Efficacy of laparoscopic subtotal gastrectomy with D2 lymphadenectomy for locally advanced gastric cancer: the protocol of the KLASS-02 multicenter randomized controlled clinical trial

Comparison of Intracorporeal and Extracorporeal Esophagojejunostomy after Laparoscopic Total Gastrectomy for Gastric Cancer: A Meta-Analysis Based on Short-Term Outcomes

Background:

Laparoscopic total gastrectomy (LTG) is increasingly performed in patients with gastric cancer. However, the usage of intracorporeal esophagojejunostomy (IEJ) following LTG is limited, as the safety and efficacy remain unclear. The present meta-analysis aimed to evaluate the feasibility and safety of IEJ following LTG.

Methods:

Studies published from January 1994 to January 2017 comparing the outcomes of IEJ and extracorporeal esophagojejunostomy (EEJ) following LTG were reviewed and collected from the PubMed, EBSCO, Cochrane Library, Embase, and China National Knowledge Internet (CNKI). Operative results, postoperative recovery, and postoperative complications were compared and analyzed. The weighted mean difference (WMD) and odds ratio (OR) with a 95% confidence interval (CI) were calculated using the Review Manager 5.3.

Results:

Seven nonrandomized studies with 785 patients were included. Compared with EEJ, IEJ has less blood loss (WMD: −13.52 ml; 95% CI: −24.82–−2.22; P = 0.02), earlier time to first oral intake (WMD: −0.49 day; 95% CI: −0.83–−0.14; P < 0.01), and shorter length of hospitalization (WMD: −0.62 day; 95% CI: −1.08–−0.16; P < 0.01). There was no significant difference between IEJ and EEJ regarding the operation time, anastomotic time, number of retrieved lymph nodes, time to first flatus, anastomosis leakage rate, anastomosis stenosis rate, and proximal resections (all P > 0.05).

Conclusions:

Compared with EEJ, IEJ has better cosmesis, milder surgical trauma, and a faster postoperative recovery. IEJ can be performed as safely as EEJ. IEJ should be encouraged to surgeons with sufficient expertise.

Hot issues in minimally invasive surgery for gastric cancer

Minimally invasive surgery has become an indispensable part of gastric cancer treatment after more than 20 years of rapid development. The change of operation indications, the innovation of minimally invasive devices and surgical technique, and the idea of innovation are hot issues in minimally invasive surgery for gastric cancer. In this paper, we will discuss these hot issues in detail.

Feasibility and Safety of Totally Laparoscopic Radical Gastrectomy for Advanced Gastric Cancer: Comparison with Early Gastric Cancer

Purpose

Totally laparoscopic gastrectomy (TLG) for advanced gastric cancer (AGC) is a technically and oncologically challenging procedure for surgeons. This study aimed to compare the oncologic feasibility and technical safety of TLG for AGC versus early gastric cancer (EGC).

Materials and Methods

Between 2011 and 2016, 535 patients (EGC, 375; AGC, 160) underwent curative TLG for gastric cancer. Clinicopathologic characteristics and surgical outcomes of both patient groups were analyzed and compared.

Results

Patients with AGC required a longer operation time and experienced more intraoperative blood loss than those with EGC did. However, patients from both the AGC and EGC groups demonstrated similar short-term surgical outcomes such as postoperative morbidity (14.4% vs. 13.3%, P=0.626), mortality (0% vs. 0.5%, P=0.879), time-to-first oral intake (2.7 days for both groups, P=0.830), and postoperative hospital stay (10.2 days vs. 10.1 days, P=0.886). D2 lymph node dissection could be achieved in the AGC group (95%), with an adequate number of lymph nodes being dissected (36.0±14.9). In the AGC group, the 3-year overall and disease-free survival rates were 80.5% and 73.7%, respectively.

Conclusions

TLG is as safe and effective for AGC as it is for EGC.

Compliance to D2 lymphadenectomy in laparoscopic gastrectomy

The objective of this study is to describe the compliance to D2 lymphadenectomy in laparoscopic gastrectomy. Radical partial or total gastrectomy with modified D2 lymphadenectomy is the standard of care for locally advanced gastric cancer. It is unclear whether compliance to D2 lymphadenectomy in laparoscopy is comparable to that in open surgery. A review of the literature was performed and results are described in a descriptive review. Available randomized trials are mostly performed for early gastric cancer, for which formal D2 lymphadenectomy is usually not required. Most trials report no differences in number of retrieved lymph nodes between open and laparoscopic gastrectomy. Only one trial used adherence to D2 lymphadenectomy as primary outcome parameter, and found no difference between laparoscopic and open gastrectomy. Results from randomized trials in advanced gastric cancer are awaited. In the meantime, the laparoscopic approach can be used in experienced centers.

Morbidity and mortality of elderly patients with advanced gastric cancer after laparoscopy-assisted or open distal gastrectomy: a randomized-controlled trial

Laparoscopy-assisted distal gastrectomy (LDG) combined with D2 lymphadenectomy may be safely performed in patients with advanced gastric cancer (AGC) by experienced surgeons at specialized high-volume institutions as shown in the Chinese Laparoscopic Gastrointestinal Surgery Study (CLASS)-01. However, studies focusing on the use of LDG in patients with gastric cancer older than 65 years are rare. This study was designed to investigate the morbidity and mortality of elderly patients with gastric cancer who underwent laparoscopic-assisted or open distal gastrectomy (ODG). In this prospective, randomized, open, parallel controlled trial, patients older than 65 years with tumor located at the middle or lower part of the stomach will be enrolled in this study. Patients will be randomly divided into a laparoscopic group and an open surgery group. The early post-operative complications, intra-operative complications and post-operative recovery will be compared between the two groups. This trial will provide valuable clinical evidence for the objective assessment of the feasibility, short-term safety, and potential benefits of LDG compared with ODG for gastric cancer in the elderly patients. This trial has been registered on ClinicalTrials.gov. (Identifier: NCT02246153.) in September 22, 2014.

Circular versus linear stapling in esophagojejunostomy after laparoscopic total gastrectomy for gastric cancer: a propensity score-matched study

PURPOSE

We used propensity score matching to compare the complication rates after laparoscopic total gastrectomy (LTG) with esophagojejunostomy (EJS) performed using a circular or a linear stapler.

METHODS

We retrospectively enrolled all patients who underwent curative LTG between November 2004 and March 2016. Patients were categorized into the circular and linear groups according to the stapler type used for the subsequent EJS. Patients in the groups were matched using the following propensity score covariates: age, sex, body mass index, American Society of Anesthesiologists physical status, extent of lymph node dissection, and Japanese Classification of Gastric Carcinoma stage. Clinicopathological characteristics and surgical outcomes were compared.

RESULTS

We identified 66 propensity score-matched pairs among 379 patients who underwent LTG. There was no significant between-group difference in the median operative time, extent of lymph node dissection, number of lymph nodes resected, rate of conversion to open surgery, or number of surgeries performed by a surgeon certified by the Japanese Society of Endoscopic Surgery. In the circular and linear groups, the rate of all complications (Clavien-Dindo [CD] classification ≥ I; 21 vs. 26%, respectively; p = 0.538), complications more severe than CD grade III (14 vs. 14%, respectively; p = 1.000), and occurrence of EJS leakage and stenosis more severe than CD grade III (5 vs. 2%, p = 0.301; 9 vs. 8%, p = 0.753, respectively) were comparable.

CONCLUSIONS

There is no difference in the postoperative complication rate related to the type of stapler used for EJS after LTG.

Factors influencing health-related quality of life after gastrectomy for cancer

AIM

Insight in health-related quality of life (HRQoL) may improve clinical decision making and inform patients about the long-term effects of gastrectomy. This study aimed to evaluate and identify factors associated with HRQoL after gastrectomy.

METHODS

This cross-sectional study used prospective databases from seven Dutch centers (2001-2015) including patients who underwent gastrectomy for cancer. Between July 2015 and November 2016, European Organization for Research and Treatment of Cancer HRQoL questionnaires QLQ-C30 and QLQ-STO22 were sent to all surviving patients without recurrence. The QLQ-C30 scores were compared to a Dutch reference population using a one-sample t test. Spearman's rank test was used to correlate time after surgery to HRQoL, and multivariable linear regression was performed to identify factors associated with HRQoL.

RESULTS

A total of 222 of 274 (81.0%) patients completed the questionnaires. Median follow-up was 29 months (range, 3-171) and 86.9% of patients had a follow-up >1 year. The majority of patients had undergone neoadjuvant treatment (64.4%) and total gastrectomy (52.7%). Minimally invasive gastrectomy (MIG) was performed in 50% of the patients. Compared to the general population, gastrectomy patients scored significantly worse on most functional and symptom scales (p < 0.001) and slightly worse on global HRQoL (78 vs. 74, p = 0.012). Time elapsed since surgery did not correlate with global HRQoL (Spearman's ρ = 0.06, p = 0.384). Distal gastrectomy, neoadjuvant treatment, and MIG were associated with better HRQoL (p < 0.050).

CONCLUSION

After gastrectomy, patients encounter functional impairments and symptoms, but experience only a slightly impaired global HRQoL. Distal gastrectomy, the ability to receive neoadjuvant treatment, and MIG may be associated with HRQoL benefits.

Long-term oncologic outcomes of robotic gastrectomy for gastric cancer compared with laparoscopic gastrectomy

BACKGROUND

Initial experiences with robotic gastrectomy (RG) for gastric cancer have demonstrated favorable short-term outcomes, suggesting that RG is an effective alternative to laparoscopic gastrectomy (LG). However, data on long-term survival and recurrence after RG for gastric cancer have yet to be reported. The objective of this study was to assess long-term outcomes after RG compared with LG.

METHODS

We retrospectively evaluated 313 and 524 patients who underwent RG or LG, respectively, for gastric cancer between July 2005 and December 2009. We compared long-term outcomes using the entire and a propensity-score matched cohort.

RESULTS

The entire cohort analysis revealed no statistically significant differences in 5-year overall survival(OS) or relapse-free survival(RFS) (p = 0.4112 and p = 0.8733, respectively): 93.3% [95% confidence interval (CI) 89.9-95.6] and 90.7% (95% CI, 86.9-93.5) after RG and 91.6% (95% CI 88.9-93.7) and 90.5% (95% CI 87.6-92.7) after LG, respectively; hazard ratios for death and recurrence in the robotic group were 0.828 (95% CI, 0.528-1.299; p = 0.4119) and 0.968 (95% CI, 0.649-1.445; p = 0.8741), respectively. The propensity-matched cohort analysis demonstrated no statistically significant differences for 5-year OS or RFS (p = 0.5207 and p = 0.2293, respectively): 93.2% and 90.7% after RG and 94.2% and 92.6% after LG, respectively; hazard ratios for death and recurrence in the robotic group were 1.194 (95% CI, 0.695-2.062; p = 0.5214) and 1.343 (95% CI, 0.830-2.192; p = 0.2321), respectively.

CONCLUSION

The potential technical superiority of robotic system over laparoscopy did not improve oncological outcomes after gastrectomy. Long-term oncological outcomes were not different between RG and LG. Nevertheless, robotic applications in minimally invasive gastric cancer surgery may be an oncologically safe alternative.

Efficacy of Adjuvant S-1 Versus XELOX Chemotherapy for Patients with Gastric Cancer After D2 Lymph Node Dissection: A Retrospective, Multi-Center Observational Study

BACKGROUND

After curative resection of gastric cancer with D2 lymph node dissection, postoperative adjuvant chemotherapy with S-1 or capecitabine plus oxaliplatin (XELOX) is considered to be standard therapy in Eastern countries. This study aimed to compare the efficacies of adjuvant S-1 and XELOX chemotherapy for gastric cancer patients after D2 dissection based on disease-free survival (DFS).

METHODS

This retrospective observational study was conducted at 29 tertiary hospitals in Korea. Of 1898 patients who underwent curative resection and received adjuvant chemotherapy for gastric cancer between February 2012 and December 2013, 1088 patients who met the eligibility criteria were enrolled in the study. After propensity score-matching, the 3-year disease-free survival rate (DFS) was used to compare efficacies directly between adjuvant XELOX and S-1 chemotherapies for patients with stage 2 or 3 gastric cancer after D2 gastrectomy.

RESULTS

The 3-year DFS rates for the S-1 and XELOX groups did not differ significantly among disease stages 2A, 2B, and 3A (all p > 0.05). However, the survival rates for the S-1 group were significantly lower than for the XELOX group for stage 3B (65.8% vs. 68.6%; p = 0.019) and stage 3C (48.4% vs. 66.7%; p = 0.002) gastric cancer. The hazard ratios (HRs) of S-1 chemotherapy for recurrence compared with XELOX for stages 3B and 3C were respectively 2.030 [95% confidence interval (CI), 1.110-3.715; p = 0.022] and 2.732 (95% CI 1.427-5.234; p = 0.002).

CONCLUSIONS

Adjuvant XELOX chemotherapy was more effective than S-1 for patients with stage 3B or 3C gastric cancer after D2 lymph node dissection.

Laparoscopic Reinforcement Suture (LARS) on Staple Line of Duodenal Stump Using Barbed Suture in Laparoscopic Gastrectomy for Gastric Cancer: a Prospective Single Arm Phase II Study

Purpose

Laparoscopic gastrectomy is accepted as a standard treatment for patients with early gastric cancer in Korea, Japan, and China. However, duodenal stump leakage remains a fatal complication after gastrectomy. We conducted a prospective phase II study to evaluate the safety of the new technique of laparoscopic reinforcement suture (LARS) on the duodenal stump.

Materials and Methods

The estimated number of patients required for this study was 100 for a period of 18 months. Inclusion criteria were histologically proven gastric adenocarcinoma treated with laparoscopic distal or total gastrectomy and Billroth II or Roux-en-Y reconstruction. The primary endpoint was the incidence of duodenal stump leakage within the first 30 postoperative days. The secondary endpoints were early postoperative outcomes until discharge.

Results

One hundred patients were enrolled between February 2016 and March 2017. The study groups consisted of 65 male and 35 female patients with a mean age (years) of 62.3. Of these, 63 (63%) patients had comorbidities. The mean number of retrieved lymph nodes was 38. The mean operation time was 145 minutes including 7.8 minutes of mean LARS time. There was no occurrence of duodenal stump leakage. Thirteen complications occurred, with one case of reoperation for splenic artery rupture and one case of mortality.

Conclusions

Based on the results of this prospective phase II study, LARS can be safely performed in a short operation period without development of duodenal stump leakage. A future randomized prospective controlled trial is required to confirm the surgical benefit of LARS compared to non-LARS.

A systematic review and meta-analysis of robot-assisted versus laparoscopically assisted gastrectomy for gastric cancer

BACKGROUND

Robotic-assisted gastrectomy (RAG) has been used for gastric cancer since 2002. This meta-analysis was carried out to evaluate whether RAG is safer and more effective than conventional laparoscopically assisted gastrectomy (LAG) for gastric cancer.

METHODS

We performed a manual search for these 2 types of operations (RAG and LAG) in the PubMed, Embase, and the Cochrane Library databases up to April 30, 2016. Twelve nonrandomized controlled trials that reported on RAG and LAG for gastric cancer were included. Outcomes evaluated included operation time, number of retrieved lymph nodes, blood loss, length of the resection margin, complications, and postoperative hospital stay.

RESULTS

A total of 3744 patients in 12 studies were included (1134 patients in the RAG group and 2610 patients in the LAG group). The operation time was significantly shorter in the LAG group [weighted mean difference (WMD) 42.0 (95% confidence interval, 95% CI 28.11-55.89) minutes; P < .00001], while the loss of blood volume was lower in the RAG group (P = .01). The number of retrieved lymph nodes, duration of postoperative stay, length of the proximal resection margin, length of the distal resection margin, and postoperative complications were similar between groups.

CONCLUSION

We conclude that RAG is a safe and appropriate treatment for gastric cancer patients in comparison to LAG. Nevertheless, RAG is not superior to LAG. Future research on RAG should focus on comparing the differences in retrieved lymph nodes in different tiers, evaluating the postoperative recovery and reducing the cost of the treatment.

Yonsei criteria: a clinical reflection of stage I left-sided pancreatic cancer

In this study, we examined associations between pancreatic cancer that met the Yonsei criteria (YC) and classifications from the 8th edition of the American Joint Committee on Cancer (AJCC) staging system. Clinicopathological and survival data were collected from132 patients who underwent distal pancreatectomy for left-sided pancreatic ductal adenocarcinoma between January 2000 and December 2015, and the utility of the YC for selecting treatment and predicting survival was evaluated using the 8th AJCC staging manual. Of the 102 patients who ultimately qualified for the study, 45 patients were reclassified as stage I based on the 8th AJCC cancer staging system. Disease-free survival and disease-specific survival periods were longer in stage I patients who met the YC than in those who did not. Clinicopathological characteristics did not differ between stage I patients who did and did not meet the YC. These results suggest that meeting the YC criteria may be a clinical indicator that left-sided pancreatic cancer patients who are candidates for resection have early-stage disease according to the 8th edition of the AJCC staging manual.

Evolution trends of indications for laparoscopic surgery in patients with gastric cancer

Laparoscopic surgery for gastric cancer has the advantages open surgery of less blood loss, shorter postoperative hospital stay, faster postoperative recovery and smaller scar and has been widely carried out worldwide. Since laparoscopic surgery for gastric cancer was carried out 20 years ago, the indications for laparoscopic gastric surgery has been expanding with the continuous progress of science and technology, the innovation of equipment, the improvement of the level of laparoscopic surgeons' awareness, and the obtainment of high quality clinical evidence. Here we review the evolution trends of indications for laparoscopic surgery in patients with gastric cancer.

Combined acupuncture and general anesthesia on immune and cognitive function in elderly patients following subtotal gastrectomy for gastric cancer

This study investigated the effects of acupuncture combined with general anesthesia on postoperative immune and cognitive functions in elderly patients undergoing subtotal gastrectomy. We recruited 96 elderly patients who received anesthesia for subtotal gastrectomy and randomly divided them into control (n=48) and experimental (n=48) groups. The control group received general anesthesia and the experimental group received combined acupuncture and general anesthesia. We measured hemodynamic immediately before and after anesthesia induction, and immune observations before and after surgery. We found no significant differences in mean heart rate (HR), mean oxygen saturation (SpO2), and partial pressure of end-tidal carbon dioxide (PETCO2) in the perioperative period between the two groups. Mean arterial pressure (MAP) was lower in the experimental group than that in the control group (P<0.05). The levels of cluster of differentiation 3 (CD3⁺), CD4⁺ and CD4⁺/CD8⁺ in both groups were significantly lower after surgery in both groups (P<0.05). We also found some time-points in which the immune markers where significantly higher in the experimental group. In terms of adverse reactions, there were no differences in nausea, vomiting, and hypoxemia between the two groups (P>0.05), but the incidence of delayed recovery and postoperative agitation were significantly lower in the experimental group compared with those in the control group (P<0.05). One day after surgery, the experimental group showed better protection of cognitive function than the control group (P<0.05). Overall, combined acupuncture and general anesthesia in elderly gastric cancer patients receiving subtotal gastrectomy showed more stable hemodynamics and fewer stress responses during surgery. Thus, combined acupuncture and general anesthesia can shorten the recovery time from anesthesia, have less negative effects on immune function and decrease the incidence of postoperative cognitive impairment.

Laparoscopic Gastrectomy Performed by an Expert in Open Gastrectomy

Purpose

Senior surgeons prefer open gastrectomy (OG), while young surgeons prefer laparoscopic gastrectomy (LG). The purpose of this study was to evaluate the surgical outcomes of LG performed by a senior surgeon who was an expert in OG during his learning period, by comparing them with LGs performed by a young surgeon.

Materials and Methods

A senior surgeon performed 50 curative gastrectomies with laparoscopy (LG-S group) from March 2015 to August 2016. A young surgeon's initial 50 LGs comprised the LG-Y group. Clinicopathological characteristics and surgical outcomes were compared between the LG-S and LG-Y groups.

Results

D2 lymphadenectomy was more frequently performed in the LG-S group than in the LG-Y group (P=0.029). The operation time and number of retrieved lymph nodes did not significantly differ between the 2 surgeons (P=0.258 and P=0.410, respectively). Postoperative hospital stay and postoperative complication rate were similar between 2 groups (P=0.234 and P=1.000, respectively). Similarly, significant decreases in operation time with increasing case numbers were observed for both surgeons, whereas the number of retrieved lymph nodes increased significantly in the LG-Y group but not in the LG-S group.

Conclusions

The LG outcomes when performed by the senior surgeon were comparable to those when performed by the young surgeon, despite performing more extended lymphadenectomies. Senior surgeons who are experts in OG should not refrain from performing LG.

Survey on laparoscopic total gastrectomy at the 11th China-Korea-Japan Laparoscopic Gastrectomy Joint Seminar

INTRODUCTION

Laparoscopic total gastrectomy (LTG) has been widely performed for gastric cancer in China, Korea, and Japan. The current status of this surgical approach needs to be investigated.

METHODS

During the 11th China-Korea-Japan Laparoscopic Gastrectomy Joint Seminar in Shanghai, China, on 5 March 2016, a questionnaire was completed by 65 experts in LTG. The survey included questions on surgical indication, operation team, laparoscopic instruments, and operative procedures.

RESULTS

Of the 65 respondents, 35 (53.8%) were from China, 18 (27.7%) were from Korea, and 12 (18.5%) were from Japan. Surgeons have various indications for LTG. Among respondents, stage II gastric cancer (42.9%) was the most acceptable indication, but Japanese surgeons were more cautious on this issue (P = 0.005). Using a flexible scope was more popular with Japanese surgeons than with others (P = 0.003). A goose-neck curved grasper was used more often in China and Korea than in Japan (P = 0.006). Chinese surgeons preferred vertical subxiphoid mini-laparotomy rather than vertical transumbilical laparotomy. Intracorporeal reconstruction (73.0%) was most frequently adopted for LTG. Linear staplers (53.8%) and circular staplers (42.1%) were both popular for esophagojejunostomy. However, jejunojejunostomy was more often conducted extracorporeally (67.7%), in which case a linear stapler (86.4%) was usually selected. Significant differences were observed between the three countries with regard to reinforcement of the duodenal stump (P = 0.018) and closure of Peterson's space (P < 0.001).

CONCLUSION

This survey on LTG involving surgeons from China, Korea, and Japan clearly informed the current practice of this surgical approach and will likely aid future research studies as well as clinical treatment for gastric cancer.

Short-term outcomes of laparoscopic total gastrectomy for gastric cancer: a comparative study with laparoscopic distal gastrectomy at a high-volume center

BACKGROUND

Laparoscopic distal gastrectomy (LDG) for gastric cancer has gradually gained popularity. However, laparoscopic total gastrectomy (LTG) has been reported rarely when compared with LDG. This study was designed to evaluate the surgical outcomes as well as the morbidity and mortality of LTG compared with LDG to confirm the feasibility and safety of LTG.

MATERIAL AND METHODS

We reviewed the data of patients at our institution undergoing LTG (n = 448) or LDG (n = 956) for gastric cancer between January 2008 and July 2016. Then the clinical characteristics and perioperative clinical outcomes of the two groups were compared.

RESULTS

Except for tumor size and stage, there were no statistically significant differences in the clinicopathological parameters between the groups. LTG was associated with significantly longer operation time, late time to postoperative diet, and longer hospital stay compared with the LDG group. Overall complications developed in 60 patients (13.4%) and surgical complications in 48 patients (10.7%) after LTG. Postoperative complications were less frequent in the LDG group than in the LTG group (8.4% versus 13.4%, p < .01), and fewer surgical complications were observed with LDG than with LTG (7.5% versus 10.7%, p = .05).

CONCLUSIONS

The results of LTG were favorable even though are not inferior to those of LDG. LTG for gastric cancer is technically feasible and safe. However, because of the limits of this study, other high-quality studies are needed for further evaluation.

Lymphadenectomy with Optimum of 29 Lymph Nodes Retrieved Associated with Improved Survival in Advanced Gastric Cancer: A 25,000-Patient International Database Study

BACKGROUND

Gastric adenocarcinoma is an aggressive disease with frequent lymph node (LN) metastases for which lymphadenectomy results in a survival benefit. In the US, the National Comprehensive Cancer Network guidelines recommend D2 lymphadenectomy or a minimum of 15 LNs retrieved. However, retrieval of only 15 LNs is considered by most international guidelines as inadequate. We sought to evaluate the survival benefits associated with a more complete lymphadenectomy.

STUDY DESIGN

An international database was constructed by combining gastric cancer cases from the Surveillance, Epidemiology, and End Results program database (n = 13,932) and the Yonsei University Gastric Cancer database (n = 11,358) (total n = 25,289). Kaplan-Meier survival analysis was performed along with Joinpoint analysis to obtain the optimal number of LNs to retrieve based on survival. Prognostic significance of number of nodes retrieved was then confirmed with univariate and multivariate analyses.

RESULTS

Analysis for both mean and median survival yielded 29 LNs removed as the Joinpoint. This was confirmed with multivariate analysis, where 15 retrieved LNs cutoff fell out of the model and 29 retrieved LNs remained intact, with a hazard ratio of 0.799 (95% CI 0.759 to 0.842; p < 0.001). Stage-stratified Kaplan-Meier analysis for a cutoff point of 29 LNs also demonstrated a statistically significant improvement in survival.

CONCLUSIONS

Joinpoint analysis has allowed for the creation of a model demonstrating the point at which additional dissection would not provide additional benefit. This large international dataset analysis demonstrates that the maximal survival advantage is seen by performing a lymphadenectomy with a minimum of 29 LNs retrieved.

Minimally invasive surgery for gastric cancer: the American experience

BACKGROUND

Minimally invasive surgical techniques are increasingly being implemented in oncologic care. This study assesses the impact of minimally invasive surgery on oncologic and perioperative outcomes in the management of gastric cancer in the USA.

METHODS

From the American College of Surgeons and American Cancer Society National Cancer Data Base, we identified 6427 patients who underwent gastrectomy for cancer from 2010 to 2012. Treatment groups were categorized with an intention-to-treat paradigm as robotic, laparoscopic, and open surgery. Univariate and multivariate analyses were performed to estimate the impact of the surgical approach on oncologic and perioperative outcomes.

RESULTS

Of patients undergoing definitive surgical intervention, 3.5 % (n = 223) underwent robotic gastrectomy, 23.1 % (n = 1487) underwent laparoscopic gastrectomy, and 73.4 % (n = 4717) underwent open surgery. Minimally invasive gastrectomy was more frequently performed on white (P = 0.018), privately insured patients (P = 0.049) treated at academic centers (P < 0.0001) in the eastern USA (P < 0.0001). After demographics, comorbidities, and tumor-related factors had been controlled for, patients who underwent laparoscopic gastrectomy had the postoperative length of stay decreased by 1.08 days (P < 0.0001) and greater odds of having at least 15 lymph nodes resected (odds ratio 1.16, P = 0.023). Use of robotic surgery did not have a statistically significant effect on the postoperative length of stay relative to open surgery (P = 0.222) but the patients so treated had greater odds of having at least 15 lymph nodes resected (odds ratio 1.51, P = 0.005). There were no differences in R0 resection rates or perioperative mortality on the basis of the surgical approach alone.

CONCLUSIONS

These findings suggest that use of minimally invasive surgery for gastric cancer in the USA is impacting the adequacy of oncologic resection but is not yet having a clinically significant impact on perioperative outcomes relative to a conventional open approach.

Differences in the multimodal treatment of gastric cancer: East versus west

There has been a great deal of interest about varying treatment paradigms of gastric cancer in Eastern and Western countries. Differences in tumor biology, screening initiatives, surgical approach, extent of lymphadenectomy, and neoadjuvant versus adjuvant chemotherapy regimens have been studied and documented in the literature. The purpose of this review is to give an updated report on the current status and management differences in the treatment of gastric cancer between Eastern and Western countries.

Timing of initiation of adjuvant chemotherapy for gastric cancer: A case-matched comparison study of laparoscopic vs. open surgery

BACKGROUND

Laparoscopic gastrectomy (LG) is reported to be associated with faster recovery than open gastrectomy (OG); however, the influence of the surgical approach on initiation timing of adjuvant chemotherapy (AC) remains unclear.

METHODS

This was a single-institutional retrospective observational study. Patients with pathological stage II/III gastric cancer undergoing LG with D2 lymphadenectomy (LG group: n = 74) were matched 1:1 with patients selected from 214 similar patients undergoing OG (OG group: n = 74), identically matching gender, age, pathological stage, and type of gastrectomy, and comparing AC initiation timing between the two groups. Factors associated with delayed initiation of AC were investigated in a multivariable analysis.

RESULTS

AC was performed in 86.5% (LG) and 83.8% (OG) of patients (p = 0.64). The median time interval before AC was significantly shorter in the LG vs. OG group (5.7 vs. 6.6 weeks, respectively, p < 0.001), and significantly more patients received AC within 6 weeks (60.8% vs. 27.0%, p < 0.001). Independent factors associated with delayed initiation of AC (>6 weeks) were: morbidity (≥grade 3a; odds ratio (OR): 16.1, 95% confidence interval (CI): 1.86-143), open surgery (OR: 5.17, 95% CI: 2.50-13.1), and postoperative weight loss ≥ 8% (OR: 2.47, 95% CI: 1.07-5.71).

CONCLUSIONS

LG may be associated with shorter intervals before AC. Postoperative morbidity should be reduced as much as possible.

Development and external validation of preoperative risk models for operative morbidities after total gastrectomy using a Japanese web-based nationwide registry

BACKGROUND

Total gastrectomy is a relatively difficult and invasive procedure among gastrointestinal surgeries, and major morbidities following total gastrectomy can be serious and fatal. This study aimed to develop and validate preoperative risk models of morbidities associated with total gastrectomy using a Japanese web-based nationwide registry.

METHODS

The national clinical database was used to retrieve the records of 39,253 patients who underwent total gastrectomy in 1,841 hospitals between January 1, 2011 and December 31, 2012.

RESULTS

Mean patient age was 69.1 years, and 73.8% of the patients were male. The overall morbidity rate was 21.5%, which included 8.1% with surgical site infection (SSI), 4.5% with anastomotic leak, 5.0% with pancreatic fistula, 3.7% with pneumonia, 1.9% with prolonged ventilation, and 1.2% with renal failure. Sex, splenectomy, and Brinkman index were selected as common risk factors for SSI, anastomotic leak, and pancreatic fistula. Pancreatectomy was the most significant preoperative risk factor in the risk model of SSI and pancreatic fistula. Need of assistance with activities of daily living, chronic obstructive pulmonary disease, previous cerebrovascular disease, American Society of Anesthesiologists score class 3 and over, presence of esophageal cancer, and body mass index more than 25 were selected as common risk factors for pneumonia, prolonged ventilation over 48 h, and renal failure.

CONCLUSIONS

We have created the first reported risk models of morbidities associated with total gastrectomy, using a Japanese nationwide database. The risk models developed in this study may be useful to preoperatively predict operative morbidities in patients undergoing total gastrectomy.

Safety and feasibility of minimally invasive gastrectomy during the early introduction in the Netherlands: short-term oncological outcomes comparable to open gastrectomy

BACKGROUND

Minimally invasive techniques for gastric cancer surgery have recently been introduced in the Netherlands, based on a proctoring program. The aim of this population-based cohort study was to evaluate the short-term oncological outcomes of minimally invasive gastrectomy (MIG) during its introduction in the Netherlands.

METHODS

The Netherlands Cancer Registry identified all patients with gastric adenocarcinoma who underwent gastrectomy with curative intent between 2010 and 2014. Multivariable analysis was performed to compare MIG and open gastrectomy (OG) on lymph node yield (≥15), R0 resection rate, and 1-year overall survival. The pooled learning curve per center of MIG was evaluated by groups of five subsequent procedures.

RESULTS

Between 2010 and 2014, a total of 277 (14%) patients underwent MIG and 1633 (86%) patients underwent OG. During this period, the use of MIG and neoadjuvant chemotherapy increased from 4% to 39% (p < 0.001) and from 47% to 62% (p < 0.001), respectively. The median lymph node yield increased from 12 to 20 (p < 0.001), and the R0 resection rate remained stable, from 86% to 91% (p = 0.080). MIG and OG had a comparable lymph node yield (OR, 1.01; 95% CI, 0.75-1.36), R0 resection rate (OR, 0.86; 95% CI, 0.54-1.37), and 1-year overall survival (HR, 0.99; 95% CI, 0.75-1.32). A pooled learning curve of ten procedures was demonstrated for MIG, after which the conversion rate (13%-2%; p = 0.001) and lymph node yield were at a desired level (18-21; p = 0.045).

CONCLUSION

With a proctoring program, the introduction of minimally invasive gastrectomy in Western countries is feasible and can be performed safely.

Laparoscopic and robot-assisted gastrectomy for gastric cancer: Current considerations

Radical gastrectomy with an adequate lymphadenectomy is the main procedure which makes it possible to cure patients with resectable gastric cancer (GC). A number of randomized controlled trials and meta-analysis provide phase III evidence that laparoscopic gastrectomy is technically safe and that it yields better short-term outcomes than conventional open gastrectomy for early-stage GC. While laparoscopic gastrectomy has become standard therapy for early-stage GC, especially in Asian countries such as Japan and South Korea, the use of minimally invasive techniques is still controversial for the treatment of more advanced tumours, principally due to existing concerns about its oncological adequacy and capacity to carry out an adequately extended lymphadenectomy. Some intrinsic drawbacks of the conventional laparoscopic technique have prevented the worldwide spread of laparoscopic gastrectomy for cancer and, despite technological advances in recent year, it remains a technically challenging procedure. The introduction of robotic surgery over the last ten years has implied a notable mutation of certain minimally invasive procedures, making it possible to overcome some limitations of the traditional laparoscopic technique. Robot-assisted gastric resection with D2 lymph node dissection has been shown to be safe and feasible in prospective and retrospective studies. However, to date there are no high quality comparative studies investigating the advantages of a robotic approach to GC over traditional laparoscopic and open gastrectomy. On the basis of the literature review here presented, robot-assisted surgery seems to fulfill oncologic criteria for D2 dissection and has a comparable oncologic outcome to traditional laparoscopic and open procedure. Robot-assisted gastrectomy was associated with the trend toward a shorter hospital stay with a comparable morbidity of conventional laparoscopic and open gastrectomy, but randomized clinical trials and longer follow-ups are needed to evaluate the possible influence of robot gastrectomy on GC patient survival.

Ongoing surgical clinical trials on minimally invasive surgery for gastric cancer: Korea

Since Korean Laparoscopic Gastrointestinal Surgery Study (KLASS) group was activated in 2003, several randomized controlled trials (RCTs) have finished or are ongoing in Korea to evaluate oncologic safety and feasibility of minimally invasive surgery (MIS) for gastric cancer by KLASS group as well as other expert surgeons. MIS in gastric cancer is regarded as one of standard treatment modality for early gastric cancer (EGC) and the indication is going expansion with the accumulation of evidence. This review covers current status of ongoing clinical trials on MIS for gastric cancer in Korea.

Worldwide practice in gastric cancer surgery

AIM: To evaluate the current status of gastric cancer surgery worldwide.

METHODS: An international cross-sectional survey on gastric cancer surgery was performed amongst international upper gastro-intestinal surgeons. All surgical members of the International Gastric Cancer Association were invited by e-mail to participate. An English web-based survey had to be filled in with regard to their surgical preferences. Questions asked included hospital volume, the use of neoadjuvant treatment, preferred surgical approach, extent of the lymphadenectomy and preferred anastomotic technique. The invitations were sent in September 2013 and the survey was closed in January 2014.

RESULTS: The corresponding specific response rate was 227/615 (37%). The majority of respondents: originated from Asia (54%), performed > 21 gastrectomies per year (79%) and used neoadjuvant chemotherapy (73%). An open surgical procedure was performed by the majority of surgeons for distal gastrectomy for advanced cancer (91%) and total gastrectomy for both early and advanced cancer (52% and 94%). A minimally invasive procedure was preferred for distal gastrectomy for early cancer (65%). In Asia surgeons preferred a minimally invasive procedure for total gastrectomy for early cancer also (63%). A D1+ lymphadenectomy was preferred in early gastric cancer (52% for distal, 54% for total gastrectomy) and a D2 lymphadenectomy was preferred in advanced gastric cancer (93% for distal, 92% for total gastrectomy)

CONCLUSION: Surgical preferences for gastric cancer surgery vary between surgeons worldwide. Although the majority of surgeons use neoadjuvant chemotherapy, minimally invasive techniques are still not widely adapted.

Laparoscopic splenic hilar lymphadenectomy for advanced gastric cancer

Laparoscopic distal gastrectomy has recently become accepted as a surgical option for early gastric cancer in the distal stomach, but laparoscopic total gastrectomy (LTG) has not become widespread because of technical difficulties of esophagojejunal anastomosis and splenic hilar lymphadenectomy. Splenic hilar lymphadenectomy should be employed in the treatment of advanced proximal gastric cancer to complete D2 dissection, but laparoscopically it is technically difficult even for skilled surgeons. Based on the evidence that prophylactic combined resection of spleen in total gastrectomy increased the risk of postoperative morbidity with no survival impact, surgeons have preferred laparoscopic spleen-preserving splenic hilar lymphadenectomy (LSPL) for advanced tumors without metastasis to splenic hilar nodes or invasion to the greater curvature of the stomach, and reports with LSPL have been increasing rather than LTG with splenectomy. In this paper, recent reports with laparoscopic splenic hilar lymphadenectomy were reviewed.

Laparoscopic mediastinal dissection via an open left diaphragm approach for advanced Siewert type II adenocarcinoma

Around the lower esophagus, the diaphragm obstructs the laparoscopic dissection of mediastinal lymph nodes in surgery for Siewert type II cancer. To address this problem, we developed the open left diaphragm approach. After dissecting the esophageal hiatus along the diaphragm, the anterior mediastinum is dissected along the pericardium. The left side of the mediastinal pleura is then opened and the left diaphragm is incised with a 60-mm linear stapler to create sufficient working space in the lower mediastinum for the lower mediastinal lymph nodes to be resected with a good view. Six patients who received neoadjuvant chemotherapy underwent mediastinal dissection using this technique. The median operative time and estimated blood loss were 479 (390-750) min and 250 (130-500) ml, respectively, and there were no deaths or severe complications. The open left diaphragm approach provides clear surgical space and a good view for performing mediastinal lymph node dissection and is useful for laparoscopic mediastinal dissection and reconstruction.

A Step-Wise Approach to Total Laparoscopic Gastrectomy with Jejunal Pouch Reconstruction: How and Why We Do It

Laparoscopic gastrectomy (LG) is a safe alternative compared to open gastrectomy for cancer. To increase the uptake of minimally invasive approaches and facilitate their analysis and improvement a stepwise approach is warranted. This study describes our technique and experiences total laparoscopic gastrectomy (TLG) with jejunal pouch reconstruction for gastric cancer. Technical modifications throughout the years were described. In patients with anastomotic leakage, the CT-scan and reoperation report were reviewed to identify the location and cause of the leak. A total of 47 patients who underwent laparoscopic total gastrectomy with extracorporeal jejunal pouch reconstruction and stapled circular esophagojejunostomy from May 2007 to August 2015 were prospectively analyzed. A stepwise approach of 10 steps was designed based on video and case analysis. Median operation time was 301 (148-454) minutes and median blood loss was 300 (30-900) milliliters. Anastomotic leakage occurred in six (12.8 %) patients; additionally, one (2.12 %) jejunal-pouch staple line leak was identified. An important modification in our technique was a purse-string suture around the anvil of the circular stapler to prevent esophageal mucosa to slip away. After this modification, the leakage rate was reduced to 7 % in the last 15 procedures. In conclusion, TLG with jejunal pouch reconstruction is a feasible procedure in a selected group of patients. Our stepwise approach and technique may help surgeons to introduce jejunal pouch reconstruction during laparoscopic gastrectomy in their center.