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Gastrectomy for gastric cancer is still performed in Western countries with high morbidity and mortality. Post-operative complications are frequent, and effective diagnosis and treatment of complications is crucial to lower the mortality rates. In 2015, a project was launched by the EGCA with the aim of building an agreement on list and definitions of post-operative complications specific for gastrectomy. In 2018, the platform www.gastrodata.org was launched for collecting cases by utilizing this new complication list. In the present paper, the Italian Research Group for Gastric Cancer endorsed a collection of complicated cases in the period 2015-2019, with the aim of investigating the clinical pictures, diagnostic modalities, and treatment approaches, as well as outcome measures of patients experiencing almost one post-operative complication. Fifteen centers across Italy provided 386 cases with a total of 538 complications (mean 1.4 complication/patient). The most frequent complications were non-surgical infections (gastrointestinal, pulmonary, and urinary) and anastomotic leaks, accounting for 29.2% and 17.3% of complicated patients, with a median Clavien-Dindo score of II and IIIB, respectively. Overall mortality of this series was 12.4%, while mortality of patients with anastomotic leak was 25.4%. The clinical presentation with systemic septic signs, the timing of diagnosis, and the hospital volume were the most relevant factors influencing outcome., (© 2022. The Author(s).)

Objective: Utilizing a standardized dataset based on a newly developed list of 27 univocally defined complications, this study analyzed data to assess the incidence and grading of complications and evaluate outcomes associated with gastrectomy for cancer in Europe., Summary Background Data: The absence of a standardized system for recording gastrectomy-associated complications makes it difficult to compare results from different hospitals and countries., Methods: Using a secure online platform (www.gastrodata.org), referral centers for gastric cancer in 11 European countries belonging to the Gastrectomy Complications Consensus Group recorded clinical, oncological, and surgical data, and outcome measures at hospital discharge and at 30 and 90 days postoperatively. This retrospective observational study included all consecutive resections over a 2-year period., Results: A total of 1349 gastrectomies performed between January 2017 and December 2018 were entered into the database. Neoadjuvant chemotherapy was administered to 577 patients (42.8%). Total (46.1%) and subtotal (46.4%) gastrectomy were the predominant resections. D2 or D2+ lymphadenectomy was performed in almost 80% of operations. The overall complications' incidence was 29.8%; 402 patients developed 625 complications, with the most frequent being nonsurgical infections (23%), anastomotic leak (9.8%), other postoperative abnormal fluid from drainage and/or abdominal collections (9.3%), pleural effusion (8.3%), postoperative bleeding (5.6%), and other major complications requiring invasive treatment (5.6%). The median Clavien-Dindo score and Comprehensive Complications Index were IIIa and 26.2, respectively. In-hospital, 30-day, and 90-day mortality were 3.2%, 3.6%, and 4.5%, respectively., Conclusions: The use of a standardized platform to collect European data on perioperative complications revealed that gastrectomy for gastric cancer is still associated with heavy morbidity and mortality. Actions are needed to limit the incidence of, and to effectively treat, the most frequent and most lethal complications.

Background: The aim of this study is to report the experience with conversion surgery from six Gruppo Italiano Ricerca Cancro Gastrico (GIRCG) centers, focusing our analysis on factors affecting survival and the risk of recurrence., Methods: A retrospective, multicenter cohort study was performed in patients who had undergone conversion gastrectomy between 2005 and 2017. Data were extracted from a GIRCG database including all metastatic gastric cancer patients submitted to surgery. Only stage IV unresectable tumors/metastases which became resectable after chemotherapy were included in this analysis., Results: Forty-five resected M1 patients were included in the analysis. Reasons for being deemed unresectable at diagnosis were peritoneal involvement (PCI > 6) (n = 38, 84.4%), distant metastatic nodes (n = 3, 6.6%) and extensive liver involvement (n = 4, 8.8%). Median follow-up was 25 months (IQR 9-50). Median overall survival from surgery was 15 months and 1-, 3- and 5-year survivals were 57.2, 36.1 and 24%, respectively. Median progression-free survival was 12 months with 1- and 3-year survival of 46.4 and 33.9%, respectively. At cox regression analysis the only independent prognostic factor for OS was the presence of more than one type of metastasis (HR 4.41, 95% CI 1.72-11.3, p = 0.002). A positive microscopic resection margin was the only risk factor for recurrence (HR 5.72, 95% CI 1.04-31.4, p = 0.045)., Conclusions: Unresectable stage IV GC patients could benefit from radical surgery after chemotherapy and achieve long survivals. The main prognostic factor for these patients was the presence of more than one type of extra-gastric metastatic involvement.

Background: The aim of this study was compare short- and long-term outcomes between robotic (RG) and standard open gastrectomy (OG)., Methods: This is a single-center propensity score-matched study including patients who underwent RG or OG for gastric cancer between 2008 and 2018., Results: In total, 191 patients could be included for analysis. Of 60 RG patients, 49 could be matched. After matching, significant differences in baseline characteristics were no longer present. Operative time was significantly longer (451 min, IQR: 392-513) in the RG group than in the OG (262 min, IQR: 225-330) (P < .0001). No significant differences in postoperative complications between RG (n = 15, 30.6%) and OG (n = 15, 30.6%) were seen (P = 1.000). Overall survival was comparable between the groups., Conclusions: RG is feasible and safe. With regard to long-term oncologic outcomes, survivals in the RG group were similar to those in OG group., (© 2019 John Wiley & Sons, Ltd.)

Background: Perioperative complications can affect outcomes after gastrectomy for cancer, with high mortality and morbidity rates ranging between 10 and 40%. The absence of a standardized system for recording complications generates wide variation in evaluating their impacts on outcomes and hinders proposals of quality-improvement projects. The aim of this study was to provide a list of defined gastrectomy complications approved through international consensus., Methods: The Gastrectomy Complications Consensus Group consists of 34 European gastric cancer experts who are members of the International Gastric Cancer Association. A group meeting established the work plan for study implementation through Delphi surveys. A consensus was reached regarding a set of standardized methods to define gastrectomy complications., Results: A standardized list of 27 defined complications (grouped into 3 intraoperative, 14 postoperative general, and 10 postoperative surgical complications) was created to provide a simple but accurate template for recording individual gastrectomy complications. A consensus was reached for both the list of complications that should be considered major adverse events after gastrectomy for cancer and their specific definitions. The study group also agreed that an assessment of each surgical case should be completed at patient discharge and 90 days postoperatively using a Complication Recording Sheet., Conclusion: The list of defined complications (soon to be validated in an international multicenter study) and the ongoing development of an electronic datasheet app to record them provide the basic infrastructure to reach the ultimate goals of standardized international data collection, establishment of benchmark results, and fostering of quality-improvement projects.

Background: To investigate the role of Kodama PenA subtype in influencing survival in patients with early gastric cancer (EGC)., Methods: All patients surgically treated for EGC at 7 Italian centers (Forlì, Varese, Siena, Verona, Milan, Rome and Perugia) belonging to the Italian Research Group for Gastric Cancer (GIRCG) from January 1982 and December 2009 were included., Results: PenA patients were 230 (21.5%) while other types were 839 (78.5%). Nodal metastases were more common in PenA (30.7%) than non-PenA (10.4%) EGCs. Among preoperative variables, only age (OR 1.02; 95% CI 1.00-1.03, p = 0.009) and macrotype III (OR 1.95; 95% CI 1.39-2.75, p = 0.0001) were significantly associated with Pen A type. Survival analysis performed on N0 patients demonstrated that only size >2 cm (HR 1.85; 95% CI 1.12-3.05, p = 0.017) and age (HR 1.06; 95% CI 1.03-1.08, p < 0.0001) were independent poor prognostic factor. Among N+ patients age (HR 1.04; 95% CI 1.00-1.07, p = 0.048), number of positive lymph nodes (HR 1.13; 95% CI 1.05-1.20, p = 0.0002) and PenA (HR 4.23; 95% CI 1.70-10.55, p = 0.002) were significantly correlated with poor prognosis at multivariate analysis., Conclusions: Kodama PenA subtype was the most powerful independent prognostic factor in patients with nodal metastases. Its status should always be investigated in EGCs patients., (Copyright © 2018 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

The optimal management of patients with resection line involvement after endoscopic or surgical treatment for gastric cancer is debated. In contrast to previous reports, we examined both the experience of endoscopists and surgeons in early-stage lesions and the wide variation in treatments proposed for advanced disease in case of infiltration of resection margins. A PubMed search for papers using the key words: gastric or stomach cancer, or Carcinoma; gastrectomy and positive margins; surgical margins or resection line or endoscopic margin involvement; and R1 resection, from January 2000 to July 2015 was undertaken. Fifty-three studies were considered pertinent to the study. Many endoscopists report that some cases of early gastric cancer with resection line involvement after endoscopic resection have good outcomes notwithstanding incomplete resection, but few surgeons share this opinion. Conversely, it is unanimously agreed that very advanced stages should not be surgically retreated because they are expression of systemic disease. Between early and very advanced cancer the usefulness of re-resection for microscopic resection lines involvement is still debated and surgery may be proposed only when radicality can be achieved. When surgery is not feasible, radiochemotherapy may represent a valid alternative.

Background: Advanced unresectable gastric cancer has a dismal prognosis. The aim of this study was to evaluate the short- and long-term outcomes of patients who underwent induction chemotherapy ± gastrectomy for advanced gastric cancer., Material and Methods: All patients referred to our center with a clinical diagnosis of unresectable locally advanced or stage IV gastric adenocarcinoma between April 2005 and August 2016 were included in the study. Cox regression was performed to find independent prognostic factor among the considered variable., Results: The cohort included 73 patients: 16 had best supportive care, 35 chemotherapy alone and 22 chemotherapy plus radical surgery. Thirty-three patients underwent surgery after chemotherapy. Twenty-two patients had R0 surgery, while the remaining 11 had only an exploratory procedure. Nine patients (40.9%) underwent gastrectomy plus hyperthermic intraperitoneal chemotherapy. Three patients out of 22 developed postoperative complications with a Clavien-Dindo grade above 2. Median survival was 50 months for patients who had chemotherapy plus surgery while it was 14 and 3 for those who had chemotherapy alone and best supportive care, respectively (p < 0.0001). Cox regression analysis performed on the whole cohort identified only radical conversion surgery as an independent factor positively associated with survival (HR 0.12, 95% CI 0.05-0.29, p < 0.0001)., Conclusion: Conversion gastrectomy, when R0 could be achieved, is associated with long survivals and it is the most important prognostic factor in patients with advanced gastric cancer. Further studies are needed to define the ideal patient who can really benefit from this treatment., (Copyright © 2018. Published by Elsevier Ltd.)

Surgery for gastric cancer is associated with significant major morbidity and an estimated mortality rate of about 5%. A reliable comparison of post-operative outcomes is hampered by the lack of a clear, universally recognized, definition of the most frequent complications. This paper reports the final results of a project launched by the Italian Research Group for Gastric Cancer in September 2015, whose goal was to propose a comprehensive list of surgical-related, gastric cancer-specific complications, with their definitions. The project was carried out through a multicentric, mainly web-based, consensus of experts. The proposed list, following assessment and validation by a group of experts of the European Chapter of the International Gastric Cancer Association, will form the basis for implementing a "Complications Recording Sheet" that can be disseminated worldwide for proper and reliable post-operative assessment.

Background: Gastrectomy with extended lymphadenectomy is considered the gold standard treatment for advanced gastric cancer, with no age- or comorbidity-related limitations. We evaluated the safety and efficacy of curative gastrectomy with extended nodal dissection, verifying survival in elderly and highly co-morbid patients., Methods: In a retrospective multicenter study, we examined 1322 non-metastatic gastric-cancer patients that underwent curative gastrectomy with D2 versus D1 lymphadenectomy from January 2000 to December 2009. Postoperative complications, overall survival (OS), and disease-specific survival (DSS) according to age and the Charlson Comorbidity Score were analyzed in relation to the extent of lymphadenectomy., Results: Postoperative morbidity was 30.4%. Complications were more frequent in highly co-morbid elderly patients, and, although general morbidity rates after D2 and D1 lymphadenectomy were similar (29.9% and 33.2%, respectively), they increased following D2 in highly co-morbid elderly patients (39.6%). D2-lymphadenectomy significantly improved 5-year OS and DSS (48.0% vs. 37.6% in D1, p < 0.001 and 72.6% vs. 58.1% in D1, p < 0.001, respectively) in all patients. In elderly patients, this benefit was present only in 5-year DSS. D2 nodal dissection induced better 5-year OS and DSS rates in elderly patients with positive nodes (29.7% vs. 21.2% in D1, p = 0.008 and 47.5% vs. 30.6% in D1, p = 0.001, respectively), although it was present only in DSS when highly co-morbid elderly patients were considered., Conclusion: Extended lymphadenectomy confirmed better survival rates in gastric cancer patients. Due to high postoperative complication rate and no significant improvement of the OS, D1 lymphadenectomy should be considered in elderly and/or highly co-morbid gastric cancer patients., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Purpose: Presently, there is no scientific evidence supporting a definite role for follow-up after gastrectomy for cancer, and clinical practices are quite different around the globe. The aim of this consensus conference was to present an ideal prototype of follow-up after gastrectomy for cancer, based on shared experiences and taking into account the need to rationalize the diagnostic course without losing the possibility of detecting local recurrence at a potentially curable stage., Methods: On June 19-22, 2013 in Verona (Italy), during the 10th International Gastric Cancer Congress (IGCC) of the International Gastric Cancer Association, a consensus meeting was held, concluding a 6-month, Web-based, consensus conference entitled "Rationale of oncological follow-up after gastrectomy for cancer.", Results: Forty-eight experts, with a geographical distribution reflecting different health cultures worldwide, participated in the consensus conference, and 39 attended the consensus meeting. Six statements were finally approved, displayed in a plenary session and signed by the vast majority of the 10th IGCC participants. These statements are attached as an annex to the Charter Scaligero on Gastric Cancer., Conclusion: After gastrectomy for cancer, oncological follow-up should be offered to patients; it should be tailored to the stage of the disease, mainly based on cross-sectional imaging, and should be discontinued after 5 years.

Background: Duodenal stump fistula (DSF) is a severe complication of gastrectomy. Although nonsurgical therapy is preferred, surgery is still mandatory in one third of DSF patients. The aim of this article is to analyze the surgical management of DSF and factors related to its outcome., Methods: We performed a retrospective multicenter study using data from January 1990 to November 2011 in 16 Italian surgery centers. We collected 8,268 elective gastrectomies for malignancies, 7,987 by the laparotomic and 281 by the laparoscopic approach. Two hundred five patients developed a DSF, 75 of whom underwent surgery for DSF. We analyzed mortality and DSF healing time as well as the impact of clinical, oncological, and surgical characteristics., Results: The laparoscopic approach increased the risk of DSF development (odds ratio 5.6, 95% confidence interval 2.7-10.6, P < 0.001). The indication for first DSF surgery was intra-abdominal sepsis; the failure rate was over 30%, associated with the appearance of fistulas of neighboring organs, bleeding, and the need for reoperations. The mortality rate was 28% and was related to the presence of vascular disease (P = 0.04), more than one reoperation (P = 0.05), sepsis (P < 0.001), and renal failure (P < 0.001). Fifty-four patients recovered after a median of 39 days (interquartile range 22-68 days); the need to perform more reoperations (P < 0.01) and the presence of an abdominal abscess (P < 0.01) led to an increase in healing time., Conclusions: Surgery for DSF has a poor prognosis. Our data will help to identify patients at risk of death, but unfortunately could not establish the best surgical procedure applicable to all cases of DSF.

Background: A score predictive of tumor recurrence after radical surgery for non-cardia gastric cancer was previously developed in Italian centers. The aim of this study was to validate the score in a consecutive cohort with prospectively collected follow-up data., Study Design: Of 1,178 patients surgically treated between 1998 and 2006, six hundred and thirty-five patients who fulfilled the selection criteria and completed the follow-up program were available for analysis. The score value for each patient was calculated using the formula obtained from a logistic regression model. Discrimination and calibration of the score in the validation group were evaluated and compared with the data of 438 patients in the study group where the score was developed., Results: Most patients in both groups had very low or very high score values. In the validation group, the observed recurrence rates ranged from 5% to 92% in different score strata. The area under the receiver operating characteristic curve was 0.889 (95% CI, 0.864-0.914; p < 0.001), indicating a high discrimination value of the score for recurrence. A good calibration was observed by comparing the predicted risk with the actual risk of recurrence. With a score cut-off value of 50, sensitivity, specificity, and overall accuracy were 74%, 86%, and 81%, respectively. An inverse correlation between the time to recurrence and score level was also estimated (R(2) = 0.119; p < 0.001)., Conclusions: The high predictive value of the score was validated in a consecutive cohort. These results might allow the introduction of the score in clinical practice for Western patients., (Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Gastric stump carcinoma (GSC) has been studied after primary gastrectomy for benign disease but few studies have evaluated its correlation with gastric cancer., Patients: We assessed 541 patients submitted to subtotal gastrectomy for early gastric cancer at least 15 years ago., Results: GSC was diagnosed in 16 (2.9%) patients, giving a 4% cumulative risk of GSC 20 years after surgery. Diagnosis was made within 5 years of surgery in 10 patients and after 8 years in 6 cases. GSC occurred in 13/470 (2.8%) patients submitted to Billroth 2 reconstruction, 2/30 (6.7%) patients who underwent Billroth 1, and 1/41 (2.4%) patients after Roux-en-Y reconstruction. Significant risk factors observed for GSC were histologic type and sex. Other synchronous or metachronous extragastric tumors were registered in 56 (11.2%) patients., Conclusions: The risk of GSC was low, even 20 years after subtotal gastrectomy for early gastric cancer. Lauren intestinal histotype and male sex were frequently associated with GSC. No correlation was observed between GSC and reconstruction technique or multifocality. Clinically speaking, GSC could be considered a subset of gastric cancer., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Only a few, small, monocentric randomized controlled trials (RCTs) have compared routine vs. no placement of a nasogastric or nasojejunal tube decompression (NG/NJT) in patients undergoing partial distal gastrectomy (PDG) for gastric cancer. However, to our knowledge, no multicenter prospective RCT has analyzed the role of decompression after both the Billroth II (BII) procedure and Roux-en-Y (RY) gastrojejunostomy. The aim of this study was to determine whether NG/NJT prevents the consequences of postoperative ileus after PDG for gastric cancer after both BII reconstruction and RY., Methods: Two hundred seventy patients undergoing PDG for gastric cancer were randomly assigned NG/NJT placement (NG/NJT group) or not (no-NG/NJT group) with either Billroth II gastrojejunostomy or Roux-en-Y gastrojejunostomy. The patients were monitored for postoperative complications, mortality, and postoperative course., Results: By January 2010 to June 2012, among 270 patients undergoing PDG for gastric cancer, 134 were randomly assigned to NG/NJT placement (NG/NJT group) and 136 to no decompression (no-NG/NJT group). Time to passage of flatus was significantly shorter in the NG/NJT group than in the no-NG/NJT group, but only after RY reconstruction (3.3 ± 1.5 vs. 4.3 ± 1.6 days, P < 0.001, respectively). Postoperative abdominal distention was significantly lower in the NG/NJT group than in the no-NG/NJT group after both BII and the RY procedure (P < 0.001). No significant differences in postoperative mortality or morbidity, especially anastomotic leakage or intra-abdominal sepsis, were observed between the groups., Conclusion: Routine placement of an NG/NJT after BII and RY PDG is not necessary in elective surgery for gastric cancer.

Oncological follow-up after radical gastrectomy for cancer still represents a discrepancy in the field, with many retrospective series demonstrating that early diagnosis of recurrence does not result in an improvement in patient survival; yet, many centers with high quality of care still provide routine patient follow-up after surgery by clinical and instrumental controls. This was the topic for a web round table entitled "Rationale and limits of oncological follow-up after gastrectomy for cancer" that was launched one year before the 10(th) International Gastric Cancer Congress. Authors having specific expertise were invited to comment on their previous publications to provide the subject for an open debate. During a three-month-long discussion, 32 authors from 12 countries participated, and 2299 people visited the dedicated web page. Substantial differences emerged between the participants: authors from Japan, South Korea, Italy, Brazil, Germany and France currently engage in instrumental follow-up, whereas authors from Eastern Europe, Peru and India do not, and British and American surgeons practice it in a rather limited manner or in the context of experimental studies. Although endoscopy is still considered useful by most authors, all the authors recognized that computed tomography scanning is the method of choice to detect recurrence; however, many limit follow-up to clinical and biochemical examinations, and acknowledge the lack of improved survival with early detection.

Background: The Italian Research Group for Gastric Cancer supports the practice of follow-up after radical surgery for gastric cancer., Methods: This multicenter, retrospective study (1998-2009) included patients with T1-4N0-3M0 gastric cancer who had undergone D2 gastrectomy and lymphadenectomy, with at least 15 lymph nodes examined, and who had developed recurrent disease. Timing and site of recurrence were correlated to the actual scheduled follow-up timing and modalities., Results: From eight centers, 814 patients with recurrent cancer and over 1,754 (46.4 %) patients undergoing gastrectomy were investigated (median follow-up 31 months). The most frequent sites of recurrence were local/regional lymph nodes (35.4 %), liver (24.3 %), peritoneum (30.3 %), lung (10.4 %) and intraluminal (7.5 %). Ninety-four percent of the recurrences were diagnosed within 2 years and 98 % within 3 years. Thoracoabdominal computed tomography (CT) scan and (18)F-fluoro-2-deoxy-D-glucose positron emission tomography (18-FDG-PET) detected more than 90 % of recurrences, abdominal ultrasound detected 70 % and tumor markers detected 40 %, while <10 % were identified by physical examination, chest X-ray, and upper gastrointestinal endoscopy. Twenty-six percent of patients with recurrence were treated, but only 3.2 % were treated with potentially radical intent., Conclusion: Oncological follow-up after radical surgery for gastric cancer should be focused in the first 3 years, and based mainly on thoracoabdominal CT scan and 18-FDG-PET.

Background: Duodenal fistula (DF) after gastrectomy continues to be a life-threatening problem. We performed a retrospective multicenter study analyzing the characteristics of DF after elective gastrectomy for malignant disease., Methods: Three thousand seven hundred eighty-five patients who had undergone gastrectomy with duodenal stump in 11 Italian surgical units were analyzed., Results: Sixty-eight DFs occurred, with a median frequency of 1.6% and a mortality rate of 16%. Complications were mainly septic but fistulas or bleeding of surrounding organs accounted for about 30%. Reoperation was performed in 40% of patients. We observed a correlation between mortality and age (hazard ratio 1.09; 95% CI 1.00-1.20) and serum albumin (hazard ratio 0.90; 95% CI 0.83-0.99). The appearance of further complications was associated with reoperation (P < 0.001) and death (P = 0.054), while the preservation of oral feeding was related to DF healing (P < 0.001)., Conclusions: This paper represents the largest series ever published on DF and shows that its features have changed in the last 20 years. DF alone no longer leads to death and some complications observed in the past have disappeared, while new ones are emerging. Nowadays, medical therapy is preferred and surgery is indicated only in cases of abdominal sepsis or bleeding.

Introduction: Multifocal early gastric cancer (MEGC) is frequently observed and represents a serious risk when minimally invasive treatments are performed., Patients and Methods: We present the experience of two Italian centers situated in a relatively high incidence area for gastric cancer. Out of a total of 791 surgical resections for EGC carried out in two Italian centers from 1976 to 2006, we identified 98 patients with multifocal EGC (12.3%). Two hundred and sixteen lesions were observed. Generally sited near the principal tumors, secondary lesions were, however, sometimes detected distally from the upper primary lesion. No secondary lesions were detected in the upper third when the principal lesion was sited at the lower third., Results: Survival of MEGC patients was not significantly lower than that of patients with monofocal EGC. No cases of gastric remnant relapse were observed at a mean follow-up of 9 years (range 1-28) after subtotal gastrectomy., Discussion: When EGCs are detected, the possibility of MEGC must always be investigated by endoscopy and chromoendoscopy. When a MEGC is found in the lower third of the stomach and chromoendoscopy of the upper third has been performed, subtotal gastrectomy can be considered as sufficient treatment.

Purpose: Resection line infiltration (RLI) after surgical treatment represents an unfavorable prognostic factor in advanced gastric cancer. We performed a retrospective analysis of 89 patients with resection line involvement who did not undergo reoperation., Methods: On behalf of the Italian Research Group for Gastric Cancer, we present the characteristics and outcome of 89 patients who were submitted to surgical resection for gastric cancer from 1988 to 2001 and did not undergo reoperation because of disease extension or associated pathologies., Results: RLI was significantly higher in patients with T4 tumors and diffuse histological type. Anastomotic leakages were observed in 4.8% of infiltrated esophageal resection margins, whereas 1.9% of infiltrated duodenal resection lines showed duodenal fistulas. Five-year overall survival of patients with RLI was 29%. Prognosis was not affected by RLI in early forms (100% 5-year survival); however, 5-year survival in T2 and T3 stages was significantly lower with respect to the same stages without residual tumor. The influence of RLI on prognosis was confirmed in N0 as well as in N1 and N2 patients. RLI also was an independent prognostic at multivariate analysis (odds ratio = 1.5; 95% confidence interval, 1.08-2.08; P = 0.0144)., Conclusions: RLI significantly affects long-term survival of advanced gastric cancer. The impact on prognosis is independent of lymph node involvement. Patients in good general condition for whom radical surgery is possible should be considered for reoperation.

Background and Objectives: This study was aimed at evaluating the prognostic significance of the number of metastatic nodes in early gastric cancer (EGC)., Methods: In this multicenter retrospective study 652 cases of resected EGC were analyzed. We searched for lymph node metastases-associated risk factors and to identify subsets of patients with different prognosis according to the number of involved nodes., Results: Nodal involvement was observed in 14.1%. A significant correlation was found between the presence of node metastases and tumor size (RR 1.34, P = 0.001), submucosal invasion (RR: 3.14, P = 0.007), Lauren diffuse/mixed type (RR: 4.88, P < 0.001) and Kodama Pen A type (RR: 4.59, P < 0.001). The 10-year survival rate was 92% for N0 cases, 82% and 73% for tumors with one to three and four to six positive nodes while it dropped to 27% with more than six metastatic nodes. Interestingly enough, the 10-year risk of recurrence diminished with the increasing number of retrieved nodes (>15) even in N0 patients., Conclusions: Nodal involvement confirmed to be a significant prognostic factor. In view of the trend to a lower risk of recurrence when more than 15 nodes were retrieved and the better staging achieved we consider D2 lymphadenectomy the treatment of choice., ((c) 2006 Wiley-Liss, Inc.)

Background: Resection line involvement has been indicated as an important prognostic factor for gastric cancer. Its late detection renders the choice of treatment difficult for surgeons., Materials and Methods: We describe the multicenter experience of a group of 11 patients with early gastric carcinoma (EGC) and positive resection confirmed at histological examination who did not undergo surgical retreatment for reasons of associated disease, surgical considerations on duodenal stump, or patient refusal., Results: The gastric margin was involved in 4 patients, and 7 patients had duodenal resection line involvement. No surgical complications or postoperative deaths were observed. Five and 8-year survival was 100% and 86%, respectively. The only patient who relapsed did not have lymph node involvement and died from liver metastases, without local recurrence., Conclusions: It is sometimes difficult to accurately define the resection line in gastric cancer surgery, especially in the early stages of disease, but because of the strongly negative prognostic value of an infiltrated margin, frozen sections are recommended if neoplastic invasion is suspected and a new resection is always recommended if possible. Nevertheless, the good prognosis of resected EGC patients with resection line involvement must be considered before submitting patients with associated diseases to radical surgical retreatment.

Background: The role of subtotal or total gastrectomy in the treatment of advanced gastric cancer of the antrum with serosal invasion was investigated., Methods: The investigation involved 117 patients with a cancer of the lower third of the stomach invading the serosa (pT3) who underwent R0 resection with at least D2 lymphadenectomy between 1988 and 1998 at three different Italian centers. The choice of surgical procedure (40 total gastrectomies and 77 subtotal gastrectomies) was based on the preference of the surgeon; none of the patients underwent splenectomy. The Cox regression model was used to evaluate the prognostic significance of the type of surgery (subtotal versus total gastrectomy), controlling for age, sex, histology, nodal involvement, and surgical center., Results: The morbidity and mortality rates did not vary significantly according to the type of surgery. Patients undergoing subtotal gastrectomy presented a better disease-related survival than patients undergoing total gastrectomy ( P = 0.011): the median survival times were, respectively, 38 months and 23 months, and the overall cumulative 5-year survival rates (95% confidence intervals [CI]) were, respectively, 36% (22%-50%) and 22% (11%-37%). On univariate analysis, the relative risk (RR) of disease-related death was 1.84 (1.14-2.97) after total gastrectomy, with respect to subtotal gastrectomy. This difference was blunted on multivariate analysis (RR, 1.66; 0.99-2.78): in the final model, only nodal metastasis was a significant prognostic factor, while type of surgery had a borderline significance ( P = 0.057)., Conclusions: Survival after subtotal gastrectomy is not lower than that after total gastrectomy in patients with tumor of the antrum invading the serosa. The role of subtotal or total gastrectomy in the treatment of advanced gastric cancer of the antrum with serosal invasion was investigated.

Background: The survival benefit of extended lymphadenectomy in the surgical treatment of gastric cancer is still being debated. The aim of this longitudinal multicenter study was to evaluate long-term survival in a group of patients with involvement of second level lymph nodes, which would not have been removed in the case of a limited lymphadenectomy. Results were compared with those in patients with involvement of first level lymph nodes., Methods: Between 1991 and 1997, 451 patients with primary gastric cancer underwent curative resection with extended lymphadenectomy at three surgical departments in Italy according to the rules of the Japanese Research Society for Gastric Cancer., Results: In 451 cases treated by extended lymphadenectomy, morbidity and mortality rates were 17.1% and 2%, respectively. In 126 patients (27.9%) (group A), metastases were found in lymph node stations 7 to 12; 109 patients (24.2%) had metastases confined to the first level (group B). Lymph node stations 7 and 8 showed the highest incidence of metastases in the second level (17.1% and 12.4%, respectively). A significant difference in 5-year survival was observed between group A and group B (32% vs. 54%; P =.0005). This difference disappeared when cases were stratified according to the number of positive lymph nodes. By multivariate analysis, only the number of positive lymph nodes (relative risk, 1.8; P <.0001) and the depth of invasion (relative risk, 2.1; P <.0001), but not the level of involved nodes, showed to be independent predictors of poor prognosis., Conclusions: Japanese-type extended lymphadenectomy yields low morbidity and mortality rates if performed in specialized centers. This procedure could provide a good probability of long-term survival, even for patients with involvement of regional lymph nodes.