Is recovery enhancement after gastric cancer surgery really a safe approach for elderly patients?

BACKGROUND This study aimed to evaluate the safety of enhanced recovery after surgery(ERAS)in elderly patients with gastric cancer(GC).AIM To evaluate the safety of ERAS in elderly patients with GC.METHODS The PubMed,EMBASE,and Cochrane Library databases were used to search for eligible studies from inception to April 1,2023.The mean difference(MD),odds ratio(OR)and 95%confidence interval(95%CI)were pooled for analysis.The quality of the included studies was evaluated using the Newcastle-Ottawa Scale scores.We used Stata(V.16.0)software for data analysis.RESULTS This study consists of six studies involving 878 elderly patients.By analyzing the clinical outcomes,we found that the ERAS group had shorter postoperative hospital stays(MD=-0.51,I2=0.00%,95%CI=-0.72 to-0.30,P=0.00);earlier times to first flatus(defecation;MD=-0.30,I²=0.00%,95%CI=-0.55 to-0.06,P=0.02);less intestinal obstruction(OR=3.24,I2=0.00%,95%CI=1.07 to 9.78,P=0.04);less nausea and vomiting(OR=4.07,I2=0.00%,95%CI=1.29 to 12.84,P=0.02);and less gastric retention(OR=5.69,I2=2.46%,95%CI=2.00 to 16.20,P=0.00).Our results showed that the conventional group had a greater mortality rate than the ERAS group(OR=0.24,I2=0.00%,95%CI=0.07 to 0.84,P=0.03).However,there was no statistically significant difference in major complications between the ERAS group and the conventional group(OR=0.67,I2=0.00%,95%CI=0.38 to 1.18,P=0.16).CONCLUSION Compared to those with conventional recovery,elderly GC patients who received the ERAS protocol after surgery had a lower risk of mortality.

Current clinical trials on gastric cancer surgery in China

Gastric cancer(GC)is the leading diagnosed malignancy worldwide,especially in China.Radical surgery is the cornerstone of GC treatment.We reviewed previous clinical trials and aimed to provide an update on the factors related to the surgical treatment of GC.The number of registered clinical trials in the field of GC surgery is rapidly increasing.With the development and popularization of endoscopic,laparoscopic,and robotic techniques,GC surgery has gradually entered a new era of precise minimally invasive surgery.Postoperative quality of life has become a major issue in addition to surgical oncological safety.Although great progress has been made in clinical research on GC in China,there are still deficiencies.Many studies enrolled large numbers of patients,but the research data were not of high quality.The characteristics of GC in China include a high incidence,large population,and large proportion of patients with advanced GC,which provides sufficient reason for studying this disease.There is still a need for well-designed,large,randomized clinical trials to improve our knowledge of the surgical treatment of GC.

Impact of minimally invasive surgery on immune function and stress response in gastric cancer patients

BACKGROUND Gastric cancer remains a leading cause of cancer-related mortality globally.Traditional open surgery for gastric cancer is often associated with significant morbidity and prolonged recovery.AIM To evaluate the effectiveness of laparoscopic minimally invasive surgery as an alternative to traditional open surgery for gastric cancer,focusing on its potential to reduce trauma,accelerate recovery,and achieve comparable oncological out-comes.METHODS This study retrospectively analyzed 203 patients with gastric cancer who underwent surgery at the Shanghai Health Medical College Affiliated Chongming Hospital from January 2020 to December 2023.The patients were divided into two groups:Minimally invasive surgery group(n=102),who underwent laparoscopic gastrectomy,and open surgery group(n=101),who underwent traditional open gastrectomy.We compared surgical indicators(surgical incision size,intraop-erative blood loss,surgical duration,and number of lymph nodes dissected),recovery parameters(time to first flatus,time to start eating,time to ambulation,and length of hospital stay),immune function(levels of IgA,IgG,and IgM),intestinal barrier function(levels of D-lactic acid and diamine oxidase),and stress response(levels of C-reactive protein,interleukin-6,and procalcitonin).RESULTS The minimally invasive surgery group demonstrated significantly better outcomes in terms of surgical indicators,including smaller incisions,less blood loss,shorter surgery time,and more lymph nodes dissected(P<0.05 for all).Recovery was also faster in the minimally invasive surgery group,with earlier return of bowel function,earlier initiation of diet,quicker mobilization,and shorter hospital stays(P<0.05 for all).Furthermore,patients in the minimally invasive surgery group had better preserved immune function,superior intestinal barrier function,and a less pronounced stress response postoperatively(P<0.05 for all).CONCLUSION Laparoscopic minimally invasive surgery for gastric cancer not only provides superior surgical indicators and faster recovery but also offers advantages in preserving immune function,protecting intestinal barrier function,and mitigating the stress response compared to traditional open surgery.These findings support the broader adoption of laparoscopic techniques in the management of gastric cancer.

Comparative analysis of conventional laparoscopic surgery and single-incision laparoscopic surgery in gastric cancer treatment:Outcomes and prognosis

BACKGROUND Gastric cancer surgery has advanced with minimally invasive techniques.This study compares outcomes between single-incision laparoscopic surgery plus one port(SILS+1)and conventional laparoscopic surgery(CLS)in treating gastric cancer.AIM To explore the curative effect of SILS+1 and CLS on gastric cancer and their influences on prognosis.METHODS A total of 93 patients with gastric cancer undergoing radical gastrectomy in the hospital were retrospectively analyzed between September 2019 and September 2022.According to different surgical methods,they were divided into SILS+1 group(n=56)and CLS group(n=37).The perioperative indexes,pain degree[visual analogue scale(VAS)]and stress response[C-reactive protein(CRP),white blood cell count(WBC)]in the two groups were compared.The postoperative complications,recurrence rate and mortality at 1 year after surgery were recorded.RESULTS Intraoperative blood loss was significantly lower in the SILS+1 group(76.53±8.12 mL)compared to the CLS group(108.67±12.34 mL,P<0.001),and the total incision length was also significantly shorter in the SILS+1 group(5.29±1.01 cm vs 9.45±2.34 cm,P<0.001).SILS+1 patients experienced faster recovery,with shorter times to first flatus(1.94±0.43 days vs 3.23±0.88 days,P<0.001)and ambulation(2.76±0.58 days vs 4.10±0.97 days,P<0.001).Postoperative pain,as measured by VAS scores,was significantly lower in the SILS+1 group on postoperative days 1,2,and 3(P<0.001).Additionally,stress markers(CRP and WBC)were significantly lower in the SILS+1 group on the first postoperative day(CRP:6.41±1.63 mg/L vs 7.82±1.88 mg/L,P<0.001;WBC:6.34±1.50×109/L vs 7.09±1.61×109/L,P=0.024).The complication rate in the SILS+1 group was also significantly lower than in the CLS group(8.93%vs 27.03%,P=0.020).However,there was no significant difference in recurrence rates between the two groups after one year(3.57%vs 8.11%,P>0.05).CONCLUSION SILS+1 and CLS have the comparable lymph node clearance effect in patients with gastric cancer.However,SILS+1 is more beneficial to reduce intraoperative blood loss,relieve pain,alleviate stress response,reduce the incidence of complications and promote rapid postoperative recovery.

Laparoscopic vs open surgery for gastric cancer: Assessing time, recovery, complications, and markers

BACKGROUND Gastric cancer(GC)is one of the most common cancers worldwide.Morbidity and mortality have increased in recent years,making it an urgent issue to address.La-paroscopic radical surgery(LRS)is a crucial method for treating patients with GC;However,its influence on tumor markers is still under investigation.The data of 194 patients treated at Chongqing University Cancer Hospital bet-ween January 2018 and January 2019 were retrospectively analyzed.Patients who underwent traditional open surgery and LRS were assigned to the control(n=90)and observation groups(n=104),respectively.Independent sample t-tests andχ2 tests were used to compare the two groups based on clinical efficacy,changes in tumor marker levels after treatment,clinical data,and the incidence of posto-perative complications.To investigate the association between tumor marker levels and clinical efficacy in patients with GC,three-year recurrence rates in the two groups were compared.RESULTS Patients in the observation group had a shorter duration of operation,less in-traoperative blood loss,an earlier postoperative eating time,and a shorter hospital stay than those in the control group(P<0.05).No significant difference was observed between the two groups regarding the number of lymph node dissections(P>0.05).After treatment,the overall response rate in the control group was significantly lower than that in the observation group(P=0.001).Furthermore,after treatment,the levels of carbohydrate antigen 19-9,cancer antigen 72-4,carcinoembryonic antigen,and cancer antigen 125 decreased significantly.The observation group also exhibited a significantly lower incidence rate of postoperative complications compared to the control group(P<0.001).Additionally,the two groups did not significantly differ in terms of three-year survival and recurrence rates(P>0.05).CONCLUSION LRS effectively treats early gastric cancer by reducing intraoperative bleeding,length of hospital stays,and postoperative complications.It also significantly lowers tumor marker levels,thus improving the short-term prognosis of the disease.

Pain and immune function in patients undergoing gastric cancer surgery following stellate ganglion block with total intravenous anesthesia

BACKGROUND Stellate ganglion block is a commonly used sympathetic nerve block technique that restores the balance of the sympathetic and vagal nervous systems of the body and inhibits sympathetic nerve activity.AIM To analyze the effect of a stellate ganglion block combined with total diploma intravenous anesthesia on postoperative pain and immune function in patients undergoing laparoscopic radical gastric cancer(GC)surgery to provide a refe-rence basis for the formulation of anesthesia protocols for radical GC surgery.METHODS This study included 112 patients who underwent laparoscopic radical surgery for GC between January 2022 and March 2024.There was no restriction on sex.The patient grouping method used was a digital random table method,and the num-ber of cases in each group was 56.The control group was administered total intravenous anesthesia,and the observation group compounded the stellate gan-glion block according to the total intravenous anesthesia protocol.Postoperative hemodynamics,pain levels,and immune indices were compared between the groups.RESULTS The heart rate and mean arterial pressure in the observation group after in-tubation were lower than those in the control group(P<0.05).Pain levels were compared between the two groups at 2 hours,12 hours,24 hours,and 48 hours after surgery(P>0.05).The number of CD3+,CD4+,and CD4+/CD8+cells at the end of surgery was higher in the observation group than in the control group,and the number of CD8+cells was lower in the observation group than in the control group(P<0.05).There were no significant differences between the two groups in terms of propofol dosage,awakening time,extubation time,or postoperative adverse reactions(P>0.05).CONCLUSION The application of a stellate ganglion block combined with total intravenous anesthesia had no significant effect on postoperative pain levels in patients undergoing laparoscopic radical GC surgery.However,it can safely reduce the effect of surgery on the immune function of patients and is worth applying in clinical practice.

Clinical significance of peripheral blood immune cells in patients with gastric cancer after surgery

BACKGROUND Gastric cancer is one of the most common malignant tumors worldwide,and surgical resection is one of the main ways to treat gastric cancer.However,the immune status of postoperative patients is crucial for prognosis and survival,and immune cells play an important role in this process.Therefore,it is helpful to understand the immune status of postoperative patients by evaluating the levels of peripheral blood immune cells,especially total T cells(CD3+),helper T cells(CD3+CD4+),and suppressor T cells(CD3+CD8+),and its relationship to sur-vival.AIM To analyzed the immune cells in peripheral blood of patients with gastric cancer after surgery,detect the levels of total T cells,helper T cells and suppressor T cells.METHODS A total of 58 patients with gastric cancer who received surgical treatment were included in the retrospective study.Flow cytometry was used to detect the level of peripheral blood immune cells and analyze the correlation between total T cells,helper T cells and inhibitory T cells.To explore the relationship between these immune markers and patient survival.RESULTS The results showed that the levels of total T cells,helper T cells,and suppressor T cells changed in patients after gastric cancer surgery.There was a significant positive correlation between total T cells,helper T cells and suppressor T cells(r=0.35,P<0.01;r=0.56,P<0.01).However,there was a negative correlation between helper T cells and suppressor T cells(r=-0.63,P<0.01).Follow-up showed that the survival rate of patients in the high-level total T cell group was significantly higher than that in the low-level group(28.87±24.98 months vs 18.42±16.21 months).The survival curve shows that the curve of patients in the high-level group is shifted to the upper right,and that of the low-level group is shifted downward.There was no significant difference between the levels of helper T cells and suppressor T cells and patient survival time.CONCLUSION By detecting peripheral blood immune cells with flow cytometry,we can initially evaluate the immune status of patients after gastric cancer surgery and initially explore its relationship with patient survival.

Cytoreductive surgery and hyperthermic intraperitonealchemotherapy in gastric cancer

Gastric cancer associated peritoneal carcinomatosis(GCPC) has a poor prognosis with a median survival of less than one year. Systemic chemotherapy including targeted agents has not been found to significantly increase the survival in GCPC. Since recurrent gastric cancer remains confined to the abdominal cavity in many patients, regional therapies like aggressive cytoreductive surgery( CRS) and hyperthermic intraperitoneal chemotherapy(HIPEC) have been investigated for GCPC. HIPEC has been used for three indications in GC- as an adjuvant therapy after a curative surgery, HIPEC has been shown to improve survival and reduce peritoneal recurrences in many randomised trials in Asian countries; as a definitive treatment in established PC, HIPEC along with CRS is the only therapeutic modality that has resulted in longterm survival in select groups of patients; as a palliative treatment in advanced PC with intractable ascites, HIPEC has been shown to control ascites and reduce the need for frequent paracentesis. While the results of randomised trials of adjuvant HIPEC from western centres are awaited, the role of HIPEC in the treatment of GCPC is still evolving and needs larger studies before it is accepted as a standard of care.

Application of enhanced recovery after gastric cancer surgery: An updated meta-analysis

AIM To provide an updated assessment of the safety and efficacy of enhanced recovery after surgery(ERAS) protocols in elective gastric cancer(GC) surgery.METHODS Pub Med, Medline, EMBASE, World Health Organization International Trial Register, and Cochrane Library were searched up to June 2017 for all available randomized controlled trials(RCTs) comparing ERAS protocols and standard care(SC) in GC surgery. Thirteen RCTs, with a total of 1092 participants, were analyzed in this study, of whom 545 underwent ERAS protocols and 547 received SC treatment.RESULTS No significant difference was observed between ERAS and control groups regarding total complications(P = 0.88), mortality(P = 0.50) and reoperation(P = 0.49). The incidence of pulmonary infection was significantly reduced(P = 0.03) following gastrectomy. However, the readmission rate after GC surgery nearly tripled under ERAS(P = 0.009). ERAS protocols significantly decreased the length of postoperative hospital stay(P < 0.00001) and medical costs(P < 0.00001), and accelerated bowel function recovery, as measured by earlier time to the first flatus(P = 0.0004) and the first defecation(P < 0.0001). Moreover, ERAS protocols were associated with a lower level of serum inflammatory response, higher serum albumin, and superior shortterm quality of life(QOL).CONCLUSION Collectively, ERAS results in accelerated convalescence, reduction of surgical stress and medical costs, improved nutritional status, and better QOL for GC patients. However, high-quality multicenter RCTs with large samples and long-term follow-up are needed to more precisely evaluate ERAS in radical gastrectomy.

Laparoscopic-endoscopic cooperative surgery for gastric submucosal tumors

AIM:To assess the feasibility,safety,and advantages of minimally invasive laparoscopic-endoscopic cooperative surgery(LECS)for gastric submucosal tumors(SMT).METHODS:We retrospectively analyzed 101 consecutive patients,who had undergone partial,proximal,or distal gastrectomy using LECS for gastric SMT at Peking Union Medical College Hospital from June 2006to April 2013.All patients were followed up by visit or telephone.Clinical data,surgical approach,pathological features such as the size,location,and pathological type of each tumor;and follow-up results were analyzed.The feasibility,safety and effectiveness of LECS for gastric SMT were evaluated,especially for patients with tumors located near the cardia or pylorus.RESULTS:The 101 patients included 43(42.6%)menand 58(57.4%)women,with mean age of 51.2±13.1 years(range,14-76 years).The most common symptom was belching.Almost all(n=97)patients underwent surgery with preservation of the cardia and pylorus,with the other four patients undergoing proximal or distal gastrectomy.The mean distance from the lesion to the cardia or pylorus was 3.4±1.3 cm,and the minimum distance from the tumor edge to the cardia was 1.5 cm.Tumor pathology included gastrointestinal stromal tumor in 78 patients,leiomyoma in 13,carcinoid tumors in three,ectopic pancreas in three,lipoma in two,glomus tumor in one,and inflammatory pseudotumor in one.Tumor size ranged from 1 to8.2 cm,with 65(64.4%)lesions<2 cm,32(31.7%)>2 cm,and four>5 cm.Sixty-six lesions(65.3%)were located in the fundus,21(20.8%)in the body,10(9.9%)in the antrum,three(3.0%)in the cardia,and one(1.0%)in the pylorus.During a median follow-up of 28 mo(range,1-69 mo),none of these patients experienced recurrence or metastasis.The three patients who underwent proximal gastrectomy experienced symptoms of regurgitation and belching.CONCLUSION:Laparoscopic-endoscopic cooperative surgery is feasible and safe for patients with gastric submucosal tumor.Endoscopic intraoperative localization and support can help preserve the cardia and pylorus during surgery.

Reoperation for early postoperative complications after gastric cancer surgery in a Chinese hospital

AIM:To investigate the occurrence of postoperative complications of gastric cancer surgery,and analyze the potential causes of reoperation for early postoperative complications. METHODS:A total of 1639 patients who underwent radical or palliative gastrectomies for gastric cancer were included in the study.The study endpoint was the analysis of postoperative complications in inpatients. RESULTS:About 31%of patients had early postoperative complications,and complications of infection occurred most frequently.Intra-abdominal hemorrhage and anastomotic leak were the main causes of reoperation,which accounted for about 2.2%.Mortality was 11.1%in the reoperation group,but was only 0.8%in other patients.The duration of postoperative stay in hospital was significantly longer and the total expenditure was markedly higher in the patients who underwent reoperation(P<0.001).There was no significant association of any available factors in this study with the high rate of reoperation.CONCLUSION:Reoperation significantly increases the mortality rate and raises the burden of the surgical unit.More prospective studies are required to explore the potential risk factors.

Timing of surgery after neoadjuvant chemotherapy for gastric cancer: Impact on outcomes

AIM To evaluate whether the neoadjuvant chemotherapy(NAc T)-surgery interval time significantly impacts the pathological complete response(pc R) rate and longterm survival.METHODS One hundred and seventy-six patients with gastric cancer undergoing NAc T and a planned gastrectomy at the chinese p LA General hospital were selected from January 2011 to January 2017. Univariate and multivariable analyses were used to investigate the impact of NAc T-surgery interval time(< 4 wk, 4-6 wk, and > 6 wk) on pc R rate and overall survival(OS).RESULTS The NAc T-surgery interval time and clinician T stage were independent predictors of pc R. The interval time > 6 wk was associated with a 74% higher odds of pc R as compared with an interval time of 4-6 wk(p = 0.044), while the odds ratio(OR) of clinical T3 vs clinical T4 stage for pc R was 2.90(95%c I: 1.04-8.01, p = 0.041). In cox regression analysis of long-term survival, postneoadjuvant therapy pathological N(yp N) stage significantly impacted OS(N0 vs N3: h R = 0.16, 95%c I: 0.37-0.70, p = 0.015; N1 vs N3: h R = 0.14, 95%c I: 0.02-0.81, p = 0.029) and disease-free survival(DFS)(N0 vs N3: h R = 0.11, 95%c I: 0.24-0.52, p = 0.005; N1 vs N3: h R = 0.17, 95%c I: 0.02-0.71, p = 0.020). The surgical procedure also had a positive impact on OS and DFS. The hazard ratio of distal gastrectomy vs total gastrectomy was 0.12(95%c I: 0.33-0.42, p = 0.001) for OS, and 0.13(95%c I: 0.36-0.44, p = 0.001) for DFS.CONCLUSION The NAc T-surgery interval time is associated with pc R but has no impact on survival, and an interval time > 6 wk has a relatively high odds of pc R.

New-style laparoscopic and endoscopic cooperative surgery for gastric stromal tumors

AIM: To evaluate the feasibility and safety of a new style of laparoscopic and endoscopic cooperative surgery (LECS), an improved method of laparoscopic intragastric surgery (LIGS) for the treatment of gastric stromal tumors (GSTs). METHODS: Six patients were treated with the newstyle LECS. Surgery was performed according to the following procedures: (1) Exposing and confirming the location of the tumor with gastroscopy; (2) A laparoscopy light was placed in the cavity using the trocar at the navel, and the other two trocars penetrated both the abdominal and stomach walls; (3) With gastroscopy monitoring, the operation was carried out in the gastric lumen using laparoscopic instruments and the tumor was resected; and (4) The tumor tissue was removed orally using a gastroscopy basket, and puncture holes and perforations were sutured using titanium clips. RESULTS: Tumor size ranged from 2.0 to 4.5 cm (average 3.50 ± 0.84 cm). The operative time ranged from 60 to 130 min (average 83.33 ± 26.58 min). Blood loss was less than 20 mL and hospital stay ranged from 6 to 8 d (average 6.67 ± 0.82 d). The patients were allowed out of bed 12 h later. A stomach tube was inserted for 72 h after surgery, and a liquid diet was then taken. All cases had single tumors which were completely resected using the new-style LECS. No postoperative complications occurred. Pathology of all resected specimens showed GST: no cases of implantation or metastasis were found.CONCLUSION: New-style LECS for GSTs is a quick, optimized, fast recovery, safe and effective therapy.

Current status of function-preserving surgery for gastric cancer

Recent advances in diagnostic techniques have allowed the diagnosis of gastric cancer(GC)at an early stage.Due to the low incidence of lymph node metastasis and favorable prognosis in early GC,function-preserving surgery which improves postoperative quality of life may be possible.Pylorus-preserving gastrectomy(PPG)is one such function-preserving procedure,which is expected to offer advantages with regards to dumping syndrome,bile reflux gastritis,and the frequency of flatus,although PPG may induce delayed gastric emptying.Proximal gastrectomy(PG)is another functionpreserving procedure,which is thought to be advantageous in terms of decreased duodenogastric reflux and good food reservoir function in the remnant stomach,although the incidence of heartburn or gastric fullness associated with this procedure is high.However,these disadvantages may be overcome by the reconstruction method used.The other important problem after PG is remnant GC,which was reported to occur in approximately 5%of patients.Therefore,the reconstruction technique used with PG should facilitate postoperativeendoscopic examinations for early detection and treatment of remnant gastric carcinoma.Oncologic safety seems to be assured in both procedures,if the preoperative diagnosis is accurate.Patient selection should be carefully considered.Although many retrospective studies have demonstrated the utility of function-preserving surgery,no consensus on whether to adopt functionpreserving surgery as the standard of care has been reached.Further prospective randomized controlled trials are necessary to evaluate survival and postoperative quality of life associated with function-preserving surgery.

Minimally invasive surgery for gastric cancer: A comparison between robotic, laparoscopic and open surgery

AIM To investigate the role of minimally invasive surgery for gastric cancer and determine surgical, clinical, and oncological outcomes.METHODS This is a propensity score-matched case-control study, comparing three treatment arms: robotic gastrectomy(RG), laparoscopic gastrectomy(LG), open gastrectomy(OG). Data collection started after sharing a specific study protocol. Data were recorded through a tailored and protected web-based system. Primary outcomes: harvested lymph nodes, estimated blood loss, hospital stay, complications rate. Among the secondary outcomes, there are: operative time, R0 resections, POD of mobilization, POD of starting liquid diet and soft solid diet. The analysis includes the evaluation of type and grade of postoperative complications. Detailed information of anastomotic leakages is also provided.RESULTS The present analysis was carried out of 1026 gastrectomies. To guarantee homogenous distribution of cases, patients in the RG, LG and OG groups were 1:1:2 matched using a propensity score analysis with a caliper = 0.2. The successful matching resulted in a total sample of 604 patients(RG = 151; LG = 151; OG = 302). The three groups showed no differences in all baseline patients characteristics, type of surgery(P = 0.42) and stage of the disease(P = 0.16). Intraoperative blood loss was significantly lower in the LG(95.93 ± 119.22) and RG(117.91 ± 68.11) groups compared to the OG(127.26 ± 79.50, P = 0.002). The mean number of retrieved lymph nodes was similar between the RG(27.78 ± 11.45), LG(24.58 ± 13.56) and OG(25.82 ± 12.07) approach. A benefit in favor of the minimally invasive approaches was found in the length of hospital stay(P < 0.0001). A similar complications rate was found(P = 0.13). The leakage rate was not different(P = 0.78) between groups.CONCLUSION Laparoscopic and robotic surgery can be safely performed and proposed as possible alternative to open surgery. The main highlighted benefit is a faster postoperative functional recovery.

Laparoscopic and endoscopic cooperative surgery for gastric tumors: Perspective for actual practice and oncological benefits

Laparoscopic and endoscopic cooperative surgery(LECS) is a surgical technique that combines laparoscopic partial gastrectomy and endoscopic submucosal dissection. LECS requires close collaboration between skilled laparoscopic surgeons and experienced endoscopists. For successful LECS, experience alone is not sufficient. Instead, familiarity with the characteristics of both laparoscopic surgery and endoscopic intervention is necessary to overcome various technical problems. LECS was developed mainly as a treatment for gastric submucosal tumors without epithelial lesions, including gastrointestinal stromal tumors(GISTs). Local gastric wall dissection without lymphadenectomy is adequate for the treatment of gastric GISTs. Compared with conventional simple wedge resection with a linear stapler, LECS can provide both optimal surgical margins and oncological benefit that result in functional preservation of the residual stomach. As technical characteristics, however, classic LECS involves intentional opening of the gastric wall, resulting in a risk of tumor dissemination with contamination by gastric juice. Therefore, several modified LECS techniques have been developed to av-oid even subtle tumor exposure. Furthermore, LECS for early gastric cancer has been attempted according tothe concept of sentinel lymph node dissection. LECS is a prospective treatment for GISTs and might become a future therapeutic option even for early gastric cancer. Interventional endoscopists and laparoscopic surgeons collaboratively explore curative resection. Simultaneous intraluminal approach with endoscopy allows surgeons to optimizes the resection area. LECS, not simple wedge resection, achieves minimally invasive treatment and allows for oncologically precise resection. We herein present detailed tips and pitfalls of LECS and discuss various technical considerations.

Improving the outcomes in gastric cancer surgery

Gastric cancer remains a significant health problem worldwide and surgery is currently the only potentially curative treatment option. Gastric cancer surgery is generally considered to be high risk surgery and fiveyear survival rates are poor,therefore a continuous strive to improve outcomes for these patients is warranted. Fortunately,in the last decades several potential advances have been introduced that intervene at various stages of the treatment process. This review provides an overview of methods implemented in pre-,intra- and postoperative stage of gastric cancer surgery to improve outcome. Better preoperative risk assessment using comorbidity index(e.g.,Charlson comorbidity index),assessment of nutritional status(e.g.,short nutritional assessment questionnaire,nutritional risk screening- 2002) and frailty assessment(Groningen frailty indicator,Edmonton frail scale,Hopkins frailty) was introduced. Also preoperative optimization of patients using prehabilitation has future potential.Implementation of fast-track or enhanced recovery after surgery programs is showing promising results,although future studies have to determine what the exact optimal strategy is.Introduction of laparoscopic surgery has shown improvement of results as well as optimization of lymph node dissection.Hyperthermic intraperitoneal chemotherapy has not shown to be beneficial in peritoneal metastatic disease thus far.Advances in postoperative care include optimal timing of oral diet,which has been shown to reduce hospital stay.In general,hospital volume,i.e.,centralization,and clinical audits might further improve the outcome in gastric cancer surgery.In conclusion,progress has been made in improving the surgical treatment of gastric cancer.However,gastric cancer treatment is high risk surgery and many areas for future research remain.

Prediction of lymph node metastasis and sentinel node navigation surgery for patients with early-stage gastric cancer

Accurate prediction of lymph node(LN) status is crucially important for appropriate treatment planning in patients with early gastric cancer(EGC). However,consensus on patient and tumor characteristics associated with LN metastasis are yet to be reached. Through systematic search,we identified several independent variables associated with LN metastasis in EGC,which should be included in future research to assess which of these variables remain as significant predictors of LN metastasis. On the other hand,even if we use these promising parameters,we should realize the limitation and the difficulty of predicting LN metastasis accurately. The sentinel LN(SLN) is defined as first possible site to receive cancer cells along the route of lymphatic drainage from the primary tumor. The absence of metastasis in SLN is believed to correlate with the absence of metastasis in downstream LNs. In this review,we have attempted to focus on several independent parameters which have close relationship between tumor and LN metastasis in EGC. In addition,we evaluated the history of sentinel node navigation surgery and the usefulness for EGC.

Worldwide practice in gastric cancer surgery

AIM: To evaluate the current status of gastric cancer surgery worldwide.METHODS: An international cross-sectional survey on gastric cancer surgery was performed amongst international upper gastro-intestinal surgeons. All surgical members of the International Gastric Cancer Association were invited by e-mail to participate. An English web-based survey had to be filled in with regard to their surgical preferences. Questions asked included hospital volume, the use of neoadjuvant treatment, preferred surgical approach, extent of the lymphadenectomy and preferred anastomotic technique. The invitations were sent in September 2013 and the survey was closed in January 2014.RESULTS: The corresponding specific response rate was 227/615(37%). The majority of respondents: originated from Asia( 5 4 %), performed > 2 1 gastrectomies per year(79%) and used neoadjuvant chemotherapy(73%). An open surgical procedure was performed by the majority of surgeons for distal gastrectomy for advanced cancer(91%) and total gastrectomy for both early and advanced cancer(52% and 94%). A minimally invasive procedure was preferred for distal gastrectomy for early cancer(65%). In Asia surgeons preferred a minimally invasive procedure for total gastrectomy for early cancer also(63%). A D1+ lymphadenectomy was preferred in early gastric cancer(52% for distal, 54% for total gastrectomy) and a D 2 lymphadenectomy was preferred in advanced gastric cancer(93% for distal, 92% for total gastrectomy) CONCLUSION: Surgical preferences for gastric cancer surgery vary between surgeons worldwide. Although the majority of surgeons use neoadjuvant chemotherapy, minimally invasive techniques are still not widely adapted.

MicroRNA-218 is upregulated in gastric cancer after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy and increases chemosensitivity to cisplatin

AIM: To investigate the molecular mechanisms of miRNA in advanced gastric cancers (AGCs) before and after cytoreductive surgery (CRS) + hyperthermic intraperitoneal chemotherapy (HIPEC).