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1.  Quality of Life After Gastrectomy for Adenocarcinoma: A Prospective Cohort Study 
Annals of surgery  2013;257(6):1039-1046.
Background
Gastrectomy remains a major operation with potential for significant deterioration in patients’ health-related quality of life (QOL). This study assessed differences in QOL among patients following distal (DG), proximal (PG) or total (TG) gastrectomy.
Methods
We prospectively enrolled patients undergoing gastrectomy at our institution between 2002 and 2007. Participants completed the EORTC cancer (QLQ-C30) and gastric (QLQ-STO22) questionnaires preoperatively and at five postoperative intervals up to 18 months. We compared changes from baseline in patients based on extent of resection (proximal, distal, or total) using generalized linear models, adjusting for age, stage of disease, and (neo)adjuvant therapy. We converted QOL raw scores to reflect the proportion of patients with clinically significant deterioration based on the minimal important difference (MID).
Results
We included 134 patients: 82 DG, 16 PG, and 36 TG. In the immediate postoperative period, 55% of patients suffered significant impairment in their global QOL. This improved in most patients by six months, although 20-35% continued to have substantially worse QOL than prior to surgery. Patients who underwent PG suffered from significantly more clinical reflux (70% vs 35% (DG), 40% (TG)), nausea/vomiting (60% vs 25%, 30%), and global QOL impairment (60% vs 30%, 30%) than DG or TG patients, whose QOL scores were similar. These differences persisted up to 18 months postoperatively.
Conclusions
Surgeons should discuss expectations of QOL impairment with their patients prior to gastrectomy and reassure them that most symptoms resolve by six months following operation. Patients who undergo PG suffer from worse QOL impairment than patients who undergo DG or TG.
doi:10.1097/SLA.0b013e31828c4a19
PMCID: PMC4104506  PMID: 23665970
Gastric cancer; Quality of Life; Proximal Gastrectomy; Distal Gastrectomy; Total Gastrectomy
2.  Serial Comparisons of Quality of Life after Distal Subtotal or Total Gastrectomy: What Are the Rational Approaches for Quality of Life Management? 
Journal of Gastric Cancer  2014;14(1):32-38.
Purpose
The aims of this study were to make serial comparisons of the quality of life (QoL) between patients who underwent total gastrectomy and those who underwent distal subtotal gastrectomy for gastric cancer and to identify the affected scales with consistency.
Materials and Methods
QoL data of 275 patients who were admitted for surgery between September 2008 and June 2011 and who underwent subtotal gastrectomy or total gastrectomy were obtained preoperatively and postoperatively at 3, 6, 9, 12, 18, and 24 months. The Korean versions of the European Organization for Research and Treatment (EORTC) Quality of Life Questionnaire Core 30 (QLQ-C30) and the gastric cancer specific module, the EORTC QLQ-STO22, were used to assess QoL.
Results
QoL, as assessed by the global health status/QoL and physical functioning, revealed a brief divergence with worse QoL in the total gastrectomy group 3 months postoperatively, followed by rapid convergence. QoL related to restrictive symptoms (nausea/vomiting, dysphagia, reflux, and eating restrictions) and dry mouth was consistently worse in the total gastrectomy group during the first 2 postoperative years.
Conclusions
The general QoL of patients after gastrectomy is highly congruent with subjective physical functioning, and the differences between patients who undergo total gastrectomy and subtotal gastrectomy are no longer valid several months after surgery. In order to further reduce the differences in QoL between patients who underwent total gastrectomy and subtotal gastrectomy, definitive preoperative informing, followed by postoperative symptomatic management, of restrictive symptoms in total gastrectomy patients is the most rational approach.
doi:10.5230/jgc.2014.14.1.32
PMCID: PMC3996247  PMID: 24765535
Gastrectomy; Quality of life; Stomach neoplasms
3.  Pouch Roux-en-Y vs No Pouch Roux-en-Y following total gastrectomy: a meta-analysis based on 12 studies 
Journal of Biomedical Research  2011;25(2):90-99.
After a total resection of the stomach, the continuity of the gastrointestinal tract can be restored either by Roux-en-Y esophagojejunostomy with or without a pouch. There is still no consensus on the best reconstruction technique. The aim of this report was to derive a more precise estimation of Roux-en-Y esophagojejunostomy with a pouch compared with Roux-en-Y esophagojejunostomy without a pouch. Studies were identified by PubMed and Embase searches, and the inclusion criteria were randomized controlled trials (RCTs) comparing reconstruction techniques between Roux-en-Y with and without a pouch. A total of 12 studies including 1,018 patients were included. The meta-analysis shows that pouch Roux-en-Y does not significantly increase total postoperative complications, anastomotic leakage or mortality. Importantly, there is no significant difference in 5-year survival rates between the two groups. Patients with Roux-en-Y esophagojejunostomy complained significantly less of reflux symptoms and dumping syndrome, and had significantly less severe reflux esophagitis. Quality of life was significantly improved in patients with Roux-en-Y esophagojejunostomy with a pouch compared with patients who received Roux-en-Y reconstruction without a pouch. The results indicate the need for Roux-en-Y esophagojejunostomy with a pouch is a gastric substitute after total gastrectomy by comparison with Roux-en-Y esophagojejunostomy without a pouch.
doi:10.1016/S1674-8301(11)60011-0
PMCID: PMC3596699  PMID: 23554676
gastric cancer; total gastrectomy; reconstruction; meta-analysis
4.  Surgical outcomes in patients with locally advanced gastric cancer treated with S-1 and oxaliplatin as neoadjuvant chemotherapy 
Background
We wished to evaluate the impact of S-1 combined with oxaliplatin (SOX regimen) as neoadjuvant chemotherapy on surgical outcomes after gastrectomy with D2 lymphadenectomy.
Methods
From February 2012 to September 2013, 170 patients with American Joint Committee on Cancer (AJCC) stage II–III gastric cancer were assessed retrospectively. Eighty patients underwent neoadjuvant chemotherapy before radical gastrectomy, and 90 patients received surgical treatment with adjuvant chemotherapy. Patients received S-1 (80 mg/m2/day; days 1–14) and oxaliplatin (130 mg/m2; day 1) as neoadjuvant or adjuvant chemotherapy, and this schedule was repeated every 3 weeks. Gastrectomy with D2 lymphadenectomy was standard therapy for each patient. Surgical outcomes between the two groups were analyzed statistically.
Results
There was no significant difference in the total prevalence of complications between neoadjuvant and adjuvant groups (18.8% vs. 22.2%, P = 0.704). The most common postoperative complications were surgical site infection (6.5%) and gastrointestinal motility disorders (3.5%). The clinical response rate was 68.8%, and ten patients (12.5%) had a pathological complete response after neoadjuvant chemotherapy. The SOX regimen as neoadjuvant chemotherapy for AJCC stage II/III gastric cancer can be effective without increasing the risk of postoperative complications.
Conclusions
The SOX regimen could be a neoadjuvant chemotherapy for advanced gastric cancer worldwide in the future.
Electronic supplementary material
The online version of this article (doi:10.1186/s12957-015-0444-6) contains supplementary material, which is available to authorized users.
doi:10.1186/s12957-015-0444-6
PMCID: PMC4320473  PMID: 25634099
Gastric cancer; D2 lymphadenectomy; Pathological complete response; Complications; Neoadjuvant chemotherapy
5.  Stomach cancer 
Clinical Evidence  2011;2011:0404.
Introduction
Stomach cancer is usually an adenocarcinoma arising in the stomach, and includes tumours arising at or just below the gastro-oesophageal junction (type II and III junctional tumours). The annual incidence varies among countries and by sex, with about 80/100,000 cases per year in Japanese men, 30/100,000 in Japanese women, 18/100,000 in British men, and 10/100,000 in British women.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of radical versus conservative surgical resection? What are the effects of adjuvant chemotherapy? We searched: Medline, Embase, The Cochrane Library, and other important databases up to April 2010 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 19 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review, we present information relating to the effectiveness and safety of the following interventions: adjuvant chemoradiotherapy, adjuvant chemotherapy, lymphadenectomy (radical, conservative), removal of adjacent organs, and subtotal gastrectomy for resectable distal tumours.
Key Points
Stomach cancer is usually an adenocarcinoma arising in the stomach and includes tumours arising at or just below the gastro-oesophageal junction (type II and III junctional tumours). Only non-metastatic stomach cancers are considered in this review. The incidence varies among countries and by sex, with about 80/100,000 cases per year in Japanese men, 30/100,000 in Japanese women, 18/100,000 in British men, and 10/100,000 in British women.
With regard to surgical resection, subtotal gastrectomy seems as effective as total gastrectomy. In practice, surgeons sometimes recommend total gastrectomy "de principe" in people with poorly differentiated "diffuse" cancer, to prevent infiltration of microscopic tumour deposits into the proximal resection margin.
Removal of adjacent organs (spleen and distal pancreas) is associated with increased morbidity and mortality compared with gastrectomy alone. Current consensus is that adjacent organs should only be removed to ensure complete tumour removal, or when required because of trauma during surgery.
Radical lymphadenectomy seems no more effective than conservative lymphadenectomy at increasing survival and increases operative mortality and postoperative morbidity.
Adjuvant chemoradiotherapy seems to improve survival compared with surgery alone in people with resectable stomach adenocarcinoma.
Adjuvant chemotherapy is also more effective at reducing mortality than surgery alone.
PMCID: PMC3275308  PMID: 21439098
6.  Evaluation of salvage surgery for type 4 gastric cancer 
Patients with type 4 gastric cancer and peritoneal metastasis respond better to chemotherapy than surgery. In particular, patients without gastric stenosis who can consume a meal usually experience better quality of life (QOL). However, some patients with unsuccessful chemotherapy are unable to consume a meal because of gastric stenosis and obstruction. These patients ultimately require salvage surgery to enable them to consume food normally. We evaluated the outcomes of salvage total gastrectomy after chemotherapy in four patients with gastric stenosis. We determined clinical outcomes of four patients who underwent total gastrectomy as salvage surgery. Outcomes were time from chemotherapy to death and QOL, which was assessed using the Support Team Assessment Schedule-Japanese version (STAS-J). Three of the patients received combination chemotherapy [tegafur, gimestat and otastat potassium (TS-1); cisplatin]. Two of these patients underwent salvage chemotherapy after 12 and 4 mo of chemotherapy. Following surgery, they could consume food adequately and their STAS-J scores improved, so their treatments were continued. The third patient underwent salvage surgery after 7 mo of chemotherapy. This patient was unable to consume food adequately after surgery and developed surgical complications. His clinical outcomes at 3 mo were very poor. The fourth patient received combination chemotherapy (TS-1 and irinotecan hydrochloride) for 6 mo and then underwent received salvage surgery. After surgery, he could consume food adequately and his STAS-J score improved, so his treatment was continued. After the surgery, he enjoyed his life for 16 mo. Of four patients who received salvage total gastrectomy after unsuccessful chemotherapy, the QOL improved in three patients, but not in the other patient. Salvage surgery improves QOL in most patients, but some patients develop surgical complications that prevent improvements in QOL. If salvage surgery is indicated, the surgeon and/or oncologist must provide the patient with a clear explanation of the purpose of surgery, as well as the possible risks and benefits to allow the patient to reach an informed decision on whether to consent to the procedure.
doi:10.4240/wjgs.v4.i12.301
PMCID: PMC3596528  PMID: 23493860
Type 4 gastric cancer; Quality of life; Salvage surgery; Support Team Assessment Schedule-Japanese version; Palliative care; Systemic chemotherapy; Gastric stenosis
7.  Safety and preliminary results of perioperative chemotherapy and hyperthermic intraperitoneal chemotherapy (HIPEC) for high-risk gastric cancer patients 
Background
Gastric cancer relapse occurs in about 30% of the patients treated with gastrectomy and D2-lymphadenectomy, mainly as distant or peritoneal metastases. Hyperthermic intraperitoneal chemotherapy (HIPEC) has been associated with an improvement in survival and lower peritoneal recurrence, albeit with increased morbidity. The aim of this study is to report the preliminary results of the association of perioperative chemotherapy, radical surgery and HIPEC in high-risk gastric patients in a single institution.
Methods
Treatment protocol was started in 2007 and included patients younger than 65 years old, with good performance status and gastric adenocarcinoma with serosa involvement and lymph node metastases, located in the body or antrum. Patients should receive three preoperative cycles of DCF (Docetaxel 75 mg/m2, Cisplatin 75 mg/m2 and continuous intravenous infusion of 5-Fluorouracil 750 mg/m2 for 5 days), followed by gastric resection with D2-lymphadenectomy, hyperthermic intraperitoneal chemotherapy with Mytomicin C 34 mg/m2 and three more postoperative cycles of DCF.
Results
Ten patients were included between 2007 and 2011. Their median age was 47 years old and six were male. Nine were staged with cT4 cN + tumors and one as cT3 cN+. Nine patients completed all three preoperative chemotherapy cycles. Eight individuals were treated with a total gastrectomy and the other two had a distal gastrectomy, all having HIPEC. Postoperative morbidity was 50%, with no deaths. Regarding postoperative chemotherapy, only 5 patients completed three cycles. With a median follow-up of 25 months, three relapses were identified and 7 patients remain disease-free, two with more than 4 years of follow-up.
Conclusion
The association of perioperative systemic and intraperitoneal chemotherapy plus radical surgery is a feasible multimodality treatment, with acceptable morbidity. With a longer follow-up and a larger group of patients, we hope to be able to determine if it also influences survival outcomes and patterns of recurrence.
Mini-Abstract
The association of perioperative chemotherapy, gastric resection and D2-lymphadenectomy and hyperthermic intraperitoneal chemotherapy proved to be associated with acceptable morbidity. For survival analysis, a longer follow-up is needed.
doi:10.1186/1477-7819-10-195
PMCID: PMC3495866  PMID: 22992263
Gastric cancer; HIPEC; Perioperative chemotherapy
8.  Quality-of-Life Outcomes for Adjuvant Chemotherapy in Early-Stage Non–Small-Cell Lung Cancer: Results From a Randomized Trial, JBR.10 
Journal of Clinical Oncology  2008;26(31):5052-5059.
Purpose
Adjuvant chemotherapy for early stage non–small-cell lung cancer (NSCLC) is now the standard of care, but there is little information regarding its impact on quality of life (QOL). We report the QOL results of JBR.10, a North American, intergroup, randomized trial of adjuvant cisplatin and vinorelbine compared with observation in patients who have completely resected, stages IB to II NSCLC.
Patients and Methods
QOL was assessed with the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30 and a trial-specific checklist at baseline and at weeks 5 and 9 for those who received chemotherapy and at follow-up months 3, 6, 9, 12, 18, 24, 30 and 36. A 10-point change in QOL scores from baseline was considered clinically significant.
Results
Four hundred eighty-two patients were randomly assigned on JBR.10. A total of 173 patients (82% of the expected) in the observation arm and 186 (85% of expected) in the chemotherapy arm completed baseline QOL assessments. The two groups were comparable, with low global QOL scores and significant symptom burden, especially pain and fatigue, after thoracotomy. Changes in QOL during chemotherapy were relatively modest; fatigue, nausea, and vomiting worsened, but there was a reduction in pain and no change in global QOL. Patients in the observation arm showed considerable improvements in QOL by 3 months. QOL, except for symptoms of sensory neuropathy and hearing loss, in those treated with chemotherapy returned to baseline by 9 months.
Conclusion
The findings of this trial indicate that the negative effects of adjuvant chemotherapy on QOL appear to be temporary, and that improvements (with a return to baseline function) are likely in most patients.
doi:10.1200/JCO.2007.12.6094
PMCID: PMC2652099  PMID: 18809617
9.  Quality of life after curative gastrectomy for gastric cancer in a randomised controlled trial 
British Journal of Cancer  2008;98(1):54-59.
Quality of life (QOL) was studied in gastric cancer patients treated on a randomised, controlled trial comparing D1 (level 1) with D3 (levels 1, 2 and 3) lymphadenectomy. A total of 221 patients were randomly assigned to D1 (n=110) and D3 (n=111) surgery. Quality-of-life assessments included functional outcomes (a 14-item survey about treatment-specific symptoms) and health perception (Spitzer QOL Index) was performed before and after surgery at disease-free status. Patients suffered from irrelative events such as loss of partners was excluded thereafter. Main analyses were done by intention-to-treat. Thus, 214 D1 (106/110=96.4%) and D3 (108/111=97.3%) R0 patients were assessed. Longitudinal analysis showed that functional outcomes decreased at 6 months after surgery and increased over time thereafter, while health perceptions increased over time in general. On the basis of linear mixed model analyses, patients having total gastrectomy, advanced cancer and hemipancreaticosplenectomy, but not complications had poorer QOL than those without. D1 and D3 patients showed no significant difference in QOL. The results suggest that changes of QOL were largely due to scope of gastric resection, disease status and distal pancreaticosplenectomy, rather than the extent of lymph node dissection. This indicates that nodal dissection can be performed for a potentially curable gastric cancer.
doi:10.1038/sj.bjc.6604097
PMCID: PMC2359701  PMID: 18182977
quality of life; nodal dissection; gastric cancer; trial
10.  Gastric Cancer Surgery – A Balance of Risk and Radicality 
INTRODUCTION
The aim of this study was to determine whether tailoring the extent of resection would allow radical gastric cancer surgery to be performed safely in a UK population.
PATIENTS AND METHODS
A total of 180 consecutive patients (median age 70 years; male:female ratio 2:1) undergoing resection for gastric adenocarcinoma with curative intent were studied. Extent of lymphadenectomy was based upon pre-operative and intra-operative staging, and balanced against the patient's age and fitness.
RESULTS
In the study group, 83 patients underwent subtotal or distal partial gastrectomy and 97 patients underwent total or proximal partial gastrectomy. Operative procedures were: D1 lymphadenectomy (n = 62); modified (spleen and pancreas preserving) D2 lymphadenectomy (n = 73); D2 lymphadenectomy (n = 42); and extended resection (n = 3). TNM classification was: stage 1 (n = 45); stage 2 (n = 37); stage 3 (n = 61); and stage 4 (n = 37). Of the patients, 48 developed postoperative complications including 17 patients with a major surgical complication. The in-hospital mortality was 1.7% (3 of 180). Predicted mortality according to POSSUM and P-POSSUM was 21.4% and 7.8%, respectively. Disease-specific 5-year survival according to stage was 85.4%, 64.2%, 33.3%, and 6.9%.
CONCLUSIONS
By tailoring the extent of resection and balancing risk and radicality, gastric cancer surgery can be performed with low mortality in Western patients.
doi:10.1308/003588408X261546
PMCID: PMC2430435  PMID: 18430340
Stomach neoplasms; Gastrectomy; Lymph node excision
11.  Impact of intraoperative blood loss on survival after curative resection for gastric cancer 
AIM: To elucidate the potential impact of intraoperative blood loss (IBL) on long-term survival of gastric cancer patients after curative surgery.
METHODS: A total of 845 stage I-III gastric cancer patients who underwent curative gastrectomy between January 2003 and December 2007 in our center were enrolled in this study. Patients were divided into 3 groups according to the amount of IBL: group 1 (< 200 mL), group 2 (200-400 mL) and group 3 (> 400 mL). Clinicopathological features were compared among the three groups and potential prognostic factors were analyzed. The Log-rank test was used to assess statistical differences between the groups. Independent prognostic factors were identified by the Cox proportional hazards regression model. Stratified analysis was used to investigate the impact of IBL on survival in each stage. Cancer-specific survival was also compared among the three groups by excluding deaths due to reasons other than gastric cancer. Finally, we explored the possible factors associated with IBL and identified the independent risk factors for IBL ≥ 200 mL.
RESULTS: Overall survival was significantly influenced by the amount of IBL. The 5-year overall survival rates were 51.2%, 39.4% and 23.4% for IBL less than 200 mL, 200 to 400 mL and more than 400 mL, respectively (< 200 mL vs 200-400 mL, P < 0.001; 200-400 mL vs > 400 mL, P = 0.003). Age, tumor size, Borrmann type, extranodal metastasis, tumour-node-metastasis (TNM) stage, chemotherapy, extent of lymphadenectomy, IBL and postoperative complications were found to be independent prognostic factors in multivariable analysis. Following stratified analysis, patients staged TNM I-II and those with IBL less than 200 mL tended to have better survival than those with IBL not less than 200 mL, while patients staged TNM III, whose IBL was less than 400 mL had better survival. Tumor location, tumor size, TNM stage, type of gastrectomy, combined organ resection, extent of lymphadenectomy and year of surgery were found to be factors associated with the amount of IBL, while tumor location, type of gastrectomy, combined organ resection and year of surgery were independently associated with IBL ≥ 200 mL.
CONCLUSION: IBL is an independent prognostic factor for gastric cancer after curative resection. Reducing IBL can improve the long-term outcome of gastric cancer patients following curative gastrectomy.
doi:10.3748/wjg.v19.i33.5542
PMCID: PMC3761109  PMID: 24023499
Gastric carcinoma; Intraoperative blood loss; Blood transfusion; Postoperative complication; Prognosis
12.  Stomach cancer 
Clinical Evidence  2008;2008:0404.
Introduction
Stomach cancer is usually an adenocarcinoma arising in the stomach, and includes tumours arising at or just below the gastro-oesophageal junction (type II and III junctional tumours). The annual incidence varies among countries and by sex, with about 80 cases a year per 100,000 in Japanese men, 30/100,000 in Japanese women, 18/100,000 in British men, and 10/100,000 in British women.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of radical versus conservative surgical resection? What are the effects of adjuvant chemotherapy? We searched: Medline, Embase, The Cochrane Library, and other important databases up to August 2007 (BMJ Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 18 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: adjuvant chemoradiotherapy, adjuvant chemotherapy, lymphadenectomy (radical, conservative), removal of adjacent organs, and subtotal gastrectomy for resectable distal tumours.
Key Points
Stomach cancer is usually an adenocarcinoma arising in the stomach and includes tumours arising at or just below the gastro-oesophageal junction (type II and III junctional tumours). Only non-metastatic stomach cancers are considered in this review. The incidence varies among countries and by gender, with about 80 cases a year per 100,000 in Japanese men, 30/100,000 in Japanese women, 18/100,000 in British men, and 10/100,000 in British women.
With regard to surgical resection, subtotal gastrectomy seems as effective as total gastrectomy. In practice, surgeons sometimes recommend total gastrectomy "de principe" in people with poorly differentiated "diffuse" cancer, to prevent infiltration of microscopic tumour deposits into the proximal resection margin.
Removal of adjacent organs (spleen and distal pancreas) is associated with increased morbidity and mortality compared with gastrectomy alone. Current consensus is that adjacent organs should only be removed to ensure complete tumour removal, or when required because of trauma during surgery.
We found insufficient evidence to judge the effectiveness of radical lymphadenectomy compared with conservative lymphadenectomy.
Adjuvant chemoradiotherapy seems to improve survival compared with surgery alone in people with resectable stomach adenocarcinoma.
Adjuvant chemotherapy might also be effective compared with surgery alone, although the evidence is inconsistent.
PMCID: PMC2907976  PMID: 19445803
13.  Survival Benefit of Adjuvant Radiation Therapy for Gastric Cancer following Gastrectomy and Extended Lymphadenectomy 
Purpose. Although randomized trials suggest a survival benefit of adjuvant chemotherapy and radiation therapy (XRT) for gastric adenocarcinoma, its use in patients who undergo an extended lymphadenectomy is less clear. The purpose of this study was to determine if a survival benefit exists in gastric cancer patients who receive adjuvant XRT following resection with extended lymphadenectomy. Methods. The SEER registry was queried for records of patients with resected gastric adenocarcinoma from 1988 to 2007. Multivariable Cox regression models were used to assess independent prognostic factors affecting overall survival (OS) and disease-specific survival (DSS). Results. Of 15,060 patients identified, 3,208 (21%) received adjuvant XRT. Adjuvant XRT was independently associated with improved OS (HR 0.67, CI 0.64–0.71) and DSS (HR 0.69, CI 0.65–0.73) in stages IB through IV (M0). This OS and DSS benefit persisted regardless of the extent of lymphadenectomy. Furthermore, lymphadenectomy with >25 LN resected was associated with improved OS and DSS compared with <15 LN or 15–25 LN. Conclusion. This population-based study shows a survival benefit of adjuvant XRT following gastrectomy that persists in patients who have an extended lymphadenectomy. Furthermore, removal of >25 LNs results in improved OS and DSS compared with patients who have fewer LNs resected.
doi:10.1155/2012/307670
PMCID: PMC3388431  PMID: 22778937
14.  Current State of Gastric Stump Carcinoma in Japan: Based on the Results of a Nationwide Survey 
World Journal of Surgery  2010;34(7):1540-1547.
Background
Carcinoma of the gastric remnant after partial gastrectomy for benign disease or cancer is unusual but an important cancer model. The Japanese Society for the Study of Postoperative Morbidity after Gastrectomy (JSSPMG) performed a nationwide questionnaire survey to understand the current state of gastric stump carcinoma in Japan.
Methods
In the questionnaire survey of November 2008, gastric stump carcinoma was defined as an adenocarcinoma of the stomach occurring 10 years or more after Billroth I or Billroth II gastrectomy for benign condition or cancer disease. The survey was conducted at the request of reports on five or more patients with gastric stump carcinoma for each institution. Items for the survey included gender, age, methods of reconstruction in an original gastrectomy, original diseases, time interval between original gastrectomy and first detection of stump carcinomas, locations of stump carcinomas, tumor histology, tumor depth, and extent of lymph node metastasis. The questionnaire was sent to 163 surgical institutions in the JSSPMG.
Results
Ninety-five institutions (58.3%) responded to the survey, and the data of 887 patients satisfied the required conditions for the survey. A total of 887 patients were composed of 368 patients who received Billroth I distal gastrectomy and 519 who received Billroth II. The Billroth II group has a significantly higher number of original benign lesions than the Billroth I group (P < 0.001). This study confirmed the following issues: (1) The remnant stomach after gastrectomy for cancer disease had a higher prevalence to develop stump carcinomas occurring in a shorter time interval since original gastrectomy; (2) Patients with Billroth II gastrectomy had stump carcinomas most frequently in the anastomotic area, but not in the non-stump area as in Billroth I gastrectomy; (3) Tumor histology of 72.4% of 304 stump carcinomas at an early stage was intestinal type adenocarcinoma, i.e., well or moderately differentiated adenocarcinoma, whereas it decreased to 42.2% at the locally advanced stage of 521 stump carcinomas (P = 0.0015), suggesting that stump carcinoma mostly may develop from intestinal type and change to diffuse type during the evolution to advanced stage cancers.
Conclusions
This large series of surveys suggest that there are two distinct biological plausibilities in the development of gastric stump carcinoma: (1) it develops in a shorter time interval of 10 years or less since the original gastrectomy, may come from a higher risk of gastric mucosa after gastrectomy for cancer diseases that highly predisposes to cancer, and (2) it develops during a longer time interval of 20 years or more, may come from gastrectomy-relating mechanisms after gastrectomy for original benign diseases.
doi:10.1007/s00268-010-0505-5
PMCID: PMC2895900  PMID: 20182716
15.  Evaluating the impact on quality of life of chemoradiation in gastric cancer 
Current Oncology  2010;17(4):77-84.
Objective
Our phase i study prospectively evaluated quality of life (qol) in patients undergoing adjuvant chemoradiation for gastric adenocarcinoma.
Methods
Thirty-three patients receiving radiotherapy (45 Gy in 25 fractions), together with 12 weeks of infusional 5-fluorouacil and escalating doses of cisplatin every 2 weeks, completed the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30 at five time points: baseline, completion of radiation, 4 weeks after completion of radiation, 6–12 months after completion of chemoradiation, and 2–3 years after completion of chemoradiation.
Results
Mean age of the patients was 56 years (range: 31–77 years); 55% of the patients were male. Median follow-up was 2.7 years (range: 0.3–5 years). The 3-year overall survival was 83%. Five patients experienced dose-limiting toxicity (dlt). Median scores on global qol and on the social, role, emotional, nausea and vomiting, and fatigue scales showed clinically and statistically significant worsening at completion of radiation. Statistical but not clinical worsening was found for the physical and appetite scales. By 6–12 months, no subscale showed a difference, on average, from the baseline score. However, up to 45% of the patients remained below baseline on at least 1 subscale. Patients with dlt had worse scores on the emotional and the nausea and vomiting scales. Scores for global qol and for nausea and vomiting were significantly associated with chemotherapy dose.
Conclusions
During chemoradiation, qol is impaired. Although most scores return to baseline, recovery may take 6–12 months, and subscale scores remain below baseline in a significant proportion of patients.
PMCID: PMC2913834  PMID: 20697519
Chemoradiation; gastric cancer; quality of life
16.  The Impact of Esophageal Reflux-Induced Symptoms on Quality of Life after Gastrectomy in Patients with Gastric Cancer 
Journal of Gastric Cancer  2014;14(1):15-22.
Purpose
To evaluate the prevalence of esophageal reflux-induced symptoms after gastrectomy owing to gastric cancer and assess the relationship between esophageal reflux-induced symptoms and quality of life.
Materials and Methods
From January 2012 to May 2012, 332 patients were enrolled in this cross-sectional study. The patients had a history of curative resection for gastric cancer at least 6 months previously without recurrence, other malignancy, or ongoing chemotherapy. Esophageal reflux-induced symptoms were evaluated with the GerdQ questionnaire. The quality of life was evaluated with the European Organization for Research and Treatment QLQ-C30 and STO22 questionnaires.
Results
Of the 332 patients, 275 had undergone subtotal gastrectomy and 57 had undergone total gastrectomy. The number of GerdQ(+) patients was 58 (21.1%) after subtotal gastrectomy, and 7 (12.3%) after total gastrectomy (P=0.127). GerdQ(+) patients showed significantly worse scores compared to those for GerdQ(-) patients in nearly all functional and symptom QLQ-C30 scales, with the difference in the mean score of global health status/quality of life and diarrhea symptoms being higher than in the minimal important difference. Additionally, in the QLQ STO22, GerdQ(+) patients had significantly worse scores in every symptom scale. The GerdQ score was negatively correlated with the global quality of life score (r=-0.170, P=0.002).
Conclusions
Esophageal reflux-induced symptoms may develop at a similar rate or more frequently after subtotal gastrectomy compared to that after total gastrectomy, and decrease quality of life in gastric cancer patients. To improve quality of life after gastrectomy, new strategies are required to prevent or reduce esophageal reflux.
doi:10.5230/jgc.2014.14.1.15
PMCID: PMC3996245  PMID: 24765533
Stomach neoplasms; Gastrectomy; Esophageal reflux; Quality of life
17.  Retrospective analysis of adjuvant chemotherapy for curatively resected gastric cancer 
AIM: To determine the efficacy of adjuvant chemotherapy for gastric cancer in clinical practice, a retrospective analysis was conducted in a high-volume Chinese cancer center.
METHODS: Between November 1995 and June 2007, a total of 423 gastric or esophagogastric adenocarcinoma patients who did (Arm A, n = 300) or did not (Arm S, n = 123) receive radical gastrectomy followed by postoperative chemotherapy were enrolled in this retrospective analysis. In Arm A, monotherapy(fluoropyrimidines, n = 25), doublet (platinum/fluoropyrimidines, n = 164), or triplet regimens [docetaxel/cisplatin/5FU (DCF), or modified DCF, epirubicin/cisplatin/5FU (ECF) or modified ECF, etoposide/cisplatin/FU, n = 111] were administered. Disease-free survival (DFS) and overall survival (OS) were compared between the two arms. A subgroup analysis was carried out in Arm A. A multivariate analysis of prognostic factors was conducted.
RESULTS: Stage I, II and III cancers accounted for 9.7%, 35.7% and 54.6% of the cases, respectively, according to the American Joint Committee on Cancer (AJCC) staging system, 7th edition. Only 178 (42.1%) patients had more than 15 lymph nodes harvested. Hazard ratio estimates for Arm A compared with Arm S were 0.47 (P < 0.001) for OS and 0.59 (P < 0.001) for DFS. The 5-year OS rate was 52% in Arm A vs 36% in Arm S (P = 0.01); the adverse events in Arm A were mild and easily controlled. Ultimately, 73 patients (26.5%) who received doublet or triplet regimens switched to monotherapy with fluoropyrimidines. The OS and DFS did not differ between monotherapy and the combination regimens, however, both were statistically improved in the subgroup of patients who were switched to monotherapy with fluoropyrimidines after doublet or triplet regimens as well as patients who received ≥ 8 cycles of chemotherapy.
CONCLUSION: In clinical practice, platinum/fluoropyrimidines with adequate treatment duration is recommended for stage II/III gastric cancer patients accordingto the 7th edition of the AJCC staging system after curative gastrectomyeven with limited lymphadenectomy.
doi:10.3748/wjg.v20.i12.3356
PMCID: PMC3964407  PMID: 24696615
Adjuvant chemotherapy; Gastric cancer; Lymphadenectomy; Fluoropyrimidine; Platinum
18.  Time-related improvement of survival in resectable gastric cancer: the role of Japanese-style gastrectomy with D2 lymphadenectomy and adjuvant chemotherapy 
Background
We investigated the change of prognosis in resected gastric cancer (RGC) patients and the role of radical surgery and adjuvant chemotherapy.
Methods
We retrospectively analyze the outcome of 426 consecutive patients from 1975 to 2002, divided into 2 time-periods (TP) cohort: Before 1990 (TP1, n = 207) and 1990 or after (TP2; n= 219). Partial gastrectomy and D1-lymphadenetomy was predominant in TP1 and total gastrectomy with D2-lymphadenectomy it was in TP2. Adjuvant chemotherapy consisted of mitomycin C (MMC), 10–20 mg/m2 iv 4 courses or MMC plus Tegafur 500 mg/m2 for 6 months.
Results
Positive nodes were similar in TP2/TP1 patients with 56%/59% respectively. Total gastrectomy was done in 56%/45% of TP2/TP1 respectively. Two-drug adjuvant chemotherapy was administered in 65%/18% of TP2/TP1 respectively. Survival at 5 years was 66% for TP2 versus 42% for TP1 patients (p < 0.0001). Survival by stages II, IIIA y IIIB for TP2 versus TP1 patients was 70 vs. 51% (p = 0.0132); 57 vs. 22% (p = 0.0008) y 30 vs. 15% (p = 0.2315) respectively. Multivariate analysis showed that age, stage of disease and period of treatment were independent variables.
Conclusion
The global prognosis and that of some stages have improved in recent years with case RGC patients treated with surgery and adjuvant chemotherapy.
doi:10.1186/1477-7819-4-53
PMCID: PMC1564020  PMID: 16904003
19.  Demographic factors affecting quality of life of hemodialysis patients – Lahore, Pakistan 
Pakistan Journal of Medical Sciences  2014;30(5):1123-1127.
Objective: The objective of the study was to determine the demographic factors affecting Quality Of Life (QOL) of hemodialysis (HD) patients.
Methods: This observational study was conducted at Shalamar Hospital, Lahore. Patients of End Stage Renal Disease (ESRD) and on maintenance HD for more than three months were included during the period March to June 2012. Patient of ESRD not on dialysis and Acute Renal Failure were excluded. One hundred and twenty five patients who fulfilled the criteria were included. Demographic data containing age, sex, residence, socio economic status, education, mode of traveling for dialysis, total time consumed in dialysis were collected by the investigators. QOL index was measured using 26 items, WHO QOL BREF.
Results: There were 89(71.2%) male and 36(28.8%) female patients. Environmental domain score was highest (p=0.000) than all other domains in HD Patients. In overall analysis age, marital status and total time consumed in getting HD effect QOL significantly (p=<0.05). In domain wise analysis, male has better QOL in social relationship domain than female. Age has negative relationship with physical health and psychological health domain. QOL of unmarried and literate patients is significantly better (p=<0.05) in physical health domain. Employed patients have better QOL in physical, psychological and social relationship domain (p=<0.05) than unemployed patients. Patients of residence of rural areas have better QOL in physical and environment domain. Financial status of HD patients affect QOL in social domain. Distance covered to reach hospital effect QOL in psychological domain (p=<0.05). Patients traveling in private transport have better QOL in environmental domain (p=<0.05). Total time consumed in getting HD effect social relation in QOL (p=<0.05). According to linear regression model, marital status is positive predictor and unemployment is negative predictor of QOL in physical health domain. Age is negative predictor of QOL in psychological domain, monthly income is positive predictor of QOL in domain. Unemployment is positive predictor of QOL in social relation domain. Monthly income and place of residence is positive predictor of QOL in environment domain.
Conclusion: Gender, age, marital status, unemployment, residence of rural area, economical status, distance covered to reach hospital, mode of transport, total time consumed in getting HD, effect QOL in HD patient. Education level is a positive factor for improving QOL of HD patients.
doi:10.12669/pjms.305.5239
PMCID: PMC4163245  PMID: 25225539
ESRD; Hemodialyis; QOL; Demographic factors; WHO QOL BREF
20.  Risk Factors of Postoperative Pancreatic Fistula in Curative Gastric Cancer Surgery 
Journal of Gastric Cancer  2013;13(3):179-184.
Purpose
Postoperative pancreatic fistula is a dreadful complication after gastric cancer surgery. The purpose of this study is to evaluate the actual incidence and risk factors of postoperative pancreatic fistula after curative gastrectomy for gastric cancer.
Materials and Methods
A total of 900 patients who underwent gastrectomy for gastric cancer (laparoscopic gastrectomy, 594 patients; open gastrectomy 306 patients) were enrolled between January 2009 and December 2010. Clinical outcomes, including postoperative pancreatic fistula grade based on the International Study Group on Pancreatic Fistula, were investigated.
Results
Overall, the postoperative pancreatic fistula rate was 3.3% (30/900) (1.5% in laparoscopic gastrectomy versus 6.9% in open gastrectomy, P<0.001). Patients who underwent D2 lymphadenectomy, total gastrectomy, splenectomy or distal pancreatectomy showed higher postoperative pancreatic fistula rates (4.7%, 13.8%, 13.6%, or 57.1%, respectively, P<0.001). Patients with postoperative pancreatic fistula had higher morbidity (46.7% versus 13.1%, P<0.001), delayed gas out (4.9 days versus 3.8 days, P<0.001), belated diet start (5.8 days versus 3.5 days, P<0.001) and longer postoperative hospital stay (13.7 days versus 6.8 days, P<0.001). On the multivariate analysis, total gastrectomy (odds ratio 9.751, 95% confidence interval: 3.348 to 28.397, P<0.001), distal pancreatectomy (odds ratio 7.637, 95% confidence interval: 1.668 to 34.961, P=0.009) and open gastrectomy (odds ratio 2.934, 95% confidence interval: 1.100 to 7.826, P=0.032) were the independent risk factors of postoperative pancreatic fistula.
Conclusions
Laparoscopic gastrectomy had an advantage over open gastrectomy in terms of the lower postoperative pancreatic fistula rate. Total gastrectomy and combined resection, such as distal pancreatectomy, should be performed carefully to minimize postoperative pancreatic fistula in gastric cancer surgery.
doi:10.5230/jgc.2013.13.3.179
PMCID: PMC3804677  PMID: 24156038
Stomach cancer; Gastrectomy; Pancreatic fistula; Risk factors
21.  Deep venous thrombosis after gastrectomy for gastric carcinoma: A case report 
The treatment of gastric carcinoma consists of neoadjuvant chemoradiation, partial gastrectomy, subtotal gastrectomy, total gastrectomy, extended resection, and postoperative chemotherapy. Currently, gastrectomy and extended lymphadenectomy is the optimal choice for late gastric carcinoma. Postoperative complications are common after total gastrectomy including hemorrhage, anastomotic leakage, fistula, and obstruction. However, deep venous thrombosis (DVT) is an uncommon complication after gastrectomy for gastric carcinoma. We describe a case of a 68-year-old female patient with DVT after gastrectomy for gastric carcinoma. The patient was treated with anticoagulants and thrombolytics and subjected to necessary laboratory monitoring. The patient recovered well after treatment and was symptom-free during a 3-mo follow-up. We conclude that correct diagnosis and treatment of DVT are crucial.
doi:10.3748/wjg.15.885
PMCID: PMC2653393  PMID: 19230054
Gastric carcinoma; Gastrectomy; Deep venous thrombosis; Postoperative complication; Anticoagulant; Thrombolytic therapy; Low molecular weight heparins; Streptokinase; Warfarin sodium
22.  Robotic versus Laparoscopic versus Open Gastrectomy: A Meta-Analysis 
Journal of Gastric Cancer  2013;13(3):136-148.
Purpose
To define the role of robotic gastrectomy for the treatment of gastric cancer, the present systematic review with meta-analysis was performed.
Materials and Methods
A comprehensive search up to July 2012 was conducted on PubMed, EMBASE, and the Cochrane Library. All eligible studies comparing robotic gastrectomy versus laparoscopic gastrectomy or open gastrectomy were included.
Results
Included in our meta-analysis were seven studies of 1,967 patients that compared robotic (n=404) with open (n=718) or laparoscopic (n=845) gastrectomy. In the complete analysis, a shorter hospital stay was noted with robotic gastrectomy than with open gastrectomy (weighted mean difference: -2.92, 95% confidence interval: -4.94 to -0.89, P=0.005). Additionally, there was a significant reduction in intraoperative blood loss with robotic gastrectomy compared with laparoscopic gastrectomy (weighted mean difference: -35.53, 95% confidence interval: -66.98 to -4.09, P=0.03). These advantages were at the price of a significantly prolonged operative time for both robotic gastrectomy versus laparoscopic gastrectomy (weighted mean difference: 63.70, 95% confidence interval: 44.22 to 83.17, P<0.00001) and robotic gastrectomy versus open gastrectomy (weighted mean difference: 95.83, 95% confidence interval: 54.48 to 137.18, P<0.00001). Analysis of the number of lymph nodes retrieved and overall complication rates revealed that these outcomes did not differ significantly between the groups.
Conclusions
Robotic gastrectomy for gastric cancer reduces intraoperative blood loss and the postoperative hospital length of stay compared with laparoscopic gastrectomy and open gastrectomy at a cost of a longer operating time. Robotic gastrectomy also provides an oncologically adequate lymphadenectomy. Additional high-quality prospective studies are recommended to better evaluate both short and long-term outcomes.
doi:10.5230/jgc.2013.13.3.136
PMCID: PMC3804672  PMID: 24156033
Robotics; Laparoscopy; Gastrectomy; Stomach neoplasms
23.  Prospective multicenter study of quality of life before and after lower extremity vein bypass in 1404 patients with critical limb ischemia 
Background
Patients with critical limb ischemia (CLI) have multiple comorbidities and limited life spans. The ability of infrainguinal vein bypass to improve quality of life (QoL) in patients with CLI has therefore been questioned. Prospective preoperative and postoperative QoL data for patients undergoing lower extremity vein bypass for CLI are presented.
Methods
A validated, disease-specific QoL questionnaire (VascuQoL) with activity, symptom, pain, emotional, and social domains and responses scored 1 (lowest QoL) to 7 (best QoL) was administered before surgery and at 3 and 12 months after lower extremity vein bypass for CLI. Changes in QoL at 3 and 12 months after lower extremity vein bypass and multiple predetermined variables potentially influencing QoL after lower extremity vein bypass were analyzed to determine the effect of lower extremity vein bypass on QoL in CLI patients.
Results
A total of 1404 patients had lower extremity vein bypass for CLI at 83 centers in the United States and Canada as part of the PREVENT III clinical trial. Surveys were completed in 1296 patients at baseline, 862 patients at 3 months, and 732 patients at 12 months. The global QoL score (mean ± SD) was 2.8 ± 1.1 at baseline and was 4.7 ± 1.4 and 5.1 ± 1.4 at 3 and 12 months, respectively. Mean changes from baseline at 3 and 12 months were statistically significant (P < .0001). Improved QoL scores extended across all domains. Diabetes and the development of graft-related events were associated with decreased improvement in QoL scores, though the mean relative change from baseline remained positive.
Conclusions
Patients with CLI have a low QoL at baseline that is improved at 3 and 12 months after lower extremity vein bypass. QoL improvements are lower in diabetic patients and those who develop graft-related events. Successful revascularization can be expected to improve QoL in patients with CLI, with benefits that are sustained to at least 1 year.
doi:10.1016/j.jvs.2006.07.015
PMCID: PMC2890307  PMID: 17098529
24.  Full robot-assisted gastrectomy with intracorporeal robot-sewn anastomosis produces satisfying outcomes 
AIM: To evaluate the feasibility and safety of full robot-assisted gastrectomy with intracorporeal robot hand-sewn anastomosis in the treatment of gastric cancer.
METHODS: From September 2011 to March 2013, 110 consecutive patients with gastric cancer at the authors’ institution were enrolled for robotic gastrectomies. According to tumor location, total gastrectomy, distal or proximal subtotal gastrectomy with D2 lymphadenectomy was fully performed by the da Vinci Robotic Surgical System. All construction, including Roux-en-Y jejunal limb, esophagojejunal, gastroduodenal and gastrojejunal anastomoses were fully carried out by the intracorporeal robot-sewn method. At the end of surgery, the specimen was removed through a 3-4 cm incision at the umbilicus trocar point. The details of the surgical technique are well illustrated. The benefits in terms of surgical and oncologic outcomes are well documented, as well as the failure rate and postoperative complications.
RESULTS: From a total of 110 enrolled patients, radical gastrectomy could not be performed in 2 patients due to late stage disease; 1 patient was converted to laparotomy because of uncontrollable hemorrhage, and 1 obese patient was converted due to difficult exposure; 2 patients underwent extra-corporeal anastomosis by minilaparotomy to ensure adequate tumor margin. Robot-sewn anastomoses were successfully performed for 12 proximal, 38 distal and 54 total gastrectomies. The average surgical time was 272.52 ± 53.91 min and the average amount of bleeding was 80.78 ± 32.37 mL. The average number of harvested lymph nodes was 23.1 ± 5.3. All specimens showed adequate surgical margin. With regard to tumor staging, 26, 32 and 46 patients were staged as I, II and III, respectively. The average hospitalization time after surgery was 6.2 d. One patient experienced a duodenal stump anastomotic leak, which was mild and treated conservatively. One patient was readmitted for intra-abdominal infection and was treated conservatively. Jejunal afferent loop obstruction occurred in 1 patient, who underwent re-operation and recovered quickly.
CONCLUSION: This technique is feasible and can produce satisfying postoperative outcomes. It is also convenience and reliable for anastomoses in gastrectomy. Full robotic hand-sewn anastomosis may be a minimally invasive technique for gastrectomy surgery.
doi:10.3748/wjg.v19.i38.6427
PMCID: PMC3801313  PMID: 24151361
Robotic surgery; Gastric cancer; Total gastrectomy; Esophagojejunal anastomosis
25.  Laparoscopic total gastrectomy using the transorally inserted anvil (OrVil™): a preliminary, single institution experience 
SpringerPlus  2014;3:434.
Laparoscopic total gastrectomy (LTG) is not a commonly performed procedure due to the difficulty associated with surgical reconstruction. We present our preliminary results after intracorporeal circular stapling esophagojejunostomy using the newly developed transorally inserted anvil (OrVil™, Covidien, MA, USA). Between 2008 and June 2013, 51 patients underwent laparoscopic gastrectomy with D2 lymph node dissection for gastric cancer. A total of 12 patients underwent LTG: of these, 5 received an intracorporeal linear side-to-side esophagojejunal anastomosis and the remaining 7 underwent intracorporeal circular stapling esophagojejunostomy using the OrVil™ system. Short-term outcomes were compared between the two groups. There were no intraoperative complications or conversions to open surgery in any patients. The mean operative time was significantly shorter in the OrVil™ than in the side-to-side group (261.4 ± 12.0 vs 333.0 ± 15.0 minutes, respectively, p = 0.005). Postoperative fluorography revealed no anastomosis leakage or stenosis in either groups. All patients resumed an oral liquid diet on postoperative day 5 and the mean postoperative hospital stay was 9 days. Intracorporeal circular stapling esophagojejunostomy using the OrVil™ system is technically feasible and safe in LTG. This technique may be considered a simple and time-saving alternative to the side-to-side linear esophagojejunostomy.
doi:10.1186/2193-1801-3-434
PMCID: PMC4141073  PMID: 25152855
Gastric cancer; Laparoscopic total gastrectomy; Esophagojejunal anastomosis; Intracorporeal circular stapling

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