant differences in clinicopathological characteristics between the TLTG (n = 104) and the LATG groups (n = 208). Operative time and volume of blood loss were significantly lower in the TLTG group than in the LATG group. Kaplan-Meier survival analysis revealed similar 3-year survival rates between the TLTG and LATG groups (83.7 vs. 80.3%, respectively; P = 0.462). Tolerance to nonliquid diet, decrease in body weight, and albumin levels were also significantly lower in the TLTG group than in the LATG group (all P 0.05). The HRQoL scale demonstrated that the overall score in the TLTG group was better than that in the LATG group at 3, 6, and 12 months after gastrectomy (all P 0.05).Patients with GC undergoing TLTG reported better HRQoL and experienced faster recovery of social function than those undergoing LATG, although the two groups demonstrated similar short-term outcomes and long-term prognosis.

This study aimed to compare the long-term survival of patients undergoing minimally invasive gastrectomy and those undergoing open gastrectomy for gastric adenocarcinoma (GA) in the United States and China. Data on patients with GA who underwent gastrectomy without neoadjuvant therapy were retrieved from prospectively maintained databases at Memorial Sloan Kettering Cancer Center (MSKCC) and Fujian Medical University Union Hospital (FMUUH). Using propensity score-matching (PSM), equally sized cohorts of patients with similar clinical and pathologic characteristics who underwent minimally invasive versus open gastrectomy were selected. The primary end point of the study was 5-year overall survival (OS). The study identified 479 patients who underwent gastrectomy at MSKCC between 2000 and 2012 and 2935 patients who underwent gastrectomy at FMUUH between 2006 and 2014. Of the total 3432 patients, 1355 underwent minimally invasive gastrectomy, and 2059 underwent open gastrectomy. All the patients had at least 5 years of potential follow-up evaluation. Before PSM, most patient characteristics differed significantly between the patients undergoing the two types of surgery. After PSM, each cohort included 889 matched patients, and the actual 5-year OS did not differ significantly between the two cohorts, with an OS rate of 54% after minimally invasive gastrectomy and 50.4% after open gastrectomy (p = 0.205). Subgroup analysis confirmed that survival was similar between surgical cohorts among the patients for each stage of GA and for those undergoing distal versus total/proximal gastrectomy. In the multivariable analysis, surgical approach was not an independent prognostic factor. After PSM of U.S. and Chinese patients with GA undergoing gastrectomy, long-term survival did not differ significantly between the patients undergoing minimally invasive gastrectomy and those undergoing open gastrectomy.

D-dimer (DDI) and albumin are prognostic markers for numerous cancers; however, the predictive value of the preoperative DDI-to-albumin ratio (DAR) on the survival and recurrence patterns of gastric cancer (GC) remains unclear.The aim of this study was to explore the prognostic value of the DAR in GC.Our study included 1766 patients with GC, divided into training and testing cohorts at a ratio of 7:3. Patients were classified into either a high-DAR group (0.0145) or low-DAR group (≤ 0.0145) according to the cut-off value of receiver operating characteristic (ROC) curve analysis. The relationship between the DAR and recurrence pattern was analyzed in stage II/III patients.Eight preoperative hematological factors were included and 17 composite inflammatory markers were constructed. ROC and random forest analyses indicated that among 17 markers, DAR was the best predictor for overall survival (OS) in GC (p 0.01). High DAR was significantly associated with poor OS (hazard ratio [HR] 1.89, p 0.001) and recurrence-free survival (RFS; HR 1.85, p 0.001). Subgroup analysis showed no differences in OS and RFS between the high- and low-DAR groups in stage I or pT1/2 or pN0/1 patients; however, in stage II/III or pT3/4 or pN2/3 patients, the high-DAR group had shorter OS and RFS rates than the low-DAR group (p 0.001). Similar results were found in the testing cohort. According to the multivariate analysis based on the training cohort, five indices, including DAR, cT stage, cN stage, age and body mass index (BMI), were incorporated to establish a nomogram model to predict the long-term prognosis of GC. The model showed comparable forecast performance in predicting OS (C-index: 0.773 vs. 0.786) and RFS (C-index: 0.788 vs. 0.795) compared with pTNM. Recurrence pattern analysis in stage II/III patients showed that the high-DAR group had a higher incidence of peritoneal implantation and early recurrence (ER) than the low-DAR group, and the post-recurrence survival in the high-DAR group was significantly shorter than that in the low-DAR group (p = 0.016).The preoperative DAR is a new biomarker for the long-term survival prediction of GC. In advanced GC, a preoperative DAR0.0145 aids the timely detection of ER and peritoneal recurrence after surgery, thus guiding individual follow-up strategies.

Few reports have examined the prognosis of or possible remedial treatments for patients with noncompliant D2 lymphadenectomy. We investigated the effect of noncompliance in lymph node (LN) dissection on long-term survival in gastric cancer (GC) patients after radical gastrectomy and explored intervention measures. Clinicopathological data were retrospectively analyzed in 2401 patients who underwent radical gastrectomy for GC. Noncompliance was defined as patients with more than one empty LN station, as described in the protocol of the Japanese GC Association. The overall noncompliance rate was 49.1%. The 3-year overall survival (OS) rate was significantly better in compliant than noncompliant patients (74.0% vs. 60.1%, P

The number of examined lymph nodes (ExLNs) and the rate of lymph node (LN) noncompliance are two independent indicators for evaluating the oncological efficacy for radical gastric cancer (GC) surgery. There are no studies to prove the relationship between these two indicators and their influence on the long-term prognosis of GC patients. The clinicopathological data of 1872 patients with radical GC resection with pathological stage pT2-4N0-3M0 from June 2007 to June 2013 were retrospectively analyzed. Noncompliance was defined as patients with more than one or more LN stations absence as described in the protocol for lymphadenectomy in the Japanese Gastric Cancer Association. Among 1872 patients, 941 (50.3%) had complete LN compliance, 469 (25.1%) had minor LN noncompliance, and 462 (24.6%) had major LN noncompliance. Logistic regression analysis showed that cT staging and ExLNs were independent risk factors for LN noncompliance. In the whole group, Kaplan–Meier survival curve elucidated that overall survival (OS) differences of ExLNs ≤ 25 and ExLNs > 25 were statistically significant (p

The aim of this study was to determine the prognostic significance of preoperative carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9 levels in patients with resectable gastric cancer (GC). Patients who underwent a radical resection for GC at the Fujian Medical University Union Hospital between 2007 and 2014 were included in this study. The estimated area under the curve (AUC) was compared to evaluate the discriminatory ability of tumor makers. Additional external validation was performed using a dataset from Sun Yat-sen University Cancer Center. Preoperative CEA/CA19-9 levels were identified as an independent predictor of overall survival (OS) and disease-specific survival (DSS) (both p

Previous studies have developed three nomograms for the individual prediction of overall survival after gastric cancer surgery. In this study, the performance of these nomograms was evaluated and compared with that of a simplified nomogram in a multinational cohort of patients. Clinical data from patients who underwent resection (R0) with curative intent for GC at three specialized centers (two from China and one from Italy) and data from the Surveillance, Epidemiology, and End Results database were retrospectively analyzed. The study analyzed 9810 patients, and the simplified nomogram was developed based on the following factors present in all models: age, sex, depth of invasion, and number of metastatic lymph nodes. In the decision curve analyses, the simplified nomogram demonstrated similar net benefit gains relative to previous models. The discriminative ability of the simplified nomogram was similar to those of the three existing nomograms, and calibration of the simplified nomogram resulted in a predicted survival similar to the actual survival. The predictive ability of the simplified nomogram was superior to that of the American Joint Committee on Cancer (AJCC) stage using Eastern and Western validation data (p

The aim of this work is to compare the prognostic ability between the 7th and 8th editions of the American Joint Committee on Cancer (AJCC) tumor–node–metastasis (TNM) classification for gastric cancer (GC). A total of 10,194 noncardia GC patients were identified from the Surveillance, Epidemiology, and End Results database from 1988 to 2008. Concordance index (C-index), bayesian information criterion (BIC), and time-dependent receiver operating characteristic (t-ROC) analyses were used. External validation was performed using a dataset (n = 2355) derived from Fujian Medical University Union Hospital. Overall survival for all five AJCC N categories differed significantly when patients were subgrouped into ≤ 15 versus >15 examined lymph nodes (eLNs). The prognostic ability of the 8th edition (C-index 0.716) was not improved over the 7th edition (C-index 0.716). Subgroup analysis showed superior performance of the 8th over the 7th edition in patients with > 15 eLNs (C-index 0.742 vs. 0.735); however, the two editions showed similar performance for patients with ≤ 15 eLNs (C-index 0.713 vs. 0.713). The BIC and t-ROC analyses were consistent. To better predict the prognosis of patients with ≤ 15 eLNs, we established a novel prognostic model based on independent prognostic factors (C-index 0.735). BIC analysis showed that this new model was better than the 7th and 8th editions. Similar results were obtained from the validation set. The 8th edition of the AJCC TNM classification shows better prognostic ability than the 7th edition in noncardia GC patients with > 15 eLNs, but no improvement was found in patients with ≤ 15 eLNs; therefore, a novel prognostic model is proposed.

Increasing numbers of studies have shown that skeletal muscle measures are closely associated with tumors. This study explored the relationship between skeletal muscle measures and short- and long-term outcomes after radical gastrectomy (RG) for gastric cancer (GC). The study analyzed 221 GC patients who underwent RG between December 2009 and December 2010. The total psoas area (TPA) and psoas density [Hounsfield unit average calculation (HUAC)] were measured. The total psoas gauge (TPG) was created by multiplying TPA × HUAC. Low TPA, low HUAC, and low TPG were defined in the categorical analyses as the lowest quartile. Logistic regression modeling, the Kaplan–Meier method, and three-step multivariate analysis were used. The median follow-up period was 64 months. Compared with low TPA and low HUAC, only low TPG was an independent risk factor for postoperative complications. The univariate analysis showed that low TPA, low HUAC, and low TPG were predictors of overall survival (OS), recurrence-free survival (RFS), and cancer-specific survival (CCS) after surgery. The result of the three-step multivariate analysis demonstrated that low TPG was an independent risk factor for OS, RFS, and CCS. Moreover, the prognostic value of TPG was superior to that of TPA and HUAC. The patients with low TPG experienced significantly more postoperative liver recurrence than the patients with high TPG (p = 0.011). Compared with preoperative skeletal muscle quantity (TPA) and quality (HUAC), TPG can more accurately predict complications and prognosis after RG. In addition, TPG may be an indicator for the early detection of liver recurrence after RG.

The relationship between sarcopenia and prognosis of gastric cancer (GC) is unclear. This study aimed to develop a prognostic scoring system combining sarcopenia with preoperative clinical parameters for patients with GC to predict 3-year overall survival (OS) and 3-year recurrence-free survival (RFS). In this study, 924 patients with GC who underwent radical gastrectomy were retrospectively analyzed. The data were divided into a training set and a validation set. Sarcopenia was diagnosed by the cutoff value of the skeletal muscle index (SMI) obtained by X-tile software. The study used COX regression to identify preoperative risk factors associated with 3-year OS and RFS. In the training set, 103 patients (14.8%) were sarcopenic based on the cutoff value of the SMI (32.5 cm2/m2 for men and 28.6 cm2/m2 for women). Multivariate analysis showed the following preoperative risk factors for the training set: sarcopenia and preoperative T (cT) and N (cN) stages. A prognostic scoring system was developed based on these findings. The 3-year OS rates were 89% for the low-risk patients, 77.9% for the intermediate-risk patients, and 54.8% for the high-risk patients (P

Previous studies have suggested that preoperative anemia negatively influences survival in patients with gastric cancer (GC). We sought to investigate which anemic markers can better predict the prognosis of patients with resectable GC. The study involved 2277 GC patients who underwent curative resection between December 2008 and December 2014. Cox regression models were used to identify the best anemic markers associated with prognosis. Time-dependent receiver operating characteristics analysis (t-ROC) and the estimated area under the curve (AUC) were used to compare the prognostic values. Of all patients, 1709 (75.1%) were male, and the median age was 61 years. Univariate analyses showed that preoperative hematocrit (HCT), hemoglobin, and mean corpuscular volume were associated with OS (all P

Due to increased life expectancy, the number of elderly patients with gastric cancer is increasing. This study was designed to determine the role of preoperative frailty (PF) as a risk factor for postoperative complications and prognosis in the oldest elderly gastric cancer patients undergoing curative resection.A total of 165 patients older than 80 years who underwent radical gastrectomy for primary gastric cancer between 2000 and 2012 were analyzed. We collected data on the inflammation-nutritional status, morbidity, and survival of these patients. The relationship between postoperative complications and PF was analyzed by logistic regression, and a Cox proportional hazards model was performed to identify the prognostic factors.A total of 54 (32.7%) patients were considered frail. PF was associated with an increased risk for postoperative complications [odds ratio (OR) 3.396; 95% confidence interval (CI) 1.046-11.025; P = 0.042]. With a median follow-up of 37.0 (range 1.0-77.8) months, the 3 year overall survival (OS), recurrence-free survival (RFS), and cancer-specific survival (CSS) rates in the entire cohort were 46.1, 34.4, and 49.2%, respectively. A multivariate analysis of the inflammation-based prognostic factors showed that only PF was independently associated with OS (OR 1.613; 95% CI 1.052-2.473; P = 0.028), RFS (OR 1.859; 95% CI 1.279-2.703; P = 0.001), and CSS (OR 1.859; 95% CI 1.279-2.703; P = 0.001).Frailty based on an easily calculable preoperative measure is a useful marker to identify patients at increased risk for postoperative complications and is more predictive of survival than an inflammation-based prognostic score after gastrectomy. Thus, PF status should be included in the routine assessment of the oldest elderly patients with gastric cancer.

The effects of preoperative malnutrition and preoperative correction of hypoalbuminemia (PCH) on the short- and long-term outcomes in patients with gastric cancer are unclear. This study aimed to examine the effect of preoperative nutritional status on short- and long-term outcomes in patients who underwent radical gastrectomy, and also explored the role of PCH in malnourished patients with gastric cancer. We prospectively reviewed data from patients with gastric cancer who were treated in our department between January 2009 and December 2014. The effect of preoperative nutritional status on short- and long-term outcomes in patients who underwent radical gastrectomy was investigated, and we explored whether PCH could improve the short- and long-term outcomes of these patients. A total of 1976 patients were analyzed, including 412 patients in the malnourished group and 1564 in the well-nourished group. The overall incidence of complications in the malnourished group was significantly higher than the well-nourished group (21.4 vs. 15.5%, p = 0.005). Except for incision infection (3.2 vs. 1.6%, p = 0.041), there were no significant differences for other complications. In the malnourished group, 98 cases of preoperative hypoproteinemia were corrected (PCH group), whereas 314 cases were not (NPCH group). The incidence of incision infection in the PCH group was significantly lower than in the NPCH group (0 vs. 4.1%, p = 0.041). The median follow-up time was 39 months (1.0–88.0 months), and the 3-year overall survival (OS; 59.1 vs. 75%, p

The granulocyte-to-lymphocyte ratio (GLR) in the blood may be a useful marker of surgical stress (SS) following surgery for cancer. The aim of the present study was to compare the SS by measuring the GLR, and further study the value of the GLR in predicting postoperative infectious complications (ICs). Data from 201 gastric cancer patients at Fujian Medical University Union Hospital who were enrolled in our prospective randomized controlled trial were extracted for this study. Blood samples to perioperatively measure the GLR were routinely taken. Additional external validation was performed using the dataset (n = 135) from Nanfang Hospital who were enrolled in the same trial. Patients undergoing either laparoscopic or open resection showed a similar preoperative GLR, as well as similar GLRs, on postoperative days (PODs) 1 and 3. The GLR on POD 5 was lower in the laparoscopic group compared with the open group (p = 0.014), and the optimal predictive GLR thresholds of postoperative ICs in both the laparoscopic and open groups were the same on POD 5, i.e. 6.5 and 7.4, respectively. The GLR on POD 5 was identified as an independent factor for postoperative ICs in both the laparoscopic and open groups. Similar results were found in the validation dataset. The GLR status not only correlates with SS but may also be a reliable predictor of ICs for gastric cancer patients after gastrectomy. The ideal GLR thresholds on POD 5 for ICs following laparoscopic and open gastrectomy are 6.5 and 7.4, respectively.

Although current guidelines suggest that 16 or more lymph nodes (LNs) are required for the appropriate staging of gastric cancer, the effect that the minimum number of examined LNs (eLNs) in the different types of gastrectomy has on survival remains unclear. This study retrospectively analyzed 2662 patients who underwent curative gastrectomy with D2 lymphadenectomy for gastric cancer at Fujian Medical University Union Hospital from January 2000 to December 2010 and randomly divided them into development (70 %, n = 1863) and validation (30 %, n = 799) data sets. An additional external validation was performed using the data set (n = 285) collected during the same period from the Sun Yat-sen University Cancer Center in Guangzhou, China. A hypothetical tumor-node-metastasis (TNM) classification (hTNM) was proposed based on eLNs and survival. The mean numbers of nodes removed during radical distal and total gastrectomy were respectively 26 ± 9.6 and 29 ± 10.7 (p

The oncologic outcomes of laparoscopy-assisted gastrectomy (LAG) for the treatment of patients with local advanced gastric cancer (AGC) have not been evaluated. This study aimed to validate the oncologic efficacy of LAG for AGC. The data from 539 patients who underwent LAG and 539 patients treated with open gastrectomy (OG) were selected using the propensity score-matching method from a database prospectively constructed between 2005 and 2011. The therapeutic value of lymph node (LN) dissection and the long-term surgical outcomes of these matched groups were compared. The groups were well balanced after the propensity score matched. The LAG and OG groups did not differ significantly in terms of clinicopathologic characteristics. The number of dissected LNs at stations 11 and 12a were significantly higher in the LAG group. However, the therapeutic index at each LN station did not differ significantly between the two groups. Although the overall survival curve at each stage did not differ significantly (P > 0.05), the survival rate increased overall for patients with pT4aN3bM0 in the OG group (P

Background. We developed a novel procedure for laparoscopic suprapancreatic lymph node (LN) dissection, which is compulsory and quite difficult for patients with advanced gastric cancer. 1–3 Methods. We dissected suprapancreatic LNs from the left to the right side. The No. 11p LNs were dissected first, followed by the No. 9, 7, and 8a LNs. Dissection of the No. 5 and 12a LNs was completed last. The above procedure was performed on 814 consecutive patients with stage cT2–3 disease. Results. Mean operation time was 186.9 ± 56.4 min (range 80–480 min), mean blood loss was 76.6 ± 106.8 ml (range 3–500 ml), and mean times to first flatus, fluid diet, and soft diet were 3.7 ± 1.2 days (range 1–9 days), 5.2 ± 1.7 days (range 2–14 days), and 8.3 ± 2.2 days (range 5–20 days), respectively. A mean 34.5 ± 12.9 LNs (range 22–103) were retrieved, including a mean 12.4 ± 5.7 (range 0–35) suprapancreatic area LNs. Overall postoperative morbidity rate was 14.7 % (120/814), including three cases of pancreatic fistula. All of these postoperative complications were successfully treated by conservative methods. At a median follow-up of 27 months (range 1–63), cumulative 3-year overall survival was 59.2 %. Conclusion. Laparoscopic suprapancreatic LN dissection using a left-sided approach could be safely achieved and is more convenient for advanced gastric cancer.

The delta-shaped gastroduodenostomy, an intracorporeal Billroth-I anastomosis after laparoscopic distal gastrectomy and using only endoscopic linear staplers, has been increasingly adopted by gastrointestinal surgeons.1 (-) 5 We modified this technique to simplify operation procedures and reduce surgical trauma in patients with gastric cancer.After the stomach and duodenum were transected in predetermined positions, small incisions were made on the greater curvature of the remnant stomach and the posterior side of the duodenum. The forks of the stapler in each incision were closed and fired following approximation of the posterior walls of the gastric remnant and duodenum. The involution of the common stab incision was accomplished only by the instruments of the surgeon and assistant, and the duodenal cutting edge was completely resected when the common stab incision was closed with the stapler, thus decreasing the anastomotic weak point and avoiding poor blood supply to the duodenal stump. The above procedure was performed for 41 patients with stage cT1-4a disease.Mean operation time was 143.4 ± 23.4 min, mean anastomosis time was 13.9 ± 2.8 min, mean blood loss was 34.6 ± 20.8 ml, and mean times to first flatus, fluid diet, and soft diet were 3.5 ± 1.3, 5.1 ± 1.2, and 8.1 ± 4.3 days, respectively. No patient experienced any anastomosis-related complications, such as anastomotic leakage, anastomotic stricture, or anastomotic hemorrhage. At a median follow-up of 10 months, no patient had died or experienced recurrent or metastatic disease.The modified technique was technically safe and feasible, with acceptable surgical outcomes, in patients with gastric cancer.

We developed a procedure for laparoscopic infrapyloric area lymph node (LN) dissection with No. 14v enlargement, which is complicated for patients with advanced lower gastric cancer (GC) (Xu et al., World J Gastroenterol 13:5133-5138,2007; Masuda et al., Dig Surg 25:351-358,2008; An et al., Br J Surg 98:667-672,2011].From April 2008 to December 2014, 1096 patients with GC underwent laparoscopy-assisted radical distal gastrectomy in our department. According to the Japanese GC treatment guidelines, D2 (+No. 14v) may be beneficial in tumors with apparent metastasis to the No. 6 nodes (Japanese Gastric Cancer Association, Gastric Cancer 14:113-123,2010). Thus, 151 advanced lower GC patients with apparent metastasis to the No. 6 nodes underwent additional No. 14v LN dissection. We dissected infrapyloric area LNs with No. 14v dissection from the left to the right side (i.e., middle colic vein approach).Mean operation time was 22.8 ± 10.0 min, mean blood loss was 17.1 ± 14.6 ml, and mean times to first flatus, fluid diet, and soft diet were 3.7 ± 1.2 days, 5.0 ± 1.7 days, and 8.4 ± 1.6 days, respectively. A mean of 33.7 ± 11.2 LNs were retrieved, including 3.9 ± 2.7 No. 6 LNs and 2.0 ± 1.6 No. 14v LNs. Of 151 patients, 26 had No. 14v metastasis (17.2%), and 43 (28.5%) were accompanied by an extensive infrapyloric area nodal involvement. The overall postoperative morbidity rate was 10.6% (16 of 151). At a median follow-up of 56 months (range 5-84 months), cumulative 3-year overall survival was 56.0%.Although it remains controversial whether prophylactic No. 14v dissection improves survival, laparoscopic infrapyloric area LN dissection using a middle colic vein approach may be safely achieved and is more convenient for advanced lower GC.

We developed a novel procedure for spleen-preserving No. 10 lymph node (LN) dissection, which is difficult and advocates for patients with advanced proximal gastric cancer, except those with direct tumor extension to the spleen or definite LN metastasis at the splenic hilum.The surgeon reveals the splenic vessels (SVs), and the assistant pulls up the lymphatic fatty tissue on the surface of the lower lobar vessels of the spleen (LLVSs). The surgeon then exposes the left gastroepiploic vessels (LGEVs), completely separating the LLVSs from the LGEV roots. After tracking the SV termini, the No. 11d LNs are carefully dissected and the upper lobar vessels of the spleen are exposed from their roots to the upper pole of the spleen. During this process, 2-4 branches of the short gastric vessels are skeletonized and divided at their roots. The LNs behind the SVs in front of Gerota's fascia are then dissected. The above procedure was performed on 118 consecutive patients with stage cT2-3 disease.Mean operation time was 20.4 ± 6.0 min (range 13-41 min), mean blood loss was 13.6 ± 4.0 ml (range 10-40 ml), and mean times to first flatus, fluid diet, and soft diet were 3.3 ± 1.2 days (range 2-8 days), 4.8 ± 1.6 days (range 3-14 days), and 8.1 ± 4.1 days (range 6-20 days), respectively. A mean 44.6 ± 17.3 LNs (range 22-103) were retrieved, including a mean 3.0 ± 2.4 (range 0-11) splenic hilar area LNs. At a median follow-up of 9 months, no patients had died or experienced recurrent or metastatic disease.This procedure is feasible and simplifies complicated laparoscopic No. 10 LN dissection.