Chang-Ming Huang

The impact of age and comorbidity on postoperative complications in patients with advanced gastric cancer after laparoscopic D2 gastrectomy: Results from the Chinese laparoscropic gastrointestinal surgery study (CLASS) group

BACKGROUND This study aims to evaluate the role of age and comorbidities on postoperative complications in the patients with advanced gastric cancer (AGC) following laparoscopy-assisted gastrectomy (LAG) and D2 lymphadenectomy based on the results from the Chinese Laparoscropic Gastrointestinal Surgery Study (CLASS) Group. METHODOLOGY From February 2003 and December 2009 at twenty-seven medical centers, 1184 AGC patients after LAG with D2 lymphadenectomy were entered and followed in a retrospective recorded database. The postoperative complications were recorded by using the Accordion Severity Grading System. RESULTS Postoperative morbidity and mortality after LAG and D2 dissection in the AGC patients was 10.1% and 0.1%, respectively. Multivariable analysis identified age ≥ 65 years (OR = 1.72, P = 0.024) and having two or more comorbidities (OR = 2.76, P = 0.009) as the significant predictors of the development of postoperative complications. Meanwhile, age ≥ 65 years (OR = 1.95, P = 0.016) and having two or more comorbidities (OR = 3.62, P = 0.001) were also the significant predictors of moderate or severe complications. In stratified analysis by the number of comorbidities, age ≥ 65 years was significantly associated with an excess risk of postoperative complications (OR = 2.35, P = 0.033), and the moderate or severe complications (OR = 4.36, P = 0.003) when the patients had at least one comorbidity. CONCLUSIONS LAG would be a safe and technically feasible approach for the AGC patients, despite age ≥65 years and having multiple comorbidities were the potential risk factors for postoperative complications. Importantly, elderly patients with resectable gastric cancer should not be excluded from the potential benefits of LAG provided that comorbidities are fully considered.

Tumor size as a prognostic factor in patients with advanced gastric cancer in the lower third of the stomach

AIM To explore the impact of tumor size on outcomes in patients with advanced gastric cancer in the lower third of the stomach. METHODS We retrospectively analyzed the clinical records of 430 patients with advanced gastric cancer in the lower third of the stomach who underwent distal subtotal gastrectomy and D2 lymphadenectomy in our hospital from January 1998 to June 2004. Receiver-operating characteristic (ROC) curve analysis was used to determine the appropriate cutoff value for tumor size, which was measured as maximum tumor diameter. Based on this cutoff value, patients were divided into two groups: those with large-sized tumors (LSTs) and those with small-sized tumors (SSTs). The correlations between other clinicopathologic factors and tumor size were investigated, and the 5-year overall survival (OS) rate was compared between the two groups. Potential prognostic factors were evaluated by univariate Kaplan-Meier survival analysis and multivariate Coxs proportional hazard model analysis. The 5-year OS rates in the two groups were compared according to pT stage and pN stage. RESULTS The 5-year OS rate in the 430 patients with advanced gastric cancer in the lower third of the stomach was 53.7%. The mean ± SD tumor size was 4.9 ± 1.9 cm, and the median tumor size was 5.0 cm. ROC analysis indicated that the sensitivity and specificity results for the appropriate tumor size cutoff value of 4.8 cm were 80.0% and 68.2%, respectively (AUC = 0.795, 95%CI: 0.751-0.839, P = 0.000). Using this cutoff value, 222 patients (51.6%) had LSTs (tumor size ≥ 4.8 cm) and 208 (48.4%) had SSTs (tumor size < 4.8 cm). Tumor size was significantly correlated with histological type (P = 0.039), Borrmann type (P = 0.000), depth of tumor invasion (P = 0.000), lymph node metastasis (P = 0.000), tumor-nodes metastasis stage (P = 0.000), mean number of metastatic lymph nodes (P = 0.000) and metastatic lymph node ratio (P = 0.000). Patients with LSTs had a significantly lower 5-year OS rate than those with SSTs (37.1% vs 63.3%, P = 0.000). Univariate analysis showed that depth of tumor invasion (χ² = 69.581, P = 0.000), lymph node metastasis (χ² = 138.815, P = 0.000), tumor size (χ² = 78.184, P = 0.000) and metastatic lymph node ratio (χ² = 139.034, P = 0.000) were significantly associated with 5-year OS rate. Multivariate analysis revealed that depth of tumor invasion (P = 0.000), lymph node metastasis (P = 0.019) and tumor size (P = 0.000) were independent prognostic factors. Gastric cancers were divided into 12 subgroups: pT2N0; pT2N1; pT2N2; pT2N3; pT3N0; pT3N1; pT3N2; pT3N3; pT4aN0; pT4aN1; pT4aN2; and pT4aN3. In patients with pT2-3N3 stage tumors and patients with pT4a stage tumors, 5-year OS rates were significantly lower for LSTs than for SSTs (P < 0.05 each), but there were no significant differences in the 5-year OS rates in LST and SST patients with pT2-3N0-2 stage tumors (P > 0.05). CONCLUSION Using a tumor size cutoff value of 4.8 cm, tumor size is a prognostic factor in patients with pN3 stage or pT4a stage advanced gastric cancer located in the lower third of the stomach.

Outcome of palliative total gastrectomy for stage IV proximal gastric cancer.

BACKGROUND A few studies have investigated the outcome of palliative total gastrectomy (PTG) in stage IV proximal gastric cancer. In this study, we tried to summarize the outcome of PTG in stage IV proximal gastric cancer. METHODS Between January 1991 and January 2005, complete clinical data of 197 patients with stage IV proximal gastric cancer undergoing PTG, 642 patients undergoing curative total gastrectomy (CTG), 152 nonsurgical patients, 102 patients undergoing explorative laparotomy, and 78 patients undergoing jejunostomy were enrolled in this study. Survival rates, median survival, complication rates, and mortality were analyzed. RESULTS The 1-year, 3-year, and 5-year survival rates were 61.3%, 8.9%, and 6.4% in the PTG group, respectively, and 92.3%, 58.5%, and 48.9% in the CTG group, respectively (P < .05). The median survival periods in the PTG, no surgery, laparotomy, and jejunostomy groups were 16.4, 5.5, 4.7, and 5.8 months, respectively. The median survival in the PTG group was significantly longer than that in the other 3 groups (P < .05). The postoperative complication rate and mortality rate were, respectively, 24.3% and 3.0% in the PTG group and 13.5% and 2.3% in the CTG group (P > .05). CONCLUSIONS PTG for stage IV proximal gastric cancer when compared with no surgery, laparotomy, and jejunostomy is associated with prolonged survival time and improved quality of life. However, despite the feasibility and safety of PTG, patients with stage IV proximal gastric cancer who are suitable for this treatment should be selected, and thoughtful preparation should be made in the perioperative period.

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 characteristics, 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.

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 312 patients with upper- or middle-third gastric cancer who underwent laparoscopic total gastrectomy with spleen-preserving 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/m(2)) 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/m(2) was 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 < 23 kg/m(2), 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 ± 9.56 min, 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.

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 = 0.225 for the operative time; 26.8 ± 11.3 min vs 30.6 ± 14.8 mL, P = 0.157 for the intraoperative blood loss; 4/18 vs 3/38, 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 ± 5.6 min, 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 out-of-bed activities; 3.2 ± 0.9 d vs 3.5 ± 1.3 d, P = 0.295 for 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 Mod-Groups (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.

Antitumor and antimetastasis effects of carboplatin liposomes with polyethylene glycol-2000 on SGC-7901 gastric cell-bearing nude mice

The present study aimed to analyze the characteristics of polyethylene glycol (PEG)ylated carboplatin liposomes (PL-CBPs), including size, stability, their release, entrapping and loading efficiencies, and their antitumor and antimetastatic effects on the lymph nodes. The PL-CBPs were prepared using PEG-2000 with the thin film hydration method. The liposome size and release, entrapping and loading efficiencies were detected by ultra-violet/visible spectrophotometry. A nude mouse model was established with the SGC-7901 gastric cell line to evaluate the antitumor effect of the PL-CBP. After 7 days, the mice were randomly divided into three groups (the control, CBP, and PL-CBP groups). CBP and PL-CBP were administered at a dose of 10 mg/kg for two consecutive cycles of treatment, 5 days apart, to their respective groups. In each group, two doses of 5 mg/kg were administered every 48 h. The tumor weight and volume were detected, and the food intake and body weight were measured during the administration. Apoptosis in the tumor cells was evaluated by terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling and platinum (Pt) accumulation was detected by atomic absorption spectroscopy. Lastly, lymph node metastasis was evaluated by hematoxylin and eosin staining. The PL-CBPs were more stable when comapred with CBP alone, and the drug release efficiency was 0.7, 22.5, 48.7 and 65.1% at 37°C for 0, 12, 24 and 48 h. The results showed that the encapsulation efficiency was 85% and the loading efficiency was 0.15 mg/mg lipid. After 35 days, PL-CBP induced potent antitumor effects compared with the control and CBP groups (PL-CBP vs. control, P<0.01; PL-CBP vs. CBP, P<0.05). PL-CBP and CBP induced a lower and the lowest body weight and level of food intake, respectively, compared with the control group (CBP vs. control, P<0.05). The apoptosis rate and lymph node metastasis in the PL-CBP group was higher than that in the CBP and control groups (PL-CBP vs. control, P<0.01; PL-CBP vs. CBP, P<0.05). Pt accumulation in the tumors was higher in the PL-CBP group than in the CBP group (PL-CBP vs. CBP, P<0.05). The PL-CBPs were more stable in the circulation and could be released more slowly at the tumor site than compared with CBP injection. The PL-CBPs showed potent antitumor and antimetastatic effects on the lymph nodes.

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 (SpA) 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 arterys 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%) SpA. 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 seven patients (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 mL; 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 SpA may be optimal patients for training new surgeons.

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 mL/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 ≥32 harvested LNs, ≥3 metastatic LNs, or No. 8 or No. 9 LN metastasis. SVCA, which was successfully treated with conservative management, was associated with a prolonged hospital stay but was not associated with the prognosis.

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 cyclin-dependent 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.