Meta-analysis of laparoscopic and open distal gastrectomy for gastric carcinoma

Comparative analysis of station-specific lymph node yield in laparoscopic and open distal gastrectomy for early gastric cancer

BACKGROUND

Randomized trials and cohort studies show that laparoscopic distal gastrectomy (LDG) achieves similar oncological results to open distal gastrectomy (ODG). However, studies have consistently demonstrated lower lymph node yield (LNY) for laparoscopic lymphadenectomy. Analysis of station-specific LNY may be useful in evaluating the reasons behind this difference.

OBJECTIVES

Comparison of station-specific LNY, surgical, and oncological outcomes between LDG and ODG for early gastric cancer.

METHODS

Patients who underwent R0 distal gastrectomy with histologically confirmed early gastric cancer were eligible for the study. All consecutive cases of LDG since the beginning of our experience with laparoscopic gastrectomy and synchronous cases of ODG with R0 resection were included in the study. Demographic, operative, histopathologic, and follow-up data were recorded in all patients.

RESULTS

A total of 259 cases of LDG and 95 cases of ODG were performed between 2000 and 2009. Patients undergoing LDG had longer operations but less bleeding (P<0.05). Postoperative complications were similar in both groups. The preoperatively planned extent of lymphadenectomy was D1 (stations 1, 3, 4sb, 4d, 5, 6, and 7), D1+ (D1with stations 8a and 9), or D2 (D1+ with stations 11p and 12a). During surgery, dissection of stations 3, 4d, 5, 6, and 7 was performed in all cases of LDG and ODG. Dissection of stations 1, 4sb, 8a, 9, 11p, and 12a was performed more frequently during ODG than during LDG. Consequently, the total LNY was 26.71 and 31.43 for LDG and ODG, respectively. Station-specific LNY was significantly lower for LDG than for ODG in the common hepatic artery nodes only (P<0.05). The mean follow-up was 43.6 months. Lymph node metastases, metastatic-to-resected lymph node ratio, recurrence, and cancer-related deaths were similar for LDG and ODG.

CONCLUSIONS

LDG was associated with less extensive lymph node dissection compared with ODG. Station-specific LNY was similar in all nodal stations except for the common hepatic artery nodes. In our experience, laparoscopic sub-D2 lymphadenectomy was adequate in the context of early gastric cancer and represents the future of gastric cancer resection in Japan.

Laparoscopic versus open gastrectomy with D2 lymph node dissection for gastric cancer: a meta-analysis

BACKGROUND

Nowadays laparoscopic gastrectomy with D2 lymph node dissection (LGD2) is used for gastric cancer, which provides an alternative to open radical gastrectomy (OGD2). But it has not gained wide acceptance, and its oncological safety remains controversial. The aim of this study is to evaluate the efficiency and safety of LGD2 through a meta-analysis.

MATERIALS AND METHODS

Original articles of clinical trials comparing LGD2 and OGD2 for gastric cancer, published in English language from January 2001 to April 2010 were searched in the MEDLINE, Current Contents, and Pubmed. Strict literature appraisal and data extraction were carried out independently by 2 reviewers and then a meta-analysis was performed using RevMan 4.2.5 to evaluate the items of operative time, blood loss, harvested lymph nodes, analgesic medication, first flatus day, postoperative hospital stay, postoperative complications, and cumulative survival rate.

RESULTS

Ten trials were involved in the meta-analysis, concerning a total of 1039 patients (495 in LGD2 and 544 in OGD2). Compared with OGD2, LGD2 showed advantages of less blood loss during operation [weighed mean difference (WMD), -114.98; 95% confidence interval (CI), -160.44 to -69.52; P<0.00001], less postoperative pain (WMD, -0.89; 95% CI, -1.54 to -0.32; P=0.002), earlier passage of flatus (WMD, -0.84; 95% CI, -1.25 to -0.43; P<0.0001), shorter hospital stay (WMD, -3.27; 95% CI, -4.54 to -2.00; P<0.00001), and less postoperative complications [odds ratio (OR), 0.56; 95% CI, 0.32-0.59; P=0.03]; but with longer operative time [WMD, 57.14; 95% CI, 38.12-76.15; P<0.00001]. There were no significant differences between LGD2 and OGD2 in harvested lymph nodes (WMD, -2.07; 95% CI, -4.27 to -0.14; P=0.07) and overall survival rate of 11 to 60 months' follow-up (OR, 1.44; 95% CI, 0.92-2.27; P=0.11).

CONCLUSIONS

The results of this meta-analysis suggest that LGD2 results in less blood loss and postoperative complications and also less pain and faster bowel function recovery, with similar harvested lymph nodes and overall survival rate comparing to OGD2. However, we also see the need for further high-quality randomized controlled trials comparing the 2 procedures.

Laparoscopic gastrectomy for patients with advanced gastric cancer produces oncologic outcomes similar to those for open resection

BACKGROUND

Laparoscopic gastrectomy has gained acceptance as treatment for early gastric cancer. However, its role for advanced gastric cancer remains unclear. This study aimed to compare the oncologic outcomes between laparoscopic and open gastrectomy in the management of advanced gastric cancer for patients receiving adjuvant chemoradiotherapy.

METHODS

This study reviewed consecutive patients treated with gastric cancer resection and adjuvant chemoradiation (45 Gy/25 with 5-fluorouracil [FU]-based chemotherapy), at a quaternary care comprehensive cancer center between 1 Jan 2000 and 30 Nov 2009. Of 203 patients, 21 were treated with laparoscopic gastrectomy. These patients were compared with patients who had open surgery and evaluated for overall survival, relapse-free survival, and site of first disease recurrence.

RESULTS

The 21 patients in the laparoscopic group had a median age of 61.3 years (range, 28.2-76.6 years) and a median follow-up period of 21.3 months (range, 6.7-50.4 months). The majority of the patients (71%) were men. Most of these patients had tumor node metastasis (TNM) v6 stage 2 (33%) or 3 (52%) disease as classified by the American Joint Committee on Cancer (AJCC) and the Union for International Cancer Control (UICC). The demographic characteristics of the laparoscopic and open groups were similar. The incidence of recurrence was 38.1% (8/21) in the laparoscopic group and 36.8% (67/182) in the open group. In the laparoscopic group, the site of first recurrence was distant in three patients, peritoneal in four patients, and mixed in one patient (locoregional and distant). The recurrence patterns did not differ significantly between the laparoscopic and open surgery groups. In the open group, recurrence was distant in 26 patients, peritoneal in 12 patients, and locoregional in 15 patients. At presentation, 14 patients showed a mixed pattern. The 3-year relapse-free survival rate was 58% (range, 50-66%), and the difference between the two groups by Gray's test was not significant (P = 0.32). The 3-year overall survival rate was 65.9% (range, 58-73%) and did not differ significantly between the two groups in the univariate (P = 0.92) or multivariate (P = 0.54) analysis.

CONCLUSION

The study findings suggest that laparoscopic gastrectomy is an oncologically safe procedure for advanced gastric cancer with outcomes similar to those for open resection.

Novel technique for intraoperative tumor localization during totally laparoscopic distal gastrectomy: endoscopic autologous blood tattooing

BACKGROUND

Knowledge of the intraoperative location of lesions is a prerequisite for deciding the proper extent of gastric resection or the choice of anastomosis technique during totally laparoscopic distal gastrectomy (TLDG) for early gastric cancer (EGC). In this study we introduce a novel tumor localization method for TLDG: endoscopic blood tattooing.

METHODS

Twenty-three consecutive patients scheduled for TLDG for EGC were enrolled in this prospective study. The day before surgery, 2-3 ml of autologous blood was injected into the gastric muscle layer at 3-4 cm proximal to the lesion during endoscopy.

RESULTS

The study subjects consisted of 15 males and 8 females with a mean age of 61 ± 10.4 years. During surgery, the endoscopic blood tattooed sites were successfully identified in all 23 patients. No complications associated with the procedure occurred, and no patient had microscopic residual tumor cells at the proximal resection margin, with a mean proximal margin length of 3.3 ± 2.7 cm. Eighteen patients underwent TLDG with Billroth II anastomosis, four patients with Roux-en-Y gastrojejunostomy, and one patient with laparoscopic total gastrectomy. At final pathologic examinations, 20 patients were of stage IA and 3 were of stage IB according to the UICC TNM classification (6th ed.).

CONCLUSIONS

Endoscopic blood tattooing provides a simple and useful means of localizing lesions during TLDG for EGC. Although the superiority of this technique over other localization methods needs to be evaluated further, the authors recommend endoscopic blood tattooing as an alternative to other intraoperative localization methods for laparoscopic surgery for EGC.

[Minimally invasive gastric surgery]

The interest in minimally invasive surgery (MIS) for the treatment of gastric carcinoma has increased in recent years worldwide. In particular, for early gastric carcinoma (EGC) many retrospective comparative trials and some prospective randomized trials have confirmed that laparoscopy-assisted distal gastrectomy shows a better short-term outcome in terms of lower morbidity, less pain, faster recovery and shorter hospital stay in contrast to open surgery. In this group of selected patients MIS is safe and feasible but at present not widely accepted because of a limited evaluation in oncologic long-term follow-up. In cases of EGC limited to the mucosal layer and under the condition that endoscopic resection is not suitable, laparoscopic local wedge resection or intragastric resection can be an alternative option with good results in long-term follow-up. The data for laparoscopic total gastrectomy and MIS for advanced gastric cancer have confirmed that both are technically feasible and extended lymph node dissection can also be laparoscopically performed. However, laparoscopic total gastrectomy is much more complex and even in expert hands more complications and a higher morbidity have been observed in contrast to laparoscopic distal resections.

Comparison of short-term outcomes and perioperative systemic immunity of laparoscopy-assisted and open radical gastrectomy for gastric cancer

OBJECTIVE

To compare the perioperative systemic immunity of laparoscopy-assisted and open radical gastrectomy for gastric cancer.

METHODS

Patients with gastric adenocarcinoma proven by endoscopy and biopsy were eligible, while patients with preoperative staging of T4, N2-3, or M1 were excluded. Eligible patients willing to undertake laparoscopic surgery in the consecutive cohort were assigned to the laparoscopy-assisted gastrectomy (LAG) group, while concurrent patients were assigned to the conventional open gastrectomy (OG) group. All operations were performed with the intention of radical resection. Various immunological parameters were tested in peripheral venous blood collected at preoperative 1(st) day and postoperative 2(nd) day (POD2) and 7(th) day (POD7). SPSS 13.0 software was used for statistical analysis.

RESULTS

Thirty patients were included, 15 each in the LAG and OG groups. The general characteristics and short-term outcomes (harvested lymph nodes number, hospital stay, complications, and mortality rate) of the two groups were comparable, but the operation time was significantly longer in LAG (P = 0.001). Moreover, intergroup comparisons indicated no significant differences between the groups in levels of neutrophils, T-lymphocytes, natural killer cells, IgG, IgM, IgA, C3, C4, interleukin-6, or interleukin-10 at any time point (P>0.05). However, there was a gradual decrease in natural killer cell count in the LAG group up to POD7 (P = 0.008).

CONCLUSION

The changes in systemic immunity markers were comparable between laparoscopy-assisted and open gastrectomy for gastric cancer. However, there was a trend of suppression of natural killer cells in the laparoscopy-assisted gastrectomy group.

Completely laparoscopic versus open gastrectomy for early and advanced gastric cancer: a matched cohort study

INTRODUCTION

The application of laparoscopic gastric surgery has rapidly increased for the treatment of early gastric cancer. However, laparoscopic gastrectomy for advanced tumor remains controversial, particularly in terms of oncologic outcomes. This study was designed to compare 3-year survival of laparoscopic versus open curative gastrectomy in early and advanced gastric cancer.

METHODS

This was a retrospective matched cohort study. We included patients between 2003 and 2010 with an R0 resection. A totally laparoscopic technique was used and D2 lymph node dissection was practiced routinely. We performed an intracorporeal hand-sewn esophagojejunostomy in all laparoscopic total gastrectomy cases. We matched all laparoscopic cases 1:1 with open cases according to TNM AJCC seventh edition. We used Mann-Whitney or t test and Chi-square test to compare both groups. Kaplan-Meier analysis with log-rank test was performed to compare survival.

RESULTS

We included 31 open and 31 laparoscopic cases (mean age 63 ± 14 years; 66% males). Both groups were identical in type of gastrectomy (71% total and 29% subtotal). There were no statistical difference between laparoscopic and open groups in age, sex, N category, tumor location and size, histological differentiation, and T category (48% T1, 13% T2, 16% T3, and 23% T4 in both groups), with 48% early and 52% advanced tumors. The median number of resected lymph nodes was similar: 35 (23-53) for laparoscopic and 39 (23-45) for open cases (P = 0.81). The median follow-up was 50 months. The overall 3-year survival was 82% for laparoscopic surgery and 87% for the open surgery group (P = 0.56). There were no difference in 3-year survival for the laparoscopic versus the open surgery groups for advanced tumors (74 vs. 75%, P = 0.88), N+ tumors (73 vs. 73%, P = 0.99) and for the different AJCC stages (stage 1: 94 vs. 100%, stage 2: 89 vs. 82%, and stage 3: 50 vs. 50%, P = 0.32, 0.83, and 0.98 respectively).

CONCLUSIONS

In this preliminary report, with 52% of advanced tumor, the 3-year overall and stage-by-stage survival was comparable for laparoscopic and open curative gastrectomy.

Completely laparoscopic versus open gastrectomy for early and advanced gastric cancer: a matched cohort study

INTRODUCTION

The application of laparoscopic gastric surgery has rapidly increased for the treatment of early gastric cancer. However, laparoscopic gastrectomy for advanced tumor remains controversial, particularly in terms of oncologic outcomes. This study was designed to compare 3-year survival of laparoscopic versus open curative gastrectomy in early and advanced gastric cancer.

METHODS

This was a retrospective matched cohort study. We included patients between 2003 and 2010 with an R0 resection. A totally laparoscopic technique was used and D2 lymph node dissection was practiced routinely. We performed an intracorporeal hand-sewn esophagojejunostomy in all laparoscopic total gastrectomy cases. We matched all laparoscopic cases 1:1 with open cases according to TNM AJCC seventh edition. We used Mann-Whitney or t test and Chi-square test to compare both groups. Kaplan-Meier analysis with log-rank test was performed to compare survival.

RESULTS

We included 31 open and 31 laparoscopic cases (mean age 63 ± 14 years; 66% males). Both groups were identical in type of gastrectomy (71% total and 29% subtotal). There were no statistical difference between laparoscopic and open groups in age, sex, N category, tumor location and size, histological differentiation, and T category (48% T1, 13% T2, 16% T3, and 23% T4 in both groups), with 48% early and 52% advanced tumors. The median number of resected lymph nodes was similar: 35 (23-53) for laparoscopic and 39 (23-45) for open cases (P = 0.81). The median follow-up was 50 months. The overall 3-year survival was 82% for laparoscopic surgery and 87% for the open surgery group (P = 0.56). There were no difference in 3-year survival for the laparoscopic versus the open surgery groups for advanced tumors (74 vs. 75%, P = 0.88), N+ tumors (73 vs. 73%, P = 0.99) and for the different AJCC stages (stage 1: 94 vs. 100%, stage 2: 89 vs. 82%, and stage 3: 50 vs. 50%, P = 0.32, 0.83, and 0.98 respectively).

CONCLUSIONS

In this preliminary report, with 52% of advanced tumor, the 3-year overall and stage-by-stage survival was comparable for laparoscopic and open curative gastrectomy.

Current status of robot-assisted gastric surgery

In an effort to minimize the limitations of laparoscopy, a robotic surgery system was introduced, but its role for gastric cancer is still unclear. The objective of this article is to assess the current status of robotic surgery for gastric cancer and to predict future prospects. Although the current study was limited by its small number of patients and retrospective nature, robot-assisted gastrectomy with lymphadenectomy for the treatment of gastric cancer is a feasible and safe procedure for experienced laparoscopic surgeons. Most studies have reported satisfactory results for postoperative short-term coutcomes, such as: postoperative oral feeding, gas out, hospital stay and complications, compared with laparoscopic surgery; the difference is a longer operation time. However, robotic surgery showed a shallow learning curve compared with the familarity of conventional open surgery; after the accumulation of several cases, robotic surgery could be expected to result in a similar operation time. Robotic-assisted gastrectomy can expand the indications of minimally invasive surgery to include advanced gastric cancer by improving the ability to perform lymphadenectomy. Moreover, ”total” robotic gastrectomy can be facilitated using a robot-sewing technique and gastric submucosal tumors near the gastroesophageal junction or pylorus can be resected safely by this novel technique. In conclusion, robot-assisted gastrectomy may offer a good alternative to conventional open or laparoscopic surgery for gastric cancer, provided that long-term oncologic outcomes can be confirmed.

Open vs robot-assisted laparoscopic gastric resection with D2 lymph node dissection for adenocarcinoma: a case-control study

BACKGROUND

A population-based case-control study was conducted in order to investigate the advantages of robot-assisted gastric resection (RGR) for gastric cancer as opposed to traditional open gastrectomy (OG).

METHODS

Data were collected in two prospectively maintained databases on patients who underwent a D2 gastrectomy with curative intent for primary gastric adenocarcinoma. All (n = 29) the first consecutive gastric cancer patients submitted to RGR from a referral centre for minimally invasive surgery were matched to control cancers (n = 120) extrapolated from a high volume centre database including patients submitted to OG.

RESULTS

Robot-assisted laparoscopic procedures implied increased operative time (290 vs 222 min, p = 0.004), decreased blood loss (197.6 vs 386.1 mL, p = 0.0001) and shorter hospital stay (9.6 vs 13.4 days, p < 0.0009). There was no difference in the mean number of harvested lymph nodes between the two groups (28.0 vs 31.7, p = 0.023). The total morbidity rate, including major complications such as anastomotic and duodenal suture failure, was comparable between groups (41.4% vs 42.5%; in the RGR and OG, respectively, p = 0.764). Preliminary data on overall survival did not show prognostic differences between the two groups (p = 0.615).

CONCLUSIONS

Robot-assisted surgery fulfils oncologic criteria for D2 dissection and has an oncologic outcome comparable with that of OG. RGR resulted in shorter hospital stays, the loss of less blood and morbidity comparable with that of OG. Randomized clinical trials and longer follow-up are needed to evaluate whether RGR achieves long-term survival rates equivalent to that of open and laparoscopic surgery.

Long-term oncologic outcomes of 714 consecutive laparoscopic gastrectomies for gastric cancer: results from the 7-year experience of a single institute

BACKGROUND

Although many reports have indicated the feasibility of laparoscopic gastrectomy (LG) regarding short-term surgical outcomes, the role of LG remains controversial because studies of long-term outcomes of LG are insufficient. The purpose of this study was to evaluate the long-term oncologic outcomes of patients who have undergone LG.

METHODS

Between May 2003 and December 2009, 714 consecutive patients underwent LG for gastric cancer. After excluding operative mortality (n = 4) and a case of Krukenberg tumor that was not identified at the time of surgery (n = 1), a total of 709 patients were analyzed for long-term oncologic outcomes. Gastric cancer cases were analyzed according to the American Joint Committee on Cancer classification (seventh edition). Overall survival and relapse-free survival were estimated by using the Kaplan-Meier method.

RESULTS

Median follow-up was 46.2 months. Postoperative recurrence was observed in 26 patients (3.7%). The instances of recurrence were as follows: seven peritoneal, six locoregional, five hematogenous, four distant lymph nodes, and four mixed recurrence. There were neither port-site nor wound site metastases. The 5-year relapse-free survival rates were: 95.8% in stage I, 83.4% in stage II, and 46.4% in stage III. Five-year overall survival rates were: 96.4% in stage I, 83.1% in stage II, and 50.2% in stage III. The independent risk factors for recurrence were T stage and N stage. For survival, age, T stage, and N stage were statistically independent prognostic factors

CONCLUSIONS

Our single-center study of a large patient series revealed that LG for gastric cancer had acceptable long-term oncologic outcomes comparable to those of conventional open surgery.

Totally laparoscopic gastrectomy for gastric cancer: meta-analysis of short-term outcomes

INTRODUCTION

We present a review of the literature, together with a meta-analysis of short-term outcomes of totally laparoscopic gastrectomy (TLG) compared with open gastrectomy (OG).

MATERIAL & METHODS

We carried out a search in the Pubmed and Cochrane databases from September 2003 to May 2009. Controlled studies on early outcomes were included, both prospective and retrospective, randomized and non-randomized.

RESULTS

We found nine eligible studies, one of which was a randomized controlled trial (RCT), while eight were series of patients (three consecutive). The study group consisted of 1,492 patients, 828 of whom had been treated with TLG and 664 treated with OG. TLG for gastric cancer shows a 32.5% (p < 0.001) longer operative time than OG, whereas TLG demonstrated a 44% (p < 0.001) reduction in blood loss, a 34% (p < 0.001) reduction time to first flatus and a 33.7% reduced (p < 0.001) hospital stay. No notable differences were registered regarding morbidity and mortality rates, and no significant difference was observed between the two groups regarding the extent of the lymphadenectomy.

CONCLUSIONS

Despite a longer operative time for TLG, with a gastrointestinal recovery rate faster than the OG one for gastric cancer results, no notable differences were recorded between the two techniques for the morbidity and mortality rates and in the spread of the lymphadenectomy.

Updating controversies on the multidisciplinary management of gastric cancer

The rates of relapse and death remain high in gastric cancer patients, especially in advanced stages. Local relapses in the tumour bed and regional lymph nodes, peritoneal spread as abdominal carcinomatosis, and distant metastasis are common mechanisms of failure after a R0 resection. To overcome this, a multidisciplinary approach has been prompted. In recent years, multidisciplinary treatment has been strengthened by some randomised controlled trials and it is now considered the standard by most groups, although the improvement in long-term survival rates achieved is still limited. This new therapeutic approach in gastric cancer is rapidly evolving and has led to a series of controversies on the best strategy to follow. Some of these controversies are discussed in this paper.

Laparoscopic gastrectomy for gastric cancer

BACKGROUND

Surgery in gastric cancer (GC) aims to achieve resection of the primary tumor and its lymphatic drain, with a minimal adverse effect on morbidity and mortality, and the best possible quality of life.

METHODS

From June 1993 to May 2008, 113 patients with a preoperative diagnosis of the GC were considered for laparoscopic gastrectomy at our institution. There was a predominance of males and mean age was 60 years. After peritoneal cavity inspection, laparoscopic ultrasound was used to determine the presence of deep liver metastasis. Total gastrectomy and Roux-en-Y reconstruction were performed in upper and middle-third tumors, and subtotal gastrectomy, either with Billroth II or Roux-en-Y reconstruction, in tumors affecting the lower third of the stomach. D2 lymphadenectomy was performed in both cases.

RESULTS

There were 21 cases (18.5%) with distant metastases and/or an unresectable tumor due to the invasion of adjacent organs. In these patients the procedure was limited to laparoscopic biopsy in 16 cases and laparoscopic gastrojejunostomy in 5 cases. Laparoscopic gastrectomy was performed in 92 patients with a mean surgical time of 162 minutes and a mortality rate of 5.4%. Conversion was necessary in 7 cases (7.6%).

CONCLUSIONS

The benefits and safety of laparoscopic gastrectomy are evident, with similar outcomes to conventional surgery and all the advantages of minimally invasive access. The learning curve is long. Laparoscopic gastrectomy is a safe and effective option for the treatment of GC, avoiding nontherapeutic laparotomy in patients with advanced disease. Comparative prospective studies evaluating the long-term survival of these patients are still necessary.

A case-control study of laparoscopy-assisted and open distal gastrectomy for advanced gastric cancer

BACKGROUND

The application of laparoscopy-assisted gastric surgery has been increasing rapidly for the treatment of early gastric cancer. However, there were few reports of laparoscopic surgery in the management of advanced gastric cancer (AGC), especially with T3 depth of invasion. The aim of this study was to compare the technical feasibility and oncologic efficacy of laparoscopy-assisted distal gastrectomy (LADG) versus open distal gastrectomy (ODG) for advanced gastric cancer.

METHODS

A retrospective case-control study was performed comparing LADG and ODG for AGC. Thirty-five consecutive patients with AGC undergoing LADG between August 2005 and December 2007 were enrolled and these patients were compared with 35 AGC patients undergoing ODG during the same period.

RESULTS

Forty-two (60.0%) patients were T3 in terms of depth of invasion. Tumor location and histology were similar between the two groups. Operation time was significantly longer in the LADG group than in the ODG group. Estimated blood loss was significantly less in the LADG group. Hospital length of stay after LADG was significantly shorter than in the open group. Postoperative pain was significantly lower for laparoscopic patients. There were no significant differences in postoperative early and late complication and in the number of lymph nodes retrieved between the two groups, and the cumulative survival of the two groups was similar.

CONCLUSION

Our data indicate that LADG for AGC, mostly with T3 depth of invasion, yields good oncologic outcomes including the similar early and late complication and the cumulative survival between the two groups after 50 months of follow-up. To be accepted as a choice treatment for advanced distal gastric cancer, well-designed prospective trial to assess long-term outcomes is necessary.

Full robotic gastrectomy with extended (D2) lymphadenectomy for gastric cancer: surgical technique and preliminary results

BACKGROUND

Widespread diffusion of minimally-invasive surgery for gastric cancer treatment is limited by the complexity of performing an extended D2-lymphadenectomy. This surgical step can be facilitated by using robot-assisted surgery. The aim of this study is to describe our technique and short-term results of a consecutive series of full robotic gastrectomies with D2-lymphadenectomy for gastric cancer, using the da Vinci Surgical System.

MATERIALS AND METHODS

Between May 2004 and December 2009, we performed 24 consecutive full robot-assisted total and subtotal gastrectomies with extended D2-lymphadenectomy for histologically-proven gastric adenocarcinoma. Data referring to 11 robot-assisted total gastrectomies and 13 subtotal gastrectomies were collected in a database and analyzed.

RESULTS

Median operative time was 267.50 min (255-305). Median intraoperative blood loss was 30 mL. Median number of harvested lymph nodes was 28 (23-34). Resection margins were negative in all cases. No conversions occurred. Surgery-related morbidity was 8%. Thirty-day mortality was 0%. Liquid diet started on postoperative d 5 (2-5). Median length of stay was 6 d (5-8).

CONCLUSIONS

Robot-assisted gastrectomy with D2-lymphadenectomy is a safe technique and allows achieving an adequate lymph node harvest and optimal R0-resection rates with low postoperative morbidity and the learning curve appears to be shorter than in laparoscopic surgery. Longer follow-up and randomized clinical trials are needed to define the role of robot-assistance in gastric cancer surgery.

The extent of lymph node dissection for gastric cancer: a critical appraisal

The extent of lymphadenectomy during therapeutic gastrectomy for gastric cancer remains a protracted and controversial issue. While traditionally extended lymphadenectomy is performed in Eastern Asia, limited lymphadenectomy is advocated by most western surgeons. Two large western randomized trials, meta-analyses and a recent systematic review were unable to demonstrate overall benefit from extended lymphadenectomy. In this review, the currently available data on this topic are critically evaluated, while ongoing studies and future perspective are discussed.

Comparison of invasiveness between laparoscopy-assisted total gastrectomy and open total gastrectomy

BACKGROUND

Because only a few studies have been performed to date on the invasiveness of laparoscopy-assisted total gastrectomy (LATG) compared with open total gastrectomy (OTG), the minimal invasiveness of LATG has been unclear.

METHODS

The OTG cohort contained 35 cases, which were performed from April 2003 to October 2005. The LATG cohort contained 46 cases, which were performed from November 2005 to November 2008. Postoperative changes over time in various parameters relating to minimal invasiveness were evaluated. We used the Wong-Baker FACES Pain Rating Scale to evaluate pain. Vital signs and a face scale were analyzed using daily maximum values on postoperative days (POD) 1-7. A hematological examination was performed on the preoperative day and POD 1, 4, 7, and 10. The number of days until oxygen saturation level (SaO2) was 95% or more in room air was used to evaluate respiratory function.

RESULTS

Significantly lower pain scores were obtained in the LATG group on POD 1, 4, 5, and 7. There was a significantly lower body temperature in the LATG group on POD 7. A significantly lower white blood cell count was revealed for LATG patients on POD 10, and for C-reactive protein on POD 1. Significantly higher serum total protein values were observed in the LATG group on POD 1, 4, and 7. Significantly lower blood sugar level was found in the LATG group on POD 4 and 7. The number of days until SaO2 was 95% or more in room air was significantly fewer in the LATG group.

CONCLUSIONS

LATG seems to be a less invasive procedure than OTG.

Subtotal gastrectomy with D2 dissection by minimally invasive surgery for distal adenocarcinoma of the stomach: results and 5-year survival

BACKGROUND

The purpose of this study is to assess outcomes and 5-year survival after subtotal gastrectomy (SG) for early and advanced distal adenocarcinoma with D2 dissection performed by minimally invasive surgery (MIS).

METHODS

From June 2000 to October 2009 a total of 70 patients with adenocarcinoma of the lower third of the stomach underwent SG with D2 nodal clearance by MIS. This series enrolled 37 patients with early gastric cancer (EGC) and 33 with advanced gastric cancer (AGC). SG was attempted by conventional laparoscopy (CL) in 52 cases and by robot-assisted (RA) technique in 18. Clinical and histopathologic results with 5-year survival were analyzed.

RESULTS

No intraoperative complication was registered. Conversion to laparotomy was required in five patients. Overall, the mean operating time for SG was 254 min (range = 145-460) and estimated mean blood loss was 146 ml (range = 45-250). Postoperative complications occurred in seven patients, including two duodenal leakages none of which required laparotomy. There were two postoperative deaths, one caused by hepatic failure and one by hemorrhagic stroke. Preoperative understaging occurred in ten cases (three were AGC). On average, 30 ± 8 lymph nodes were collected. The distance of proximal resection margin was 6.6 cm (range = 4-8.5 cm). Short-term results were equal with those of laparoscopic and RA gastrectomy. The mean hospital stay of all patients was 10 days (range = 7-24). The mean follow-up span was 53 months (range = 3-112). Relapse of disease occurred in 12 patients, 10 of whom died from the disease and their mean survival was 25 months (range = 12-38). The overall 3-year survival was 85% for CL gastrectomy and 78% for RA gastrectomy, but this difference was not significant with the log rank test (p > 0.05). The overall 5-year survival was 81% (97% for EGC and 67% for AGC).

CONCLUSION

D2 subtotal gastrectomy performed by MIS is reproducible and safe. The long-term outcomes and 5-year survival are acceptable. Extended lymphadenectomy was carried out for both EGC and AGC so as to ensure adequate nodal clearance and compensate preoperative underestimation.

Assessment of open versus laparoscopy-assisted gastrectomy in lymph node-positive early gastric cancer: a retrospective cohort analysis

BACKGROUND

Laparoscopy-assisted gastrectomy (LAG) is still limited for early gastric cancer (EGC) with low possibility of lymph node (LN) metastasis, due to the concern for incomplete LN dissection and controversial long-term outcomes. We assessed oncological outcomes of laparoscopy-assisted versus open gastrectomy (OG) for patients with LN positive EGC.

METHODS

Between 2003 and 2007, 204 patients underwent surgery for LN positive EGC. We evaluated adequacy of LN dissection and early and long-term outcomes after OG (n = 162) and LAG (n = 42).

RESULTS

Operative time was longer but hospital stay was shorter for LAG than OG. Postoperative complications occurred in 14 patients (8.6%) after OG and 1 patient (2.4%) after LAG (P = 0.316). Mean number of retrieved LNs and number of retrieved and metastatic LNs for each station did not differ between the two groups. During median 35 months of follow-up, 14 patients (8.6%) developed recurrence after OG, compared with 4 patients (9.5%) after LAG (P = 0.769). Overall 5-year disease-free survival was 89.9% and 89.7% after OG and LAG. Status of LN metastasis was the only independent prognostic factor for disease-free survival.

CONCLUSIONS

LAG is an oncologically safe procedure even for LN positive EGC. Adequate LN dissection and comparable long-term outcomes to OG can be achieved by LAG.

Feasibility of laparoscopic gastrectomy with radical lymph node dissection for gastric cancer: from a viewpoint of pancreas-related complications

BACKGROUND

There is little evidence for the technical feasibility of laparoscopic gastrectomy (LG) with peripancreatic lymphadenectomy in terms of postoperative complications. To evaluate the technical feasibility of LG with radical lymphadenectomy, we focused on pancreas-related complications in LG and open gastrectomy (OG), and then investigated whether such complications increased in LG.

METHODS

We reviewed the surgical outcomes of 138 consecutive patients with gastric cancer who underwent LG with peripancreatic lymphadenectomy in our hospital between July 2005 and February 2009. As a control group, we used 95 consecutive OG cases with peripancreatic lymphadenectomy without splenectomy or para-aortic lymphadenectomy. LG and OG were compared for clinicopathologic characteristics, operative outcomes, postoperative morbidities and mortalities, and amylase concentration of drainage fluid (d-AMY).

RESULTS

The overall operative morbidity rates were 15% in the LG and 20% in the OG group. Rates of postoperative pancreatic fistula (POPF), Grade B and C in the International Study Group on Pancreatic Fistula definition, were 7% in the LG group and 2% in the OG group, indicating no statistical difference (P = .149). There were no in-hospital deaths. The median value of d-AMY in LG was 934.5 IU/L, while that in OG was 349 IU/L; d-AMY after LG was significantly higher than that after OG (P < .01).

CONCLUSION

Considering low morbidity and mortality rates, LG with peripancreatic lymphadenectomy is technically feasible. Although POPF after LG was infrequent, d-AMY level was higher than after OG. We should pay attention to the potential risk of pancreatic leakage when carrying out LG with peripancreatic lymphadenectomy.

The issue of lymphadenectomy during laparoscopic gastrectomy for gastric carcinoma

Surgical resection remains the mainstay of treatment for gastric cancer. Laparoscopic assisted gastrectomy has failed to gain universal acceptance as an alternative to the open approach for a number of reasons, one of which includes the issue of oncological radicality in terms of lymph node dissection. Nodal status, which is one of the most crucial and independent predictors of patient survival, therefore has been examined both in single institutional trials and also in randomised controlled trials especially on early gastric cancer. The issue of oncological adequacy for laparoscopic lymph node harvesting for advanced gastric cancer remains a contentious issue because of the unique challenges it poses in terms of complexity, safety and time, and also the lack of randomised controlled trials in this area. It is thus imperative that good quality multicentre randomised controlled trials are designed to investigate the benefits of extended lymphadenectomy in the setting of laparoscopic surgery, especially for advanced gastric cancer and its impact on both short and long term survival.

Recurrence following laparoscopy-assisted gastrectomy for gastric cancer: a multicenter retrospective analysis of 1,417 patients

BACKGROUND

The risk of recurrence and recurrence patterns after laparoscopy-assisted gastrectomy for gastric cancer remain unclear. The objective of this study is to assess recurrence and its timing, patterns, and risk factors following laparoscopy-assisted gastrectomy from multicenter data.

METHODS

A retrospective multicenter study was performed using data from 1,485 patients who had undergone laparoscopy-assisted gastrectomy for gastric cancer at ten institutions from 1998 to 2005. Recurrence and its timing and patterns were reviewed. Univariate and multivariate analyses were performed to identify risk factors for recurrence.

RESULTS

Excluding 68 patients (9 postoperative mortalities, 1 synchronous distant metastasis, 2 nonadenocarcinomas, and 56 losses to follow-up), 50 of 1,417 patients (3.5%) had recurrences. Incidence of recurrence was 1.6% (19/1186) in early gastric cancer and 13.4% (31/231) in advanced gastric cancer. Recurrence occurred in 34 of 50 patients (68.0%) within 2 years of surgery, and in 45 of 50 patients (90.0%) within 3 years. The recurrence pattern was hematogenous in 17 patients (34.0%), peritoneal in 11 (22.0%), locoregional in 10 (20.0%), distant lymph nodes in 2 (4.0%), and mixed in 10 (20.0%). Advanced T-classification and lymph node metastases were risk factors for recurrence.

CONCLUSIONS

Laparoscopy-assisted gastrectomy showed satisfactory long-term oncologic outcomes similar to those of open surgery. The study provides additional evidence suggesting that laparoscopy-assisted gastrectomy is a good alternative to open gastrectomy in patients with gastric cancer of relatively early stage, although results of a randomized controlled trial and more long-term follow-up are needed to provide conclusive evidence.

Gastrointestinal symptomatic outcomes of laparoscopic and open gastrectomy

AIM: To compare the laparoscopic and the open gastrectomy approaches for short term morbidity, length of hospital stay and also long term gastrointestinal symptoms.

METHODS: Patients who have undergone gastrectomy had their medical records reviewed for demographic data, type of gastrectomy, short term morbidity, and length of hospital stay. Patients were contacted and asked to complete the Gastrointestinal Symptom Rating Scale (GSRS). The GSRS measures three domains of GI symptoms: Dyspepsia Syndrome (DS) for the foregut (best score 0, worse score 15), indigestion syndrome (IS) for the midgut (best score 0, worse score 12), and bowel dysfunction syndrome (BDS) for the hindgut (best score 0, worse score 16). Statistical analysis was done using the Mann-Whitney U-test.

RESULTS: We had complete data on 32 patients: 7 laparoscopic and 25 open. Of these, 25 had a gastroenteric anastomosis and 6 did not. The table shows the results as medians with interquartile range. Laparoscopic gastrectomy had a better score than open gastrectomy in the DS domain (0 vs 1, P = 0.02), while gastrectomy without anastomosis had a better score than gastrectomy with anastomosis in the IS domain (0 vs 1, P = 0.05).

CONCLUSION: Patients have little adverse gastrointestinal symptoms and preserve good gastrointestinal function after undergoing any type of gastrectomy. Laparoscopic approach had better dyspepsia and foregut symptoms. Performing an anastomosis led to mild adverse midgut and indigestion effects

Short-term evaluation of laparoscopy-assisted distal gastrectomy for predictive early gastric cancer: a meta-analysis of randomized controlled trials

BACKGROUND

In recent decade, laparoscopy-assisted distal gastrectomy (LADG) has been introduced to treatment of early gastric cancer (EGC). Previous meta-analyses included the randomized controlled trial (RCT) apparently contaminated with advanced gastric cancer. Besides, more RCTs enrolling the predictive EGC are available. The present meta-analysis was aimed to compare LADG with open distal gastrectomy (ODG) by updating the literature search and repooling the RCTs of only predictive EGC with improved methodology.

METHODS

Comprehensive search of PubMed, EmBase, and multiple websites of clinical trials registration and oncologic groups were performed. Only short-term outcomes measures were considered to meta-analysis. The RevMan 5.0 was used for pooled estimates.

RESULTS

Six RCTs of 629 patients totally were included for meta-analysis. Comparing LADG to ODG, results found less postoperative early morbidity (risk ratios=0.61, P=0.01), similar mortality (risk difference=0.01, P=0.32), prolonged operation time [mean difference (MD)=86.64 min, P<0.00001], decreased intraoperative blood loss (MD=-108.33 mL, P=0.001), decreased number of harvested lymph nodes (MD=-4.88, P<0.00001), forwarded time to oral intake (MD=-0.48 d, P=0.32), and shortened hospital stay (MD=-2.03 d, P=0.14).

CONCLUSIONS

LADG could bring the patients with EGC slight benefits by decreasing intraoperative blood loss and postoperative early morbidity, but unfavorably, might increase the operation time and decease the number of harvested lymph nodes. The long-term survival benefit is still eager to be proven by further outcomes of RCTs.

Association of allogeneic blood transfusions and long-term survival of patients with gastric cancer after curative gastrectomy

INTRODUCTION

The relationship between perioperative allogeneic blood transfusions and poor prognosis in patients with gastric cancer remains controversial. The aim of this study is to examine the effect of perioperative blood transfusions on long-term survival of patients undergoing curative gastric resection for gastric cancer.

METHODS

Eight hundred fifty-six consecutive patients with gastric cancer who underwent curative gastrectomy (R0) from January 1, 1991 through December 31, 2002 were enrolled in this retrospective study.

RESULTS

A multivariate overall survival analysis using Cox proportional hazard regression model revealed macroscopically infiltrative tumor, tumor infiltration of serosa, lymph node metastasis, blood transfusions (hazard ratio, 2.69), pulmonary disease, and liver dysfunction as prognostic factors for long-term survival. Blood transfusion was an independent prognostic factor at all stages of disease. Disease-specific and overall survival showed significant differences between the transfused and nontransfused groups (log-rank, P < 0.0001). Based on multivariate logistic regression analysis, the need for blood transfusion was significantly associated with advanced age (>or=65 years), long duration of operation (>or=300 min), massive blood loss (>or=1,000 ml), and anemia (Hb < 10 g/dl).

CONCLUSIONS

Allogeneic blood transfusion is an independent prognostic factor for long-term survival in gastric cancer patients.

Laparoscopic major hepato-biliary-pancreatic surgery: formidable challenge to standardization

INTRODUCTION

Although laparoscopic colorectal or gastric surgery has become widely accepted as a superior alternative to conventional open surgery, the surgical management of hepato-biliary-pancreatic disease has traditionally involved open surgery. Recently, many reports have described laparoscopic partial liver resection, lateral segmentectomy, and distal pancreatectomy. However, laparoscopic major hepato-biliary-pancreatic surgery, such as hepatic lobectomy and pancreaticoduodenectomy, has not been widely developed because of technical difficulties.

METHODS

We describe our experience with laparoscopic major hepato-biliary-pancreatic surgery, including right hepatectomy using hilar Glissonean pedicle transaction, and pylorus-preserving pancreaticoduodenectomy.

CONCLUSION

Although our experience is limited, and randomized study is necessary to elucidate the appropriate indications for and effects of the present procedures, we believe that laparoscopic major hepato-biliary-pancreatic surgery can be feasible, safe, and effective in highly selected patients, and that it will be one of the standard therapeutic options for carefully selected patients with hepato-biliary-pancreatic disease.

Robot-assisted gastrectomy with lymph node dissection for gastric cancer: lessons learned from an initial 100 consecutive procedures

OBJECTIVE

To evaluate the technical feasibility, effectiveness, and safety of robot-assisted gastrectomy (RAG) with lymphadenectomy, using the da Vinci system through analyses of our initial series of 100 consecutive patients.

SUMMARY BACKGROUND DATA

The application of robotic surgery was proven to be one of the best cutting-edge technologies for successful minimally invasive surgery by providing solutions to the many drawbacks of laparoscopic surgery, yet few reports have studied robotic surgery in gastric cancer.

METHODS

A review of a prospectively designed database at our institute from July 2005 to October 2007 revealed a series of 100 consecutive RAG patients with a preoperative diagnosis of early gastric cancer. Clinicopathologic characteristics and surgical outcomes were analyzed.

RESULTS

All operations were performed successfully without open or laparoscopic conversion. There were 33 total gastrectomies and 67 subtotal gastrectomies with D1+beta or extended lymphadenectomy (D2). The mean total operation time and console time were 231 and 150 minutes, respectively. There were 13 postoperative morbidities and 1 postoperative mortality. The first flatus was noted on postoperative day 2.9, soft diet was started on postoperative day 4.2, and the mean postoperative hospital stay was 7.8 days. Although all patients were diagnosed as early gastric cancer preoperatively, the final pathology report revealed that 19 patients exhibited a depth deeper than T2. The mean number of retrieved lymph nodes was 36.7 (range, 11-83). None of the specimens showed microscopic tumor involvement in the resection line.

CONCLUSIONS

This study demonstrated that RAG with lymphadenectomy can be applied safely and effectively for patients with gastric cancer.

Totally laparoscopic gastric resection with extended lymphadenectomy for gastric adenocarcinoma

BACKGROUND

Laparoscopic gastric resection with extended lymphadenectomy is being evaluated in North America for the surgical treatment of gastric cancer. The aim of this study is to compare short-term postoperative and oncologic outcomes of laparoscopic and open resection for gastric cancer at a single cancer center.

METHODS

The study population consisted of patients with gastric adenocarcinoma who underwent a completely abdominal intervention with curative intent. Laparoscopic and open gastric resections were compared. A totally laparoscopic technique was employed with a robotic extended lymphadenectomy in a subset of patients.

RESULTS

A total of 78 consecutive patients were evaluated, including 30 laparoscopic and 48 open procedures. An extended lymphadenectomy was performed in 58 patients and was executed robotically in 16 of these. There was no difference in the mean number of lymph nodes retrieved by laparoscopic or open approach (24 +/- 8 vs. 26 +/- 15, P = .66). Laparoscopic procedures were associated with decreased blood loss (200 vs. 383 mL, P = .0009) and length of stay (7 vs. 10 days, P = .0009), but increased operative time (399 vs. 298 minutes, P < .0001).

CONCLUSION

Completely laparoscopic gastric resection yields similar lymph node numbers compared with open surgery for gastric cancer. It was found to be advantageous in terms of operative blood loss and length of stay. Minimally invasive techniques represent an oncologically adequate alternative for the surgical treatment of gastric adenocarcinoma.

[Gastric cancer and laparoscopy: analysis of data from the national register of laparoscopic gastric surgery]

OBJECTIVE

To study the data from the Laparoscopic Gastric Surgery Spanish National Register of laparoscopic Gastric Surgery and to analyse the type of surgery, the conversion to laparotomy, postoperative complications and mortality.

PATIENTS AND METHOD

From March 2005 to July 2008, details of 302 laparoscopic gastric surgical interventions were sent to the Association of Spanish Surgeons web-site. Details of surgical technique, reconversion, clinical and pathological data, morbidity and mortality were collected and analysed.

RESULTS

A total of 245 patients had gastric adenocarcinoma, 35 of them stromal tumours and 22 other gastric pathologies. In gastric adenocarcinoma patients, resection was performed in 232 cases (95%). The most frequent histology was intestinal, mainly located in the distal third of the stomach, with 34% of the tumours being locally advanced. D2 lymphadenectomy was performed in 117 cases, D1 in 105, and D0 in 6. Reconversion was needed in 21 cases (9%), with technical difficulty being the most frequent cause. Postoperative complications were reported in 72 patients (31%), with anastomotic leak being one of the most significant. Postoperative mortality was 6%, with sepsis due to anastomotic leak and cardiac or respiratory complications the most frequent causes. The mean hospital stay of patients without complications was 9.2 +/- 3 days.

CONCLUSIONS

Laparoscopic gastrectomy for gastric cancer is a feasible but technically demanding procedure. Potential benefits of minimal invasive surgery can be reduced due to a high rate of postoperative complications.

Risk factors for operative complications in elderly patients during laparoscopy-assisted gastrectomy

BACKGROUND

We evaluated the feasibility of laparoscopy-assisted gastrectomy in elderly patients with gastric cancer.

STUDY DESIGN

We performed a retrospective analysis of 632 patients who underwent laparoscopy-assisted gastrectomy from May 2003 to December 2007 at Seoul National University Bundang Hospital. Postoperative complication rates were compared between patients older and younger than 70 years of age.

RESULTS

Of the 632 patients, 515 (81.5%) were younger than 70 years and 117 (18.5%) were aged 70 years or older. Significant differences in the prevalence of cardiovascular disease and hypertension were observed in patients older than 70 years (p < 0.05). Although the overall complication rates of the patients younger and older than 70 years were 12.6% and 17.9%, respectively, there was no statistically significant difference between groups (p=0.12). Multiple logistic regression analysis revealed that comorbidities with hypertension or with liver cirrhosis were the only variables that correlated independently with postoperative complications.

CONCLUSIONS

Complications after laparoscopy-assisted gastrectomy for patients older than 70 years of age with gastric cancer were similar to those of younger patients. But a careful approach is required when patients older than 70 years of age have hypertension or liver cirrhosis.