Background:Elderly patients with early gastric cancer (EGC) represent a clinically challenging and growing surgical population. Compared to advanced gastric cancer (AGC), the evidence available for this population is limited. As such, no validated composite risk scoring tool currently exists for postoperative risk stratification in this population. Therefore, this study aimed to identify the negative prognostic factors for long-term survival that may be used for developing a risk scoring tool for elderly EGC patients undergoing curative gastrectomy. Methods:This retrospective single high-volume tertiary center study enrolled patients aged 75 years or older who underwent curative gastrectomy for histopathologically confirmed stage I gastric cancer between January 2007 and December 2016. Univariable and multivariable Cox proportional hazard regression analyses were performed using more than ten variables, including age, sex, Prognostic Nutritional Index (PNI), Charlson Comorbidity Index (CCI), preoperative hemoglobin level, and extent of gastrectomy. The 5-year overall survival (OS), assessed by the Kaplan-Meier method with log-rank testing, was the primary endpoint. A composite risk score was derived by assigning one point per independently significant risk factor. Results:534 patients were enrolled with a mean age of 77.6±2.8 years. 366 patients (68.5%) were male and 450 (84.3%) underwent distal gastrectomy. The age-independent CCI was 3 or higher in 155 patients (29.0%), and preoperative anemia was present in 213 patients (39.9%). Multivariable analysis identified five independent negative prognostic factors: age ≥80 years [hazard ratio (HR) 2.0, 95% confidence interval (CI): 1.3-3.1; P=0.002], male sex (HR 2.1, 95% CI: 1.2-3.7; P=0.009), CCI ≥3 (HR 1.6, 95% CI: 1.1-2.4; P=0.03), preoperative anemia (HR 1.7, 95% CI: 1.1-2.6; P=0.01), and total gastrectomy (HR 2.0, 95% CI: 1.3-3.2; P=0.003). A composite risk score (range, 0-5) stratified patients into low-risk (score 0-1; n=252), intermediate-risk (score 2; n=184), and high-risk (score ≥3; n=98) groups. 5-year OS rates were 91.2%, 82.5%, and 61.2%, respectively (P<0.0001). The 5-year OS for the entire cohort was 82.7%. Conclusions:This composite risk score stratifies postoperative risk in elderly patients with EGC by predicting long-term survival according to each risk category. In selected high-risk elderly patients with EGC, future prospective evaluation of less invasive or function-preserving surgical strategies is warranted.

Postoperative anastomotic luminal obstruction is a rare but clinically significant complication after distal gastrectomy. Endoscopic balloon dilatation (EBD) is a minimally invasive treatment; however, some patients require additional interventions. This study aimed to evaluate the clinical outcomes of EBD for postoperative anastomotic luminal narrowing and to identify predictors associated with treatment failure. We retrospectively reviewed 56 patients who developed anastomotic strictures after distal gastrectomy, and treated with EBD between January 2010 and December 2022 at Asan Medical Center, Seoul, Korea. Clinical data, including patient characteristics, surgical factors, and endoscopic findings, were analyzed. Patients were classified into an EBD-only group and an additional-intervention group (stent insertion or surgery). Univariate and multivariable logistic regression analyses were performed to identify predictors of EBD refractoriness. Of the 56 patients, 45 (80.3

Introduction Total gastrectomy (TG) is associated with comparable survival outcomes but poorer short-term postoperative outcomes than distal gastrectomy (DG) in the general population with gastric cancer. However, evidence regarding these outcomes in the older population with early gastric cancer remains limited. This study compared long-term treatment outcomes after TG and DG, including longitudinal nutritional indicators, in this cohort. Materials and methods Patients aged ≥75 years with pathologically confirmed stage I gastric cancer were included. Among the 534 enrolled patients, 450 underwent DG and 84 underwent TG. Propensity score matching was performed to minimize baseline differences between the two groups. Results After 1:1 matching, 84 patients were included in each treatment group. Surgical outcomes, including hospital days and readmission rates, did not show significant differences. The overall complication rate was higher in the TG group (34.5% vs. 25.0%), although not significantly. 5-year overall survival rates were 79.8% in the DG group and 69.9% in the TG group. Body weights and hemoglobin levels declined more significantly in the TG group over time. Conclusion TG showed a numerically lower 5-year overall survival than DG, and was accompanied by less favorable longitudinal nutritional outcomes, although postoperative complication rates did not differ significantly between the two groups. The oncological benefit of TG may be expected primarily in disease-specific rather than overall survival in this age group, where non-cancer mortality contributes substantially. These observations may suggest that, in older adults with early gastric cancer at relatively low oncological risk, surgical strategies that minimize functional loss without compromising oncological adequacy deserve further investigation. Our findings could indirectly support stomach-preserving approaches in selected older patients with early gastric cancer.

PURPOSE:Esophagojejunal anastomotic leakage (EJAL) represents a severe postoperative complication following total or proximal gastrectomy. Treatment strategies include conservative management, endoscopic interventions, and surgery; however, comparative data remain limited. This study aimed to compare clinical outcomes of different strategies to identify the optimal approach based on anastomotic defect size. MATERIALS AND METHODS:This retrospective study reviewed 100 patients diagnosed with EJAL between January 2015 and October 2024. Patients were categorized into four groups: conservative management, endoscopic vacuum-assisted closure (E-VAC), other endoscopic treatments, and surgery. The primary outcomes were leakage duration and length of hospital stay after EJAL diagnosis, whereas the secondary outcome was time to C-reactive protein normalization. Subgroup analyses were performed according to defect size. RESULTS:Among the 100 patients, 76 were male and 24 were female, with a mean age of 65.7 years. Conservative treatment was the most common modality (53%), followed by other endoscopic treatments (19%), E-VAC (14%), and surgery (14%). In patients with a defect size <1 cm, conservative treatment was associated with significantly shorter leakage duration (P=0.035) and earlier resumption of diet (P=0.029) compared with endoscopic treatment. Among those with defects ≥2 cm, E-VAC demonstrated the most favorable median outcomes across all variables; however, statistical significance was not achieved because of the small sample size. CONCLUSIONS:Conservative treatment appears to be the most effective treatment strategy for EJAL with anastomotic defects <1 cm. For larger defects (≥2 cm), E-VAC may offer clinical benefit, although further studies are needed to confirm its efficacy. These findings highlight the importance of individualized treatment selection based on defect size.

Despite long-term survival reports in early gastric cancer, comparative life expectancy data with the general population is scarce. This study aimed to estimate patients' life expectancy and analyze disparities between early gastric cancer patients and the general population. Patients with stage 1 gastric cancer who underwent curative gastrectomy at Asan Medical Center were enrolled. Survival status was tracked via national health insurance records. Life expectancy was compared with general population data from the Korean Statistical Information Service database. The cohort comprised 8,637 patients (64.7% men, 17.3% aged 70+). Approximately 20% of patients underwent total gastrectomy. Life expectancy was favorable among women. Across all age groups, women's life expectancy generally exceeded 80 years. Male patients showed a reduced life expectancy, typically 4-10 years shorter than their female counterparts. The average life expectancy of male patients aged over 80 years who underwent total gastrectomy was about 5 years, whereas that of their female counterparts was approximately 7 years. Female patients undergoing distal gastrectomy did not demonstrate a statistically significant variance in life expectancy compared to the general population. This study provided comprehensive life expectancy data, organized by age, sex, and type of gastrectomy in a large stage 1 gastric cancer cohort. Our findings are expected to alleviate uncertainties and anxieties for individuals diagnosed with early gastric cancer.

Purpose:Multidisciplinary treatment (MDT) in gastric cancer is an effective approach for establishing treatment plans. However, the appropriateness of using "ratio of MDT" as an item for evaluating the adequacy of gastric cancer treatment in Korea has not been previously researched. The purpose of this study is to verify whether the "ratio of MDT" is appropriate as an item for gastric cancer adequacy evaluation from the surgeon's perspective. Methods:This study involved 142 patients who received MDT at our hospital between December 2015 and January 2023. Patients were divided into 2 groups based on the date when gastric cancer adequacy evaluation was implemented; there were 71 patients before and after the evaluation was conducted, respectively. Based on electronic medical records, the initial plan prepared before the MDT clinic and the final plan prepared after the clinic were compared to determine whether the plan was changed. Results:The average age of patients who received MDT before and after the evaluation was 64.8 and 62.2 years, respectively. Overall, 50 and 21 patients were male (70.4%) and female (29.6%), respectively, in both groups. Before the evaluation, 26 patients (36.6%) who received MDT changed their treatment plans after visiting the clinic, and 15 patients (21.1%) who received MDT after the evaluation had their treatment plans modified. Groups who received MDT and changes in treatment plans were significantly correlated (P = 0.042). Conclusion:Our findings suggest that including the "ratio of MDT" as an item of gastric cancer adequacy evaluation needs reassessment.

Purpose:This study aimed to define an optimal age cutoff for early-onset gastric cancer (EOGC) and compare its characteristics with those of late-onset gastric cancer (LOGC) using nationwide survey data. Methods:Using data from a nationwide survey, this comprehensive population-based study analyzed data spanning 3 years (2009, 2014, and 2019). The joinpoint analysis and interrupted time series (ITS) methodology were employed to identify age cutoffs for EOGC based on the sex ratio and tumor histology. Clinicopathologic characteristics and surgical outcomes were compared between the EOGC and LOGC groups. Results:The age cutoff for defining EOGC was suggested to be 50 years, supported by joinpoint and ITS analyses. Early gastric cancer was predominantly present in the EOGC and LOGC groups. Patients with EOGC comprised 20.3% of the total study cohort and demonstrated a more advanced disease stage compared to patients with LOGC. However, patients with EOGC underwent more minimally invasive surgeries, experienced shorter hospital stays, and had lower postoperative morbidity and mortality rates. Conclusion:This study proposes an age of ≤50 years as a criterion for defining EOGC and highlights its features compared to LOGC. Further research using this criterion should guide tailored treatment strategies and improve outcomes for young patients with gastric cancer.

[This corrects the article on p. 245 in vol. 108, PMID: 40226172.].

BackgroundLimited research has examined the direct effectiveness of Helicobacter pylori eradication (HPE) on the remnant stomach neoplasms after curative gastrectomy. This study aims to assess whether HPE could prevent the development of gastric neoplasms in the remnant stomach after curative gastrectomy through a double-blinded, randomized controlled trial.MethodsAfter curative gastrectomy, patients with HP infection and pathologically proven stage 1 tumors will be enrolled and randomly assigned to eradication (n = 492) and placebo (n = 492) groups. Patients in the eradication arm will be given the eradication regimen, which will comprise 40 mg of esomeprazole, 1 g of amoxicillin, and 500 mg of clarithromycin twice a day for 14 days. The primary endpoint is the development of gastric neoplasms, including adenoma or adenocarcinoma. The secondary endpoints are the 10-year overall survival, improvement rates of gastric glandular atrophy and/or intestinal metaplasia, and incidence of new-onset hyperplastic polyps among the groups.SignificanceThis research will be the first randomized controlled clinical study in which a thorough long-term follow-up will be needed to evaluate the effectiveness of HPE for remnant stomach neoplasms after curative gastrectomy. Its results will serve as a basis for developing future strategies in the management of patients with HP infection who undergo curative gastrectomy.Trial registrationhttps://cris.nih.go.kr/ KCT0008855. October 10, 2023.

Background : To determine how patients who underwent bariatric surgery at a tertiary hospital in Korea first considered and then decided to get the surgery and identify information gaps among patients and healthcare professionals. Methods : This study included 21 patients who underwent bariatric surgery to treat morbid obesity (body mass index [BMI] ≥35 or ≥30 kg/m2 together with obesity-related comorbidities) between August 2020 and February 2022. A telephone interview was conducted with the patients after at least 6 months had elapsed since the surgery. We asked how the patients decided to undergo bariatric surgery. We also inquired about their satisfaction with and concerns about the surgery. Results : Seventy-one percent of the patients were introduced to bariatric surgery following a recommendation from healthcare professionals, acquaintances, or social media. Most of the patients (52%) decided to undergo bariatric surgery based on recommendations from healthcare professionals in non-surgical departments. Satisfaction with the information provided differed among the patients. Post-surgical concerns were related to postoperative symptoms, weight regain, and psychological illness. Conclusion : Efforts are needed to raise awareness about bariatric surgery among healthcare professionals and the public. Tailored pre- and postoperative consultation may improve quality of life after bariatric surgery.

Clinical trials frequently include multiple end points that mature at different times. The initial report, typically based on the primary end point, may be published when key planned co-primary or secondary analyses are not yet available. Clinical Trial Updates provide an opportunity to disseminate additional results from studies, published in JCO or elsewhere, for which the primary end point has already been reported. The phase III PRODIGY study demonstrated that neoadjuvant chemotherapy with docetaxel, oxaliplatin, and S-1 (DOS) followed by surgery and adjuvant S-1 chemotherapy (CSC) improved progression-free survival (PFS) compared with surgery followed by adjuvant S-1 (SC) for patients with resectable locally advanced gastric cancer (LAGC) with clinical T2-3N+ or T4Nany disease. The primary end point was PFS. Overall survival (OS) was the secondary end point. We herein report the long-term follow-up outcomes, including OS, from this trial. A total of 238 and 246 patients were randomly assigned to the CSC and SC arms, respectively, and were treated (full analysis set). As of the data cutoff (September 2022), the median follow-up duration of the surviving patients was 99.5 months. Compared with SC, CSC significantly increased the OS (adjusted hazard ratio [HR], 0.72; stratified log-rank P = .027) with an 8-year OS rate of 63.0% and 55.1% for the CSC and SC arms, respectively. CSC also significantly improved the PFS (HR, 0.70; stratified log-rank P = .016). In conclusion, neoadjuvant DOS chemotherapy, as part of perioperative chemotherapy, prolonged the OS of Asian patients with LAGC relative to patients treated with surgery and adjuvant S-1. It should be considered one of the standard treatment options for patients with LAGC in Asia.

This corrects the article on p. 341 in vol. 24, PMID: 38960892.

D2 lymphadenectomy is the standard approach for lymph node dissection in curable gastric cancer. However, paraaortic lymph node (PALN) dissection in addition to D2 lymphadenectomy has not been shown to improve survival rates and is therefore not routinely performed. Nevertheless, PALN sampling may be indicated for diagnostic purposes because it can provide critical information for accurate staging and treatment planning. Laparoscopic PALN sampling, however, poses significant challenges due to limited accessibility and visibility in the paraaortic region. Moreover, the proximity of major blood vessels, such as the abdominal aorta and renal vein, is another difficult aspect of the procedure. In this context, we present two cases to demonstrate practical strategies for facilitating laparoscopic PALN sampling. The procedure can be effectively performed by first identifying the ligament of Treitz and then, when necessary, fixing the small bowel mesentery to the abdominal wall using a tagging suture so that there is adequate vision and enough working space. This enables careful and precise dissection of the target tissue without compromising the feasibility and safety of the operation.

Purpose: Textbook outcome is a comprehensive measure used to assess surgical quality and is increasingly being recognized as a valuable evaluation tool. Delta-shaped anastomosis (DA), an intracorporeal gastroduodenostomy, is a viable option for minimally invasive distal gastrectomy in patients with gastric cancer. This study aims to evaluate the surgical outcomes and calculate the textbook outcome of DA. Materials and Methods: In this retrospective study, the records of 4,902 patients who underwent minimally invasive distal gastrectomy for DA between 2009 and 2020 were reviewed. The data were categorized into three phases to analyze the trends over time. Surgical outcomes, including the operation time, length of post-operative hospital stay, and complication rates, were assessed, and the textbook outcome was calculated. Results: Among 4,505 patients, the textbook outcome is achieved in 3,736 (82.9%). Post-operative complications affect the textbook outcome the most significantly (91.9%). The highest textbook outcome is achieved in phase 2 (85.0%), which surpasses the rates of in phase 1 (81.7%) and phase 3 (82.3%). The post-operative complication rate within 30 d after surgery is 8.7%, and the rate of major complications exceeding the Clavien-Dindo classification grade 3 is 2.4%. Conclusions: Based on the outcomes of a large dataset, DA can be considered safe and feasible for gastric cancer.

Elderly patients with early gastric cancer exhibit a relatively shorter life expectancy and lower recurrence risk, prompting consideration of whether the regular follow-up strategy should apply to this demographic. This study was designed to determine the effect of routine postoperative follow-up on the elderly patients, specifically those pathologically diagnosed with stage I gastric cancer. This retrospective analysis was conducted at a single tertiary center and enrolled patients aged ≥ 75 years who underwent curative gastrectomy for stage I gastric cancer between January of 2007 and December of 2016. The patients were divided into routine and nonroutine follow-up groups, depending on whether the recommended follow-up examinations (endoscopy, CT, and blood tests) were complete. Propensity score matching was performed to compare the overall survival (OS) and disease-specific survival (DSS) between the two study groups. Among 385 patients enrolled, 301 (78.2

Background We aimed to examine the technical and oncological safety of curative gastrectomy for gastric cancer patients who underwent liver transplantation. Methods In this study, we compared the surgical and oncological outcomes of two groups. The first group consisted of 32 consecutive patients who underwent curative gastrectomy for gastric cancer after liver transplantation (LT), while the other group consisted of 127 patients who underwent conventional gastrectomy (CG). In addition, a subgroup analysis was performed to evaluate the impact of the background differences and the surgical outcomes on the involvement of a specialized liver transplant surgery team. Results The mean operative time was significantly longer in the LT group ( p < 0.05). Furthermore, there were more frequent cases of postoperative transfusion in the LT group compared to the CG group ( p < 0.05). However, there were no significant differences in the overall complications between the groups (25.00 vs 23.62%, p = 0.874). The 5-year overall survival rates of the LT and CG groups were 76.7% and 90.1%, respectively ( p < 0.05). The results of the subgroup analysis demonstrated no statistically significant difference in various early surgical outcomes, such as time to transfusion during surgery, first flatus, time to first soft diet, postoperative complications, hospital stay after surgery, and the number of harvested lymph nodes except for operation time. Conclusions Despite one’s medical history of undergoing LT, our study demonstrated that curative gastrectomy could be a surgically safe treatment for gastric cancer. However, further study should be conducted to identify the reason gastric cancer patients who underwent liver transplant surgery have lower overall survival rate.

PURPOSE:Despite scientific evidence regarding laparoscopic gastrectomy (LG) for advanced gastric cancer treatment, its application in patients receiving neoadjuvant chemotherapy remains uncertain. MATERIALS AND METHODS:We used the 2019 Korean Gastric Cancer Association nationwide survey database to extract data from 489 patients with primary gastric cancer who received neoadjuvant chemotherapy. After propensity score matching analysis, we compared the surgical outcomes of 97 patients who underwent LG and 97 patients who underwent open gastrectomy (OG). We investigated the risk factors for postoperative complications using multivariate analysis. RESULTS:The operative time was significantly shorter in the OG group. Patients in the LG group had significantly less blood loss than those in the OG group. Hospital stay and overall postoperative complications were similar between the two groups. The incidence of Clavien-Dindo grade ≥3 complications in the LG group was comparable with that in the OG group (1.03% vs. 4.12%, P=0.215). No statistically significant difference was observed in the number of harvested lymph nodes between the two groups (38.60 vs. 35.79, P=0.182). Multivariate analysis identified body mass index (odds ratio [OR], 1.824; 95% confidence interval [CI], 1.029-3.234; P=0.040) and extent of resection (OR, 3.154; 95% CI, 1.084-9.174; P=0.035) as independent risk factors for overall postoperative complications. CONCLUSIONS:Using a large nationwide multicenter survey database, we demonstrated that LG and OG had comparable short-term outcomes in patients with gastric cancer who received neoadjuvant chemotherapy.

Gastrointestinal stromal tumours (GISTs) with high-risk features have poor prognosis even if adjuvant treatment is given. Neoadjuvant imatinib may increase the cure rate by shrinking large GISTs and preserve organ function. We conducted an Asian multinational phase II study for patients with gastric GISTs ≥10 cm. Patients received neoadjuvant imatinib (400 mg/day) for 6–9 months. The primary end point was R0 resection rate. A total of 56 patients were enroled in this study. In the full analysis set of 53 patients, neoadjuvant imatinib for ≥6 months was completed in 46 patients. Grade 3–4 neutropenia and rash occurred in 8% and 9%, respectively, but there were no treatment-related deaths. The response rate by RECIST was 62% (95% CI, 48–75%). The R0 resection rate was 91% (48/53) (95% CI, 79–97%). Preservation of at least half of the stomach was achieved in 42 of 48 patients with R0 resection. At the median follow-up time of 32 months, 2-year overall and progression-free survival rates were 98% and 89%, respectively. Neoadjuvant imatinib treatment for 6–9 months is a promising treatment for large gastric GISTs, allowing a high R0 resection rate with acceptable toxicity.

Background There remains a lack of robust evidence regarding the prognostic value of myocardial perfusion imaging (MPI) before noncardiac surgery in large and diverse patient populations.Methods This retrospective observational cohort study from single, tertiary, high surgical volume center in South Korea included 82,441 patients aged >40 years who underwent MPI using pharmacologic stress single photon emission computed tomography within 6 months before elective noncardiac surgery from January 2000 to December 2021. Results of MPI were classified as abnormal (any fixed or reversible perfusion defect) vs normal MPI before noncardiac surgery. The primary outcome was a composite of cardiac death or myocardial infarction within 30 days.Results Among the 82441 patients (mean±standard deviation age, 65.7±9.6 years; 47417 [57.5%] men), 184 (0.2%) experienced cardiac death or myocardial infarction within 30 days after noncardiac surgery. MPI were abnormal in 5603 patients (6.8%). Compared with a normal MPI, an abnormal MPI had a higher risk of the primary outcome (crude incidence, 1.2% vs 0.1%; adjusted odds ratio, 4.64; 95% confidence interval, 3.29-6.50; P <.001). The presence of an abnormal MPI improved discrimination for the primary outcome (area under the receiver operating characteristic curve with MPI vs without MPI (0.77 vs 0.73; P <0.001)) and significantly increased net reclassification improvement (0.26; 95% confidence interval, 0.11-0.40; P <.001). Among patients with an abnormal MPI, 378 (6.7%) underwent pre-operative coronary revascularization; however, this was not associated with a lower risk of the primary outcome ( P =.56).Conclusion An abnormal myocardial perfusion imaging appeared to be an important risk factor for adverse postoperative events and provided additional prognostic value for patients undergoing noncardiac surgery. Nevertheless, preoperative MPI was limited by its low positive predictive value for postoperative cardiac events, leading to potentially unnecessary coronary revascularization procedures with unproven prognostic value.What is new? What are the clinical implications? ### Competing Interest StatementThe authors have declared no competing interest.### Funding StatementThis research was supported by a grant of the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (grant number: HC19C0022).### Author DeclarationsI confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.YesThe details of the IRB/oversight body that provided approval or exemption for the research described are given below: the institutional review board of Asan Medical CenterI confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.YesI understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).YesI have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.Yesdrjmahn{at}gmail.com