Yuji Shishido

Prognostic Significance of Pre- and Postoperative Lymphocyte Counts in Patients with Gastric Cancer

Background: Although preoperative lymphopenia is reportedly a prognostic factor in cancer patients, the association between postoperative lymphopenia and patient prognosis has not been widely studied. Methods: We enrolled 352 patients who underwent surgery for gastric cancer (GC) between January 2005 and April 2013 to analyze correlations among pre- and postoperative lymphocyte counts (LCs) and prognosis in GC patients. Results: Pre- and postoperative (obtained 1 day after surgery) LCs were significantly correlated (r = 0.496, p < 0.0001). Pre- and postoperative LCs of elderly patients were significantly lower than those of non-elderly patients. Postoperative lymphocyte count was significantly lower in patients with a differentiated tumor than in those with an undifferentiated tumor. Based on the results of receiver operating characteristic analysis, patients were classified into subgroups as: preoperative LC ≥1,676 (pre-LCHigh), preoperative LC <1,676 (pre-LCLow); and as postoperative LC ≥855 (post-LCHigh), and postoperative LC <855 (post-LCLow). Five-year overall survival rates significantly differed between pre-LCHigh (82.5%) and pre-LCLow (71.6%) groups (p = 0.023); and also between the post-LCHigh (81.5%) and post-LCLow (69.5%) groups (p = 0.0072). The 5-year disease specific survival rates were 91.3 and 82.4% in patients with post-LCHigh and those with post-LCLow, respectively, and differences were statistically significant (p = 0.015). Multivariate analysis indicated that postoperative lymphocyte count was an independent prognostic indicator, along with age, gender, tumor size, lymph node metastasis, and venous invasion. Conclusions: Postoperative lymphocyte count is a useful predictive factor for prognosis in GC patients.

Prognostic Significance of the Preoperative Ratio of C-Reactive Protein to Albumin and Neutrophil–Lymphocyte Ratio in Gastric Cancer Patients

BackgroundThe ratio of C-reactive protein to albumin (CRP/Alb) is a biochemical marker of systemic inflammatory response and has been associated with poor survival in cancer. This study retrospectively investigated the relationship between the CRP/Alb ratio and prognosis in gastric cancer patients.MethodsThis study enrolled 453 patients with a histopathological diagnosis of gastric adenocarcinoma who underwent curative surgery.ResultsA statistically significant weak correlation was observed between CRP/Alb ratio and neutrophil/lymphocyte ratio (NLR) (rxa0=xa00.19; Pxa0<xa00.0001). There were statistically significant correlations between high CRP/Alb ratio and age (Pxa0=xa00.0004), tumor size (Pxa0=xa00.02), depth of invasion (Pxa0=xa00.012), and lymph node metastasis (Pxa0=xa00.022). A high NLR was significantly correlated with age (Pxa0=xa00.0027), tumor size (Pxa0=xa00.0006), depth of invasion (Pxa0<xa00.0001), lymphatic involvement (Pxa0=xa00.0031), venous involvement (Pxa0=xa00.0022), and stage of disease (Pxa0=xa00.0024). Based on results by receiver operating characteristic analysis, patients were divided as follows: CRP/Alb ratioxa0≥xa00.0232 (CARHigh), CRP/Alb ratioxa0<xa00.0232 (CARLow), NLRxa0≥xa02.43 (NLRHigh), and NLRxa0<xa02.43 (NLRLow). Five-year survival rates of patients with both CARHigh and NLRHigh, either CARHigh or NLRHigh, and both CARLow and NLRLow were 59.6, 75.8, and 87.5%, respectively, with statistically significant differences (Pxa0<xa00.0001). Multivariate analysis revealed that the combination of CRP/Alb ratio and NLR was an independent prognostic indicator.ConclusionsThe combination of CRP/Alb ratio and NLR may be useful in predicting prognosis in gastric cancer patients.

Risk and incidence of perioperative deep vein thrombosis in patients undergoing gastric cancer surgery

Background and purposeVenous thromboembolism (VTE) is a potentially fatal perioperative complication. Understanding the risk factors for deep vein thrombosis (DVT) and initiating appropriate prophylaxis is pivotal for reducing the risk of VTE. The purpose of this study was to clarify the perioperative risk factors for DVT in patients undergoing surgery for gastric cancer.MethodsWe reviewed the findings of lower limb ultrasonography performed in 160 patients who underwent gastrectomy for gastric cancer.ResultsThe preoperative and postoperative incidence of DVT was 4.4% (7/160) and 7.2% (11/153), respectively. All postoperative DVTs were of the distal type, whereas preoperative DVTs were of the proximal (nu2009=u20093) and distal type (nu2009=u20094). None of the patients suffered symptomatic VTE. Multivariate analysis indicated that depth of invasion and D-dimer concentration were independent risk factors for preoperative DVT and that gender and performance status were risk factors for postoperative DVT. Receiver operating characteristic analysis revealed that the optimal cut-off D-dimer concentration was 1.4xa0μg/mL.ConclusionsThe incidence of perioperative DVT was low for patients undergoing gastric cancer surgery. Therefore, the risk-stratified application of perioperative pharmacologic thromboprophylaxis is thought to be more appropriate than routine pharmacologic thromboprophylaxis for Japanese patients undergoing surgery for gastric cancer.

Clinical Outcomes of Gastric Cancer Patients Who Underwent Proximal or Total Gastrectomy: A Propensity Score-Matched Analysis

BackgroundTotal gastrectomy (TG) and proximal gastrectomy (PG) are used to treat upper-third early gastric cancer. To date, no consensus has been reached regarding which procedure should be selected. The aim of this study was to validate the usefulness of preserving the stomach in early upper-third gastric cancer.MethodsBetween 2004 and 2013, 201 patients underwent PG or TG at our institution for treatment of upper-third early gastric cancer. According to the defined inclusion and exclusion criteria, 192 cases were enrolled in this study. One-to-one propensity score matching was performed to compare the outcomes between the two groups.ResultsThe operation time was shorter in the PG group. Although no significant difference was observed, the PG group had less bleeding and fewer postoperative complications. R0 resection rate was 100%, and no surgery-related deaths were observed. The frequencies of reflux symptoms and anastomotic stenosis were significantly higher in the PG group, but could be controlled by balloon dilation and drug therapy. The maintenance rates of body mass index and lean body mass were significantly higher in patients who underwent PG than TG. The total protein and serum albumin values were higher in the PG group than in the TG group and remained statistically superior.ConclusionPG group exhibited better perioperative performance. Furthermore, better nutritional results were obtained in the PG group. Although the late stenosis and reflux symptoms must be addressed, the PG is a preferable surgical procedure for the treatment of early proximal gastric cancer.

Prognostic Significance of Platelet-Based Inflammatory Indicators in Patients with Gastric Cancer

BackgroundThrombocytosis develops in association with malignant tumors and may reflect the inflammation status in cancer patients. This study retrospectively investigated the prognostic significance of two platelet-based inflammatory indicators, the plateletxa0×xa0C-reactive protein multiplier value (P-CRP), and platelet-lymphocyte ratio (PLR), in gastric cancer patients.MethodsThe 453 enrolled patients had a histopathological diagnosis of gastric adenocarcinoma and underwent curative surgery.ResultsP-CRP correlated significantly with age, tumor size, depth of invasion, lymph node metastasis, and disease stage. A high PLR correlated significantly with tumor size, depth of invasion, lymph node metastasis, lymphatic involvement, venous involvement, and disease stage. In the ROC analysis, the optimal cutoff value of P-CRP and PLR was 3.689 and 173.3, respectively. Five-year survival rates were 62.9 and 82.1% in patients with P-CRPHigh (≥3.689) and P-CRPLow (<3.698), respectively (Pxa0<xa00.0001). Five-year survival rates were 66.3 and 81.3% in patients with PLRHigh (≥173.3) and PLRLow (<173.3), respectively (Pxa0=xa00.0022). The prognosis of the P-CRPHigh/PLRHigh group was significantly worse than that of the P-CRPHigh or PLRHigh and P-CRPLow/PLRLow groups in terms of overall survival (Pxa0<xa00.0001) and disease-specific survival (Pxa0=xa00.029). In a multivariate analysis, the combination of P-CRP and PLR was an independent prognostic indicator.ConclusionsThe combination of P-CRP and PLR may be useful in predicting prognosis in gastric cancer patients.

A novel liver retraction method in laparoscopic gastrectomy for gastric cancer

BackgroundRetracting the lateral liver segment during laparoscopic distal gastrectomy is important for achieving an optimal surgical field. However, excessive force may injure the liver, causing temporary abnormalities of liver function tests after laparoscopic surgery. We developed a new liver retraction method and assessed its safety and utility.Patients and methodsWe retrospectively analyzed records in our surgical database of consecutive surgical patients who underwent laparoscopic distal gastrectomy for early gastric cancer. We divided the 229 patients into two groups based on the liver retraction method used, either flexible liver retraction with clipping and suturing (FLICS) or the Nathanson retractor (NR). One-to-one propensity score matching was performed to match patients, resulting in the records of 53 pairs of cases extracted from the database. Operative and postoperative outcomes were assessed, including following the values of serum liver enzymes, total bilirubin, and C-reactive protein until postoperative day 30.ResultsThere were no significant differences in patient characteristics or preoperative data in the two groups. The retraction method was not changed intraoperatively for any patients. The operative time was significantly shorter in the FLICS group, but the amount of bleeding did not differ. Liver injury was not observed as a result of liver retraction during surgery. In both groups, serum liver enzymes temporarily increased after surgery but improved rapidly thereafter. The postoperative increases in aspartate transaminase, alanine transaminase, and C-reactive protein levels were significantly lower in the FLICS than in the NR group. No serious complications associated with liver retraction were observed in either group.ConclusionsOur new liver retraction technique provided an optimal surgical field without inducing liver dysfunction. It is a simple, safe, and effective liver retraction technique.

Successful repair using thymus pedicle flap for tracheoesophageal fistula: a case report

BackgroundTreatment for tracheoesophageal fistula (TEF), a life-threatening complication after esophagectomy, is challenging.Case presentationA 75-year-old man with thoracic esophageal cancer underwent subtotal esophagectomy and gastric tube reconstruction through the post-mediastinal root after neoadjuvant chemotherapy. Owing to postoperative anastomotic leakage, an abscess formed at the anastomotic region. Sustained inflammation from the abscess caused refractory TEF between the esophagogastric anastomotic site and membrane of the trachea, and several conservative therapies for TEF failed. Hence, the patient underwent surgery including division of the fistula, direct suturing of the leakage sites, and reinforcement with the flap of the thymus pedicle. As a result, the abscess and TEF disappeared after surgery and the patient was immediately administered an oral diet and discharged home 103xa0days after initial surgery.ConclusionsAlthough pedicle flaps for the reinforcement of TEF are usually obtained from muscle or pericardium, these flaps need enough lengths to overcome moving distance. We are the first in the existing literature to have successfully treated TEF with surgical repair using a thymus flap located close to TEF. The thymus pedicle might be another candidate for the reinforcement flap in TEF.

Combined analysis of the preoperative and postoperative prognostic nutritional index offers a precise predictor of the prognosis of patients with gastric cancer

PurposeThe prognostic nutritional index (PNI) is considered useful for predicting the prognosis of patients with gastric cancer (GC). This retrospective study investigated the relationship between both the pre- and postoperative PNI and the prognosis of GC patients.MethodsThe subjects of this study were 254 patients who underwent curative surgery for histopathologically diagnosed GC.ResultsPatients were divided according to their pre- and postoperative PNI as follows: preoperative PNI of ≥xa052 (pre-PNIHigh), preoperative PNI of <xa052 (pre-PNILow), postoperative PNI of ≥xa049 (post-PNIHigh), and postoperative PNI of <xa049 (pre-PNILow). Both pre- and postoperative PNI were significantly associated with GC prognosis. Patients were then divided as follows: group A, patients with pre-PNIHigh and post-PNIHigh; group B, patients with either pre-PNIHigh and post-PNILow or pre-PNILow and post-PNIHigh; and group C, patients with pre-PNILow and post-PNILow. The 5-year survival rates were 100.0, 83.0, and 67.1% for groups A, B, and C, respectively. Multivariate analysis indicated that the combination of pre- and postoperative PNI was an independent prognostic indicator.ConclusionsCombined analysis of the pre- and postoperative PNI offers accurate information about the prognosis of patients with GC.

Postoperative ratio of the maximum C-reactive protein level to the minimum peripheral lymphocyte count as a prognostic indicator for gastric cancer patients

PurposeInflammation, together with immune and nutritional status, are associated with the progression of various cancer types. We evaluated the prognostic significance of the postoperative ratio (post-CLR) of the maximum C-reactive protein value (post-CRPMax) to the minimum peripheral lymphocyte count (post-LCMin) in patients with gastric cancer (GC).MethodsThe subjects of this retrospective study were 227 patients who underwent curative surgery for histopathologically diagnosed gastric adenocarcinoma.ResultsThe 5-year overall survival (OS) rates differed significantly between the post-CLRHigh (≥u2009152.6) group and the post-CLRLow (<u2009152.6) group for all patients (45.0% vs. 68.4%, respectively; Pu2009<u20090.001). The 5-year disease-specific survival (DSS) rates were also significantly related to post-CLR for all patients, (80.6% vs. 64.3% for the post-CLRLow and the post-CLRHigh groups, respectively; Pu2009=u20090.002). Among patients without infectious complications, the CLR affected both the 5-year OS rate (48.4% vs. 69.2% for the post-CLRHigh and the post-CLRLow groups, respectively; Pu2009=u20090.006) and the 5-year DSS rate (80.2% vs. 67.0% for the post-CLRLow and the post-CLRHigh groups, respectively; Pu2009=u20090.027). Multivariate analysis revealed that post-CLR was an independent prognostic indicator for both the OS and DSS of all patients.ConclusionsOur finding show that the post-CLR can help predict the prognosis of GC patients.

Successful resection after neoadjuvant chemotherapy for esophageal cancer with posterior thoracic paraaortic lymph node metastasis: a case report and literature review

Metastasis to the posterior thoracic paraaortic lymph nodes rarely occurs in esophageal cancer, and a treatment strategy has not been established. We treated two cases of esophageal cancer with this type of metastasis; in both cases, we successfully performed surgical resection after neoadjuvant chemotherapy. In case 1, the patient received neoadjuvant chemotherapy, which consisted of docetaxel, cisplatin and 5-fluorouracil, and then underwent dissection of the posterior thoracic paraaortic lymph nodes. The left thoracic approach was used together with subtotal esophagectomy via a right thoracotomy. In case 2, the patient also received neoadjuvant chemotherapy and underwent dissection of the posterior thoracic paraaortic lymph nodes. The left thoracoscopic approach was used together with a subtotal esophagectomy and a right upper and middle pulmonary lobectomy (due to lung cancer) with a right thoracotomy. After 42 and 12xa0months’ post-surgery, respectively, the patients were doing well without any evidence of recurrence.