Search Results (57)

Background and Objectives: The tumor-node-metastasis (TNM) classification system is the standard for staging gastric cancer and predicting survival. However, its accuracy can be compromised by insufficient lymph node (LN) dissection during surgery or inadequate pathologic examination. Alternative staging systems, such as the lymph node ratio (LNR) and log odds of positive lymph nodes (LODDS), may provide better prognostic value when LN examination is suboptimal. Because the current N staging system was not able to accurately stratify patients relative to their survival outcomes in our series, this study assessed the prognostic impact of LNR and LODDS on overall survival (OS) of patients who underwent radical gastrectomy for cancer. Materials and Methods: Between March 2005 and June 2025, the authors performed gastrectomy for gastric carcinoma in 114 patients. Out of these patients, 39 were excluded (19 had stage IV, while 20 underwent palliative gastrectomy with D1 lymphadenectomy). Thus, the study cohort included 75 patients who underwent curative gastrectomy, with 4 (5.3%) of them dying postoperatively. Potential prognostic factors associated with OS (including age, sex, tumor location, T stage, N stage, TNM stage, LNR, and LODDS) were evaluated by univariate and multivariate analysis. Because the recurrence data were missing in 41 patients, the disease-free survival (DFS) analysis would not be meaningful. Results: The OS analysis was based on the 71 patients surviving postoperatively. Because successive N stage groups could not accurately stratify patients according to their OS, we used X-tile software version 3.6.1 to identify two cut-offs (both for LNR and LODDS) that were able to stratify patients in three subgroups with significantly distinct survival outcomes. Multivariate analysis found that both LODDS and LNR systems were independent prognostic factors for OS. Conclusions: LNR and LODDS provide more detailed insights into lymph node status and have demonstrated potential for enhancing prognostic accuracy compared to N staging, even in patients who underwent curative gastrectomy with D2 lymphadenectomy. Although LNR and LODDS are usually useful in patients who underwent suboptimal lymphadenectomy, the current study demonstrated that these systems could improve prognostic stratification even in patients with more than 15 retrieved LNs. However, due to the small sample size, the current observations and proposed cut-offs of LNR and LODDS have to be validated in larger studies including such patients. Full article

Background/Objectives: Robotic-assisted surgery (RAS) has emerged as a technological advancement in gastrointestinal (GI) procedures, addressing limitations of conventional laparoscopy through enhanced dexterity, three-dimensional visualization, and ergonomic improvements. While its clinical use is expanding, the comparative benefits and cost-effectiveness of RAS across different GI domains remain unclear. Methods: An umbrella review was conducted to evaluate RAS across six GI domains: esophageal, gastric, liver, biliary, pancreatic, and colorectal. A systematic literature search of PubMed was performed in April 2025, yielding 8961 articles. Reviews published in English since 2018 and comparing RAS with laparoscopic or open approaches in human GI surgery were eligible. A total of 250 articles met the inclusion criteria. Data on technical feasibility, clinical outcomes, and cost-effectiveness were extracted. Methodological quality was appraised using the AMSTAR 2 checklist. Results were synthesized narratively. The study was supported by the National Research Foundation of Korea grant, and the protocol was registered in PROSPERO (CRD420251042541). Results: RAS demonstrated domain-specific advantages. Esophageal and gastric surgeries benefited from enhanced precision and lymphadenectomy, while long-term outcomes were comparable to laparoscopy. Robotic liver and biliary surgeries offered technical advantages in complex cases, but evidence was limited. The most significant clinical benefits were observed in pancreatic and colorectal procedures, in which RAS reduced conversion rates and improved short-term outcomes in anatomically challenging scenarios. Cost-effectiveness was generally unfavorable but showed improvement in high-volume centers due to reduced complications and shorter hospital stays. Conclusions: Robotic assistance provides the most consistent clinical benefit in pancreatic and colorectal surgery, especially for complex, high-risk cases. While high procedural costs remain a barrier, selective use of RAS in appropriate settings may yield improved outcomes. These findings support the need for ongoing evaluation of cost-effectiveness and long-term results to guide evidence-based integration of robotics into GI surgery. Full article

The vascular anatomy of the stomach is both complex and highly variable, with direct implications for oncologic, bariatric, esophageal, and interventional procedures. This comprehensive review combines anatomical, radiological, and surgical evidence on arterial and venous variations in the stomach. The left gastric artery, traditionally the first branch of the coeliac trunk, often shows variants such as a direct aortic origin or association with an abnormal left hepatic artery. The right gastric artery most frequently arises from the proper hepatic artery, but its origin can vary significantly. The gastroepiploic arteries exhibit diversity in their origin, size, and connection patterns, with occasional duplication or absence. Additional vessels, including the posterior gastric artery and the short gastric arteries, also contribute to variations in arterial supply. Venous drainage largely follows the arterial pattern. The left and right gastric veins and the gastroepiploic venous arcade are major routes, while variants of the left gastric vein and the gastrocolic trunk (Henle’s trunk) contribute to complexity through different convergence patterns. These vascular variations have significant clinical implications, as they impact the safety of D2 lymphadenectomy, the risk of ischemic complications during laparoscopic sleeve gastrectomy, the success of gastric conduit formation in esophagectomy, and the effectiveness of transarterial embolization for upper gastrointestinal bleeding. Preoperative vascular mapping with multidetector computed tomography angiography and 3D reconstruction reliably defines individual anatomy, allowing for customized surgical planning and reducing operative risks. Recognizing both common and rare gastric vascular variants is essential for safe and effective surgical and endovascular management of gastric disease. Full article

Background/Objectives: Advanced gastric cancer usually has an unfavorable prognosis. Stroma AReactive Invasion Front Area (SARIFA) is a newly recognized biomarker of aggressiveness, easily recognized as five tumor cells in direct contact with adipocytes in perigastric, submucosal, and perivascular adipose tissue. We investigated this phenomenon and correlated it with other pathohistological variables. Material and Methods: The sample includes 102 Croatian patients with locally advanced gastric cancer, who underwent total gastrectomy/lymphadenectomy between 2012–2018 and in 2023 at University Hospital Split, Croatia, and had pathological stage pT3 or pT4. Representative histological specimens were analyzed for SARIFA, and results were compared with other variables and overall survival. External validation and gene expression analysis of CD36 and FABP4 were performed using the TCGA-STAD cohort. Results: SARIFA was significantly associated with positive pN status (p = 0.009) and perineural invasion (p = 0.043). Patients with SARIFA had a more than fivefold increased risk of nodal involvement (OR = 6.35; 95% CI: 1.35–29.84; p = 0.019). Lymphovascular invasion (LVI) was associated with nodal disease (OR = 4.39; 95% CI: 1.194–16.143; p = 0.026), and SARIFA was marginally associated (OR = 4.886; 95% CI: 0.985–24.241; p = 0.052). Patients who had both LVI and SARIFA had a higher proportion of affected lymph nodes (p = 0.009). SARIFA status did not significantly affect overall survival. Gene expression analysis showed a significant increase in CD36 expression, while FABP4 expression was elevated but not statistically significant, in SARIFA-positive cases. Conclusions: SARIFA could be used as a marker for invasiveness and further investigated due to its predictive potential. Full article

Background/Objectives: Gastric cancer remains a leading cause of cancer-related mortality, with over 50% of cases diagnosed at a locally advanced or metastatic stage. High-quality surgical resection within the embryological mesogastric layer is critical for achieving optimal oncological outcomes but is often complicated by anatomical distortion in advanced tumors. This study aimed to develop and validate a system of topographic and anatomical navigation landmarks for embryologically guided laparoscopic gastrectomy, leveraging 3D modeling to enhance precision and safety. Methods: A single-center study was conducted, analyzing 78 patients undergoing emergency laparoscopic gastrectomy for locally advanced gastric cancer. Preoperative 3D models were generated from CT data annotations to map the stomach, tumor, vascular structures, and mesogastric adipose tissue. Thirty biomodels were used to refine dissection techniques. Surgical procedures adhered to embryological principles, with lymphadenectomy guided by predefined landmarks. Histopathological validation assessed resection margins and tumor infiltration in resected specimens. Statistical analysis compared outcomes between patients with and without 3D planning. Results: The 3D models demonstrated 100% concordance with intraoperative vascular anatomy. Radiologically dense adipose tissue, resected as potentially tumor-infiltrated, showed histopathological invasion in 74% of cases. R0 resection was achieved in 74.4% of patients. Operative time decreased from 300 to 250 min after technical optimization, with a 7.7% conversion rate (primarily due to vascular injury or tumor fixation). Postoperative mortality was 5.1%, attributed to comorbidities. Patients with 3D planning had significantly higher lymph node yields (p < 0.00001) and R0 rates (p = 0.045). Conclusions: The integration of embryologically based topographic landmarks and 3D navigation improves the safety and standardization of laparoscopic gastrectomy for locally advanced gastric cancer. This approach enhances oncological radicality, reduces operative time, and mitigates risks in anatomically distorted fields. Further validation in larger cohorts is warranted. Full article

Objective: This study aimed to investigate the prognostic value of the preoperative monocyte-to-high-density lipoprotein cholesterol ratio (MHR) and clinicopathological parameters for predicting survival outcomes in patients undergoing curative-intent gastrectomy for gastric adenocarcinoma. Methods: This retrospective cohort study analyzed data from 304 patients with histopathologically confirmed gastric adenocarcinoma who underwent curative-intent gastrectomy with standardized D1+ or D2 lymphadenectomy. The MHR was calculated using preoperative monocyte counts and HDL cholesterol levels. Patients were dichotomized based on the optimal MHR cutoff determined via receiver operating characteristic curve analysis with the Youden index. Survival outcomes, including overall survival (OS) and progression-free survival (PFS), were assessed using Kaplan–Meier analysis and compared with log-rank tests. Results: ROC analysis determined an optimal MHR cutoff of ≥11.02 (AUC: 0.654; 95% CI: 0.59–0.718), yielding sensitivities and specificities of 62.6% and 62.4%, respectively. Patients with an elevated MHR (≥11.02) had worse 5-year OS (51.4 vs. 72.2%; p < 0.001) and PFS (65.2 vs. 80.5%; p = 0.003). In the multivariate Cox regression model, elevated MHR emerged as an independent predictor of disease progression (HR: 1.93; 95% CI: 1.17–3.18; p = 0.010), while parameters such as signet ring cell histology, lymphovascular invasion, and perineural invasion were significant in univariate analyses but not in the adjusted multivariate model. Conclusions: MHR should not be regarded as a definitive predictor in isolation but rather as a cost-effective, readily obtainable adjunct within a broader preoperative risk assessment framework. Integration with other inflammation-based and clinicopathological factors may enhance predictive performance and clinical applicability. Full article

Background/Objectives: Neo-adjuvant chemotherapy (NACT) is increasingly utilized in Western countries for the treatment of gastric cancer (GC). While its oncologic benefits are well established, its impact on surgical safety and long-term outcomes remain a matter of debate. This study evaluates the real-world effect of NACT on perioperative and oncologic outcomes in a high-volume Western center. Methods: Data from 254 patients who underwent gastrectomy with D2 lymphadenectomy for GC between March 2016 and January 2024 were prospectively collected and retrospectively analyzed. Patients were categorized into an upfront surgery group (n = 144, 56.7%) and a NACT group (n = 110, 43.3%). The primary outcome was to compare the two study groups in terms of perioperative outcomes, as well as overall (OS) and disease-free survival (DFS). Multivariate analyses were conducted to identify factors associated with perioperative complications and long-term survival. Results: Patients in the NACT group were younger (median age 65 vs. 72 years; p = 0.001) and had fewer comorbidities. NACT was associated with a higher incidence of proximal tumors (54–49.1% vs. 37–25.7%; p = 0.001), diffuse-type tumors (27–45.8% vs. 39–31.7%; p = 0.03), and lymph-node metastases (82–74.1% vs. 84–58%; p = 0.007). No significant differences were observed in median hospital stay (9 (7–16) and 10 (8–22) days for the upfront and NACT groups, respectively; p = 0.26), post-operative mortality (11–7.6% and 5–4.5% for the upfront and NACT groups, respectively; p = 0.32), and major complications (30–20.8% and 23–20.9% for the upfront and NACT groups, respectively; p = 0.99). Among patients receiving NACT, the FLOT regimen was associated with a lower rate of complications (12–16.2% vs. 11–30.5% in the non-FLOT cohort; p = 0.05) and reoperations (4–5.4% vs. 8–22.2% in the non-FLOT group; p = 0.008). Tumor location was identified as an independent predictor of perioperative complications (OR 4.7, 95% C.I.: 1.56–14.18; p = 0.006), while non-FLOT regimens were independently associated with higher reoperation rates (OR 0.22, 95% C.I.: 0.06–0.86; p = 0.003). Five-year OS was comparable between the two groups (44.6% in the NACT group vs. 47.7% in the upfront surgery group; p = 0.96). N+ status (OR 2.5, 95% C.I. 1.42–4.40; p = 0.001) and R+ margins (OR 1.89, 95% C.I. 0.98–3.65; p = 0.006) were negative independent prognostic factors for DFS. Conclusions: Although several selection biases limit the generalizability of our findings, our results suggest that NACT prior to gastrectomy for GC does not increase postoperative morbidity and mortality in appropriately selected patients. However, its use in elderly and polymorbid patients should be carefully considered to determine the safest and most effective therapeutic approach, particularly in selecting the appropriate chemotherapy regimen, to minimize the risk of postoperative complications requiring surgical reintervention. Full article

Background: Proximal gastrectomy (PG) with double tract reconstruction (DTR) offers organ preservation for early gastric cancers, leading to reduced vitamin B12 deficiency, less weight loss, and improved quality of life. The JCOG1401 study confirmed excellent long-term outcomes for PG in stage I gastric cancer. However, in locally advanced proximal gastric cancer (LAPGC), preserving the gastric body and lymph node station 4d may compromise margin clearance and adequate lymphadenectomy. Methods: We propose a modified PG that removes the distal esophagus, gastroesophageal junction (GEJ), cardia, fundus, and gastric body, preserving only the antrum and performing DTR. Lymphadenectomy is also adapted, removing stations 1, 2, 3a, 4sa, 4sb, 4d, 7, 8, 9, 10 (spleen preserving), 11, and lower mediastinal nodes (stations 19, 20, and 110), while preserving stations 3b, 5, and 6. Indications for this procedure include GEJ (Siewert type II and III) and proximal gastric cancers with ≤2 cm distal esophageal involvement and ≤5 cm gastric involvement. Results: In our initial experience with 14 patients, we achieved R0 resection in all patients, adequate lymph node harvest (median 24 nodes, IQR 18–38), and no locoregional recurrences at a median follow-up of 18 months. We also found favorable postoperative weight loss, reflux, and anemia in the PG cohort. Conclusion: While larger studies and long-term data are still needed, our early results suggest that modified PG—despite sparing only the antrum—retains the key benefits of PG over total gastrectomy, including better weight maintenance and improved hemoglobin levels, while maintaining oncologic outcomes for LAPGC. Full article

Background and Objectives: Gastric cancer treatment of partial or complete gastrectomy includes lymph nodes dissection (D2) to remove microscopic lymph node metastases adjacent to the tumor. A more extensive approach, an extended dissection (D2plus) has recently been employed, which includes resection of the lymph nodes in the pancreatic and periportal areas. However, despite its potential benefits of longer survival for patients diagnosed with advanced cancer, there are increased risks due to surgical complications. The current study aims to examine the balance between clinical benefit and higher risks of the extended dissection approach versus standard dissection. Materials and Methods: This retrospective analysis of gastric cancer patients treated in Bnai-Zion medical center examined the survival rates, oncological outcomes, and complication rates according to medical records data files. Results: The D2plus group experienced increased postoperative complications rate (56% vs. 20.6% D2 group p = 0.005) with mean survival time, shorter than the D2 standard approach (2.07 years vs. 3.44 years p = 0.01). A higher number of lymph nodes was removed on average in the D2plus group (29.4 ± 11.2), but without statistical significance in comparison to the D2 group (22.6 ± 8.9, p = 0.013). D2plus patients had reduced disease recurrence rates (20% vs. 32.4% in D2 group p = 0.29). Weight loss of D2plus patients was noted for higher rates than the D2 group (40% vs. 17.6% p = 0.056. Conclusions: Our study provides preliminary insights into the comparison between D2 and D2plus dissection in a single-center Western cohort. However, significant baseline differences between groups, particularly age, gender, and histopathological characteristics, limit definitive conclusions. The findings should be interpreted as hypothesis-generating rather than practice-changing. Larger, prospective, multicenter studies with propensity score matching or randomized design are needed to definitively establish the optimal surgical approach for different patient subgroups. Full article

Total gastrectomy with D2 lymphadenectomy for gastric cancer is a complex surgical procedure with a moderate complication rate. Sometimes, some complications may have a misleading onset without a clear clinical presentation and blood test changes. In this case report, hiccups were the main symptom of subdiaphragmatic fluid collection after total gastrectomy. Full article

Background: Gastric neoplasms remain pathologies of the malignant spectrum with high incidence and prevalence, with their management requiring a precise histopathological characterization for optimal treatment planning. Methods: The present study is a retrospective analysis that included 67 histopathologically confirmed gastric neoplasia subjects and was performed at a single surgical center from January 2020 to December 2021. Demographics, tumor characteristics, surgical procedures, and oncologic outcomes were included, filtered, and subsequently analyzed using SPSS Statistics 29.0. Results: This study involved 67 patients (mean age 65.7 years, 56.7% men), with adenocarcinoma being the most common histologic type (91.0%) and most tumors being diagnosed directly as Stage III (40.3%). Lauren classification revealed the intestinal type as the most common (49.2%), followed by diffuse (36.1%) and mixed (14.8%). Poorly differentiated tumors (G3) accounted for 53.7% of cases. The surgical team performed curative resection in 75% (n = 50) of patients, achieving R0 margins in 88% of these cases. Subtotal gastrectomy with D2 lymphadenectomy yielded the highest curative success rate with 96.6% R0 resection. Statistically, we identified two significant correlations between age and tumor grade (rho = 0.28; p = 0.021) and between the number of lymph nodes examined and the number of lymph nodes invaded (rho = 0.65, p < 0.001). This study again revealed that adenocarcinomas showed higher rates of lymph node invasion than other tumor types (p = 0.017). Conclusions: The analysis of patients with gastric neoplasms is vital for appropriate therapeutic management. Even though the study period included a pandemic, the analysis remained a complex one with high-quality surgical outcomes, confirming the importance of maintaining oncologic standards during medical crises. Full article

Background/Objectives: Gastric adenocarcinoma and proximal polyposis of the stomach (GAPPS) is a recently discovered autosomal dominant transmission disease. Patients with this condition have a higher risk of developing gastric cancer. There are numerous questions regarding the natural history of this condition, as well as concerning the diagnostic and therapeutic management of these patients. In this systematic review, we aimed to examine the current literature to determine the role of prophylactic gastrectomy in patients diagnosed with gastric adenocarcinoma and proximal polyposis of the stomach. Additional outcomes are Helicobacter pylori (HP) infection, treatment with proton pump inhibitors (PPI), and colonoscopic examination and abdominal imaging examination, as they are important factors in the therapeutic decision. Methods: We performed a systematic review of the articles published in PubMed and Google Scholar, according to the PRISMA 2020 criteria. Results: We obtained 24 studies that included 83 patients diagnosed with GAPPS, of which 42 underwent prophylactic gastrectomy, 24 benefited from endoscopic follow-up, and 17 were diagnosed with gastric cancer at the first gastroscopic examination. In the prophylactic gastrectomy specimens, malignant gastric disease was confirmed in 10% of cases. GAPPS has been diagnosed more frequently in women. Conclusions: So far, the specialized literature includes a limited number of patients diagnosed with GAPPS. There are also no guidelines yet for the diagnosis and treatment of these patients. Prophylactic gastrectomy or endoscopic surveillance are the only options for patients diagnosed with GAPPS without gastric cancer at the initial examination. For prophylactic gastrectomy, the robotic and laparoscopic approach was preferred. For establishing appropriate lymphadenectomy in prophylactic gastrectomy, future research on gastrectomy specimens is necessary. Most of the included studies were deficient in terms of postoperative follow-up of patients. Thus, we consider it useful to include these patients in a single database. For a comprehensive examination of these and making an appropriate therapeutic decision, we consider it necessary to perform a colonoscopic evaluation, take abdominal imaging, and determine the Helicobacter pylori infection status. Full article

Background/Objectives: The Lymph Node Ratio (LNR) index is the proportion of lymph nodes with present metastases to lymph nodes removed and examined. This is an additionally established parameter for predicting the prognosis of gastric cancer patients. The most popular cancer classification, TNM, describes only the number of affected lymph nodes. It can result in a negative overestimation of the prognosis of patients with gastric cancer if the number of nodes examined is relatively limited. Methods: In this study, we retrospectively analyzed 194 patients diagnosed with gastric cancer operated on between 2017 and 2021 at the Clinical Department of Oncological Surgery, University Centre of General and Oncological Surgery of the University Clinical Hospital in Wroclaw. In total, 133 patients underwent gastrectomy with D2 lymphadenectomy and 61 remaining patients had the resection procedure abandoned due to an unresectable lesion. The LNR index was calculated based on histopathological examination, and postoperative complications were assessed using the Clavien–Dindo (C-D) scale. Statistical analysis was performed regarding the dependence of LNR on the following patient characteristics: sex, age, TNM features, tumor stage, tumor location, performed procedure, chemotherapy application, C-D complication rate, and survival rate. Results: The value of the LNR index significantly depends on TNM features (p < 0.05), clinical tumor stage (p < 0.05), and patient survival (p < 0.05), while no statistically significant relationship with C-D complication rate was demonstrated. Conclusions: The LNR index is a relevant parameter in predicting prognosis and survival time in gastric cancer patients, but future studies on larger and differentiated groups of patients could further confirm its usefulness in the development of guidelines. Full article

Introduction: Robot-assisted minimally invasive gastrectomy (RAMIG) represents a significant advancement in the surgical management of gastric cancer, offering superior dexterity, enhanced visualization, and improved ergonomics compared to laparoscopic gastrectomy (LG). This review systematically evaluates the current evidence on perioperative outcomes, oncological efficacy, learning curves, and economic considerations, providing insights into RAMIG’s potential role in modern gastric cancer surgery. Methods: A thorough analysis of retrospective, prospective, and meta-analytic studies was conducted to compare RAMIG with LG. Key outcomes, including operative time, intraoperative blood loss, lymph node retrieval, postoperative complications, learning curve duration, and cost-effectiveness, were assessed. Emphasis was placed on both short-term and long-term oncological outcomes to determine the clinical value of RAMIG. Results: Evidence indicates that RAMIG is associated with reduced intraoperative blood loss, lower morbidity rates, and a shorter learning curve, with proficiency achieved after 11–25 cases compared to 40–60 cases for LG. The robotic platform’s articulated instruments and enhanced three-dimensional visualization enable more precise lymphadenectomy, particularly in complex anatomical regions. Despite these advantages, operative time remains longer, and costs remain higher due to system acquisition, maintenance, and consumable expenses. However, emerging data suggest a gradual narrowing of cost disparities. While short-term outcomes are favorable, further high-quality, multicenter studies are needed to validate long-term oncological efficacy and survival outcomes. Conclusion: RAMIG offers significant technical and clinical advantages over conventional LG, particularly in terms of precision and learning efficiency. However, the long-term oncological benefits and economic feasibility require further validation. Future research should focus on cost optimization, advanced technological integration such as near-infrared fluorescence and artificial intelligence, and multicenter trials to solidify RAMIG’s role as a standard approach for gastric cancer surgery. Full article

Background: Lymphadenectomy is a fundamental part of surgical strategy in patients with gastric cancer. Lymph node (LN) status is a key point in assessment of prognosis in gastric cancer. The LN ratio (LNR)—number of positive LNs/number of sampled LNs—offers a new approach for predicting survival. The aim of the study was to find factors affecting LN yield and the impact of LNR on 5-year survival. Methods: Prospective multicenter quality assurance study. Only LN-positive patients were included in the LNR calculations. Results: 4946 patients from 149 hospitals were enrolled. The inclusion criteria were met by 1884 patients. Patients were divided into two groups: Group 1 (<16 LN), 456 patients and Group 2 (≥16 LN), 1428 patients. The multivariate analysis found G2 (OR 1.98; 95%CI 1.11–3.54), G3 (OR 2.15; 95%CI 1.212–3.829), UICC-stage II (OR 1.44; 95%CI 1.01–2.06) and III (OR 1.71; 95%CI 1.14–2.57), age < 70 (OR 1.818 95%CI 1.19–2.78) and female gender (OR 1.37; 95%CI 1.00–1.86) as independent factors of ≥16 LN yield. Patients with a LNR ≥ 0.4 have a lower probability of survival (p = 0.039 and <0.001) than patients with a LNR = 0.1. Patients with UICC-II have a lower probability of survival than UICC-I (p = 0.023). Age 70–80 (p = 0.045) and > 80 years (p = 0.003) were negative prognostic factors for long-term survival. Conclusion: Long-term survival is directly related to adequate lymphadenectomy. LNR could be superior to pN-stage for estimating survival and adds remarkable nuances in prognosis compared to UICC-stage. LNR also appears valid, even in the case of insufficient LN yield. Full article