Background: Laparoscopy-assisted gastrectomy (LAG) is a complex and time-consuming procedure, which is increasingly used for early gastric cancer (EGC). We provide a multidimensional analysis of the learning curve in LAG. Methods: Cumulative sum method was used to analyze outcomes of 109 patients undergoing LAG for EGC by one surgeon over a two year period; the influence of patient selection was evaluated. Target failure rate was set at 10%, with failure defined as open conversion, mortality, major morbidity, residual tumor, or inappropriate lymphadenectomy. Results: There were 19 failures-fourteen performance and five oncologic. The learning curve, which displayed a slight rising trend and three phases was achieved after 40 cases with selected patients; it was broken, however, by the introduction of advanced procedures and unselected patients. Conclusions: Advanced procedures and broad indications in LAG should be delayed until a learning curve is completed under the target failure rate.

Background Complications associated with laparoscopically assisted gastrectomy (LAG) are not significantly different from those associated with open gastrectomy. However, additional risks related to abdominal access, pneumoperitoneum, and special electrosurgical instruments result in an increased incidence of complications with LAG. This study analyzed the causes and risk factors linked to postoperative morbidity. Methods A retrospective review analyzed the data of 300 patients who underwent consecutive LAG for gastric cancer in our department from May 2003 to October 2006. Among the 300 patients, total gastrectomy was performed for 42 patients, distal gastrectomy for 258 patients, and proximal gastrectomy for 3 patients. The clinical and operative data obtained included body mass index, medical comorbidities, history of previous abdominal surgery, operative time, type of surgery, extent of lymph node dissection according to the Japanese Guideline, number of retrieved lymph nodes and lymph node metastases, additional operative procedure, depth of tumor invasion, and disease stage. The outcome data consisted of mortality, major morbidities, and postoperative hospital stay. The 300 cases were divided into two periods: 50 cases in the first period and 250 cases in the second period. Results Postoperative complications developed in 61 cases (20.3%), wound infection in 21 cases (7%), intraabdominal abscess in 3 cases (1%), bleeding in 12 cases (4%), stenosis in 13 cases (4.3%), leakage in 3 cases (1%), acute pancreatitis in 2 cases (0.7%), pulmonary complication in 4 cases (1.3%), renal complication in 4 cases (1.3%), and cardiac complication in 2 cases (0.7%). The 30-day mortality rate was 0.7% (n = 2). Univariate analysis proved that gender, operative period, comorbidity, and operative times were important risk factors. Multivariate analysis proved that cormobidity and operative period were important risk factors. Conclusion The data suggest that LAG can be performed with acceptable perioperative complication rates. The surgeon's experience and careful patient selection determined optimal patient outcomes.

In pT4b gastric cancer, pancreatic invasion was found to portend the least favorable prognosis, especially in cases requiring pancreaticoduodenectomy. However, prognoses were more favorable after curative resection in patients without advanced lymph node stages (N2, N3a, and N3b), an encircling type of gastric tumor, or pancreatic invasion. We propose a novel therapeutic strategy for patients with T4b gastric cancer.

PurposeThe effects of hepatic resection on patients with metastatic tumors from gastric adenocarcinomas are unclear. Therefore, we analyzed early clinical outcomes in patients who underwent surgical resection for hepatic metastases from gastric adenocarcinomas.Materials and MethodsFrom January 2003 to December 2010, 1,508 patients with primary gastric cancers underwent curative gastric resections at the Korea Cancer Center Hospital. Of these patients, 12 with liver-only metastases underwent curative hepatic resection. Their clinical data were analyzed retrospectively.ResultsThe median follow-up period was 12.5 months (range, 1~85 months); no operative mortalities or major complications were observed. Three patients underwent synchronous resections, and 9 underwent metachronous resections. In the latter group, the median interval between gastrectomy and hepatectomy for hepatic metastasis was 10.5 months (range, 5~47 months). The overall 1- and 5-year survival rates of these 12 patients were 65% and 39%, respectively, with a median overall survival of 31.0 months; 2 patients survived for >5 years.ConclusionsHepatic resection can be a feasible procedure for treating hepatic metastases from gastric adenocarcinomas. Although this study was small and involved only selected cases, the outcomes of the hepatic resections were comparable and long-term (>5 years) survivors were identified. Surgical resection of the liver can be considered a feasible option in managing hepatic metastases from gastric adenocarcinomas.

Because of insufficient clinical data regarding acute radiation damage after single high-dose radiation exposure, acute radiation-induced gastrointestinal (GI) syndrome remains difficult to treat. The goal of this study was to establish an appropriate and efficient minipig model to study high-dose radiation-induced GI syndrome after radiation exposure. For endoscopic access to the ileum, ileocutaneous anastomosis was performed 3 weeks before irradiation in six male Göttingen minipigs. Minipigs were locally irradiated at the abdominal area using a gamma source as follows: 1,000 cGy (n = 3) and 1,500 cGy (n = 3). Endoscopic evaluation for the terminal ileum was periodically performed via the ileocutaneous anastomosis tract. Pieces of tissue were serially taken for histological examination. The irradiated intestine presented characteristic morphological changes over time. The most obvious changes in the ileum were mucosal atrophy and telangiectasia from day 1 to day 17 after abdominal irradiation. Microscopic findings were characterized as architectural disorganization, loss of villi and chronic active inflammation. Increase in cyclooxygenase-2 (COX-2) expression was closely correlated with severity of tissue damage and inflammation. Particularly, the plasma citrulline level (PCL), a potential marker for radiation-induced intestinal damage, was significantly decreased the day after irradiation and recovered when irradiated mucosa was normalized. Our results also showed that PCL changes were positively correlated with microscopic changes and the endoscopic score in radiation-induced mucosal damage. In conclusion, the ileocutaneous anastomosis model using the minipig mimics human GI syndrome and allows the study of sequential changes in the ileum, the main target tissue of abdominal irradiation. In addition, PCL could be a simple biomarker for radiation-induced intestinal damage.

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.

Therapy using bisphosphonates might be effective at increasing BMD and reducing fracture risk in gastric cancer patients after gastrectomy. Further well-designed randomized controlled trials are needed for confirmation.

Background/Aims: The purpose of this study was to determine the effect of performing laparoscopic cholecystectomy on patients undergoing laparoscopic-assisted gastrectomy for gastric cancer. Methods: This single center study involved a retrospective review of a database of 400 patients who underwent consecutive laparoscopic-assisted gastrectomy for early gastric cancer from June 2003 to July 2007. Outcomes in 26 patients who underwent both laparoscopic-assisted gastrectomy and laparoscopic cholecystectomy were compared with outcomes from 364 patients who underwent laparoscopic-assisted gastrectomy without laparoscopic cholecystectomy. Results: There were no postoperative 30-day mortalities in the combined cholecystectomy group. The mean surgery duration, time to first flatus and postoperative hospital stay for the laparoscopic gastric resection without combined operation were 181.7 min, 2.7 days and 9.7 days, respectively, and 196.7 min, 2.6 days and 8.8 days, respectively, for the combined cholecystectomy group. None of the postoperative complications was related to combined cholecystectomy. Conclusion: Performing a combined cholecystectomy prolonged the mean surgery duration by approximately 15 min, but had no effect on surgical outcomes. It appears that performing a cholecystectomy at the same time as laparoscopic gastric resection is safe and feasible in patients with both early gastric cancer and gallbladder disease.