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Background: There remain concerns about the safety and functional benefit of laparoscopic pylorus-preserving gastrectomy (LPPG) compared with laparoscopic distal gastrectomy (LDG). This study evaluated short-term outcomes of a randomized clinical trial (RCT) comparing LPPG with LDG for gastric cancer., Methods: The Korean Laparoendoscopic Gastrointestinal Surgery Study (KLASS)-04 trial was an investigator-initiated, open-label, parallel-assigned, superiority, multicentre RCT in Korea. Patients with cT1N0M0 cancer located in the middle third of the stomach at least 5 cm from the pylorus were randomized to undergo LPPG or LDG. Participants, care givers and those assessing the outcomes were not blinded to group assignment. Outcomes were 30-day postoperative morbidity rate and death at 90 days., Results: Some 256 patients from nine institutions were randomized (LPPG 129 patients, LDG 127 patients) between July 2015 and July 2017 and outcomes for 253 patients were analysed. Postoperative complications within 30 days were seen in 19.3 and 15.5 per cent in the LPPG and LDG groups respectively (P = 0·419). Postoperative pyloric stenosis was observed in nine (7.2 per cent) and two (1·5 per cent) patients in the LPPG and LDG groups (P = 0·026) respectively. In multivariable analysis higher BMI was a risk factor for postoperative complications (odds ratio 1·17, 95 per cent c.i. 1·04 to 1·32; P = 0·011). Death at 90 days was zero in both groups., Conclusion: Postoperative complications and mortality was comparable in patients undergoing LPPG and LDG. Registration number: NCT02595086 (http://www.clinicaltrials.gov)., (© The Author(s) 2021. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: The degree of neuromuscular blockade is one of the important factors that determine the condition of surgical space during laparoscopic surgery. Magnesium sulfate potentiates the actions of neuromuscular blocking agent, and we hypothesized that intraoperative magnesium sulfate infusion may improve surgical space condition during laparoscopic surgery., Methods: Eighty-four patients undergoing elective laparoscopic gastrectomy were randomized to receive isotonic saline (group C) or magnesium sulfate (group M, loading dose with 50 mg/kg over 10 min and then 15 mg/kg/h by continuous infusion) to maintain the moderate neuromuscular blockade using rocuronium. Two experienced surgeons scored the quality of surgical space condition using a 5-point surgical rating scale (SRS). The secondary outcomes included recovery profiles, postoperative pain and adverse events., Results: The SRS in group M was higher than that of group C. The proportion of patients with a SRS of 5 (optimal) was 2.7 % in the group C and 40.5 % in the group M (P < 0.0001) although a lower amount of rocuronium was required in group M than group C [24.2 (6.5) mg/h for group M vs. 27.5 (6) mg/h for group C; P = 0.017]. Pain after operation site was less severe in group M than in group C at postoperative 24 h (P = 0.009). Recovery profiles and adverse events were similar between the two groups., Conclusion: Intraoperative administration of magnesium sulfate improved the quality of surgical space conditions and decreased neuromuscular blocking agent requirement and postoperative pain in patients undergoing laparoscopic gastrectomy.

The short-term responses of gut hormones and the compensative interaction during a one-week period after subtotal gastrectomy in early gastric cancer (EGC) patients were assessed. Previous studies have reported gut hormonal changes after Roux-en-Y gastric bypass surgery. Blood samples were collected from 40 patients with EGC preoperatively, at 1 h after gastric resection, and on postoperative day (POD) 1, 3, and 7. Levels of active ghrelin, total ghrelin, obestatin, and PYY3-36 were measured. Total ghrelin level rapidly reached a nadir of 69.1%, while active ghrelin level had increased to 135.5% at 1 h after resection. Then, both returned to preoperative level. On the contrary, active/total ghrelin reached its nadir quickly at 1 h after resection and had returned to the preoperative level by POD 3. The nadir PYY3-36 level was 71.4% on POD 1, followed by a gradual recovery, and had increased to 116.5% by POD 7. The same pattern was observed for obestatin. Active ghrelin/obestatin showed an increase on POD 1 while total ghrelin/obestatin showed a decrease on POD 3. Then, both returned to preoperative level. These results suggest that a rapid interactive compensatory mechanism of gut hormones does exist in the remnant gastrointestinal tract after abrupt changes in the production reservoir in nonobese people., (© Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: As the laparoscopic approach has become a popular gastric cancer treatment in Korea and Japan, the need for sharing current practices of surgeons who are experienced in laparoscopic gastric cancer surgery has increased., Methods: We sent a questionnaire on laparoscopic instruments, image documentation, preoperative evaluation, surgical indication, operative methods, and postoperative management to laparoscopic experts in Korea and Japan, and 24 (14 from Korea and 10 from Japan) responded., Results: Endoscopic ultrasound and preoperative endoscopy-guided clipping are routinely employed, respectively, by 14 (58%) and 20 (83%) of the surgeons. Surgeons perform laparoscopy-assisted distal gastrectomy (LADG) based on varying indications. Five surgeons (21%) performed LADG only for cases of stage T1 cancer, 15 (63%) performed LADG on patients with less than T2 lesions, and 4 (17%) performed LADG on patients with less than T3 lesions. With regard to postoperative anastomosis, 18 surgeons (75%) preferred extracorporeal anastomosis and 6 (25%) preferred intracorporeal anastomosis. The mean postoperative hospital stay was 6.5 days in Korea and 10.1 days in Japan (P < 0.001)., Conclusion: This survey can help to inform the current practice of laparoscopic gastric cancer surgery in Korea and Japan, where laparoscopic surgery is frequently performed., (© 2011 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Blackwell Publishing Asia Pty Ltd.)

Introduction: Lifting the stomach using laparoscopic instruments during laparoscopic gastrectomy is difficult and increases the risk of crushing the tumor. In this study, we present a stomach hanging technique using gauze pieces that reduces the risk to the tumor., Materials and Surgical Technique: After a partial omentectomy and the opening of the lesser sac, the antrum was wrapped with a 15-20-cm gauze piece. Next, a straight needle with 2-0 monofilament suture material pierced the abdominal cavity through the right subcostal area on the mid-clavicular line, and the gauze was then sutured twice in a figure of eight manner. The needle was removed percutaneously through the right middle quadrant of the abdomen. Another suture was applied to wrap the left side of the stomach. The stomach was easily lifted and positioned by pulling the four suture strings in different directions. After the suture materials were fastened to the abdominal wall using hemostat forceps, the surgical field was sufficiently exposed, facilitating lymph node dissection on the superior surface of the pancreas. This method freed the assistant from holding the stomach and enabled this individual to assist the operation in other ways., Discussion: This stomach lifting technique using gauze is a good option for exposing the surgical field, enables the assistant to perform other tasks, and reduces the risk of crushing the tumor during laparoscopic gastrectomy., (© 2012 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Blackwell Publishing Asia Pty Ltd.)

Background: The pattern of gastric cancer in the Western world is changing, with an increased proportion of tumours in the upper stomach. The aim of this study was to investigate changes in clinicopathological features and survival of patients with resected gastric cancer at a single institution, in an area of high incidence in the Far East., Methods: Clinical features and pathological findings were compared in patients with gastric cancer who underwent gastrectomy at Seoul National University Hospital during four consecutive periods (1986-1990, 1991-1995, 1996-2000 and 2001-2006)., Results: There were 12 026 patients. The mean age increased from 53·4 years in the first period to 57·4 years in the last (P < 0·001). The proportion of patients aged 70 years or older also increased, reaching 16·1 per cent in the final period. Upper-third cancer increased from 5·3 per cent in the first period to 14·0 per cent in the fourth (P < 0·001). Early gastric cancer (pathological T1) increased continuously over the four time intervals, from 24·8 to 48·9 per cent (P < 0·001). The overall 5-year survival rate increased from 64·0 per cent in the first period to 73·2 per cent at the end (P < 0·001), and this survival improvement was apparent in patients aged 40 years or more., Conclusion: The mean age of patients with gastric cancer has increased during the past 20 years. The proportion of early gastric cancer and overall survival have gradually increased, especially in patients aged over 40 years.

Background/objectives: No prospective study on the long-term effects of gastric resection on gastrointestinal hormonal changes in patients with normal body weight has been reported. The aim of this study was to evaluate the 1-year effect of subtotal gastrectomy on ghrelin and peptide YY (PYY)(3-36) levels., Subjects/methods: Eighteen patients with early gastric cancer underwent subtotal gastrectomy with Billroth I reconstruction. We assessed appetite, food intake, body composition, and ghrelin and PYY(3-36) levels preoperatively and 1 year after surgery., Results: There were no significant difference in the preoperative daily food intake and 1 year after subtotal gastrectomy. Weight loss occurred in all study subjects; 11.7% (n=2), 55.5% (n=10) and 33.3% (n=6) of the patients lost <5%, 5-10% and >10% of their preoperative body weight, respectively. Body mass index, waist circumference and body fat significantly decreased 1 year after subtotal gastrectomy. There were no significant differences in the appetite visual analogue scale preoperatively and 1 year after subtotal gastrectomy. The plasma ghrelin concentration decreased significantly (P=0.006), whereas PYY(3-36) did not show a significant change 1 year after subtotal gastrectomy., Conclusions: Ghrelin levels and body fat decreased significantly, whereas PYY(3-36) levels as well as appetite and food intake did not change significantly 1 year after subtotal gastrectomy with normal body weight. These findings suggest that decreased ghrelin might contribute directly to reduced body fat.

Background: The aim of this study was to assess the safety and short-term value of laparoscopic gastrectomy in the elderly with gastric cancer compared with a younger cohort., Methods: Data on all patients with gastric cancer undergoing laparoscopic gastrectomy at ten institutions in Korea between May 1998 and December 2005 were collected. Patients under the age of 45 years and those undergoing total gastrectomy, proximal gastrectomy and pylorus-preserving gastrectomy were excluded. An analysis of clinicopathological data for patients aged 45-69 years (average-age group) and those aged 70 years or more (elderly group) was undertaken., Results: Co-morbidity was more common and postoperative hospital stay was longer in elderly patients. Pre-existing pulmonary and cardiovascular disease in the elderly contributed to respiratory dysfunction and intraperitoneal complications respectively. Tumour size and location, stage, methods of reconstruction and the number of combined operations were similar in the two groups. There were no significant differences in postoperative morbidity or mortality., Conclusion: Although elderly patients had greater co-morbidity, laparoscopic gastrectomy was a safe treatment for gastric cancer in this age group., (Copyright (c) 2009 British Journal of Surgery Society Ltd.)

Aim: Recently, LADG has become a viable alternative for the treatment of patients with early gastric cancer. Surgeons who are seeking to undertake, or currently practicing LADG, are concerned about unpredictable intraoperative events that occur during LADG. The aims of this study were to investigate intraoperative and postoperative complications in laparoscopy-assisted distal gastrectomy (LADG) with more than D1+beta lymphadenectomy for gastric cancer., Materials and Methods: Of 219 patients who underwent laparoscopy-assisted gastrectomy for gastric cancer by a single surgeon between April 2003 and January 2006, 128 patients were enrolled in this study. The operative procedure was divided into five steps. Various intraoperative complications, such as bleeding and perigastric organ injuries, that occurred during different operative steps were investigated by reviewing videotapes., Results: A total of 839 events of bleeding were encountered during the procedure with a mean of 6.6 per patient. The mean number of bleeding during each step was significantly different and more bleedings occurred during steps II and IV (P<0.0001). Sixteen cases of complications other than bleeding occurred in 15 patients (11.7%), and they were all managed properly without conversion or reoperation. Postoperative morbidity and mortality rates were 15.6 and 0.7%, respectively., Conclusion: LADG with more than D1+beta lymphadenectomy is a technically feasible and acceptable surgical modality for gastric cancer. Intraoperative bleeding was found to be the most common complication during LADG for gastric cancer, and more bleedings occurred during steps II and IV.

Aim: The aim of this study was to determine the feasibility of laparoscopy-assisted gastrectomy (LAG) with extraperigastric lymph node dissection for gastric cancer., Methods: The authors attempted LAG with extraperigastric lymph node dissection in 117 consecutive gastric cancer patients between May 1998 and January 2004. The clinico-pathologic characteristics, operative outcomes, post-operative morbidities and mortalities, and follow-up findings of patients with advanced gastric cancer were evaluated., Results: LAG with extraperigastric lymph node dissection were successfully performed in 114 of 117 patients (success rate, 97%). Of these 114 successful cases, 100 cases were early gastric cancers and 14 cases were advanced gastric cancers. The mean operation time for the 114 cases was 259 (range 150-415) min, and the mean number of retrieved lymph nodes was 23 (range 6-66). Operative mortality, hospital death, and overall post-operative complication rates were 0, 1.7 and 14.7%, respectively. Follow-up was available in 110 of the 112 patients (two post-operative hospital deaths were excluded from the 114). Follow-up ranged from 6 to 74 months (median: 19). 108 patients remain alive without recurrence or port-site metastasis., Conclusions: LAG with extraperigastric lymph node dissection is a technically feasible and acceptable method for the surgical treatment of gastric cancer.

Background: We aimed to evaluate the immunologic nature of sentinel lymph nodes (SLNs) in gastric cancer patients and to determine whether it can predict non-SLN metastasis.Methods: Sentinel lymph node samples were collected from 64 gastric carcinoma patients who had undergone gastrectomy with SLN biopsy. One representative SLN sample was selected from each patient and was subjected to immunostaining for CD8, CD57, FOXP3, and DC-LAMP. The numbers of marker-positive cells in each sample were counted. The relationships between various immune cell densities and clinicopathologic parameters or metastasis status of SLNs and non-SLNs were sought.Results: High FOXP3+ Treg density of the SLN was found to be significantly associated with the presence of metastasis in either SLNs or non-SLNs. DC-LAMP+ cell density of the SLN was the highest at the isolated tumours cell level, and this decreased along with an increase in tumour metastasis in either SLNs or non-SLNs. Univariate and multivariate logistic regression models revealed that high FOXP3+ Treg density of the SLN was an independently significant predictor of non-SLN metastasis.Conclusions: This study is the first to indicate an important role of SLNs in metastatic dissemination of gastric cancer. Our findings suggest that Tregs could be a new therapeutic target for regulating the metastasis of gastric cancer. [ABSTRACT FROM AUTHOR]

Focuses on the identification of factors that predict morbidity and mortality in gastric cancer surgery. Number of patients in the study; Overall morbidity and mortality rates; Association of subtotal gastrectomy with the development of complications after gastric cancer surgery.

Background This study was conducted to determine the incidence and clinical characteristics of lacrimal drainage obstruction (LDO) in patients receiving S-1 chemotherapy. Patients and methods Consecutive 170 patients with gastric cancer who underwent curative surgery and received adjuvant S-1 chemotherapy were enrolled. S-1 was administered orally (40 mg/m2 b.i.d. on days 1–28 every 6 weeks) for 1 year. Ophthalmologic examinations were carried out on patients complaining of epiphora. Results Thirty-one patients (18%) developed epiphora. Among 31 patients, 25 underwent ophthalmologic examinations and 22 (88%) were diagnosed with LDO. The median time to the onset of LDO was 2.9 months. The most common site of obstruction was the nasolacrimal duct [86% (19/22)]; punctal [23% (5/22)] and canalicular obstruction [14% (3/22)] were also noted. In multivariate analysis, total gastrectomy [versus partial gastrectomy: hazard ratio (HR), 2.9; P = 0.014] and creatinine clearance <50 ml/min (versus ≥50 ml/min: HR, 2.9; P = 0.038) were independent risk factors for the development of LDO. Conclusion Considering the high incidence of LDO in patients receiving S-1 chemotherapy, oncologists should be alert to epiphora and cooperate with ophthalmologists in the early stages to improve the quality of life of patients and avoid more complicated ophthalmologic procedures. [ABSTRACT FROM AUTHOR]