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Comment & Response
August 14, 2019

Combination of Surgery With Extensive Intraoperative Peritoneal Lavage for Patients With Advanced Gastric Cancer—Reply

Author Affiliations
  • 1Sun Yat-sen University Cancer Center, Guangzhou, China
JAMA Surg. Published online August 14, 2019. doi:10.1001/jamasurg.2019.2667

In Reply This letter is in response to the letters by Batista, Tai et al, and Kanemoto et al. We thank the editors for giving us the opportunity to rebut the issues raised about our study.1

We are grateful for Batista’s remarks because they reflect a common misinterpretation of postoperative complications. For the Japanese CCOG 1102 randomized clinical trial,2 the primary end point is disease-free survival, and secondary end points are overall survival, peritoneal recurrence-free survival, and incidence of adverse events. Thus, detailed records and observations may be lacking in “postoperative complications” such as abdominal pain. Moreover, in the trial including 27 patients by Ronellenfitsch et al,3 only half (14 cases) were pT3/4. Because peritoneal metastasis is caused by direct cancer cell dissemination from serosa-invasive tumors, the low number of patients with free peritoneal tumor cells was detected and the trial was closed early. As the author himself describes, “our study population is too small and long-term follow-up data are presently unavailable, so no sound conclusions can be drawn to that regard.”3 The study of Batista is similar, where only 8 patients were allocated to extensive intraoperative peritoneal lavage (EIPL) protocol. In our study, all surgeons have enough experience for D2 gastrectomy (>100 procedures per year) to ensure the quality of surgery. Therefore, few patients had postoperative complication, including gastrointestinal leakage. Indeed, in the CCOG 1102 study, only 2% cases had gastrointestinal leakages in non-EIPL and EIPL group, respectively.

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