Huang's three-step maneuver for laparoscopic spleen-preserving No.10 lymph node dissection for advanced proximal gastric cancer

Due to the complexity of the splenic hilar vessels, their anatomical variation and the narrow and deep space, as well as the bleeding-prone splenic parenchyma and the difficulty to manage splenic or vascular bleeding at the splenic hilum,the procedure remains challenging and technically demanding procedure for the performance of laparoscopic pancreas- and spleen-preserving splenic hilar lymph nodes dissection. Based on our experiences, we gradually explored a set of procednral operation steps called ＂Huang＇s three-step maneuver＂. In this paper, we not only provide the concrete operation steps for the surgeon, but we also provide our recommended technique of pulling and exposure for assistants. This new maneuver simplifies the complicated procedure and improves the efficiency of laparoscopic spleen-preserving splenic hilar lymphadenectomy, making it easier to master and allowing for its widespread adoption.

Short-term efficacy of robotic and laparoscopic spleen-preserving splenic hilar lymphadenectomy via Huang’s three-step maneuver for advanced upper gastric cancer: Results from a propensity scorematched study

BACKGROUND Robotic surgery has been considered to be significantly better than laparoscopic surgery for complicated procedures.AIM To explore the short-term effect of robotic and laparoscopic spleen-preserving splenic hilar lymphadenectomy(SPSHL)for advanced gastric cancer(GC)by Huang’s three-step maneuver.METHODS A total of 643 patients who underwent SPSHL were recruited from April 2012 to July 2017,including 35 patients who underwent robotic SPSHL(RSPSHL)and 608 who underwent laparoscopic SPSHL(LSPSHL).One-to-four propensity score matching was used to analyze the differences in clinical data between patients who underwent robotic SPSHL and those who underwent laparoscopic SPSHL.RESULTS In all,175 patients were matched,including 35 patients who underwent RSPSHL and 140 who underwent LSPSHL.After matching,there were no significant differences detected in the baseline characteristics between the two groups.Significant differences in total operative time,estimated blood loss(EBL),splenic hilar blood loss(SHBL),splenic hilar dissection time(SHDT),and splenic trunk dissection time were evident between these groups(P<0.05).Furthermore,no significant differences were observed between the two groups in the overall noncompliance rate of lymph node(LN)dissection(62.9%vs 60%,P=0.757),number of retrieved No.10 LNs(3.1±1.4 vs 3.3±2.5,P=0.650),total number of examined LNs(37.8±13.1 vs 40.6±13.6,P=0.274),and postoperative complications(14.3%vs 17.9%,P=0.616).A stratified analysis that divided the patients receiving RSPSHL into an early group(EG)and a late group(LG)revealed that the LG experienced obvious improvements in SHDT and length of stay compared with the EG(P<0.05).Logistic regression showed that robotic surgery was a significantly protective factor against both SHBL and SHDT(P<0.05).CONCLUSION RSPSHL is safe and feasible,especially after overcoming the early learning curve,as this procedure results in a radical curative effect equivalent to that of LSPSHL.

Comparision of modified and conventional delta-shaped gastroduodenostomy in totally laparoscopic surgery

AIM:To evaluate the safety and feasibility of a modified delta-shaped gastroduodenostomy(DSG)in totally laparoscopic distal gastrectomy(TLDG).METHODS:We performed a case-control study enrolling 63 patients with distal gastric cancer(GC)undergoing TLDG with a DSG from January 2013 to June 2013.Twenty-two patients underwent a conventional DSG(Con-Group),whereas the other 41 patients underwent a modified version of the DSG(Mod-Group).The modified procedure required only the instruments of the surgeon and assistant to complete the involution of the common stab incision and to completely resect the duodenal cutting edge,resulting in an anastomosis with an inverted T-shaped appearance.The clinicopathological characteristics,surgical outcomes,anastomosis time and complications of the two groups were retrospectively analyzed using a prospectively maintained comprehensive database.RESULTS:DSG procedures were successfully completed in all of the patients with histologically complete(R0)resections,and none of these patients required conversion to open surgery.The clinicopathological characteristics of the two groups were similar.There were no significant differences between the groups in the operative time,intraoperative blood loss,extension of the lymph node(LN)dissection and number of dissected LNs(150.8±21.6 min vs 143.4±23.4 min,P=0.225for the operative time;26.8±11.3 min vs 30.6±14.8mL,P=0.157 for the intraoperative blood loss;4/18 vs3/38,P=0.375 for the extension of the LN dissection;and 43.9±13.4 vs 39.5±11.5 per case,P=0.151 for the number of dissected LNs).The anastomosis time,however,was significantly shorter in the Mod-Group than in the Con-Group(13.9±2.8 min vs 23.9±5.6min,P=0.000).The postoperative outcomes,including the times to out-of-bed activities,first flatus,resumption of soft diet and postoperative hospital stay,as well as the anastomosis size,did not differ significantly(1.9±0.6 d vs 2.3±1.5 d,P=0.228 for the time to outof-bed activities;3.2±0.9 d vs 3.5±1.3 d,P=0.295for the first flatus time;7.5±0.8 d vs 8.1±4.3 d,P=0.489 for the resumption of a soft diet time;14.3±10.6 d vs 11.5±4.9 d,P=0.148 for the postoperative hospital stay;and 30.5±3.6 mm vs 30.1±4.0 mm,P=0.730 for the anastomosis size).One patient with minor anastomotic leakage in the Con-Group was managed conservatively;no other patients experienced any complications around the anastomosis.The operative complication rates were similar in the Con-and ModGroups(9.1%vs 7.3%,P=1.000).CONCLUSION:The modified DSG,an alternative reconstruction in TLDG for GC,is technically safe and feasible,with a simpler process that reduces the anastomosis time.

Digestive tract reconstruction using isoperistaltic jejunumlater-cut overlap method after totally laparoscopic total gastrectomy for gastric cancer: Short-term outcomes and impact on quality of life

AIM To evaluate the short-term outcomes and quality of life(Qo L) in gastric cancer patients undergoing digestive tract construction using the isoperistaltic jejunum-latercut overlap method(IJOM) after totally laparoscopic total gastrectomy(TLTG).METHODS A total of 507 patients who underwent laparoscopic gastrectomy(D2) from January 2014 to March 2016 were originally included in the study. The patients were divided into two groups to undergo digestive tract construction using either IJOM after TLTG(group T, n = 51) or Roux-en-Y anastomosis after laparoscopic-assisted total gastrectomy(LATG)(group A, n = 456). The short-term outcomes and Qo L were compared between the two groups after 1:2 propensity-score matching(PSM). We used a questionnaire to assess Qo L.RESULTS Before matching, age, sex, tumor size, tumor location, preoperative albumin and blood loss were significantly different between the two groups(P < 0.05). After PSM, the patients were well balanced in terms of their clinicopathological characteristics, although both blood loss and in-hospital postoperative days in group T were significantly lower than those in group A(P < 0.05). After matching, group T reported better Qo L in the domains of pain and dysphagia. Among the items evaluating pain and dysphagia, group T tended to report better Qo L("Have you felt pain" and "Have you had difficulty eating solid food")(P < 0.05).CONCLUSION The IJOM for digestive tract reconstruction after TLTG is associated with reduced blood loss and less pain and dysphagia, thus improving Qo L after laparoscopic gastrectomy.

Role of 3DCT in laparoscopic total gastrectomy with spleen-preserving splenic lymph node dissection

AIM:To investigate whether computed tomography with 3D imaging(3DCT)can reduce the risks associated with laparoscopic surgery.METHODS:We performed a retrospective case-control study evaluating the efficacy of preoperative 3DCT of the splenic vascular anatomy on surgical outcomes in patients undergoing laparoscopic spleen-preserving splenic hilar lymph node(LN)dissection for upper-or middle-third gastric cancer.The clinical records of 312patients with upper-or middle-third gastric cancer who underwent laparoscopic total gastrectomy with spleenpreserving splenic lymph node dissection in our hospital from January 2010 to June 2013 were collected,and the patients were divided into two groups(group 3DCT vs group NO-3DCT)depending on whether they underwent 3DCT or not.Clinicopathologic characteristics,operative and postoperative measures,the number of retrieved LNs,and complications were compared between these two groups.Patients were further compared regarding operative and postoperative measures,the number of retrieved LNs,and complications when subdivided by body mass index(≥23 and<23 kg/m2)and the number of operations performed by their surgeon(≤40 vs>40).RESULTS:The mean numbers of retrieved splenic hilar LNs were similar in patients in group 3DCT and group NO-3DCT(2.85±2.33 vs 2.48±2.18,P>0.05).The operation time and blood loss at the splenic hilum were lower in the patients in group 3DCT(P<0.05 each).The postoperative recovery time and complication rates were similar between the two groups(P>0.05 each).Subgroup analysis showed that the operation time at the splenic hilum in patients with a BMI≥23 kg/m2was significantly shorter in patients in group 3DCT than in group NO-3DCT(20.27±5.84 min vs 26.17±11.01 min,P=0.003).In patients with a BMI<23kg/m2,the overall operation time(171.8±26.32 min vs 188.09±52.63 min,P=0.028),operation time at the splenic hilum(19.39±5.46 min vs 23.74±9.56min,P=0.001),and blood loss at the splenic hilum(13.27±4.96 mL vs 17.98±8.12 mL,P=0.000)were significantly lower in patients in group 3DCT than in group NO-3DCT.After 40 operations,the operation time(18.63±4.40 min vs 23.85±7.92 min,P=0.000)and blood loss(13.10±4.17 mL vs 15.10±4.42 mL,P=0.005)at the splenic hilum were significantly lower in patients who underwent 3DCT,but there were no significant between-group differences prior to 40 operations.CONCLUSION:3DCT is critical for surgical guidance to reduce the risks of splenic LN dissection.This method may be important in safely facilitating laparoscopic spleen-preserving splenic LN dissection.

Anatomy and influence of the splenic artery in laparoscopic spleen-preserving splenic lymphadenectomy

AIM: To investigate the splenic hilar vascular anatomy and the influence of splenic artery(Sp A) type in laparoscopic total gastrectomy with spleen-preserving splenic lymphadenectomy(LTGSPL).METHODS:The clinical anatomy data of 317 patients with upper- or middle-third gastric cancer who underwent LTGSPL in our hospital from January 2011 to December 2013 were collected. The patients were divided into two groups(concentrated group vs distributed group) according to the distance between the splenic artery's furcation and the splenic hilar region. Then, the anatomical layout, clinicopathologic characteristics, intraoperative variables, and postoperative variables were compared between the two groups.RESULTS: There were 205 patients with a concentrated type(64.7%) and 112 patients with a distributed type(35.3%) Sp A. There were 22 patients(6.9%) with a single branch of the splenic lobar vessels, 250(78.9%) with 2 branches, 43(13.6%) with 3 branches, and 2 patients(0.6%) with multiple branches. Eighty sevenpatients(27.4%) had type?Ⅰ?splenic artery trunk, 211(66.6%) had type Ⅱ, 13(4.1%) had type Ⅲ, and 6(1.9%) had type Ⅳ. The mean splenic hilar lymphadenectomy time(23.15 ± 8.02 vs 26.21 ± 8.84 min; P = 0.002), mean blood loss resulting from splenic hilar lymphadenectomy(14.78 ± 11.09 vs 17.37 ± 10.62 m L; P = 0.044), and number of vascular clamps used at the splenic hilum(9.64 ± 2.88 vs 10.40 ± 3.57; P = 0.040) were significantly lower in the concentrated group than in the distributed group. However, the mean total surgical time, mean total blood loss, and the mean number of harvested splenic hilar lymph nodes were similar in both groups(P > 0.05 for each comparison). There were also no significant differences in clinicopathological and postoperative characteristics between the groups(P > 0.05).CONCLUSION: It is of value for surgeons to know the splenic hilar vascular anatomy when performing LTGSPL. Patients with concentrated type Sp A may be optimal patients for training new surgeons.

Laparoscopic spleen-preserving splenic hilar lymphadenectomy in 108 consecutive patients with upper gastric cancer

AIM: To evaluate the feasibility and short-term efficacy of laparoscopic spleen-preserving splenic hilar(No. 10) lymphadenectomy to treat advanced upper gastric cancer(AUGC).METHODS: Between January and December 2012, 108 laparoscopic spleen-preserving No. 10 lymphadenectomy along with total gastrectomy with routine D2 lymphadenectomy were performed consecutively at our hospital to treat clinical T2-3(cT2-3) upper gastric cancers. The preoperative clinical T stage was cT2 in 36 patients and cT3 in 72 patients. A prospectively designed database tracked the 108 patients, including the completeness of their medical records and the adequacy of follow-up. Patient clinicopathological char-acteristics, intraoperative and postoperative surgical outcomes, morbidity and mortality, lymph node(LN) dissection, and postoperative follow-up were analysed retrospectively.RESULTS: Laparoscopic spleen-preserving No. 10 lymphadenectomy was successful in all 108 patients. The mean operation time was 169.3 ± 27.1 min, and the mean No. 10 lymphadenectomy time was 20.0 ± 5.7 min. The mean total blood loss was 46.2 ± 11.3 mL, and the mean blood loss from No. 10 lymphadenectomy was 14.3 ± 3.8 mL. The mean postoperative hospital stay was 11.9 ± 6.0 d. The intraoperative and postoperative morbidity rates were 3.7% and 12.0%, respectively; however, there was no postoperative mortality. A mean of 44.4 ± 17.6 LNs were retrieved from each specimen, including 3.0 ± 2.4 No. 10 LNs. Three patients(2.8%) with cT3 cancer had LN metastasis of the splenic hilus, including two patients with pathological T3(pT3) and one patient with pathological T4a(pT4a) tumours, all located in the greater curvature. No splenic hilar LNs metastasis was evident in the patients with pT1 and pT2 tumours. At a median follow-up time of 18 mo(range, 12 to 23 mo), all patients were alive and none had experienced recurrent or metastatic disease.CONCLUSION: Laparoscopic spleen-preserving No. 10 lymphadenectomy is feasible and effective to treat AUGC. Routine No. 10 lymphadenectomy may be unnecessary for AUGC without serosa invasion, unless T3 tumours are located in the greater curvature.

Small-volume chylous ascites after laparoscopic radical gastrectomy for gastric cancer:Results from a large population-based sample

AIM:To report the incidence and potential risk factors of small-volume chylous ascites(SVCA)following laparoscopic radical gastrectomy(LAG).METHODS:A total of 1366 consecutive gastric cancer patients who underwent LAG from January 2008 to June 2011 were enrolled in this study.We analyzed the patients based on the presence or absence of SVCA.RESULTS:SVCA was detected in 57(4.17%)patients,as determined by the small-volume drainage(range,30-100 m L/24 h)of triglyceride-rich fluid.Both univariate and multivariate analyses revealed that the total number of resected lymph nodes(LNs),No.8 or No.9 LN metastasis and N stage were independent risk factors for SVCA following LAG(P<0.05).Regarding hospital stay,there was a significant difference between the groups with and without SVCA(P<0.001).The 3-year disease-free and overall survival rates of the patients with SVCA were 47.4%and 56.1%,respectively,which were similar to those of the patients without SVCA(P>0.05).CONCLUSION:SVCA following LAG developed significantly more frequently in the patients with≥32harvested LNs,≥3 metastatic LNs,or No.8 or No.9LN metastasis.SVCA,which was successfully treated with conservative management,was associated with a prolonged hospital stay but was not associated with the prognosis.

Application of preoperative artificial neural network based on blood biomarkers and clinicopathological parameters for predicting longterm survival of patients with gastric cancer

BACKGROUND Because of the powerful abilities of self-learning and handling complex biological information,artificial neural network(ANN)models have been widely applied to disease diagnosis,imaging analysis,and prognosis prediction.However,there has been no trained preoperative ANN(preope-ANN)model to preoperatively predict the prognosis of patients with gastric cancer(GC).AIM To establish a neural network model that can predict long-term survival of GC patients before surgery to evaluate the tumor condition before the operation.METHODS The clinicopathological data of 1608 GC patients treated from January 2011 to April 2015 at the Department of Gastric Surgery,Fujian Medical University Union Hospital were analyzed retrospectively.The patients were randomly divided into a training set(70%)for establishing a preope-ANN model and a testing set(30%).The prognostic evaluation ability of the preope-ANN model was compared with that of the American Joint Commission on Cancer(8th edition)clinical TNM(cTNM)and pathological TNM(pTNM)staging through the receiver operating characteristic curve,Akaike information criterion index,Harrell's C index,and likelihood ratio chi-square.RESULTS We used the variables that were statistically significant factors for the 3-year overall survival as input-layer variables to develop a preope-ANN in the training set.The survival curves within each score of the preope-ANN had good discrimination(P<0.05).Comparing the preope-ANN model,cTNM,and pTNM in both the training and testing sets,the preope-ANN model was superior to cTNM in predictive discrimination(C index),predictive homogeneity(likelihood ratio chi-square),and prediction accuracy(area under the curve).The prediction efficiency of the preope-ANN model is similar to that of pTNM.CONCLUSION The preope-ANN model can accurately predict the long-term survival of GC patients,and its predictive efficiency is not inferior to that of pTNM stage.

Expression of CRM1 and CDK5 shows high prognostic accuracy for gastric cancer

AIM To evaluate the predictive value of the expression of chromosomal maintenance(CRM)1 and cyclindependent kinase(CDK)5 in gastric cancer(GC) patients after gastrectomy.METHODS A total of 240 GC patients who received standard gastrectomy were enrolled in the study. The expression level of CRM1 and CDK5 was detected by immunohistochemistry. The correlations between CRM1 and CDK5 expression and clinicopathological factors were explored. Univariate and multivariate survival analyses were used to identify prognostic factors for GC. Receiver operating characteristic analysis was used to compare the accuracy of the prediction of clinical outcome by the parameters. RESULTS The expression of CRM1 was significantly related to size of primary tumor(P = 0.005), Borrmann type(P = 0.006), degree of differentiation(P = 0.004), depth of invasion(P = 0.008), lymph node metastasis(P = 0.013), TNM stage(P = 0.002) and distant metastasis(P = 0.015). The expression of CDK5 was significantly related to sex(P = 0.048) and Lauren's classification(P = 0.011). Multivariate Cox regression analysis identified that CRM1 and CDK5 co-expression status was an independent prognostic factor for overall survival(OS) of patients with GC. Integration of CRM1 and CDK5 expression could provide additional prognostic value for OS compared with CRM1 or CDK5 expression alone(P = 0.001).CONCLUSION CRM1 and CDK5 co-expression was an independent prognostic factors for GC. Combined CRM1 and CDK5 expression could provide a prognostic model for OS of GC.

Novel abdominal negative pressure lavage-drainage system for anastomotic leakage after R0 resection for gastric cancer

BACKGROUND Anastomotic leakage(AL) is a severe complication associated with high morbidity and mortality after radical gastrectomy(RG) for gastric cancer(GC).We hypothesized that a novel abdominal negative pressure lavage-drainage system(ANPLDS) can effectively reduce the failure-to-rescue(FTR) and the risk of reoperation, and it is a feasible management for AL.AIM To report our institution's experience with a novel ANPLDS for AL after RG for GC.METHODS The study enrolled 4173 patients who underwent R0 resection for GC at our institution between June 2009 and December 2016. ANPLDS was routinely used for patients with AL after January 2014. Characterization of patients who underwent R0 resection was compared between different study periods. AL rates and postoperative outcome among patients with AL were compared before and after the ANPLDS therapy. We used multivariate analyses to evaluate clinicopathological and perioperative factors for associations with AL and FTR after AL.RESULTS AL occurred in 83(83/4173, 2%) patients, leading to 7 deaths. The mean time of occurrence of AL was 5.6 days. The AL rate was similar before(2009-2013, period1) and after(2014-2016, period 2) the implementation of the ANPLDS therapy(1.7% vs 2.3%, P = 0.121). Age and malnourishment were independently associated with AL. The FTR rate and abdominal bleeding rate after AL occurred were respectively 8.4% and 9.6% for the entire period; however, compared with period 1, this significantly decreased during period 2(16.2% vs 2.2%, P = 0.041;18.9% vs 2.2%, P = 0.020, respectively). Moreover, the reoperation rate was also reduced in period 2, although this result was not statistically significant(13.5% vs2.2%, P = 0.084). Additionally, only ANPLDS therapy was an independent protective factor for FTR after AL(P = 0.04).CONCLUSION Our experience demonstrates that ANPLDS is a feasible management for AL after RG for GC.

New metastatic lymph node classification for early gastric cancer should differ from those for advanced gastric adenocarcinoma: Results based on the SEER database

AIM To establish an appropriate N classification system for early gastric cancer(EGC).METHODS Data from 10714 patients who underwent radical gastrectomy between 1988 and2011 were retrieved from the National Cancer Institute's Surveillance,Epidemiology, and End Result database. The overall survival(OS) based on the eighth edition and new tumor lymph node metastasis(TNM) staging systems were compared, and the analysis was repeated in an external validation set from the Fujian Medical University Union Hospital database.RESULTS There were no significant differences in OS between N1 and N2 cancers or between N3a and N3b cancers in cases of EGC. The X-tile program identified that the new staging system for EGC consisted of T1N0, T1N1' [1-6 metastatic lymph nodes(LNs)], and T1N2'( ≥ 7 metastatic LNs). Compared with the eighth edition of the TNM staging system, the OS of patients in T1N1' stage was similar to that of patients with stage IIA disease, whereas the OS of patients in T1N2' stage was similar to that of patients with stage IIB disease. The new TNM staging system exhibited a slightly lower Akaike Information Criterion value and higher χ~2 and c-statistic compared with the eighth edition of the TNM classification system.Similar results were found in the external validation dataset from the external validation set.CONCLUSION We have developed an optional new TNM staging system with a better predictive ability that can be used to accurately predict the 5-year OS of patients with EGC.

Strategies of laparoscopic spleen-preserving splenic hilar lymph node dissection for advanced proximal gastric cancer

For advanced proximal gastric cancer(GC),splenic hilar(No.10) lymph nodes(LN) are crucial links in lymphatic drainage.According to the 14^(th) edition of the Japanese GC treatment guidelines,a D2 lymphadenectomy is the standard surgery for advanced GC,and No.10 LN should be dissected for advanced proximal GC.In recent years,the preservation of organ function and the use of minimally invasive technology are being accepted by an increasing number of clinicians.Laparoscopic spleenpreserving splenic hilar LN dissection has become more accepted and is gradually being used in operations.However,because of the complexity of splenic hilar anatomy,mastering the strategies for laparoscopic spleen-preserving splenic hilar LN dissection is critical for successfully completing the operation.

Low expression of CDK5RAP3 and DDRGK1 indicates a poor prognosis in patients with gastric cancer

AIM To investigate the effects of different levels of expression of CDK5RAP3 and DDRGK1 on long-term survival of patients undergoing radical gastrectomy.METHODS The expression of CDK5RAP3 and DDRGK1 was detected by immunohistochemistry in 135 patients who received standard gastrectomy were enrolled in the study. Western Blot was used to detect the expression of CDK5RAP3 and DDRGK1 in gastric cancer and its adjacent tissues and cell lines. The correlations between the expression of CDK5RAP3 and DDRGK1 and clinicopathological factors were analyzed, and the value of each parameter to the prognosis of the patients was compared. Receiver operating characteristic analysis was used to compare the accuracy of the prediction of clinical outcome by the parameters.RESULTS CDK5RAP3 and DDRGK1 expression was downregulated in the gastric cancer compared to its respective adjacent non-tumor tissues. The expression of CDK5RAP3 was closely related to the age of the patients(P = 0.035) and the T stage of the tumor(P = 0.017). The expression of DDRGK1 was correlated with the sex of the patients(P = 0.080), the degree of tumor differentiation(P = 0.036), the histological type(P = 0.036) and the N stage of the tumor(P = 0.014). Low expression CDK5RAP3 or DDRGK1 is a poor prognostic factor for gastric cancer patients. Prognostic analysis showed that the co-expression of CDK5RAP3 and DDRGK1 was an independent prognostic factor correlating with the overall survival of gastric cancer patients. Combined expression analysis of CDK5RAP3 and DDRGK1 may provide a more accurate prognostic value for overall survival.

Blood parameters score predicts long-term outcomes in stage Ⅱ-Ⅲ gastric cancer patients

BACKGROUND Increasing numbers of laboratory blood parameters(BPM)have been reported to greatly affect the long-term outcomes of gastric cancer(GC)patients.However,the existing prognostic models do not comprehensively analyze these predictors.AIM To construct a new prognostic tool,based on all the prognostic BPM,to achieve more accurate prognosis prediction for GC.METHODS We retrospectively assessed 850 consecutive patients who underwent curative resection for stage II-III GC from January 2010 to April 2013.The patients were classified into developing(n=567)and validation(n=283)cohorts using computer-generated random numbers.A scoring system,namely BPM score,was then constructed using least absolute shrinkage and selection operator(LASSO)Cox regression model in the developing cohort,and validated in the validation cohort.A nomogram consisting of BPM score and tumor-lymph node-metastasis(TNM)stage was further created.The discrimination and calibration of the nomogram were evaluated via Harrell’s C-statistic and the Hosmer-Lemeshow test.RESULTS Using the LASSO model,we established the BPM score based on five BPM:Albumin,lymphocyte-to-monocyte ratio,neutrophil-to-lymphocyte ratio,carcinoembryonic antigen,and carbohydrate antigen 19-9.The BPM scores were divided into high-and low-BPM groups based on a cut-off value of-0.93.High-BPM patients were significantly older and had more advanced,larger tumors.In the developing cohort,significant differences were found in 5-year overall survival(OS)and 5-year disease-specific survival between the high-BPM and low-BPM patients.Similar results were found in the validation group.Multivariable analysis showed that the BPM score was an independent predictor of OS.High-BPM patients had a poorer 5-year OS for each subgroup.Furthermore,a nomogram that combined the BPM score and TNM stage had significantly better prognostic value compared with TNM stage alone.CONCLUSION The BPM score provides more accurate prognosis prediction in stage Ⅱ-Ⅲ GC patients and is an effective complement to the TNM staging system.

多发性胃癌的临床病理特征及辅助化疗对其长期生存的影响:一项倾向评分匹配分析

背景与目的人们对多发性胃癌(multiple gastric cancers,MGC)的临床病理学特征、术后治疗和预后之间的关系知之甚少。在本研究中,我们旨在研究MGC的临床病理学特征以及术后辅助化疗对其长期生存的影响。方法分析2007年1月至2016年12月期间,经根治性胃切除术治疗的胃腺癌患者的临床和病理资料。采用倾向评分匹配法比较MGC和单发性胃癌(solitary gastric cancers,SGC)患者的预后差异及术后辅助化疗对预后的影响。结果在4107例患者中,MGC的发生率为3.2%(133/4107)。匹配前,MGC和SGC患者在胃切除术类型、病理肿瘤分期(pathological tumor stage,pT)、病理淋巴结分期(pathological node stage,pN)和病理肿瘤–淋巴结–转移分期(pathological tumor-node-metastasis stage,pT NM)方面存在差异。按照1∶4比例匹配后,133例MGC患者和532例SGC患者的临床数据具有可比性。整个匹配队列中的5年总生存(overall survival,OS)率为56.6%,MGC组和SGC组分别为48.1%和58.7%(P=0.013)。多变量分析结果显示,MGC、年龄、pT分期、pN分期和辅助化疗是OS的独立预测因素(均P<0.05)。分层分析结果表明,在未接受辅助化疗的进展期胃癌(advanced gastric cancer,AGC)患者中,进展期MGC患者的5年OS率低于SGC患者(分别为34.0%和46.1%;P=0.025)。而进行辅助化疗的进展期MGC患者和SGC患者的5年OS率无显著差异(分别为48.0%和53.3%;P=0.292)。此外,我们发现进行辅助化疗的进展期MGC患者的5年OS率显著高于未接受辅助化疗的患者(分别为48.0%和34.0%,P=0.026)。结论进展期MGC患者的生存率低于SGC患者,术后辅助化疗可能会显著改善MGC患者的长期预后。

Nomograms for pre-and postoperative prediction of long-term survival among proximal gastric cancer patients: A large-scale,single-center retrospective study

BACKGROUND The incidence of proximal gastric cancer(GC)is increasing,and methods for the prediction of the long-term survival of proximal GC patients have not been well established.AIM To develop nomograms for the prediction of long-term survival among proximal GC patients.METHODS Between January 2007 and June 2013,we prospectively collected and retrospectively analyzed the medical records of 746 patients with proximal GC,who were divided into a training set(n=560,75%)and a validation set(n=186,25%).A Cox regression analysis was used to identify the preoperative and postoperative risk factors for overall survival(OS).RESULTS Among the 746 patients examined,the 3-and 5-year OS rates were 66.1%and 58.4%,respectively.In the training set,preoperative T stage(cT),N stage(cN),CA19-9,tumor size,ASA core,and 3-to 6-mo weight loss were incorporated into the preoperative nomogram to predict the OS.In addition to these variables,lymphatic vascular infiltration(LVI),postoperative tumor size,T stage,N stage,blood transfusions,and complications were incorporated into the postoperative nomogram.All calibration curves used to determine the OS probability fit well.In the training set,the preoperative nomogram achieved a C-index of 0.751[95%confidence interval(CI):0.732-0.770]in predicting OS and accurately stratified the patients into four prognostic subgroups(5-year OS rates:86.8%,73.0%,43.72%,and 20.9%,P<0.001).The postoperative nomogram had a C-index of 0.758 in predicting OS and accurately stratified the patients into four prognostic subgroups(5-year OS rates:82.6%,74.3%,45.9%,and 18.9%,P<0.001).CONCLUSION The nomograms accurately predicted the pre-and postoperative long-term survival of proximal GC patients.

Nomogram based on tumor-associated neutrophil-tolymphocyte ratio to predict survival of patients with gastric neuroendocrine neoplasms

AIM To assess the predictive value of the tumor-associated neutrophil-to-lymphocyte ratio in terms of the clinical outcomes of patients with gastric neuroendocrine neoplasms after radical surgery.METHODS Data were retrospectively collected from 142 patients who were diagnosed with gastric neuroendocrine neoplasms and who underwent radical gastrectomy at our department from March 2006 to March 2015. These data were retrospectively analyzed, and a receiver operating characteristic curve analysis was used to identify the optimal value of the tumorassociated neutrophil-to-lymphocyte ratio. Univariate and multivariate survival analyses were used to identify prognostic factors. A nomogram was then applied to predict clinical outcomes after surgery.RESULTS The tumor-associated neutrophil-to-lymphocyte ratio was significantly associated with tumor recurrence, especially with liver metastasis and lymph node metastasis(P < 0.05 for both), but not with clinical characteristics(P > 0.05 for all). A multivariate Cox regression analysis identified the tumor-associatedneutrophil-to-lymphocyte ratio as an independent prognostic factor for recurrence-free survival and overall survival(P < 0.05 for both). The concordance index of the nomograms, which included the tumorassociated neutrophil-to-lymphocyte ratio, Ki-67 index, and lymph node ratio, was 0.788(0.759) for recurrence-free survival(overall survival) and was higher than the concordance index of the traditional TNM staging system [0.672(0.663)].CONCLUSION The tumor-associated neutrophil-to-lymphocyte ratio is an independent prognostic factor in patients with gastric neuroendocrine neoplasms. Nomograms that include the tumor-associated neutrophil-to-lymphocyte ratio, Ki-67 index, and lymph node ratio have a superior ability to predict clinical outcomes of postoperative patients.

经自然腔道取标本手术(NOSES)治疗胃癌的国际共识(2019)

At present,natural orifice specimen extraction surgery(NOSES)has attracted more and more attention worldwide,because of its great advantages including minimal cutaneous trauma and post-operative pain,fast post-operative recovery,short hospital stay,and positive psychological impact.However,NOSES for the treatment of gastric cancer(GC)is still in its infancy,and there is great potential to improve its theoretical system and clinical practice.Especially,several key points including oncological outcomes,bacteriological concerns,indication selection,and standardized surgical procedures are raised with this innovative technique.Therefore,it is necessary to achieve an international consensus to regulate the implementation of GC-NOSES,which is of great significance for healthy and orderly development of NOSES worldwide.

Clinicopathological features and impact of adjuvant chemotherapy on the long-term survival of patients with multiple gastric cancers:a propensity score matching analysis

Background:Little is known about the correlation between the clinicopathological features,postoperative treatment,and prognosis of multiple gastric cancers(MGCs).In this study,we aimed to investigate the correlation between these features and the impact of postoperative adjuvant chemotherapy on the long-term survival of patients with MGC.Methods:The clinical and pathological data of patients diagnosed with gastric adenocarcinoma who had radical gastrectomy from January 2007 to December 2016 were analyzed.Using propensity score matching,the prognostic differences,and the impact of postoperative adjuvant chemotherapy between those with MGC and solitary gastric cancers(SGC)were compared.Results:Among the 4107 patients investigated,the incidence of MGC was 3.2%(133/4107).Before matching,patients with MGC and SGC had disparities in the type of gastrectomy,pathological tumor stage(pT),pathological node stage(pN),and pathological tumor-node-metastasis stage(pTNM).After a 1:4 ratio matching,the clinical data of 133 cases of MGC and 532 cases of SGC were found to be comparable.The 5-year overall survival(OS)rate was 56.6%in the entire matched cohort,48.1%in the MGC group,and 58.7%in the SGC group(P=0.013).Multivariate analysis revealed that MGC,age,pT stage,pN stage,and adjuvant chemotherapy were independent predictors of OS(all P<0.05).Stratified analyses demonstrated that for the cohort of advanced gastric cancer(AGC)patients who did not had adjuvant chemotherapy,the 5-year OS rate of advanced cases of MGC was inferior than that of SGC patients(34.0%vs.46.1%,respectively;P=0.025)but there were no significant difference in the 5-year OS rate between advanced MGC and SGC patients who had adjuvant chemotherapy(48.0%vs.53.3%,respectively;P=0.292).Further,we found that the 5-year OS rate of advanced MGC who had adjuvant chemotherapy was significantly higher than those who did not had adjuvant chemotherapy(48.0%vs.34.0%,P=0.026).Conclusions:Patients with advanced MGC was identified as having a poorer survival as to SGC patients,but the implementation of postoperative adjuvant chemotherapy showed that it had the potential to significantly improve the long-term prognoses of MGC patients.