Countries differ in their treatment expertise and research results regarding gastric cancer; hence, treatment guidelines are diverse based on evidence and medical situations. A comprehensive and comparative review of each country’s guidelines is imperative to understand the similarities and differences among countries. We reviewed and compared five gastric cancer treatment guidelines in terms of endoscopic, surgical, perioperative, and palliative systemic treatment based on evidence levels and recommendation grades, as well as the postoperative follow-up strategies for each guideline. The Korean, Chinese, and European guidelines provided evidence and grading of the recommendations. The United States guidelines suggested categories for evidence and consensus. The Japanese guidelines suggested evidence and recommendations only for systemic treatment. The Korean and Japanese guidelines described endoscopic treatment, surgery, and lymphadenectomy in detail. The Chinese, United States, and European guidelines more intensively considered perioperative chemotherapy. In particular, the indications for chemotherapy and the regimens recommended by each guideline differed slightly. Considering their medical situations, each guideline had some diversity in terms of adopting evidence, which resulted in heterogeneous recommendations. This review will help medical personnel to comprehensively understand the diversity in gastric cancer treatment guidelines for each country in terms of evidence and recommendations.

IMPORTANCEThe long-term safety of laparoscopic distal gastrectomy for locally advanced gastric cancer (AGC) remains uncertain given the lack of 5-year follow-up results.OBJECTIVE To compare the 5-year follow-up results in patients with clinically AGC enrolled in the Korean Laparoendoscopic Gastrointestinal Surgery Study (KLASS)-02 randomized clinical trial who underwent laparoscopic or open distal gastrectomy. DESIGN, SETTING, AND PARTICIPANTSThe KLASS-02, a multicenter randomized clinical trial, showed that laparoscopic surgery was noninferior to open surgery for patients with locally AGC. The present study assessed the 5-year follow-up results, including 5-year overall survival (OS) and relapse-free survival (RFS) rates and long-term complications, in patients enrolled in KLASS-02. From November 21, 2011, to April 29, 2015 aged 20 to 80 years diagnosed preoperatively with locally AGC were enrolled. Final follow-up was on June 15, 2021. Data were analyzed June 24 to September 9, 2021. INTERVENTIONS Patients were treated with R0 resection either by laparoscopic gastrectomy or open gastrectomy as the full analysis set of the KLASS-02 trial. MAIN OUTCOMES AND MEASURES Five-year OS and RFS rates, recurrence patterns, and long-term surgical complications were evaluated. RESULTS This study enrolled a total of 1050 patients. A total of 974 patients were treated with R0 resection; 492 (50.5%) in the laparoscopic gastrectomy group (mean [SD] age, 59.8 [11.0] years; 351 men [71.3%]) and 482 (49.5%) in the open gastrectomy group (mean [SD] age, 59.4 [11.5] years; 335 men [69.5%]). In patients who underwent laparoscopic and open distal gastrectomy, the 5-year OS (88.9% vs 88.7%) and RFS (79.5% vs 81.1%) rates did not differ significantly. The most common types of recurrence were peritoneal carcinomatosis (73 of 173 [42.1%]), hematogenous metastases (36 of 173 [20.8%]), and locoregional recurrence (23 of 173 [13.2%]), with no between-group differences in types of recurrence at each cancer stage. The correlation between 3-year RFS and 5-year OS at the individual level was highest in patients with stage III gastric cancer (ρ = 0.720). The late complication rate was significantly lower in the laparoscopic than in the open surgery group (32 of 492 [6.5%] vs 53 of 482 [11.0%]). The most common type of complication in both groups was intestinal obstruction (13 of 492 [2.6%] vs 24 of 482 [5.0%]). CONCLUSIONS AND RELEVANCEThe 5-year outcomes of the KLASS-02 trial support the 3-year results, which is the noninferiority of laparoscopic surgery compared with open gastrectomy for locally AGC. The laparoscopic approach can be recommended in patients with locally AGC to achieve the benefit of low incidence of late complications.

This study aimed to compare the efficacy of laparoscopic total gastrectomy (LTG) with that of open total gastrectomy (OTG) in terms of postoperative complications and long-term survival. We retrospectively reviewed the clinicopathological data of 560 patients, who underwent total gastrectomy between 2012 and 2016 at the National Cancer Center, Korea. Propensity-score matching (PSM) was performed to correct for discrepancies between the two groups. Matched variables included sex, age, body mass index, American Society of Anesthesiologists score, and pathological Tumor–Node–Metastasis stage. After PSM, 238 patients were included in this analysis. The rate of D2 lymph node dissection was significantly higher in the OTG group than in the LTG group. The estimated blood loss was significantly lower in the LTG group than in the OTG group. The overall complication rate was not significantly different between the two groups. There was no significant difference in the 3-year disease-free and 5-year overall survival rates between the two groups. LTG and OTG had comparable efficacies in gastric cancer patients regarding short- and long-term surgical outcomes. This study suggests that LTG could be an alternative approach to the OTG.

We introduced SPADE operation, a novel anastomotic method after laparoscopic proximal gastrectomy (PG). Technical modifications were performed and settled. This report aimed to demonstrate the short-term clinical outcomes after settlement. Data from 34 consecutive patients who underwent laparoscopic PG with SPADE between June 2017 and March 2020 were retrospectively reviewed. Reflux was evaluated based on the patients’ symptoms and follow-up endoscopy using Los Angeles (LA) classification and RGB Classification (Residue, Gastritis, Bile). Other complications were classified using the Clavien–Dindo method. The incidence of reflux esophagitis was 2.9% (1/34). Bile reflux was observed in six patients (17.6%), and residual food was observed in 16 patients (47.1%) in the endoscopy. Twenty-eight patients had no reflux symptoms (82.4%), while five patients (14.7%) and one patient (2.9%) had mild and moderate reflux symptoms, respectively. The rates of anastomotic stricture and ileus were 14.7% (5/34) and 11.8% (4/34), respectively. No anastomotic leakage was observed. The incidence of major complications (Clavien-Dindo grade III or higher) was 14.7%. The SPADE operation following laparoscopic PG is effective in reducing gastroesophageal reflux. Its clinical usefulness should be validated using prospective clinical trials.

This study examined the nutritional status of patients with hepatobiliary-pancreatic diseases before surgery to establish basic reference data. Materials and Methods: This study evaluated retrospectively 2,322 patients admitted for hepatobiliary-pancreatic surgery between 2014 and 2016 at four Korean medical institutions using the body mass index (BMI) score. The prognostic nutrition index (PNI) was calculated in patients diagnosed with malignant diseases. Results: The mean BMI was 24.0 kg/m 2 (range, 13.2~39.1 kg/m 2 ). The patients were classified as low BMI (<21.5 kg/ m 2 , below 25 percentile), intermediate BMI (21.5~25.5 kg/m 2 ), and high BMI (>25.5 kg/m 2 , above 75 percentile). There were significant differences in the age, sex distribution, ASA classification, type of hospitalization, biliary drainage, organ, and pathology diagnosis between the pairs among the low, intermediate, and high BMI groups. Among the three BMI groups, the complication rate of the low BMI group was highest (34.4% vs. 29.7% vs. 25.8% P=0.005). The median lengths of hospital stay in the low, intermediate, and high BMI groups were 9, 9, and 7 days, respectively (P<0.001). Multivariate analysis revealed the risk factors of the low BMI group to be a higher ASA classification, biliary drainage, pancreatic disease, and malignant disease. The group with PNI<45 had significantly longer hospital stays than the group with PNI≥45 (P<0.001). Conclusion:Patients with a low BMI had a higher ASA classification, preoperative biliary drainage, pancreatic disease, and malignant disease. The low PNI group had significantly longer hospital stays than the high PNI group. Screening of the preoperative nutritional status is necessary for assessing the risk of malnutrition and its treatment.