Reconstruction after Laparoscopic Distal Gastrectomy

Laparoscopy-assisted distal gastrectomy (LADG) has advanced much in the past 10 years in the eastern countries, due to the high gastric cancer incidences. Reconstruction is the major hurdle for perfect laparoscopic distal gastrectomy (LDG). Initially, hand-associated or small incisional open laparotomy reconstruction, the so-called associated operation, was performed. A full laparoscopic operation is much better for the patient—small wound, less pain, and quick recovery. Several reconstruction methods have been developed by experts during more than 10 years. The question of what method is the best after distal gastrectomy is still controversial. This chapter focuses on the reconstruction methods in the total laparoscopy distal gastrectomy (LDG) operation, explains the merits and demerits of several methods, and introduces our original method, named augmented rectangle technique (ART)

Current status of technique for Billroth-I anastomosis in totally laparoscopic distal gastrectomy for gastric cancer

Several reconstruction techniques are possible after totally laparoscopic distal radical gastrectomy. An optimal technique of digestive tract reconstruction after distal gastrectomy has not yet been established. The ideal reconstruction should be not only for doctors but also for patients. Alimentary intake, satisfactory nutritional status and easy performing should be all considered. The aim of the study was to describe the different Billroth-I reconstruction techniques that can be proposed after totally laparoscopic distal radical gastrectomy

Impact of Sex-Specific Preoperative Fat Mass Assessment on Long-Term Prognosis after Gastrectomy for Gastric Cancer

We investigated the impact of the difference in fat distribution between men and women on long-term prognosis after gastrectomy in patients with advanced gastric cancer. Patients with advanced gastric cancer deeper than p-T2 who underwent gastrectomy between April 2008 and June 2018 were included. Visceral fat mass index (VFI) and subcutaneous fat mass index (SFI) were calculated by dividing the cross-sectional area at the umbilical level by the height squared. The medians of VFI and SFI by sex were defined as cut-off values, below which values were defined as low VFI and low SFI. Of the 485 patients, 323 (66.6%) were men and 162 (33.4%) were women. Men with a low VFI had a significantly worse overall survival (OS) (p = 0.004) and women with a low SFI had a significantly worse OS (p = 0.007). Patients with a low VFI and low SFI had the worst prognosis. Multivariate analysis showed that a low VFI was an independent poor prognostic factor in men, while a low SFI was an independent poor prognostic factor in women. In conclusion, a low visceral fat mass in men and a low subcutaneous fat mass in women were independent poor prognostic factors after radical gastrectomy for advanced gastric cancer

Association of GLIM Defined Malnutrition According to Preoperative Chronic Inflammation with Long-Term Prognosis after Gastrectomy in Patients with Advanced Gastric Cancer

This study aimed to investigate the association of malnutrition, defined by the Global Leadership Initiative on Malnutrition (GLIM) according to preoperative chronic inflammation with long-term prognosis after gastrectomy in patients with advanced gastric cancer. We included patients with primary stage I-III gastric cancer who underwent gastrectomy between April 2008 and June 2018. Patients were categorized as normal, moderate malnutrition, and severe malnutrition. Preoperative chronic inflammation was defined as a C-reactive protein level of >0.5 mg/dL. The primary endpoint was overall survival (OS), compared between the inflammation and non-inflammation groups. Among the 457 patients, 74 (16.2%) and 383 (83.8%) were included in the inflammation and non-inflammation groups, respectively. The prevalence of malnutrition was similar in both groups (p = 0.208). Multivariate analyses for OS showed that moderate malnutrition (hazard ratios: 1.749, 95% concordance interval: 1.037–2.949, p = 0.036) and severe malnutrition (hazard ratios: 1.971, 95% CI: 1.130–3.439, p = 0.017) were poor prognostic factors in the non-inflammation group, but malnutrition was not a prognostic factor in the inflammation group. In conclusion, preoperative malnutrition was a poor prognostic factor in patients without inflammation, but it was not a prognostic factor in patients with inflammation

Preoperative Chronic Inflammation Is a Risk Factor for Postoperative Complications Independent of Body Composition in Gastric Cancer Patients Undergoing Radical Gastrectomy

The purpose of this study was to investigate the association between preoperative inflammation and postoperative complications in gastric cancer patients having elective gastrectomy. Participants in this study were those who underwent radical gastrectomy between April 2008 and June 2018 and were diagnosed with stage I–III primary gastric cancer. Preoperative CRP values were used to divide the patients into two groups: the inflammation group comprised individuals having a CRP level of ≥0.5 mg/dL; the other was the non-inflammation group. The primary outcome was overall complications of Clavien–Dindo grade II or higher after surgery. Using propensity score matching to adjust for background, we compared the postoperative outcomes of the groups and conducted a multivariate analysis to identify risk variables for complications. Of 951 patients, 852 (89.6%) were in the non-inflammation group and 99 (10.4%) were in the inflammation group. After matching, both groups included 99 patients, and no significant differences in patient characteristics were observed between both groups. The inflammation group had a significantly greater total number of postoperative complications (p = 0.019). The multivariate analysis revealed that a preoperative CRP level of ≥0.5 mg/dL was an independent risk factor for total postoperative complications in all patients (odds ratio: 2.310, 95% confidence interval: 1.430–3.730, p < 0.001). In conclusion, in patients undergoing curative resection for gastric cancer, preoperative inflammation has been found to be an independent risk factor for overall complications after surgery. Patients with chronic inflammation require preoperative treatment to reduce inflammation because chronic inflammation is the greatest risk factor for postoperative complications

Impact of Perioperative Immunonutrition on Postoperative Outcomes in Patients with Upper Gastrointestinal Cancer: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

There is no consensus on the efficacy of perioperative immunonutrition in patients with upper gastrointestinal (GI) cancer surgery. We clarified the impact of perioperative immunonutrition on postoperative outcomes in patients with upper GI cancers. We searched MEDLINE (PubMed), MEDLINE (OVID), EMBASE, Cochrane Central Register of Controlled Trials, Web of Science Core Selection, and Emcare from 1981–2022 using search terms related to immunonutrition and upper GI cancer. We included randomized controlled trials. Intervention was defined as immunonutritional therapy, including arginine, n-3 omega fatty acids, or glutamine during the perioperative period. The control was defined as standard nutritional therapy. The primary outcomes were infectious complications, defined as events with a Clavien–Dindo classification grade ≥ II that occurred within 30 days after surgery. After screening, 23 studies were included in the qualitative synthesis and in the quantitative synthesis. The meta-analysis showed that immunonutrition reduced infectious complications (relative risk ratio: 0.72; 95% confidence interval: 0.57–0.92; certainty of evidence: Moderate) compared with standard nutritional therapy. In conclusion, nutritional intervention with perioperative immunonutrition in patients with upper GI cancers significantly reduced infectious complications. The effect of immunonutrition for upper GI cancers in reducing the risk of infectious complications was about 30%

Impact of Preoperative Handgrip Strength on Postoperative Outcome after Radical Gastrectomy for Gastric Cancer Patients

In this study, we investigated whether preoperative low-handgrip strength (HGS) defined by the Asian working group for sarcopenia could be a predictor of postoperative outcomes in patients with gastric cancer. A total of 327 patients who underwent radical gastrectomy for c-stage I–III primary gastric cancer with pre-operative HGS records were included. The cut-off values of HGS were defined as 28 kg for males and 18 kg for females, with values below and above the cut-off defined as low-HGS and high-HGS, respectively. The primary outcome was infectious complications. We compared the postoperative outcomes of the groups after adjusting for the background using propensity score matching. Of the 327 patients, 246 (75.2%) and 81 (24.8%) were in the high and low-HGS groups, respectively. After adjusting for background, there were 57 patients in both groups. After matching, the low-HGS group had significantly more infectious complications (17.5% vs. 1.8%, p = 0.008). Multivariate analysis of infectious complications in the low-HGS group demonstrated chronic kidney disease and diabetes as independent risk factors (odds ratio 4.390, 95% confidence interval 1.120–17.20, p = 0.034). Preoperative low-HGS according to the Asian criteria was associated with infectious complications after gastrectomy. Chronic kidney disease and diabetes were independent risk factors for infectious complications among patients with low-HGS