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Backgrounds: Strong evidence is lacking as no confirmatory randomized controlled trials (RCTs) have compared the efficacy of totally laparoscopic distal gastrectomy (TLDG) with laparoscopy-assisted distal gastrectomy (LADG). The authors performed an RCT to confirm if TLDG is different from LADG., Methods: The KLASS-07 trial is a multi-centre, open-label, parallel-group, phase III, RCT of 442 patients with clinical stage I gastric cancer. Patients were enroled from 21 cancer care centres in South Korea between January 2018 and September 2020 and randomized to undergo TLDG or LADG using blocked randomization with a 1:1 allocation ratio, stratified by the participating investigators. Patients were treated through R0 resections by TLDG or LADG as the full analysis set of the KLASS-07 trial. The primary endpoint was morbidity within postoperative day 30, and the secondary endpoint was quality of life (QoL) for 1 year. This trial is registered at ClinicalTrials.gov (NCT03393182)., Results: Four hundred forty-two patients were randomized (222 to TLDG, 220 to LADG), and 422 patients were included in the pure analysis (213 and 209, respectively). The overall complication rate did not differ between the two groups (TLDG vs. LADG: 12.2% vs. 17.2%). However, TLDG provided less postoperative ileus and pulmonary complications than LADG (0.9% vs. 5.7%, P= 0.006; and 0.5% vs. 4.3%, P= 0.035, respectively). The QoL was better after TLDG than after LADG regarding emotional functioning at 6 months, pain at 3 months, anxiety at 3 and 6 months, and body image at 3 and 6 months (all P< 0.05). However, these QoL differences were resolved at 1 year., Conclusions: The KLASS-07 trial confirmed that TLDG is not different from LADG in terms of postoperative complications but has the advantages to reduce ileus and pulmonary complications. TLDG can be a good option to offer better QoL in terms of pain, body image, emotion, and anxiety at 3-6 months., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose: Textbook outcome is a comprehensive measure used to assess surgical quality and is increasingly being recognized as a valuable evaluation tool. Delta-shaped anastomosis (DA), an intracorporeal gastroduodenostomy, is a viable option for minimally invasive distal gastrectomy in patients with gastric cancer. This study aims to evaluate the surgical outcomes and calculate the textbook outcome of DA., Materials and Methods: In this retrospective study, the records of 4,902 patients who underwent minimally invasive distal gastrectomy for DA between 2009 and 2020 were reviewed. The data were categorized into three phases to analyze the trends over time. Surgical outcomes, including the operation time, length of post-operative hospital stay, and complication rates, were assessed, and the textbook outcome was calculated., Results: Among 4,505 patients, the textbook outcome is achieved in 3,736 (82.9%). Post-operative complications affect the textbook outcome the most significantly (91.9%). The highest textbook outcome is achieved in phase 2 (85.0%), which surpasses the rates of in phase 1 (81.7%) and phase 3 (82.3%). The post-operative complication rate within 30 d after surgery is 8.7%, and the rate of major complications exceeding the Clavien-Dindo classification grade 3 is 2.4%., Conclusions: Based on the outcomes of a large dataset, DA can be considered safe and feasible for gastric cancer., Competing Interests: No potential conflict of interest relevant to this article was reported., (Copyright © 2024. Korean Gastric Cancer Association.)

Purpose: We conducted a randomized prospective trial (KLASS-07 trial) to compare laparoscopy-assisted distal gastrectomy (LADG) and totally laparoscopic distal gastrectomy (TLDG) for gastric cancer. In this interim report, we describe short-term results in terms of morbidity and mortality., Methods and Methods: The sample size was 442 participants. At the time of the interim analysis, 314 patients were enrolled and randomized. After excluding patients who did not undergo planned surgeries, we performed a modified per-protocol analysis of 151 and 145 patients in the LADG and TLDG groups, respectively., Results: The baseline characteristics, including comorbidity status, did not differ between the LADG and TLDG groups. Blood loss was somewhat higher in the LADG group, but statistical significance was not attained (76.76±72.63 vs. 62.91±65.68 mL; P=0.087). Neither the required transfusion level nor the operation or reconstruction time differed between the 2 groups. The mini-laparotomy incision in the LADG group was significantly longer than the extended umbilical incision required for specimen removal in the TLDG group (4.79±0.82 vs. 3.89±0.83 cm; P<0.001). There were no between-group differences in the time to solid food intake, hospital stay, pain score, or complications within 30 days postoperatively. No mortality was observed in either group., Conclusions: Short-term morbidity and mortality rates did not differ between the LADG and TLDG groups. The KLASS-07 trial is currently underway., Trial Registration: ClinicalTrials.gov Identifier: NCT03393182., Competing Interests: No potential conflict of interest relevant to this article was reported., (Copyright © 2024. Korean Gastric Cancer Association.)

Background: Radical gastrectomy is composed of gastrectomy, lymph node dissection, and omentectomy. Total omentectomy (TO) is expected to reduce the incidence of peritoneal recurrence. We aimed to investigate the necessity of TO for advanced gastric cancer (AGC) with serosal invasion., Methods: We retrospectively reviewed 310 patients who underwent radical gastrectomy with TO and 93 patients who underwent partial omentectomy (PO) for gastric cancer with serosal invasion between August, 2005 and December, 2017. Finally, 91 patients in the PO group and 91 in the TO group were enrolled based on a 1:1 propensity-score matching analysis. We evaluated surgical and oncological outcomes, including 5-year overall and recurrence-free survival rates., Results: There was no statistically significant difference between the two groups in postoperative complications. Recurrence sites showed similar patterns in both groups, including peritoneal recurrence (PO vs. TO, 18.7% vs. 28.6%; p = 0.188). Five-year overall survival was better in the PO group (p = 0.018), while 5-year recurrence-free survival was similar in both groups (p = 0.066)., Conclusion: TO might not be an essential part of preventing peritoneal recurrence for AGC with serosal invasion. PO could be considered a radical gastrectomy for T4a gastric cancer., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Backgrounds: This study aimed to compare the incidence of bile reflux, quality of life (QoL), and nutritional status among Billroth II (BII), Billroth II with Braun anastomosis (BII-B), and Roux-en-Y (RY) reconstruction after laparoscopic distal gastrectomy (LDG)., Materials and Methods: We reviewed the prospective data of 397 patients from a multicentre database who underwent LDG for gastric cancer between 2018 and 2020 at 20 tertiary teaching hospitals in Korea. Postoperative endoscopic findings, QoL surveys using the European Organization for Research and Treatment of Cancer questionnaire (C30 and STO22), and nutritional and surgical outcomes were compared among groups., Results: In endoscopic findings, bile reflux was the lowest in the RY group ( n =67), followed by the BII-B ( n =183) and BII groups ( n =147) at 1 year (3.0 vs. 67.8 vs. 84.4%, all P <0.05). The anti-reflux capability of BII-B was statistically better than that of BII, but not as perfect as that of RY. From the perspective of QoL, BII-B was not inferior to RY, but better than BII reconstruction in causing fewer STO22 reflux symptoms at 6 and 12 months. However, only RY caused fewer C30 nausea symptoms than BII at 6 and 12 months, but not BII-B. Nutritional status and morbidities were similar among the three groups, and the operative time did not differ between the BII-B and RY groups., Conclusions: BII-B cannot substitute for RY in preventing bile reflux, shortening the operative time, or reducing morbidities. Regarding short-term QoL, BII-B was sufficient to reduce STO22 reflux symptoms but failed to reduce C30 nausea symptoms postoperatively., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Factors predicting postoperative complications after gastrectomy for elderly patients with gastric cancer have been analyzed in several previous studies. However, there is limited research available on risk factors related to long-term survival., Aims: This study aimed to analyze factors affecting long-term survival after curative gastrectomy in elderly patients with advanced gastric cancer., Methods: This study included patients aged > 75 years with histologically confirmed advanced gastric cancer stage II or greater. Before analysis, risk factors were categorized into four groups: baseline characteristics, underlying diseases, surgical and pathologic factors, and nutritional factors., Results: The mean follow-up duration was 71.0 months. The 5-year overall survival and disease-specific survival rates were 51.5% and 58.3%, respectively. Kaplan-Meier curves showed that patients who were female and overweight had significantly longer survival rates than those who were male and underweight. Elderly patients who underwent a total gastrectomy had poorer survival rates than those who underwent a distal gastrectomy. Multivariate analysis demonstrated that tumor stage, extent of gastrectomy, overweight status and overall complication were independent risk factors for overall survival., Discussion: Our study show that the overweight patients, the extent of gastrectomy, tumor stage and overall complications are significant risk factors affecting long-term survival., Conclusions: Therefore, surgeons may be cautious in performing total gastrectomy in elderly gastric cancer patients. Additionally, it is important to focus on improving nutritional status and mitigating overall complications., (© 2023. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Background: Owing to the rising number of screening endoscopies and instrumental advances in endoscopic ultrasound (EUS), colorectal subepithelial tumors (SETs) are being increasingly detected. We aimed to determine the feasibility of endoscopic resection (ER) and the impact of EUS-based surveillance on colorectal SETs., Methods: The medical records of 984 patients with incidentally detected colorectal SETs between 2010 and 2019 were retrospectively reviewed. Overall, 577 colorectal SETs underwent ER, and 71 colorectal SETs underwent serial colonoscopy for > 12 months., Results: The mean tumor size (± standard deviation) of 577 colorectal SETs for which ER was performed was 7.0 ± 5.7 (median, 55; range, 1-50) mm; 475 tumors were located in the rectum and 102, in the colon. En bloc resection was achieved in 560/577 treated lesions (97.1%), and complete resection was achieved in 516/577 (89.4%). ER-related adverse events occurred in 15/577 (2.6%) patients. SETs originating from the muscularis propria showed a higher risk of ER-related adverse events and perforation than SETs arising from the mucosal or submucosal layer (odds ratio [OR] 19.786, 95% confidence interval [CI] 4.556-85.919; P = 0.002 and OR 141.250, 95% CI 11.596-1720.492; P = 0.046, respectively). Seventy-one patients were followed up after EUS without any treatment for > 12 months, during which three showed progression; eight, regression; and sixty, no changes., Conclusions: ER for colorectal SETs showed excellent efficacy and safety. Additionally, colorectal SETs without high-risk features in surveillance with colonoscopy showed an excellent prognosis., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Gastric cancer (GC) is among the most common types of gastrointestinal cancers and has a high incidence and mortality around the world. To suppress the progression of GC, it is essential to develop diagnostic markers. MicroRNAs regulate GC development, but a clearer insight into their role is needed before they can be applied as a molecular markers and targets., Methods: In this study, we assessed the diagnostic value of differentially expressed microRNAs as potential diagnostic biomarkers for GC using data for 389 tissue samples from the Cancer Genome Atlas (TCGA) and 21 plasma samples from GC patients., Results: The expression of hsa-miR-143-3p (also known as hsa-miR-143) was significantly downregulated in GC according to the TCGA data and plasma samples. The 228 potential target genes of hsa-miR-143-3p were analyzed using a bioinformatics tool for miRNA target prediction. The target genes correlated with extracellular matrix organization, the cytoplasm, and identical protein binding. Furthermore, the pathway enrichment analysis of target genes showed that they were involved in pathways in cancer, the phosphoinositide 3-kinase (PI3K)-protein kinase B (Akt) signaling pathway, and proteoglycans in cancer. The hub genes in the protein-protein interaction (PPI) network, were matrix metallopeptidase 2 (MMP2), CD44 molecule (CD44), and SMAD family member 3 (SMAD3)., Conclusions: This study suggests that hsa-miR-143-3p may be used as a diagnostic marker for GC, contributing via the pathways involved in the development of GC., (© 2023. The Author(s).)

Background: We aimed to examine the technical and oncological safety of curative gastrectomy for gastric cancer patients who underwent liver transplantation., Methods: In this study, we compared the surgical and oncological outcomes of two groups. The first group consisted of 32 consecutive patients who underwent curative gastrectomy for gastric cancer after liver transplantation (LT), while the other group consisted of 127 patients who underwent conventional gastrectomy (CG). In addition, a subgroup analysis was performed to evaluate the impact of the background differences and the surgical outcomes on the involvement of a specialized liver transplant surgery team., Results: The mean operative time was significantly longer in the LT group (p < 0.05). Furthermore, there were more frequent cases of postoperative transfusion in the LT group compared to the CG group (p < 0.05). However, there were no significant differences in the overall complications between the groups (25.00 vs 23.62%, p = 0.874). The 5-year overall survival rates of the LT and CG groups were 76.7% and 90.1%, respectively (p < 0.05). The results of the subgroup analysis demonstrated no statistically significant difference in various early surgical outcomes, such as time to transfusion during surgery, first flatus, time to first soft diet, postoperative complications, hospital stay after surgery, and the number of harvested lymph nodes except for operation time., Conclusions: Despite one's medical history of undergoing LT, our study demonstrated that curative gastrectomy could be a surgically safe treatment for gastric cancer. However, further study should be conducted to identify the reason gastric cancer patients who underwent liver transplant surgery have lower overall survival rate., (© 2023. The Author(s).)

Background: Subepithelial tumors (SETs) in the upper gastrointestinal (GI) tract are frequently discovered during upper endoscopy, and their management is determined based on size and histopathological diagnosis. We aimed to evaluate the diagnostic performance of endoscopic ultrasonography-guided fine-needle biopsy (EUS-FNB) in upper GI SETs of 2-5 cm in size., Methods: We included 63 patients who underwent EUS-FNB for upper GI SETs of 2-5 cm in size between January 2013 and February 2020. The diagnostic yield of EUS-FNB, ability of EUS-FNB in discriminating malignant from non-malignant lesions, and histopathological concordance between EUS-FNB specimens and resected specimens were evaluated., Results: Successful acquisition of macroscopic tissue cores was possible in all 63 cases, and the diagnostic yield of EUS-FNB was 92.1% (58/63). The sensitivity, specificity, and accuracy of EUS-FNB in discriminating malignant from non-malignant lesions were 100% (95% confidence interval [CI] 85.3-100%), 87.8% (95% CI 79.9-87.8%), and 92.1% (95% CI 81.8-92.1%), respectively. Of the 26 SETs that were endoscopically or surgically resected after EUS-FNB, the histopathological concordance rate between the EUS-FNB specimens and resected specimens was 100% (24/24), except in two cases of inadequate results with EUS-FNB specimens., Conclusion: EUS-FNB provides high diagnostic yield and high capability in discriminating malignant from non-malignant lesions in upper GI SETs of 2-5 cm in size., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: Laparoscopic gastrectomy (LG) has gradually increased for treating advanced gastric cancer (AGC). However, there is a lack of evidence on oncologic safety for AGC, especially with serosal invasion. This study evaluates the surgical and oncologic outcomes between laparoscopic and open gastrectomy (OG) for gastric cancer with serosal invasion., Methods: We retrospectively reviewed 256 patients who underwent OG and 147 patients who underwent LG for gastric cancer with serosal invasion between August 2005 and December 2017. Finally, 124 patients in the LG group and 124 in the OG group were enrolled according to one-to-one propensity score matching (PSM) analysis. We evaluated surgical and oncological outcomes, including overall survival (OS) and recurrence-free survival (RFS)., Results: There were no statistical differences in hospital stay and major complications between the two groups. The retrieved lymph nodes of the LG group were similar to those of OG (40 ± 16.23 vs. 38 ± 14.42, p = 0.306), and it showed a similar operation time compared with the other (164 ± 43.86 vs. 156 ± 37.66, p = 0.063). There was no statistical difference in OS (p = 0.761) and RFS (p = 0.121) for survival analysis between the two groups., Conclusion: LG for gastric cancer with serosal invasion is feasible and could be considered as a standard treatment., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: A history of abdominal surgery is associated with difficulty in colonoscopy insertion. Few studies have reported effective colonoscopy insertion for patients who underwent abdominal surgery due to stomach cancer., Aim: We aimed to compare the impact of supine position (SP) and left lateral position (LLP) as the starting position of colonoscopy insertion in patients who underwent abdominal surgery due to stomach cancer., Methods: This was a prospective, randomized controlled trial. Patients undergoing colonoscopy for screening or post-polypectomy surveillance after gastrectomy due to stomach cancer were enrolled and randomized to the SP or LLP group as the starting position of colonoscopy insertion. All colonoscopic examinations were performed with a transparent cap. The primary outcome was to compare the cecal intubation time between the two groups., Results: A total of 224 patients were enrolled. The mean cecal intubation time was not significantly different between the SP and LLP groups (364.5 s versus 306.9 s; p = 0.105). In patients with a lower body mass index (< 21 kg/m 2 ) or who underwent gastrectomy within three years, the mean cecal intubation time of the LLP group was shorter than the SP group. In the multivariate analysis for the factors affecting to increase in the cecal intubation time (> 5 min), the starting position was not an independent factor., Conclusion: Either the SP or LLP could serve as a possible starting position of colonoscopy insertion for patients who underwent abdominal surgery due to stomach cancer., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Knowledge on the optimal extent of lymphadenectomy among elderly patients with advanced gastric cancer is limited. This study was designed to compare standard D2 and limited lymphadenectomy for evaluating the appropriate extent of lymphadenectomy., Patients and Methods: We retrospectively reviewed patient's data based on a prospectively collected gastric cancer registry. The inclusion criteria were age above 75 years and histologically confirmed stage II or more advanced gastric cancer. In this study, 103 patients who underwent limited lymph node dissection and 134 patients who underwent standard D2 lymph node dissection were included to evaluate surgical and oncological outcomes using propensity score matching (PSM) analysis., Results: The mean age after PSM was approximately 78 years in both groups. The Charlson Comorbidity Index was 5.81 ± 0.87 and 5.75 ± 0.76, respectively, and 12.5% of the patients in both groups had American Society of Anesthesiologists scores of more than 3. The limited lymphadenectomy group showed a shorter operation time and fewer retrieved lymph. However, other surgical outcomes and pathological data were not significantly different between the groups. No postoperative mortality within 30 days was observed. There were no significant differences in overall complications between the groups. The 3-year overall survival rates of the limited and standard lymphadenectomy groups were 58.3% and 73.6%, respectively. The 3-year recurrence-free survival rate of the limited lymphadenectomy group was lower than that of the standard lymphadenectomy group; however, the difference was not statistically significant., Conclusions: Standard D2 lymphadenectomy has better oncological outcomes in elderly patients with advanced gastric cancer., (© 2022. Society of Surgical Oncology.)

Background: For successful treatment of early gastric cancers (EGCs), it is crucial to define the horizontal border of the lesion with high accuracy. Acetic acid-indigo carmine (AI) chromoendoscopy has been used to determine the horizontal border in EGCs, but this technique is less potent in certain situations. Mucin phenotype in gastric cancers refers to biological differences in precursor lesions and differences in histopathologic findings, and it might affect AI chromoendoscopy findings. We aimed to investigate the association between mucin phenotype and AI chromoendoscopy findings in EGCs., Methods: We prospectively evaluated 126 lesions in 126 patients with endoscopically diagnosed EGCs. Conventional endoscopy and AI chromoendoscopy findings of these lesions before treatment were prospectively analyzed. The border distinction between the lesion and surrounding mucosa was classified as distinct or indistinct on conventional endoscopy and AI chromoendoscopy, respectively. Mucin phenotypes were classified as gastric, intestinal, gastrointestinal, or null type by immunohistochemistry., Results: The lesion borders were distinct in 46.8% (59/126) of the lesions assessed using conventional endoscopy and in 73.0% (92/126) of those assessed with AI chromoendoscopy (p < 0.001). The border distinction rate of differentiated-type cancers on AI chromoendoscopy was significantly higher than that on conventional endoscopy (66/71 [93.0%] vs. 34/71 [47.9%], p < 0.001), but the border distinction rate of undifferentiated-type cancers on AI chromoendoscopy was not different from that on conventional endoscopy (26/55 [47.3%] vs. 25/55 [45.5%], p = 0.848). Compared with conventional endoscopy, AI chromoendoscopy identified borders in a significantly higher percentage of gastric, intestinal, and gastrointestinal mucin types; however, there was no difference in AI chromoendoscopy findings according to the mucin phenotype (p = 0.271)., Conclusion: AI chromoendoscopy was effective in horizontal border delineation in differentiated-type EGCs, but not in undifferentiated-type EGCs. Mucin phenotype had no effect on border distinction using AI chromoendoscopy., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Although the criteria for the indication of endoscopic submucosal dissection (ESD) for undifferentiated early gastric cancer (UD-EGC) have been recently proposed, accumulating reports on the non-negligible rate of lymph node metastasis (LNM) after indicated ESD raise questions on the reliability of the current criteria., Aim: To investigate the prevalence and risk factors of LNM in UD-EGC cases meeting the expanded indication for ESD., Methods: We retrospectively reviewed 4780 UD-EGC cases that underwent surgical resection between January 2008 and February 2019 at Asan Medical Center, a tertiary university hospital in Korea. To identify the risk factors of LNM of UD-EGC meeting the expanded criteria for ESD, we performed a case-control study by matching the cases with LNM to those without at a ratio of 1:4. We reviewed the clinical, endoscopic, and histologic features of the cases to identify features with a significant difference according to the presence of LNM. Univariate and multivariate logistic regression analyses were performed to estimate the odds ratios (ORs)., Results: Of the 4780 UD-EGC cases, 1240 (25.9%) were identified to meet the expanded indication for ESD. Of the 1240 cases, 14 (1.1%) cases had LNM. Among the various clinical, endoscopic, and histopathological features that were evaluated, mixed histology (tumors consisting of 10%-90% of signet ring cells) had a marginally significant association ( P = 0.059) with the risk of LNM. Moreover, diffuse blurring of the muscularis mucosae (MM) underneath the tumorous epithelium, a previously unrecognized histologic feature, had a significant association with the absence of LNM ( P = 0.028). Multivariate logistic regression analysis showed that the blurring of MM was the only explanatory variable significantly associated with a reduced risk of LNM (OR: 0.12, 95%CI: 0.02-0.95; P = 0.045)., Conclusion: The risk of LNM is higher than expected when using the current expanded indication for UD-EGC. Histological evaluation could provide useful clues for reducing the risk of LNM., Competing Interests: Conflict-of-interest statement: All authors have no conflict of interest related to the study., (©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.)

The advantages of laparoscopic resection over open surgery in the treatment of gastric gastrointestinal stromal tumor (GIST) are not conclusive. This study aimed to evaluate the postoperative and oncologic outcome of laparoscopic resection for gastric GIST, compared to open surgery. We retrospectively reviewed the prospectively collected database of 1019 patients with gastric GIST after surgical resection at 13 Korean and 2 Japanese institutions. The surgical and oncologic outcomes were compared between laparoscopic and open group, through 1:1 propensity score matching (PSM). The laparoscopic group (N = 318) had a lower rate of overall complications (3.5% vs. 7.9%, P = 0.024) and wound complications (0.6% vs. 3.1%, P = 0.037), shorter hospitalization days (6.68 ± 4.99 vs. 8.79 ± 6.50, P < 0.001) than the open group (N = 318). The superiority of the laparoscopic approach was also demonstrated in patients with tumors larger than 5 cm, and at unfavorable locations. The recurrence-free survival was not different between the two groups, regardless of tumor size, locational favorableness, and risk classifications. Cox regression analysis revealed that tumor size larger than 5 cm, higher mitotic count, R1 resection, and tumor rupture during surgery were independent risk factors for recurrence. Laparoscopic surgery provides lower rates of complications and shorter hospitalizations for patients with gastric GIST than open surgery., (© 2022. The Author(s).)

Rationale: Amyloidosis is a general term that refers to the extracellular deposition of amyloid. The amyloid can also be deposited in a single organ. However, cases of localized gastric amyloidosis have rarely been reported. Here, we report a case of localized gastric amyloidosis that was successfully treated with endoscopic submucosal dissection., Patient Concern: A 60-years-old man underwent esophagogastroduodenoscopy as part of a regular check-up without any comorbidities or symptoms., Diagnostics: A 12 mm-sized, round, elevated lesion with a central depression, which was covered with normal mucosa, and located on the greater curvature of the lower body of the stomach was discovered during endoscopy. Subsequently, endoscopic ultrasonography was performed, which revealed a 11.7 mm-sized, hypoechoic, heterogeneous lesion located in the muscularis mucosa and submucosa. A biopsy was performed, and amyloid deposition was confirmed. Although other investigations for checking systemic amyloidosis were performed, there were no specific findings. Therefore, the final diagnosis was localized gastric amyloidosis., Interventions: Endoscopic submucosal dissection was performed according to the patient's request and the lesion was completely removed., Outcomes: The patient was followed-up for 3 years without any recurrence., Conclusions: Endoscopic submucosal dissection can be good diagnostic and treatment option for localized gastric amyloidosis., Competing Interests: The authors have no funding and conflicts of interests to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Introduction: Patients who underwent curative gastrectomy for gastric cancer are regularly followed-up for the early detection of recurrence and postoperative symptom management. However, there is a lack of evidence with regard to proper surveillance intervals and diagnostic tools. This study aims to evaluate whether frequent surveillance tests have a survival benefit or improve the quality of life in patients who underwent curative resection for advanced gastric cancer., Methods and Analysis: The STOFOLUP trial is an investigator-initiated, parallel-assigned, multicentre randomised controlled trial involving 16 hospitals in the Republic of Korea. Patients (n=886) diagnosed with pathological stage II or III gastric adenocarcinoma will be randomised to either the 3-month or the 6-month group at a 1:1 ratio, stratified by trial site and tumour stage. Patients allocated to the 3-month group will undergo an abdominal CT scan every 3 months postoperatively and those allocated to the 6-month group will undergo CT every 6 months. The primary endpoint is 3-year overall survival and the secondary endpoints are quality of life, as assessed using KOrean QUality of life in Stomach cancer patients Study group-40, the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 and the stomach cancer-specific module (STO22), and nutritional outcomes. Other survival data including data concerning 3-year disease-free survival, recurrence-free survival, gastric cancer-specific survival and postrecurrence survival will also be estimated. The first patient was enrolled on July 2021 and active patient enrolment is currently underway., Ethics and Dissemination: This study has been approved by the Institutional Review Board of eight of the participating hospitals (NCC 2021-0085, KBSMC2021-01-059, SMC 2021-01-140, KC21OEDE0082, 4-2021-0281, AJIRB-MED-INT-20-608, 2021-0515 and H-2102-093-1198). This study will be disseminated through peer-reviewed publications, national or international conferences., Trial Registration Number: NCT04740346., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Adjuvant chemotherapy after D2 gastrectomy is standard for resectable locally advanced gastric cancer (LAGC) in Asia. Based on positive findings for perioperative chemotherapy in European phase III studies, the phase III PRODIGY study (ClinicalTrials.gov identifier: NCT01515748) investigated whether neoadjuvant docetaxel, oxaliplatin, and S-1 (DOS) followed by surgery and adjuvant S-1 could improve outcomes versus standard treatment in Korean patients with resectable LAGC., Patients and Methods: Patients 20-75 years of age, with Eastern Cooperative Oncology Group performance status 0-1, and with histologically confirmed primary gastric or gastroesophageal junction adenocarcinoma (clinical TNM staging: T2-3N+ or T4Nany) were randomly assigned to D2 surgery followed by adjuvant S-1 (40-60 mg orally twice a day, days 1-28 every 6 weeks for eight cycles; SC group) or neoadjuvant DOS (docetaxel 50 mg/m 2 , oxaliplatin 100 mg/m 2 intravenously day 1, S-1 40 mg/m 2 orally twice a day, days 1-14 every 3 weeks for three cycles) before D2 surgery, followed by adjuvant S-1 (CSC group). The primary objective was progression-free survival (PFS) with CSC versus SC. Two sensitivity analyses were performed: intent-to-treat and landmark PFS analysis., Results: Between January 18, 2012, and January 2, 2017, 266 patients were randomly assigned to CSC and 264 to SC at 18 Korean study sites; 238 and 246 patients, respectively, were treated (full analysis set). Follow-up was ongoing in 176 patients at data cutoff (January 21, 2019; median follow-up 38.6 months [interquartile range, 23.5-62.1]). CSC improved PFS versus SC (adjusted hazard ratio, 0.70; 95% CI, 0.52 to 0.95; stratified log-rank P = .023). Sensitivity analyses confirmed these findings. Treatments were well tolerated. Two grade 5 adverse events (febrile neutropenia and dyspnea) occurred during neoadjuvant treatment., Conclusion: PRODIGY showed that neoadjuvant DOS chemotherapy, as part of perioperative chemotherapy, is effective and tolerable in Korean patients with LAGC., Competing Interests: Yoon-Koo KangConsulting or Advisory Role: DAEHWA Pharmaceutical, Bristol-Myers Squibb, Zymeworks, ALX Oncology, Amgen, Novartis, MacroGenics, Surface Oncology Min-Hee RyuHonoraria: DAEHWA Pharmaceutical, Bristol-Myers Squibb, Lilly, Ono Pharmaceutical, MSD, Taiho Pharmaceutical, Novartis, Daiichi Sankyo, AstraZenecaConsulting or Advisory Role: DAEHWA Pharmaceutical, Bristol-Myers Squibb, Lilly, Ono Pharmaceutical, MSD, Taiho Pharmaceutical, Novartis, Daiichi Sankyo, AstraZeneca Sun Young RhaConsulting or Advisory Role: MSD Oncology, Ipsen, Daiichi Sankyo, Eisai, Amgen, IndivumedSpeakers' Bureau: Lilly, EisaiResearch Funding: MSD Oncology, Bristol-Myers Squibb, Eisai, Roche/Genentech, MedPacto, ASLAN Pharmaceuticals, SillaJen, Bayer, Immunomet Gyunji KimEmployment: Sanofi, NovartisStock and Other Ownership Interests: Sanofi YeonJu LeeEmployment: SanofiStock and Other Ownership Interests: Sanofi Jee Hyun LeeEmployment: SanofiNo other potential conflicts of interest were reported.

Background: Few studies have presented evidence pertaining to the adequate minimum number of adjuvant chemotherapy (AC) cycles required to achieve an oncologic benefit for gastric cancer., Methods: From January 2012 to December 2013, data from patients who underwent curative radical gastrectomy and consequently received AC for pathologic stage 2 or 3 gastric cancer at 27 institutions in South Korea were analyzed., Results: The study enrolled 925 patients, 661 patients (71.5%) who completed 8 cycles of AC and 264 patients (28.5%) who did not. Compared with the mean disease-free survival (DFS) of the patients who completed 8 AC cycles (69.3 months), the mean DFS of patients who completed 6 AC cycles (72.4 months; p = 0.531) and those who completed 7 AC cycles (63.7 months; p = 0.184) did not differ significantly. However, the mean DFS of the patients who completed 5 AC cycles (48.2 months; p = 0.016) and those who completed 1-4 AC cycles (62.9 months; p = 0.036) was significantly lower than the DFS of those who completed 8 AC cycles. In the multivariate Cox proportional hazards analysis, the mean DFS was significantly affected by advanced stage, large tumor size, positive vascular invasion, and number of completed AC cycles (1-5 cycles: hazard ratio 1.45; 95% confidence interval 1.01-2.08; p = 0.041)., Conclusion: The current multicenter observational cohort study showed that the mean DFS for 6 or 7 AC cycles was similar to that for 8 AC cycles as an adjuvant treatment for gastric cancer.

Purpose: Patients who have undergone gastrectomy have unique symptoms that are not appropriately assessed using currently available tools. This study developed and validated a symptom-focused quality of life (QoL) questionnaire for patients who have received gastrectomy for gastric cancer., Materials and Methods: Based on a literature review, patient interviews, and expert consultation by the KOrean QUality of life in Stomach cancer patients Study group (KOQUSS), the initial item pool was developed. Two large-scale developmental studies were then sequentially conducted for exploratory factor analyses for content validity and item reduction. The final item pool was validated in a separate cohort of patients and assessed for internal consistency, test-retest reliability, construct validity, and clinical validity., Results: The initial questionnaire consisted of 46-items in 12 domains. Data from 465 patients at 11 institutions, followed by 499 patients at 13 institutions, were used to conduct item reduction and exploratory factor analyses. The final questionnaire (KOQUSS-40) comprised 40 items within 11 domains. Validation of KOQUSS-40 was conducted on 413 patients from 12 hospitals. KOQUSS-40 was found to have good model fit. The mean summary score of the KOQUSS-40 was correlated with the EORTC QLQ-C30 and STO22 (correlation coefficients, 0.821 and 0.778, respectively). The KOQUSS-40 score was also correlated with clinical factors, and had acceptable internal consistency (> 0.7). Test-retest reliability was greater than 0.8., Conclusion: The KOQUSS-40 can be used to assess QoL of gastric cancer patients after gastrectomy and allows for a robust comparison of surgical techniques in clinical trials.

Abstract: Malignant gastric lymphoma (MGL) accounts for a small proportion (upto 5%) of gastric malignancies. However, unlike for advanced gastric cancer (AGC) that requires surgical treatment, the standard treatments for MGL are chemotherapy and radiotherapy. Hence, the initial impression of the endoscopist is critical for the differential diagnosis and for planning future treatment. The purpose of this study was to assess the endoscopic diagnostic accuracy and the possibility of distinguishing between AGC and MGL depending on the endoscopist's experience.A total of 48 patients who had MGL, and 48 age and sex-matched patients who had AGC were assessed by endoscopic review at a tertiary referral hospital between June 2008 and February 2017. Two endoscopic specialists reviewed the endoscopic findings and divided these diagnoses into 5 groups: Borrmann type (1, 2, 3, and 4) and early gastric cancer-like type. After this, 7 experts and 8 trainees were asked to complete a quiz that was comprised of 6 images for each of the 96 cases and to provide an endoscopic diagnosis for each case. The test results were analyzed to assess the diagnostic accuracy according to the pathologic results, endoscopic subgroups, and endoscopists' experience. For inter-observer agreement was calculated with Fleiss kappa values.The overall diagnostic accuracy of endoscopic findings by the experts was 0.604 and that by the trainees was 0.493 (P = .050). There was no significant difference in the diagnosis according to the final pathology (lymphoma cases, 0.518 vs 0.440, P = .378; AGC cases, 0.690 vs 0.547, P = .089, respectively). In the subgroup analysis, the experts showed significantly higher diagnostic accuracy for the endoscopic Borrmann type 4 subgroup, including lymphoma or AGC cases, than the trainees (P = .001). Inter-observer agreement of final diagnosis (Fleiss kappa, 0.174) and endoscopic classification groups (Fleiss kappa, 0.123-0.271) was slightly and fair agreement.The experts tended to have a higher endoscopic diagnostic accuracy. Distinguishing MGL from AGC based on endoscopic findings is difficult, especially for the beginners. Even if the endoscopic impression is AGC, it is important to consider MGL in the differential diagnosis., Competing Interests: The authors have no funding and conflicts of interests to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Competing Interests: The authors declare that they have no conflict of interest.

Importance: The incidence of gallstones has been reported to increase after gastrectomy. However, few studies have been conducted on the prevention of gallstone formation in patients who have undergone gastrectomy., Objective: To evaluate the efficacy and safety of ursodeoxycholic acid (UDCA) in preventing gallstone formation after gastrectomy in patients with gastric cancer., Design, Setting, and Participants: The PEGASUS-D study (Efficacy and Safety of DWJ1319 in the Prevention of Gallstone Formation after Gastrectomy in Patient with Gastric Cancer: A Multicenter, Randomized, Double-blind, Placebo-controlled Study) was a randomized, double-blind, placebo-controlled clinical trial conducted at 12 institutions in the Republic of Korea. Adults (aged ≥19 years) with a diagnosis of gastric cancer who underwent total, distal, or proximal gastrectomy were enrolled between May 26, 2015, and January 9, 2017; follow-up ended January 8, 2018. Efficacy was evaluated by both the full analysis set, based on the intention-to-treat principle, and the per-protocol set; full analysis set findings were interpreted as the main results., Interventions: Eligible participants were randomly assigned to receive 300 mg of UDCA, 600 mg of UDCA, or placebo at a ratio of 1:1:1. Ursodeoxycholic acid and placebo were administered daily for 52 weeks., Main Outcomes and Measures: Gallstone formation was assessed with abdominal ultrasonography every 3 months for 12 months. Randomization and allocation to trial groups were carried out by an interactive web-response system. The primary end point was the proportion of patients developing gallstones within 12 months after gastrectomy., Results: A total of 521 patients (175 received 300 mg of UDCA, 178 received 600 mg of UDCA, and 168 received placebo) were randomized. The full analysis set included 465 patients (311 men; median age, 56.0 years [interquartile range, 48.0-64.0 years]), with 151 patients in the 300-mg group, 164 patients in the 600-mg group, and 150 patients in the placebo group. The proportion of patients developing gallstones within 12 months after gastrectomy was 8 of 151 (5.3%) in the 300-mg group, 7 of 164 (4.3%) in the 600-mg group, and 25 of 150 (16.7%) in the placebo group. Compared with the placebo group, odds ratios for gallstone formation were 0.27 (95% CI, 0.12-0.62; P = .002) in the 300-mg group and 0.20 (95% CI, 0.08-0.50; P < .001) in the 600-mg group. No significant adverse drug reactions were detected among the enrolled patients., Conclusions and Relevance: Administration of UDCA for 12 months significantly reduced the incidence of gallstones after gastrectomy for gastric cancer. These findings suggest that UDCA administration prevents gallstone formation after gastrectomy in patients with gastric cancer., Trial Registration: ClinicalTrials.gov Identifier: NCT02490111.

Background/aims: Recently, increased body weight has been found to be associated with an increasing risk of several cancers, including gastric cancer. The true pathogenic role of hyperglycemia in the development of gastric cancer remains unclear as hyperglycemia and its associated conditions may work as carcinogenic factors. The goal of this study was to clarify the factors associated with early gastric cancer and evaluate a homeostasis model assessment of the insulin resistance (HOMA-IR) index, fasting glucose, and lipid profile as predictors of early gastric cancer., Methods: A total of 63 patients with early gastric cancer between November 2012 and March 2013 were included. Preoperative serum lipid profile levels and serum fasting glucose were examined prospectively in patients with early gastric cancer. The same number of controls were evaluated and matched to the early gastric cancer group for age and gender. We performed multivariate logistic regression analysis to identify independent risk factors for early gastric cancer., Results: Univariate analysis showed that risk for early gastric cancer was associated with diastolic blood pressure (BP), total cholesterol, fasting glucose, and HOMA-IR. In the multivariate-adjusted model, higher total cholesterol, fasting glucose, body mass index, and diastolic BP were strongly associated with an increased risk of early gastric cancer., Conclusions: Hyperglycemia, a lower high-density lipoprotein cholesterol level, and a low HOMA-IR level appear to be associated with early gastric cancer risk.

Early detection and accurate monitoring of cancer is important for improving clinical outcomes. Endoscopic biopsy and/or surgical resection specimens are the gold standard for diagnosing gastric cancer and are also useful for selecting therapeutic strategies based on the analysis of genomic/immune parameters. However, these approaches cannot be easily performed because of their invasiveness and because these specimens do not always reflect tumor dynamics and drug sensitivities during therapeutic processes, especially chemotherapy. Accordingly, many researchers have tried to develop noninvasive novel biomarkers that can monitor real-time tumor dynamics for early diagnosis, prognostic evaluation, and prediction of recurrence and therapeutic efficacy. Circulating tumor cells (CTCs) are metastatic cells that are released from the primary tumors into the blood stream and comprise a crucial step in hematogenous metastasis. CTCs, as a liquid biopsy, have received a considerable amount of attention from researchers since they are easily accessible in peripheral blood, avoiding the invasiveness associated with traditional biopsy techniques; they can also be used to derive clinical information for monitoring disease status. In this review, with respect to CTCs, we summarize the metastatic cascade, detection methods, clinical applications, and prospects for patients with gastric cancer.

Background: With the increase in the prevalence of overweight, percentage of overweight patients with gastric cancer has also increased. This 5-year retrospective cohort study was performed to investigate long-term changes in the metabolic and nutritional parameters of early gastric cancer (EGC) patients with overweight after gastrectomy., Methods: EGC patients who underwent gastrectomy were followed up over a 5-year period. We included 393 patients (261 men, 132 women) who had an initial body mass index (BMI) of ≥23 kg/m 2 , and analyzed the longitudinal changes in the metabolic and nutritional parameters., Results: Body weight and random glucose, alanine aminotransferase (ALT), hemoglobin, and serum calcium levels significantly decreased, while serum protein and albumin levels increased in both men and women after gastrectomy. The odds ratios (ORs) for BMI ≥ 25 kg/m 2 (P < 0.001 for men and women), random glucose ≥ 126 mg/dL (men; P = 0.001, women; P < 0.001), and ALT > 40 IU/dL (men; P < 0.001, women; P = 0.018) were lower in both men and women after 5 years. The ORs for low protein and albumin levels decreased, although the ORs for anemia and hypocalcemia increased in both sexes at 5 years after gastrectomy., Conclusion: Gastrectomy in overweight patients followed up over 5-year could lead to approximately 10% weight loss and favorable changes in the metabolic parameters in both men and women. The risk of anemia and hypocalcemia increased, and the risk of low protein and albumin levels decreased in both sexes., (Copyright © 2018. Published by Elsevier Taiwan LLC.)

Purpose: The purpose of this study was to evaluate the efficacy and safety of induction chemotherapy with docetaxel, capecitabine, and cisplatin (DXP) plus bevacizumab (BEV) on initially unresectable locally advanced gastric cancer (LAGC) or paraaortic lymph node (PAN) metastatic gastric cancer (GC)., Materials and Methods: Patients with LAGC or unresectable PAN metastatic GC received six induction chemotherapy cycles (60 mg/m 2 docetaxel intravenously on day 1, 937.5 mg/m 2 capecitabine orally twice daily on days 1-14, 60 mg/m 2 cisplatin intravenously on day 1, and 7.5 mg/kg BEV intravenously on day 1 every 3 weeks), followed by conversion surgery. The primary endpoint was R0 resection rate., Results: Thirty-one patients with invasion to adjacent organs but without PAN metastasis (n=14, LAGC group) or with PAN metastasis regardless of invasion (n=17, PAN group) were enrolled between July 2010 and December 2014. Twenty-seven patients (87.1%) completed six chemotherapy cycles. The most common grade ≥ 3 toxicities were neutropenia (71%), neutropenia with fever/infection (22.6%/3.2%), and stomatitis (16.1%). The clinical response and R0 resection rates were 64.3% (95% confidence interval [CI], 46.6 to 82.0) and 64.5% (LAGC group, 71.4%; PAN group, 58.8%), respectively. The pathological complete regression rate was 12.9%. After a median follow-up of 44.5 months (range, 39.4 to 49.7 months), the median progression-free survival and overall survival were 13.1 months (95% CI, 8.9 to 17.3) and 38.6 months (95% CI, 22.0 to 55.1), respectively., Conclusion: Induction chemotherapy with DXP+BEV displayed antitumor activities with encouraging R0 resection rate and manageable toxicity profiles on patients with LAGC or PAN metastatic GC.

Background: This study was conducted to determine the recommended dose (RD) of intraperitoneal docetaxel (ID) in combination with systemic capecitabine and cisplatin (XP) and to evaluate its efficacy and safety at the RD in advanced gastric cancer (AGC) patients with peritoneal metastasis., Methods: AGC patients with peritoneal metastasis received XP ID, which consists of 937.5 mg/m 2 of capecitabine twice daily on days 1-14, 60 mg/m 2 of intravenous cisplatin on day 1, and intraperitoneal docetaxel at 3 different dose levels (60, 80, or 100 mg/m 2 ) on day 1, every 3 weeks. In the phase I study, the standard 3 + 3 method was used to determine the RD of XP ID. In the phase II study, patients received RD of XP ID., Results: In the phase I study, ID 100 mg/m 2 was chosen as the RD, with one dose-limiting toxicity (ileus) out of six patients. The 39 AGC patients enrolled in the phase II study received the RD of XP ID. The median progression-free survival was 11.0 months (95% CI 6.9-15.1), and median overall survival was 15.1 months (95% CI 9.1-21.1). The most frequent grade 3/4 adverse events were neutropenia (38.6%) and abdominal pain (30.8%). The incidence of abdominal pain cumulatively increased in the later treatment cycles., Conclusions: Our study indicated that XP ID was effective, with manageable toxicities, in AGC patients with peritoneal metastasis. As the cumulative incidence of abdominal pain was probably related to bowel irritation by ID, it might be necessary to modify the dose.

Background & Aims: Early-onset gastric cancer, which develops in patients younger than most gastric cancers, is usually detected at advanced stages, has diffuse histologic features, and occurs more frequently in women. We investigated somatic genomic alterations associated with the unique characteristics of sporadic diffuse gastric cancers (DGCs) from younger patients., Methods: We conducted whole exome and RNA sequence analyses of 80 resected DGC samples from patients 45 years old or younger in Korea. Patients with pathogenic germline mutations in CDH1, TP53, and ATM were excluded from the onset of this analysis, given our focus on somatic alterations. We used MutSig2CV to evaluate the significance of mutated genes. We recruited 29 additional early-onset Korean DGC samples and performed SNP6.0 array and targeted sequencing analyses of these 109 early-onset DGC samples (54.1% female, median age, 38 years). We compared the SNP6.0 array and targeted sequencing data of the 109 early-onset DGC samples with those from diffuse-type stomach tumor samples collected from 115 patients in Korea who were 46 years or older (late onset) at the time of diagnosis (controls; 29.6% female, median age, 67 years). We compared patient survival times among tumors from different subgroups and with different somatic mutations. We performed gene silencing of RHOA or CDH1 in DGC cells with small interfering RNAs for cell-based assays., Results: We identified somatic mutations in the following genes in a significant number of early-onset DGCs: the cadherin 1 gene (CDH1), TP53, ARID1A, KRAS, PIK3CA, ERBB3, TGFBR1, FBXW7, RHOA, and MAP2K1. None of 109 early-onset DGC cases had pathogenic germline CDH1 mutations. A higher proportion of early-onset DGCs had mutations in CDH1 (42.2%) or TGFBR1 (7.3%) compared with control DGCs (17.4% and 0.9%, respectively) (P < .001 and P = .014 for CDH1 and TGFBR1, respectively). In contrast, a smaller proportion of early-onset DGCs contained mutations in RHOA (9.2%) than control DGCs (19.1%) (P = .033). Late-onset DGCs in The Cancer Genome Atlas also contained less frequent mutations in CDH1 and TGFBR1 and more frequent RHOA mutations, compared with early-onset DGCs. Early-onset DGCs from women contained significantly more mutations in CDH1 or TGFBR1 than early-onset DGCs from men. CDH1 alterations, but not RHOA mutations, were associated with shorter survival times in patients with early-onset DGCs (hazard ratio, 3.4; 95% confidence interval, 1.5-7.7). RHOA activity was reduced by an R5W substitution-the RHOA mutation most frequently detected in early-onset DGCs. Silencing of CDH1, but not RHOA, increased migratory activity of DGC cells., Conclusions: In an integrative genomic analysis, we found higher proportions of early-onset DGCs to contain somatic mutations in CDH1 or TGFBR1 compared with late-onset DGCs. However, a smaller proportion of early-onset DGCs contained somatic mutations in RHOA than late-onset DGCs. CDH1 alterations, but not RHOA mutations, were associated with shorter survival times of patients, which might account for the aggressive clinical course of early-onset gastric cancer. Female predominance in early-onset gastric cancer may be related to relatively high rates of somatic CDH1 and TGFBR1 mutations in this population., (Copyright © 2017 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: Several studies have suggested no difference in the liver function of early gastric cancer (EGC) patients with liver cirrhosis (LC) between laparoscopic and open distal gastrectomy. However, the number of patients and comparison of long-term survival rates between the two groups are limited. The purpose of this study was to compare the long-term survival and immediate postoperative liver function of EGC patients with LC after laparoscopic and open distal gastrectomy., Materials and Methods: The clinical data of EGC patients with LC who had no other malignancy and underwent distal gastrectomy at Asan Medical Center between January 2005 and April 2013 were investigated retrospectively. All patients were divided into two groups: the open group (OG) and laparoscopic group (LG). The clinicopathologic data of the two groups were compared., Results: The number of patients in each group was 48 and 27 in the OG and LG, respectively. There were no significant differences in the age, sex ratio, ASA score, cause of liver cirrhosis, preoperative Child-Pugh classification, tumor location, TNM stage, total postoperative drain amount, albumin, total bilirubin, alkaline phosphatase, alanine aminotransferase, prothrombin time, morbidity and recurrence rate. Shorter hospital stay, longer operative time and more retrieved lymph nodes were observed in LG. The long-term overall survival rate was not different between the two groups (P = 0.356)., Conclusions: For EGC patients with liver cirrhosis, especially Child A cirrhosis, laparoscopic or laparoscopy-assisted distal gastrectomy can be a safe surgical procedure in comparison to open distal gastrectomy in terms of the long-term survival rate and immediate postoperative liver function.

Background Self-expandable metallic stent (SEMS) placement is a well-established palliative treatment approach for malignant gastroduodenal obstruction. In patients with a long (>10 cm) stricture, multiple stents placed in an overlapping fashion are often required. Purpose To investigate the outcomes of overlapping SEMS placement for the palliative treatment of malignant gastroduodenal obstruction in patients with a long (>10 cm) stricture. Material and Methods The medical records of 40 patients who underwent fluoroscopic overlapping SEMS placement for malignant gastroduodenal obstruction due to a long (>10 cm) stricture were reviewed. Results The technical and clinical success rates were 100% and 65.0%, respectively. The mean length of the stricture was 17.0 ± 4.7 cm and the mean number of stents placed in each patient was 2.2 ± 0.5. Metastatic cancer (odds ratio [OR], 0.315; P = 0.018), Eastern Cooperative Oncology Group (ECOG) score ≥3 (OR, 0.018; P = 0.006), and carcinomatosis with ascites (OR, 0.025; P = 0.017) were independent predictors of poor clinical success. The rates of minor and major complications were 27.5% and 2.5%, respectively. The median stent patency and survival were 33 days (interquartile range [IQR], 19-60 days) and 35 days (IQR, 19-73 days), respectively. An ECOG score ≥3 was an independent predictor of a poor survival outcome (hazard ratio, 4.681; P < 0.001). Conclusion Overlapping SEMS placement may be safe and effective for the palliative treatment of malignant gastroduodenal obstruction in patients with a long (>10 cm) stricture.

Current diagnostic markers for gastric cancer are not sufficiently specific or sensitive for use in clinical practice. The aims of this study are to compare the proteomes of serum samples from patients with gastric cancers and normal controls, and to develop useful tumor markers of gastric cancer by quantitative proteomic analysis. We identified a total of 388 proteins with a ≤1% FDR and with at least two unique peptides from the sera of each group. Among them, 215, 251, and 260 proteins were identified in serum samples of patients in an advanced cancer group, early cancer group, and normal control group, respectively. We selected differentially expressed proteins in cancer patients compared with those of normal controls via semiquantitative analyses comparing the spectral counts of identified proteins. These differentially expressed proteins were successfully verified using an MS-based quantitative assay, multiple reactions monitoring analysis. Four proteins (vitronectin, clusterin isoform 1, thrombospondin 1, and tyrosine-protein kinase SRMS) were shown to have significant changes between the cancer groups and the normal control group. These four serum proteins were able to discriminate gastric cancer patients from normal controls with sufficient specificity and selectivity., (© 2017 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.)

Background: Oral fluoropyrimidine S-1 contains tegafur, which is metabolized to 5-fluorouracil by cytochrome P450 2A6 (CYP2A6). We here examined associations between CYP2A6 polymorphisms and treatment outcomes of adjuvant S-1 in gastric cancer patients., Methods: Patients received adjuvant S-1 (40 mg/m 2 twice daily, days 1-28, every 6 weeks for eight cycles) after curative surgery for pathological stage II-III gastric cancer. We analyzed the wild-type allele (W) (CYP2A6*1) and four variant alleles (V) (CYP2A6*4, *7, *9, *10) that abolish or reduce this enzyme activity., Results: Patients (n = 200) were enrolled between November 2007 and July 2013 with the following clinical characteristics: median age, 57 years (range, 32-83 years); 128 men, 72 women. With a median follow-up of 46.4 months, the 3-year relapse-free survival (RFS) and overall survival (OS) rates were 83.1 % (95 % CI, 77.7-88.5 %) and 94.8 % (95 % CI, 91.6-98.0 %), respectively. Genotype distributions were as follows: W/W (n = 49, 24.5 %), W/V (n = 94, 47.0 %), and V/V (n = 57, 28.5 %). Overall toxicity did not differ according to genotype for any grade (p = 0.612) or grade ≥3 (p = 0.143). However, RFS differed significantly according to CYP2A6 genotype. The 3-year RFS rates were 95.9 % for W/W, 83.1 % for W/V, and 72.5 % for V/V (p = 0.032). Carriers of W/V and V/V genotypes had a poorer RFS with a hazard ratio of 3.41 (95 % CI, 1.01-11.52; p = 0.049) and 4.03 (95 % CI, 1.16-13.93; p = 0.028), respectively, compared with the W/W genotype., Conclusions: CYP2A6 polymorphisms are not associated with toxicity of S-1 chemotherapy, but correlate with the efficacy of S-1 in the adjuvant setting for gastric cancer.

Objective: Postoperative chemotherapy with S-1 or capecitabine plus oxaliplatin is a standard treatment for resectable gastric cancer (GC). However, survival outcomes of stage IIIB-IV (M0) GC cases are still poor. We investigated the efficacy and safety of docetaxel, capecitabine, and cisplatin (DXP) in patients with stage IIIB-IV GC., Methods: This was a single-arm phase 2 study that included patients with stage IIIB-IV GC who underwent D2 gastrectomy. Patients received six cycles of docetaxel [60 mg/m 2 on day 1 (D1)], capecitabine (1,875 mg/m 2 /day on D1-14), and cisplatin (60 mg/m 2 on D1) every 3 weeks. The primary end-point was recurrence-free survival (RFS)., Results: A total of 46 GC patients between January 2007 and August 2008 were included. After a median follow-up of 56.1 months (range 52.2-64.1), the median RFS and overall survival (OS) were 26.9 months (95 % CI 7.5-46.4) and 43.9 months (95 % CI 29.2-58.7), respectively. The 5-year RFS and OS rates were 39.1 and 41.3 %, respectively. The most common grade 3/4 toxicities were neutropenia (40 %), anorexia (22 %), and febrile neutropenia (15 %)., Conclusions: Adjuvant DXP is feasible and effective for patients with stage IIIB-IV GC. A phase 3 study comparing triplet and doublet regimens for these patients is ongoing.

Objectives: To compare the outcomes of over-the-wire (OTW) and through-the-scope (TTS) partially covered stents in patients with malignant gastric outlet obstruction (GOO)., Methods: A retrospective study was performed in 306 patients who had either OTW (n = 125) or TTS (n = 181) stents placed. Outcomes analysed included technical and clinical success, procedure time, complications, re-intervention, stent patency and survival., Results: One hundred and ninety-three patients met our inclusion criteria, including 125 patients in the OTW group and 68 patients in the TTS group. Technical and clinical outcomes were similar in the two groups. Stent migration rate was higher in the TTS than in the OTW group (P = 0.002) and was associated with straight stent and subsequent chemotherapy in the TTS group. Stent collapse was lower in the TTS than in the OTW group (P = 0.021). Six-month stent patency rate was higher in the OTW than in the TTS group (P = 0.044)., Conclusions: TTS and OTW stents for the palliation of malignant GOO resulted in similar technical and clinical outcomes, stent patency and survival. TTS stents were associated with a higher migration rate, especially use of straight stents and subsequent chemotherapy, but a lower stent collapse rate than OTW stents., Key Points: • OTW and TTS stents are equally effective in palliating GOO symptoms. • Six-month stent patency was higher for OTW than for TTS. • The straight stent and subsequent chemotherapy could increase stent migration. • Complication rates were lower for flared than for straight stents. • It is necessary to develop a multidisciplinary approach to integrate clinical experience.

Objectives: To compare the outcomes between stent placement and surgical gastrojejunostomy (GJ) for the palliation of gastric outlet obstruction (GOO) in patients with unresectable gastric cancer., Methods: A retrospective study was performed in a single university hospital in 224 patients with GOO, and who were treated either by stent placement (n = 124) or surgical GJ (n = 100). The outcomes were assessed with reference to the following variables with the use of propensity-score matching: success rates; complications; dysphagia scores, albumin, and body mass index; survival; symptom-free duration; and hospitalization., Results: We identified a well-balanced cohort of 74 pairs of patients, matched on the basis of propensity score. The dysphagia score 7 days after treatment was significantly better in the stent group (P < 0.001). Albumin level 1 month after treatment was significantly lower in the stent group (P < 0.001). Symptom-free duration and hospitalization were significantly longer in the surgery group (P = 0.002, P < 0.001, respectively). The recurrence rate was significantly higher in the stent group (P = 0.032)., Conclusions: Stent placement can provide faster symptom relief and shorter hospitalization, while surgical GJ can provide longer symptom-free duration, less recurrent obstruction symptoms and better nutritional status., Key Points: • The two methods are equally effective in palliating gastric outlet obstruction symptoms • The stent group showed rapid and efficient palliation of symptoms • Recurrent symptoms were more frequent in the stent group • Surgical gastrojejunostomy provides a longer symptom-free duration and better nutritional status.

BACKGROUND In South Korea, which has a high incidence of gastric cancer, the most common de novo malignancy associated with liver transplantation is gastric cancer. This study sought to identify clinicopathologic characteristics in gastric cancer patients after liver transplantation, and to help manage these cases. MATERIAL AND METHODS We investigated gastric cancer patients after liver transplantation at Asan Medical Center. We analyzed sex, age, cause of liver transplantation, initiating immunosuppressant, pre-transplantation gastric fibroscopy findings, time interval between transplantation and gastric cancer occurrence, follow-up period, existence of gastric cancer screening, Helicobacter pylori infection, family cancer history, gastric cancer treatment, cancer location, size of tumor, macroscopic gross type, WHO histologic type, Lauren's classification, TNM stage, and survival. RESULTS Of 2968 adult liver transplantation patients at our hospital, 19 were diagnosed with gastric cancer. The mean age at the time of gastric cancer diagnosis was 60.2±6.8 (46-71) years and mean time interval between liver transplantation and diagnosis of gastric cancer was 56.0±30.7 (3.20-113) months. Endoscopic submucosal dissection was done for 10 patients, 4 of whom underwent surgical resection. Surgical resection as an initial treatment was done in 8 patients. One patient received chemotherapy first. The standard incidence ratio of gastric cancer in these patients was 1036 per 100 000 persons (95% CI, 623.7-1,619) in men and 318.9 per 100 000 (95% CI, 4.170-1,774) in women. CONCLUSIONS For long-term survival of liver transplant patients, early detection of de novo cancer is necessary. Therefore, annual screening for gastric cancer after liver transplantation is needed, especially in areas where the incidence of gastric cancer is high, such as South Korea.

Mixed carcinoma shows a mixture of glandular and signet ring/poorly cohesive cellular histological components and the prognostic significance of each component is not fully understood. This study aimed to investigate the significance of the poorly cohesive cellular histological component as a risk factor for lymph node metastasis and to examine the diagnostic reliability of endoscopic biopsy. Clinicopathologic characteristics of 202 patients who underwent submucosal invasive gastric carcinoma resection with lymph node dissection in 2005-2012 were reviewed. Mixed carcinoma accounted for 27.2% (56/202) of cases. The overall prevalence of lymph node metastasis was 17.3% (35/202). Lymphatic invasion (P < 0.001), family history of carcinoma (P = 0.025), tumor size (P = 0.004), Lauren classification (P = 0.042), and presence of any poorly cohesive cellular histological component (P = 0.021) positively correlated with the lymph node metastasis rate on univariate analysis. Multivariate analyses revealed lymphatic invasion, family history of any carcinoma, and the presence of any poorly cohesive cellular histological component to be significant and independent factors related to lymph node metastasis. Review of preoperative biopsy slides showed that preoperative biopsy demonstrated a sensitivity of 63.6% and a specificity of 100% in detecting the presence of the poorly cohesive cellular histological component, compared with gastrectomy specimens. The presence of any poorly cohesive cellular histological component was an independent risk factor associated with lymph node metastasis in submucosal invasive gastric carcinoma. Endoscopic biopsy had limited value in predicting the presence and proportion of the poorly cohesive cellular histologic component due to the heterogeneity of mixed carcinoma.

Background: This study aimed to validate the prognostic relevance of macroscopic serosal changes in patients with resected gastric cancer. Prospectively collected databases of two multicenter randomized phase III trials of adjuvant chemotherapy were analyzed., Methods: For this study, 655 patients in the control groups of AMC 0101 and 0201 trials were selected. Macroscopic serosal changes were determined according to disruptions in serosal continuity, such as changes in color or nodular texture by the operating surgeon. Correlations with recurrence-free survival (RFS), overall survival (OS), and time to peritoneal recurrence were analyzed., Results: Macroscopic serosal changes were identified intraoperatively in 432 patients (66 %) and found to be significantly associated with multifocal or diffuse involvement (p = 0.001), Borrmann type 4 (p = 0.005), advanced pathologic T (p < 0.001), N (p < 0.001), overall stage (p < 0.001), and total gastrectomy (p < 0.001). In multivariate analyses, which included prognostic factors of localized gastric cancer, macroscopic serosal changes were significantly associated with poor RFS [hazard ratio (HR) 2.0; 95 % confidence interval (CI), 1.4-2.7; p < 0.001] and OS (HR 2.1; 95 % CI 1.5-3.0; p < 0.001). The changes also were significantly related to shorter time to peritoneal recurrence (HR 2.9; 95 % CI 1.7-5.0; p < 0.001)., Conclusions: Intraoperatively assessed macroscopic serosal changes confer a poor prognosis and increased peritoneal recurrence for patients with curatively resected gastric cancer. Macroscopic assessment of serosal changes may be a useful indicator that allows better risk stratification of patients with resected gastric cancer in terms of prognosis and peritoneal recurrence.

Background/aims: The purpose of this study was to investigate the efficacy and safety of irinotecan based FOLFIRI chemotherapy as a second-line treatment after failure of FOLFOX-4 chemotherapy in patients with advanced gastric cancer., Methods: Fifty-two patients who were pathologically diagnosed with unresectable gastric cancer and received FOLFIRI chemotherapy after failure of FOLFOX-4 chemotherapy between September 2005 and February 2012 were enrolled in this study. Data were collected by retrospectively reviewing the medical records. The response to chemotherapy was assessed every 3 cycles by World Health Organization criteria and long term survival was analyzed. The toxicities were evaluated for every course of chemotherapy according to National Cancer Institution (NCI) toxicity criteria version 3.0., Results: Median age of the patients was 57 years. Median overall survival (OS) and time to progression (TTP) were 7.8 and 5 months, respectively. The number of patients showing complete remission, partial remission, stable disease, and progressive disease were 0 (0.0%), 9 (17.3%), 30 (57.7%), and 13 (25.0%), respectively. The overall response rate was 17.3%. During a total of 345 cycles, anemia worse than NCI toxicity grade 3 occurred in 2.9%, leukopenia in 20.3%, neutropenia in 12.2%, and thrombocytopenia in 1.5%. Patients with less organ involvement by metastasis, less than 34 U/mL of CA 19-9 and good responsiveness to third cycle of second line chemotherapy were associated with longer OS and TTP., Conclusions: FOLFIRI chemotherapy has a modest efficacy with acceptable toxicities in patients with advanced gastric cancer as a second-line treatment. Further well-controlled studies are needed to elucidate the efficacy of FOLFIRI chemotherapy as second-line treatment in patients with advanced stomach cancer.

Background: The aim of this study is to compare the number of retrieved lymph nodes according to lymph node stations in laparoscopy-assisted distal gastrectomy (LADG) of the early experience of a new surgeon with that in open distal gastrectomy (ODG)., Materials and Methods: From May 2008 to August 2012, clinicopathologic data of gastric cancer patients subjected to LADG or ODG at a single institution by one surgeon were retrospectively reviewed. The surgeries were stratified as follows: early LADG (initial 30 LADGs), late LADG, and ODG. Station-specific counts of lymph nodes retrieved served for group comparisons., Results: Gender distribution (male:female ratio) was not different among the three groups (early LADG, 16:14; late LADG, 19:4; and ODG, 38:30). Mean lymph node retrieval in the early and late LADG groups (39.1 and 45.6, respectively) fell significantly below that of the ODG group (53.0) (P<.001). Compared with the ODG group, fewer station-specific lymph nodes were retrieved via LADG, both early (stations 3, 8a, and 11p) and late (station 11p)., Conclusions: Surgeons inexperienced in LADG for gastric cancer should be particularly diligent in lymph node dissection at stations 3, 8a, and 11p. Even with more experience (>30 LADGs), lymph node dissection at station 11p merits special attention.

Solitary extramedullary plasmacytoma (EMP) is a plasma cell neoplasm without bone marrow involvement. EMPs are rare in the gastrointestinal (GI) tract. We report two cases of primary EMP, one in the transverse colon and the other in the stomach. In the first case, a mass on the transverse colon was found on colonoscopy. The patient underwent left hemicolectomy and has been followed-up for 3 years without recurrence postoperatively. The latter case had several masses in the stomach. The patient underwent bypass surgery and has received supportive care for 1 month. Histopathologic specimens of both the cases showed a monoclonal lambda chain EMP. Subsequent investigations included a bone marrow biopsy, serum IgA, IgG, IgM and serum protein electrophoresis, and the results were negative for multiple myeloma in both the cases. Solitary EMP in the GI tract can be mistaken for colon cancer or stomach cancer on endoscopy; therefore, a sufficient number of biopsy specimens can help diagnose solitary EMPs. Surgical resection alone or with radiation therapy in cases with positive surgical margin is currently the only treatment for solitary EMP in the GI tract. Further study is necessary to determine disease prognosis and to investigate other treatment methods.

Background/aims: Human epidermal growth factor receptor 2 (Her2/neu) is an important target for treatment of gastric cancer using trastuzumab and Helicobacter pylori is a well-known risk factor of gastric cancer. We investigated the association of Her2/neu overexpression with Helicobacter pylori and other clinicopathologic factors in gastric cancer patients who underwent curative resection., Methodology: Her2/neu immunohistochemistry was performed in gastric cancer patients who underwent curative gastrectomy or endoscopic submucosal dissection. Analysis about its associations with clinicopathologic features such as Lauren histologic types, differentiation, Helicobacter pylori infection, location, depth of invasion, lymph node metastasis, and AJCC tumor stage was performed retrospectively., Results: The incidence of Her2/neu 3+, 2+, 1+ and 0 was 8.9%, 22.1%, 4.4% and 64.6% respectively. Intestinal type of gastric cancer showed higher incidence of Her2/neu 3+ than diffuse type. The score 2+ and 3+ was more common in Helicobacter pylori-positive patients than Helicobacter pylori-negative patients (p = 0.024). 7th American joint Cancer Committee Tumor stage, depth of tumor invasion and lymph node metastasis did not show correlation with the level of Her2/neu expression., Conclusions: Helicobacter pylori-positive gastric cancer showed more Her2/neu overexpression. Helicobacter pylori eradication may be necessary to avoid Her2/neu overexpression.

Mucinous gastric carcinoma (MGC) is an unusual histologic subtype, and early detection of MGC is very rare. Early-stage MGC appears as an elevated lesion resembling a submucosal tumor (SMT) due to abundant mucin pools in the submucosa or mucosa. We report a rare case of SMT-like early-stage MGC. Tumor type was predicted preoperatively based on characteristic endoscopic findings, in which an SMT-like mass was observed at the gastric fundus. The tumor was covered by nearly normal mucosa, but with an opening allowing for the passage of copious mucus discharge. A total gastrectomy with Roux-en-Y esophagojejunostomy was subsequently performed. Histopathology of the tumor revealed early-stage (lamina propria) mucinous adenocarcinoma.

Background/aims: Delayed bleeding is a major complication of endoscopic submucosal dissection. Second-look endoscopy is routinely performed in most hospitals to reduce the possibility of delayed bleeding without solid evidence to support this practice. The aim of this study was to evaluate whether second-look endoscopy prevents delayed bleeding, and to verify clinicopathological features of delayed bleeding in order to identify lesions that may benefit from a second-look endoscopy., Materials and Methods: We investigated 392 lesions in 388 patients who underwent endoscopic submucosal dissection for early gastric cancer from January 2006 to July 2011. Clinically evident bleeding from mucosal defects 24 hours after endoscopic submucosal dissection was considered delayed bleeding. Data including characteristics of patients, lesions, and procedures were reviewed. Furthermore, the rate of delayed bleeding before and after second-look endoscopy, performed within three days of endoscopic submucosal dissection, was investigated to determine the utility of second-look endoscopy., Results: Delayed bleeding was evident in 12 of 392 lesions (3,1%), all of which achieved endoscopic hemostasis. The only significant factor predicting delayed bleeding was a resected specimen size of over 40 mm (OR=6,200, 95% CI=1,912 - 20,108). Delayed bleeding occurred more frequently prior to the second-look endoscopy (p=0,022)., Conclusions: In our endoscopic submucosal dissection data about early gastric cancer, it is too early to conclude that second-look endoscopy is not a valuable procedure, and second-look endoscopy may be useful for preventing post-endoscopic submucosal dissection bleeding, especially in resected specimens greater than 40 mm in size.

Aim: Endoscopic submucosal dissection (ESD) has been widely accepted as a less invasive treatment for early gastric cancer and adenoma, but research on missed synchronous gastric neoplasm (SGN) with ESD has been limited. In the present study, we aimed to investigate the incidence and characteristics of missed SGN during follow-up endoscopy in patients who have undergone ESD., Method: We investigated the clinicopathological features of 602 patients and gastric neoplasms treated by ESD from January 2005 through July 2009 at our institution. We defined any second neoplasm found within 1 year after ESD as a missed SGN., Results: Out of 602 patients, 12 (2.0%) had missed SGN. Among the 12 missed SGN, seven (58.3%) cases were carcinomas. All cases of missed synchronous gastric cancer (SGC) were exclusively discovered in the posterior wall of the stomach (7 of 7 cases, 100%, P = 0.016). Missed SGN were more frequently observed when the primary gastric neoplasm was adenoma (4.0% vs 1.0%; OR = 4.114; 95% CI = 1.224-13.831). Furthermore, the risk of missed SGC increased 12-fold in the primary gastric adenoma group compared to the primary gastric carcinoma group (2.9% vs 0.24%; OR = 12.308; 95% CI = 1.472-102.939)., Conclusion: Endoscopists need to make an effort to find SGN, especially when they carry out ESD for an adenoma, which is a less serious lesion. The important blind spot in screening endoscopic examination before ESD is the posterior wall of the upper third and middle third of the stomach., (© 2012 The Authors. Digestive Endoscopy © 2012 Japan Gastroenterological Endoscopy Society.)