Minimally invasive gastrectomy for gastric adenocarcinoma in the United States: Utilization and short-term oncologic outcomes

Diagnosis to dissection: AI's role in early detection and surgical intervention for gastric cancer

Gastric cancer remains a formidable health challenge worldwide; early detection and effective surgical intervention are critical for improving patient outcomes. This comprehensive review explores the evolving landscape of gastric cancer management, emphasizing the significant contributions of artificial intelligence (AI) in revolutionizing both diagnostic and therapeutic approaches. Despite advancements in the medical field, the subtle nature of early gastric cancer symptoms often leads to late-stage diagnoses, where survival rates are notably decreased. Historically, the treatment of gastric cancer has transitioned from palliative care to surgical resection, evolving further with the introduction of minimally invasive surgical (MIS) techniques. In the current era, AI has emerged as a transformative force, enhancing the precision of early gastric cancer detection through sophisticated image analysis, and supporting surgical decision-making with predictive modeling and real-time preop-, intraop-, and postoperative guidance. However, the deployment of AI in healthcare raises significant ethical, legal, and practical challenges, including the necessity for ongoing professional education and the development of standardized protocols to ensure patient safety and the effective use of AI technologies. Future directions point toward a synergistic integration of AI with clinical best practices, promising a new era of personalized, efficient, and safer gastric cancer management.

Comparative Analysis of NSQIP National Outcomes and Projected Outcomes versus Our Institutional Outcomes for Robotic Gastrectomy: The Future of Gastric Resection

BACKGROUND

The robotic approach has vast applications in surgery; however, the utility of robotic gastrectomy has yet to be clearly defined. This study aimed to compare outcomes following robotic gastrectomy at our institution to the national patient-specific predicted outcomes data provided by the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP).

METHODS

We prospectively studied 73 patients who underwent robotic gastrectomy under our care. ACS NSQIP outcomes after gastrectomy and predicted outcomes for our patients were compared with our actual outcomes utilizing students t test and chi-square analysis, where applicable. Data are presented as median (mean ± SD).

RESULTS

Patients were 65 (66 ± 10.7) years old with a BMI of 26 (28 ± 6.5) kg/m2. 35 patients had gastric adenocarcinomas and 22 had gastrointestinal stromal tumors Operative duration was 245 (250 ± 114.7) minutes, estimated blood loss was 50 (83 ± 91.6) mL, and there were no conversions to 'open'. 1% of patients experienced superficial surgical site infections compared to the NSQIP predicted rate of 10% (P < .05). Length of stay (LOS) was 5 (6 ± 4.2) days vs NSQIP's predicted LOS of 8 (8 ± 3.2) days (P < .05). Three patients died during their postoperative hospital course (4%), due to multi-system organ failure and cardiac arrest. 1-year, 3-year, and 5-year estimated survival for patients with gastric adenocarcinoma was 76%, 63%, and 63%, respectively.

DISCUSSION

Robotic gastrectomy yields salutary patient outcomes and optimal survival for varying gastric diseases, particularly gastric adenocarcinoma. Our patients experienced shorter hospital stays and reduced complications relative to patients in NSQIP and predicted outcome for our patients. Gastrectomy undertaken robotically is the future of gastric resection.

Comparison of open and laparoscopic gastrectomy for gastric cancer: a low volume center experience

Objectives

In gastric cancer, laparoscopic gastrectomy is commonly performed in Asian countries. In other regions where tumor incidence is relatively low and patient characteristics are different, developments in this issue have been limited. In this study, we aimed to compare the early results for patients who underwent open or laparoscopic gastrectomy for gastric cancer in a low volume center.

Material and Methods

We retrospectively analyzed the data of patients who underwent curative gastric resection (open gastrectomy n: 30; laparoscopic gastrectomy n: 30) by the same surgical team between 2014 and 2019.

Results

The tumor was localized in 60% (36/60) of the patients in the proximal and middle 1/3 stomach. In laparoscopic gastrectomy group, the operation time was significantly longer (median, 297.5 vs 180 minutes; p <0.05). In open gastrectomy group, intraoperative blood loss (median 50 vs 150 ml; p <0.05) was significantly higher. Tumor negative surgical margin was achieved in all cases. Although the mean number of lymph nodes harvested in laparoscopic gastrectomy group was higher than the open surgery group, the difference was not statistically significant (28.2 ± 11.48 vs 25.8 ± 9.78, respectively; p= 0.394). The rate of major complications (Clavien-Dindo ≥ grade 3) was less common in the laparoscopic group (6.7% vs 16.7%; p= 0.642). Mortality was observed in four patients (2 patients open, 2 patients laparoscopic).

Conclusion

In low-volume centers with advanced laparoscopic surgery experience, laparoscopic gastrectomy for gastric cancer can be performed with the risk of morbidity-mortality similar to open gastrectomy.

Resultados tempranos en pacientes con cáncer gástrico sometidos a gastrectomía laparoscópica con intención curativa

Introducción. El manejo de pacientes con cáncer gástrico está determinado por el estadio preoperatorio y requiere de una estrategia multidisciplinaria. La cirugía radical, especialmente en pacientes con estadios tempranos, es potencialmente curativa. El abordaje por vía laparoscópica ofrece ventajas sobre la vía abierta, sin embargo, en nuestro medio no hay información en cuanto a resultados oncológicos y posoperatorios tempranos. Métodos. Estudio retrospectivo, descriptivo, de tipo transversal, en pacientes con cáncer gástrico llevados a gastrectomía laparoscópica con intención curativa, entre el 2014 y el 2019, en tres instituciones de la ciudad de Medellín. Se analizaron los datos demográficos, los resultados posoperatorios y oncológicos a corto plazo.  Resultados. Se incluyeron 75 pacientes sometidos a gastrectomía laparoscópica. La mediana de edad fue de 64 años y el estadio más frecuente fue el III. La gastrectomía fue subtotal en 50 pacientes (66,7 %) y total en 25 pacientes (33,3 %). Se hizo disección linfática D2 en 73 pacientes (97,3 %) con una mediana en el recuento ganglionar de 27. La tasa de resección R0 fue de 97,3 %. La mediana de estancia hospitalaria fue de seis días. La tasa de complicaciones mayores fue del 20 % y la mortalidad a 90 días fue del 4 %. Discusión. La calidad oncológica de la gastrectomía laparoscópica fue adecuada y cumple con las recomendaciones de las guías internacionales. Si bien la morbilidad sigue siendo alta, tiene una tasa de sobrevida del 96 % a 90 días.

Western population-based study of oncologic surgical quality and outcomes of laparoscopic versus open gastrectomy for gastric adenocarcinoma

BACKGROUND

While studies have reported improved morbidity of laparoscopic (LG) compared with open gastrectomy (OG), it remains unclear whether comparable oncologic outcomes can be achieved. This study aims at comparing not only short-term outcomes, including 30- and 90-day mortality, but also survival of LG vs OG.

METHODS

The National Cancer Database was searched for adult patients with histologically proven gastric cancer and complete information regarding M0 disease, tumor size, differentiation grade, T stage, nodal status, comorbidities, type of hospital, hospital stay, type of surgery, oncological treatment and survival data were included. Logistic regression analyses were performed to analyze margin status, 30- and 90-day mortality, and 30-day re-admission rate. Linear regression was performed for length of hospital stay and lymph node yield. Kaplan-Meier survival analyses were performed to evaluate median survival. Cox multivariable regression models were created to correct for confounders and identify factors affecting survival.

RESULTS

A query of the National Cancer Database identified 13,538 patients with complete dataset. A significant regression equation favoring LG for lymph node yield, hospital stay, and unplanned re-admission rate was identified. There was no significant effect of surgical approach on R1 margin rate, 30-day mortality, or 90-day mortality. Median survival was comparable between LG and OG (44.8 vs 40.2 months, p = 0.804).

CONCLUSION

LG offers a safe surgical approach to gastric cancer with shorter hospital stay and lower re-admission rates than OG, and also similar and sometimes improved operative oncologic quality parameters (margin, lymph node yield). More importantly, this Western series demonstrates that equivalent long-term outcomes of LG vs. OG are being achieved.

Gastrectomy case volume and textbook outcome: an analysis of the Population Registry of Esophageal and Stomach Tumours of Ontario (PRESTO)

OBJECTIVE

To determine the association between gastric cancer surgery case-volume and Textbook Outcome, a new composite quality measurement.

BACKGROUND

Textbook Outcome included (a) negative resection margin, (b) greater than 15 lymph nodes sampled, (c) no severe complication, (d) no re-intervention, (e) no unplanned ICU admission, (f) length of stay of 21 days or less, (g) no 30-day readmission and (h) no 30-day mortality following surgery.

METHODS

All patients undergoing gastrectomy for non-metastatic gastric adenocarcinoma registered in the Population Registry of Esophageal and Stomach Tumours of Ontario between 2004 and 2015 were included. We used multivariable generalized estimating equation (GEE) logistic regression modelling to estimate the association between gastrectomy volume (surgeon and hospital annual volumes) and Textbook Outcome. Volumes were considered as continuous variables and quintiles.

RESULTS

Textbook Outcome was achieved in 378 of 1660 patients (22.8%). The quality metrics least often achieved were inadequate lymph node sampling and presence of severe complications, which occurred in 46.1% and 31.7% of patients, respectively. Accounting for covariates and clustering, neither surgeon volume nor hospital volume were significantly associated with Textbook Outcome. However, hospital volume was associated with adequate lymphadenectomy and fewer unplanned ICU admissions.

CONCLUSIONS

Higher case volume can impact certain measures of quality of care but may not address all care structures necessary for ideal Textbook recovery. Future quality improvement strategies should consider using case-mix adjusted Textbook Outcome rates as a surgical quality metric.

Laparoscopic gastrectomy with D2 lymphadenectomy for gastric cancer: initial Egyptian experience at the National Cancer Institute

BACKGROUND

Laparoscopic gastrectomy has been used as a superior alternative to open gastrectomy for the treatment of early gastric cancer. However, the application of laparoscopic D2 lymphadenectomy remains controversial. This study aimed to evaluate the feasibility and outcomes of laparoscopic gastrectomy with D2 lymphadenectomy for gastric cancer.

RESULTS

Between May 2016 and May 2018, twenty-five consecutive patients with gastric cancer underwent laparoscopic D2 gastrectomy: eighteen patients (72%) underwent distal gastrectomy, four patients (16%) underwent total gastrectomy, and three patients (12%) underwent proximal gastrectomy. The median number of lymph nodes retrieved was 18 (5-35). A positive proximal margin was detected in 2 patients (8%). The median operative time and amount of blood loss were 240 min (200-330) and 250 ml (200-450), respectively. Conversion to an open procedure was performed in seven patients (28%). The median hospital stay period was 8 days (6-30), and the median time to start oral fluids was 4 days (3-30). Postoperative complications were detected in 4 patients (16%). There were two cases of mortality (8%) in the postoperative period, and two patients required reoperation (8%).

CONCLUSIONS

Laparoscopic gastrectomy with D2 lymphadenectomy can be carried out safely and in accordance with oncologic principles.

Advancements and challenges in treating advanced gastric cancer in the West

Gastric cancer is a leading cause of cancer incidence and death worldwide. Patients with advanced gastric cancer benefit from a multi-modality treatment regimen. Sound oncologic resection with negative margins and complete lymphadenectomy plays a crucial role in long-term survival for patients with resectable disease. The utilization of minimally invasive techniques for gastric cancer has been slowly increasing and is proving to be both technically and oncologically safe. Perioperative chemotherapy is the current standard of care for advanced gastric cancer. A variety of chemotherapy regimens have been used with the combination of docetaxel, oxaliplatin, 5-fluorouracil, and leucovorin being the current recommendation given its superior ability to induce a complete pathologic response and prolong survival. The use of radiation has been more controversial with its optimal place in the treatment sequence being unclear. There are current ongoing studies assessing the impact of radiation as an adjunct or in place of chemotherapy. Targeted treatments (e.g., trastuzumab for human epidermal growth factor receptor 2 positive tumors and pembrolizumab for programmed death-ligand 1 positive tumors) are showing promise and are part of a continued emphasis on individualized care. Intraperitoneal chemotherapy may also play a role in preventing peritoneal recurrences for patients with high risk lesions. The treatment of patients with advanced gastric cancer in the West continues to advance and improve with a better understanding of optimal treatment sequences and the utilization of personalized treatment regimens.

Management of Early Stage Gastric and Gastroesophageal Junction Malignancies

Esophageal and gastric carcinomas are prevalent malignancies worldwide. In contrast to the poor prognosis associated with advanced stages of disease, early stage disease has a favorable prognosis. Early stage gastric cancer (ESGC) is defined as cancer in which the depth of invasion is limited to the submucosal layer of the stomach on histologic examination, regardless of lymph node status. ESGC that meets standard or expanded criteria can be treated via endoscopic mucosal resection and endoscopic submucosal dissection. Similar indications for endoscopic interventions exist for gastroesophageal junction and esophageal malignancies."

Repeat staging laparoscopy for gastric cancer after preoperative therapy

BACKGROUND AND OBJECTIVES

Staging laparoscopy is recommended before preoperative therapy in patients with locoregional gastric cancer, but yield of repeated diagnostic laparoscopy at the time of resection is unknown.

METHODS

Retrospective review of a prospective database of patients with gastric adenocarcinoma (1994-2016) who had negative staging laparoscopy followed by preoperative therapy and subsequent attempted resection. Primary outcome was positive exploration (peritoneal or unresectable disease) at the time of resection. Multivariable logistic regression identified factors associated with positive exploration.

RESULTS

Of the 451 patients with attempted resection, 54 (12.0%) had positive explorations, including 48 with peritoneal disease. Patients with positive explorations were more likely to be female and have poorly differentiated tumors, linitis features, and signet-ring morphology. There was no significant difference by exploration results in age, race, clinical stage, or delayed definitive surgery. Positive explorations were independently associated with poor differentiation (OR 4.6, 95%CI 1.4-15.3; P = 0.01) and linitis (OR 4.2, 95%CI 1.9-9.2; P < 0.001). Positive explorations were seen in 14.0% of patients with poor differentiation, 36.6% of patients with linitis, and 5.8% of patients with neither linitis nor poor differentiation.

CONCLUSION

Despite negative pretreatment laparoscopy, post-treatment repeat laparoscopy may prevent non-therapeutic laparotomies. At a minimum, we recommend selective repeat laparoscopy for patients with linitis features.

The emerging role for robotics in cholecystectomy: the dawn of a new era?

Though laparoscopic cholecystectomy (LC) was highly criticized in its early stages, it quickly grew to become a new standard of care and has revolutionized the field of general surgery. Now emerging robotic technology is making its way into the minimally invasive arena. Robotic cholecystectomy (RC) is often disparaged as a costly technology that can lead to increased operative times with outcomes that are quite similar to LC. However, this perspective is skewed as many existing studies were performed in the early phase of learning for this procedure. RC can be performed in a cost-effective manner as the volume of robotic procedures increases. In addition, improved visualization and capability to perform fluorescence cholangiography can improve the safety profile of cholecystectomy to a level that has not yet been achieved with conventional laparoscopy. Advanced simulation technology for robotic surgery, and newer single-site robotic platforms have the potential to further revolutionize this technology and lead to improved patient satisfaction. In this review, we will present current data, trends, and controversies in robotic-assisted cholecystectomy.

Short-term outcomes in minimally invasive versus open gastrectomy: the differences between East and West. A systematic review of the literature

OBJECTIVE

Minimally invasive surgical techniques for gastric cancer are gaining more interest worldwide. Several Asian studies have proven the benefits of minimally invasive techniques over the open techniques. Nevertheless, implementation of this technique in Western countries is gradual. The aim of this systematic review is to give insight in the differences in outcomes and patient characteristics in Asian countries in comparison to Western countries.

METHODOLOGY

An extensive systematic search was conducted using the Medline, Embase, and Cochrane databases. Analysis of the outcomes was performed regarding operative results, postoperative recovery, complications, mortality, lymph node yield, radicality of the resected specimen, and survival. A total of 12 Asian and 8 Western studies were included.

RESULTS

Minimally invasive gastrectomy shows faster postoperative recovery, fewer complications, and similar outcomes regarding mortality in both the Eastern and Western studies. However, patient characteristics such as age and BMI differ between these populations. Comparison of overall outcomes in minimally invasive and open procedures between East and West showed differences in complications, mortality, and number of resected lymph nodes in favor of the Asian population.

CONCLUSION

Improved outcomes are observed following minimally invasive gastrectomy in comparison to open procedures in both Western and Asian studies. There are differences in patient characteristics between the Western and Asian populations. Overall outcomes seem to be in favor of the Asian population. These differences may fade with centralization of care for gastric cancer patients in the West and increasing surgical experience.

Contemporary reappraisal of the efficacy of adjuvant chemotherapy in resected retroperitoneal sarcoma: Evidence from a nationwide clinical oncology database and review of the literature

BACKGROUND

While margin-negative resection remains the cornerstone of therapy for retroperitoneal sarcoma (RPS), the impact of adjuvant chemotherapy (AC) on overall survival (OS) remains poorly understood.

METHODS

The National Cancer Data Base was queried for patients undergoing curative-intent resection of primary non-metastatic RPS (2004-2013). Multivariable modeling identified factors associated with AC receipt. Cox regression identified covariates associated with OS, and AC and surgery alone (SA) cohorts were matched 1:1 by propensity scores based on these covariates. In the propensity-score matched cohort, OS was compared by Kaplan-Meier estimates. Results from this analysis were presented in the context of a review of the existing literature on the impact of AC in resected RPS.

RESULTS

Of 3892 resected RPS patients, 90.0% and 10.0% received SA and AC, respectively. Predictors of AC receipt included younger age, non-Caucasian race, hospital location, histologic grade, adjacent organ invasion, and histologic subtype. The propensity score-matched cohort comprised 767 patients (SA n = 377; AC n = 390); at a median follow-up of 59.2 (IQR 35.0-85.3) months, median OS of the propensity-matched cohort was 53.6 (IQR 22.4-119.5) months. Utilization of AC was associated with significantly worse long-term survival (median OS: 47.8 vs. 68.9 months, p = 0.017; HR 1.30, 95% CI 1.05-1.61). AC was not associated with improved OS in margin-positive (R1/R2) resection, high-grade (G2/G3) and larger (>10 cm) tumors, or in any histologic subtype. Albeit not statistically significant, there was a trend toward improved OS with AC in spindle cell (HR 0.37, 95% CI 0.10-1.38), giant cell (HR 0.82, 95% CI 0.32-2.13), and synovial (HR 0.26, 95% CI 0.05-1.33) sarcoma.

CONCLUSIONS

Data from a large nationwide oncology database and review of the existing literature do not support adjuvant chemotherapy regimens following curative-intent resection of RPS, even in subgroups at high risk of failure (e.g., R1/R2 resection, high-grade or large tumors). The possible benefit of conventional adjuvant regimens in spindle cell, giant cell, and synovial sarcoma should be explored in prospective studies.

Surgeon's Experience Overrides the Effect of Hospital Volume for Postoperative Outcomes of Laparoscopic Surgery in Gastric Cancer: Multi-institutional Study

BACKGROUND

Hospital volume is known to be a crucial factor in reducing postoperative morbidity and mortality in laparoscopic gastrectomy for gastric cancer. However, it is unclear whether surgeon's individual experience can overcome the effect of hospital volume.

METHODS

Clinicopathologic data of initial 50 laparoscopic gastrectomy cases were collected from six gastric cancer surgeons. Half of the six surgeons worked in high-volume centers, and the other half worked in low-volume hospitals. Perioperative outcomes were compared between the high-volume centers and the low-volume hospitals.

RESULTS

Three low-volume hospitals in this study contained significantly more male and older patients with a higher American Society of Anesthesiologists score than high-volume centers. Although high- and low-volume hospitals mainly used laparoscopy-assisted and totally laparoscopic approach, respectively, there were no differences between the two groups in the extent of resection, operating time, estimated blood loss, and number of collected lymph nodes. Postoperative recovery such as duration to soft diet and hospital stay did not differ between the high- and the low-volume hospitals. No significant difference was found in postoperative morbidities by Clavien-Dindo classification. There was no mortality reported in both groups of the enrolled hospitals.

CONCLUSIONS

Hospital volume is not a decisive factor in affecting postoperative morbidity and mortality for well-trained beginners in laparoscopic surgery for gastric cancer.

Preoperative radiotherapy in the management of retroperitoneal liposarcoma

BACKGROUND

Histological subtype influences both prognosis and patterns of treatment failure in retroperitoneal sarcoma. Previous studies on the efficacy of neoadjuvant radiotherapy (NRT) have incorporated multiple histological types with heterogeneous tumour biology. The survival impact of NRT specifically for patients with retroperitoneal liposarcoma is poorly defined.

METHODS

Patients who underwent resection with curative intent for retroperitoneal liposarcoma and who received NRT or surgery alone were identified in the US National Cancer Data Base (2004-2013). Cox regression was used to identify co-variables associated with overall survival. NRT and surgery-alone cohorts were matched 1 : 1 by propensity scores based on the survival hazard on Cox modelling. Overall survival was compared by Kaplan-Meier estimates.

RESULTS

A total of 2082 patients with retroperitoneal liposarcoma were identified; 1908 underwent surgery alone and 174 received NRT before surgical resection. Median tumour size was 22·0 cm and 34·9 per cent of tumours were high grade. In the unmatched cohort, NRT was not associated with improved overall survival (χ²  = 3·49, P = 0·062). In the propensity score-matched cohort, NRT was associated with an improvement in survival (median overall survival 129·2 versus 84·3 months; P = 0·046; hazard ratio (HR) 1·54, 95 per cent c.i. 1·01 to 2·36). This effect appeared most pronounced for tumours with adjacent organ invasion (median overall survival not reached versus 63·8 months; P = 0·044; HR 1·79, 1·01 to 3·19).

CONCLUSION

NRT improved survival in patients undergoing surgery for retroperitoneal liposarcoma, particularly those with high-risk pathological features.

Laparoscopic Total Gastrectomy with D2 Lymphadenectomy and Side-to-Side Stapled Esophagojejunostomy

INTRODUCTION

An optimal method has yet to be established for laparoscopic total gastrectomy with intracorporeal anastomosis.

METHODS

We aim to describe a simple technique for intracorporeal anastomoses. Technique of laparoscopic total gastrectomy with side-to-side stapled intracorporeal esophagojejunostomy anastomosis and Roux-en-Y jejunojejunostomy is performed on patients with gastric malignancy in an academic community tertiary care center.

RESULTS

The anastomotic technique of laparoscopic total gastrectomy with side-to-side stapled esophagojejunostomy is described.

CONCLUSION

Laparoscopic total gastrectomy with D2 lymphadenectomy and side-to-side esophagojejunostomy is safe to perform and has the advantage of a wide lumen with low chance for stricture. A laparoscopic total gastrectomy with stapled side-to-side esophagojejunostomy is feasible and safe in advanced gastric cancer.

Use of Laparoscopy in Gastrointestinal Surgery in Sweden 1998–2014: A Nationwide Study

Background and Aims:

One by one, minimally invasive alternatives to established gastrointestinal procedures have become clinical routine. We have studied the use of laparoscopy in four common procedures—cholecystectomy, appendectomy, reflux surgery, and bariatric surgery—as well as in major resectional gastrointestinal surgery in Sweden.

Materials and Methods:

The National Patient Registry was used to identify all in-hospital procedures performed in patients above the age of 15 during 1998–2014, meeting our inclusion criteria. For each group, the annual number of procedures and proportion of laparoscopic surgery were studied, as well as applicable subgroups. Differences in age, gender, as well as geographical differences were evaluated in the most recent 3-year period (2012–2014).

Results:

In total, 537,817 procedures were studied, 43% by laparoscopic approach. In 2012–2014, the proportion of laparoscopic surgery ranged from high rates in the four common procedures (cholecystectomy 81%, appendectomy 47%, reflux surgery 72%, and bariatric surgery 97%) to rather low numbers in resectional surgery (4%–10%), however, increasing in the last years. In appendectomy and cholecystectomy, men were less likely to have laparoscopic surgery (42% versus 51% and 74% versus 85%, respectively, p < 0.001). Substantial geographical differences in the use of laparoscopy were also noted, for example, the proportion of laparoscopic appendectomy varied from 11% to 76% among the 21 different Swedish counties.

Conclusion:

The proportion of laparoscopy was high in the four common procedures and low, but rising, in major resectional surgery. A large variation in the proportion of laparoscopic surgery by age, gender, and place of residence was noted.