Ho k Seo

The Impact of an Increased Application of Critical Pathway for Gastrectomy on the Length of Stay and Cost

Purpose We developed a standardized critical pathway for gastric cancer surgery and then determined the increase of application, which resulted in an improvement in terms of measurable indices, such as hospital stay and cost. Materials and Methods A critical pathway was revised and used widely from the 2nd quarter of 2009. We collected clinical data, such as length of stay and complication rate, as clinical indices of quality prospectively. The total cost paid at the patients discharge, as well as the daily hospital income, were calculated and compared by each quarter from January 2008 to December 2009. Results The application rate of critical pathway was 11.8% and 87.8% in 2008 and 2009, respectively. There were no perioperative deaths. There was no difference in the complication rates between 2008 and 2009 (P=0.45). However, the mean length of stay was significantly different between the 2 years (P<0.05). Although the total cost was not different, the daily hospital income was significantly higher in the latter year (P<0.05). Conclusions An increase in the application of critical pathway for gastrectomy resulted in significant decreases in length of stay and increases in the daily hospital income without a compromise on the clinical indices.

Comparison of the Differences in Survival Rates between the 7th and 8th Editions of the AJCC TNM Staging System for Gastric Adenocarcinoma: a Single-Institution Study of 5,507 Patients in Korea

Purpose The aims of this study were to compare the 7th and 8th editions of the American Joint Committee on Cancer (AJCC) staging manuals on tumor, node, and metastasis (TNM) staging systems and to evaluate whether the 8th edition represents a better refinement of the 7th staging system, when applied for the classification of gastric cancers. Materials and Methods A total of 5,507 gastric cancer patients, who underwent treatment from January 1989 to December 2013 at a single institute, were included. We compared patient survival rates across the disease groups classified according to the 7th and 8th editions of the AJCC TNM staging systems. Results Stage migration was observed in 6.4% (n=355) of the patients. Of these, 3.5% (n=192) and 2.9% (n=158) of patients showed a higher stage and lower stage, respectively. According to the 8th edition of the AJCC TNM staging criteria, the 5-year overall survival rates of the patients with stage IIIB and IIIC showed a significant difference (40.8% vs. 20.2%, P<0.001) whereas no significant differences in the 5-year overall survival rates were observed according to the 7th edition criteria (37.6% vs. 33.2%, P=0.381). Conclusions Restaging stage III cancers according to the 8th edition of the AJCC TNM classification criteria improved survival rate discrimination, particularly, in institutes where the stage III patients were not distinctly categorized.

Venous Thromboembolism Incidence and Prophylaxis Use After Gastrectomy Among Korean Patients With Gastric Adenocarcinoma: The PROTECTOR Randomized Clinical Trial

Importance The guidelines by the National Comprehensive Cancer Network and the American Society for Clinical Oncology recommend the routine use of thromboprophylaxis for patients with gastric adenocarcinoma. However, many physicians in Asian countries use venous thromboembolism (VTE) prophylaxis much less often because of the perceived lower VTE incidence in this population. Objectives To evaluate the incidence of postgastrectomy VTE in Korean patients with gastric adenocarcinoma, and to identify the complications and evaluate the efficacy and safety of VTE prevention methods. Design, Setting, and Participants The Optimal Prophylactic Method for Venous Thromboembolism After Gastrectomy in Korean Patients (PROTECTOR) randomized clinical trial was conducted between August 1, 2011, and March 31, 2015. Patients with histologically confirmed gastric adenocarcinoma presenting to a single center (Seoul St Mary’s Hospital in Seoul, South Korea) were enrolled. Patients were randomized to either an intermittent pneumatic compression (IPC)–only group or an IPC+low-molecular-weight (LMW) heparin sodium group. The data were analyzed on intention-to-treat and per protocol bases. Data analysis was performed from April 1, 2016, to October 30, 2017. Main Outcomes and Measures Venous thromboembolism incidence was the primary outcome. Postoperative complications, particularly those associated with VTE prophylaxis methods, were the secondary end point. Results Of the 682 patients enrolled and randomized, 447 (65.5%) were male and 245 (34.5%) were female, with a mean (SD) age of 57.67 (12.94) years. Among the 666 patients included in the analysis, the overall incidence of VTE was 2.1%. The incidence of VTE was statistically significantly higher in the IPC-only group compared with the IPC+LMW heparin group (3.6%; 95% CI, 2.05%-6.14% vs 0.6%; 95% CI, 0.17%-2.18%; P = .008). Among the 14 patients (2.1%) with VTE, 13 were asymptomatic and received a deep vein thrombosis diagnosis, whereas 1 patient received a symptomatic pulmonary thromboembolism diagnosis. The overall incidence of bleeding complications was 5.1%. The incidence of bleeding complications was significantly higher in the IPC+LMW heparin group compared with the IPC-only group (9.1% vs 1.2%; P < .001). No cases of VTE–associated mortality were noted. Conclusions and Relevance Use of IPC alone is inferior to the use of IPC+LMW heparin in preventing postoperative VTE. Because LMW heparin is associated with a high bleeding risk, further study is needed to stratify the patients at high risk for perioperative development of VTE. Trial Registration ClinicalTrials.gov Identifier: NCT01448746

A one-day surgical-skill training course for medical students’ improved surgical skills and increased interest in surgery as a career

BackgroundDespite many high-quality programs in basic surgical-skill education, the surgical skill of junior doctors varies widely. This, together with the waning interest in surgery as a career among medical students, is a serious issue confronted by hospitals and healthcare systems worldwide. We, therefore, developed and implemented an intensive one-day surgical-skill training course for two purposes; it would improve surgical skills and increase interest in surgery among medical students.MethodsThe surgical-skill training program is named Surgical Skill Weekend (SSW) and it includes hands-on training sessions for surgical-suturing techniques and advanced surgical procedures (i.e. laparoscopic and robot-assisted surgery), hybrid simulation sessions, and an operating-room session where aforementioned sessions are all put together. By the end of the program, students’ improvements in surgical-suturing skills were assessed by experts in a form of checklist, and changes in the interest in a surgical career, if there were any, were answered by the students who participated in the program.ResultsA total of ninety-one (91) medical students participated in the 2015 and 2016 SSW courses. Their overall satisfaction level with the course was very high (Very satisfied: 78%, Quite satisfied: 22%). All of the participant’s surgical-suturing skills significantly improved (median score range: 14–20, P < 0.05) and their interest in a surgical career increased significantly (from 56% to 81%, P < 0.05) by completing the program.ConclusionsAn intensive and comprehensive surgical-skill training program for medical students can not only improve surgical-suturing skills but also increase interest in surgery as a career.

Radical Gastrectomy After Chemotherapy May Prolong Survival in Stage IV Gastric Cancer: A Korean Multi-institutional Analysis

AbastractBackground Despite the development of newer treatments, the prognosis for patients with stage IV gastric cancer remains grave. This study evaluated the efficacy of gastrectomy following response to chemotherapy in patients with stage IV gastric cancer.MethodsA total of 419 patients who were diagnosed with stage IV gastric cancer were identified from the multi-institutional Catholic Gastric Cancer Study Group database. The patients were divided into four groups: 212 were in the chemotherapy only (CTx) group, 124 were in the chemotherapy after palliative gastrectomy (G-CTx) group, 23 were in the radical gastrectomy after chemotherapy (CTx-G) group, and 60 were in the best supportive care group. To compensate for the effects of chemotherapy, cases of chemotherapy responsive were analyzed separately. To identify factors affecting survival rates, cure rates for surgery in the surgery group were analyzed.ResultsThe 3-year survival rate of the CTx-G group was significantly higher than that of the CTx group (42.8 vs. 12.0%, p = 0.001). Moreover, the CTx-G group’s 3-year survival rate was greater than that of the G-CTx group (42.8 vs. 37.1%, p = 0.207). Chemotherapy-responsive patients in the CTx-G group had a better 3-year survival rate than those in the G-CTx group (46.1 vs. 18.4%, respectively, p = 0.011). In the surgery group, R0 resection led to a significantly better 3-year survival rate than palliative gastrectomy (61.1 vs. 16.2%, p = 0.003).ConclusionsAdjuvant surgery might improve the survival rate of patients with stage IV gastric cancer, particularly in R0 resection cases.

IgG4-related Disease in the Stomach which Was Confused with Gastrointestinal Stromal Tumor (GIST): Two Case Reports and Review of the Literature

Immunoglobulin G4-related disease (IgG4-RD) is an immune-mediated fibro-inflammatory disorder characterized by specific pathological findings and elevated serum IgG4 level. IgG4-RD in the stomach is rare, and occasionally diagnosed as gastric subepithelial tumor (SET) by endoscopy or computed tomography scan. Two female patients in the age group of 40–50 years were diagnosed with 4 cm sized gastric SET. One underwent laparoscopic gastric wedge resection. Another one had a history of subtotal gastrectomy for early gastric cancer and idiopathic thrombocytopenic purpura with oral steroids administration. She underwent a completion total gastrectomy with splenectomy for the gastric SET and ITP. The pathology showed storiform fibrosis, and IgG4 was positive in immunohistochemistry (IHC) stain. IgG4-RD is known as a medical disease that could be treated with oral steroids. The difficulty in preoperative diagnosis of the disease occasionally causes unnecessary gastric resection. Thus, preoperative diagnostic methods for IgG4-RD such as deep biopsy with IHC stain or magnetic resonance imaging are needed.

Borrmann Type 1 Cancer is Associated with a High Recurrence Rate in Locally Advanced Gastric Cancer

BackgroundThis study aimed to investigate the clinicopathologic characteristics and outcomes of Borrmann type 1 gastric cancer and evaluate its clinical significance in advanced gastric cancer compared with Borrmann types 2 and 3 cancer.MethodsBetween January 1989 and December 2013, 1949 patients with advanced gastric cancer who underwent curative gastrectomy at our institution were enrolled in the study.ResultsOf the 1949 patients, 59 (3%) exhibited Borrmann type 1 cancer, characterized by a large size, rare serosal invasion, lower lymph node involvement, location in the upper third of the stomach, intestinal type, and differentiated histology. The recurrence rate was higher for Borrmann type 1 than for Borrmann types 2 and 3 cancer. In addition, more than half of the Borrmann type 1 recurrences showed a hematogenous pattern. However, overall survival did not differ significantly among the three cancer types. In the multivariate analysis, Borrmann type 1 cancer, with tumor depth, node metastasis, and vascular invasion, was an independent risk factor associated with recurrence. Particularly, Borrmann type 1 cancer showed a worse prognosis in both overall survival and recurrence-free survival than the other Borrmann types in the upper third of the stomach.ConclusionsBorrmann type 1 gastric cancer is associated with a higher recurrence rate than Borrmann types 2 and 3, but not with a difference in the overall survival rate.

Necessity of D2 lymph node dissection in older patients ≥ 80 years with gastric cancer

OBJECTIVES This study analyzed the effect of D2 lymph node (LN) dissection on complications and survival in older patients with gastric cancer. MATERIALS AND METHODS A total of 103 octogenarian patients who underwent curative gastrectomy for gastric cancer were divided into two groups (D2 and D1) according to the extent of LN dissection and analyzed retrospectively for complications and survival. RESULTS No differences were observed in short-term postoperative outcomes, including complication rates, between the two groups. In a survival analysis, D2 LN dissection did not improve overall survival (OS) in any patient, including advanced cases. A Cox regression analysis revealed that the independent risk factors for OS were history of coronary artery disease (hazard ratio [HR], 11.095), postoperative short-term complications (HR, 9.939), and TNM stage (HR, 6.299). The extent of LN dissection was not an independent risk factor for OS, and D2 or more LN dissection (odds ratio, 10.89) increased the risk independently. CONCLUSIONS D2 or more LN dissection did not improve survival, but rather increased the risk of complications. Thus, LN dissection should be performed sparingly in octogenarian patients with gastric cancer.