Laparoscopy-assisted gastrectomy for early gastric cancer in young and elderly patients

EAES/SAGES evidence-based recommendations and expert consensus on optimization of perioperative care in older adults

BACKGROUND

As the population ages, more older adults are presenting for surgery. Age-related declines in physiological reserve and functional capacity can result in frailty and poor outcomes after surgery. Hence, optimizing perioperative care in older patients is imperative. Enhanced Recovery After Surgery (ERAS) pathways and Minimally Invasive Surgery (MIS) may influence surgical outcomes, but current use and impact on older adults patients is unknown. The aim of this study was to provide evidence-based recommendations on perioperative care of older adults undergoing major abdominal surgery.

METHODS

Expert consensus determined working definitions for key terms and metrics related to perioperative care. A systematic literature review and meta-analysis was performed using the PubMed, Embase, Cochrane Library, and Clinicaltrials.gov databases for 24 pre-defined key questions in the topic areas of prehabilitation, MIS, and ERAS in major abdominal surgery (colorectal, upper gastrointestinal (UGI), Hernia, and hepatopancreatic biliary (HPB)) to generate evidence-based recommendations following the GRADE methodology.

RESULT

Older adults were defined as 65 years and older. Over 20,000 articles were initially retrieved from search parameters. Evidence synthesis was performed across the three topic areas from 172 studies, with meta-analyses conducted for MIS and ERAS topics. The use of MIS and ERAS was recommended for older adult patients particularly when undergoing colorectal surgery. Expert opinion recommended prehabilitation, cessation of smoking and alcohol, and correction of anemia in all colorectal, UGI, Hernia, and HPB procedures in older adults. All recommendations were conditional, with low to very low certainty of evidence, with the exception of ERAS program in colorectal surgery.

CONCLUSIONS

MIS and ERAS are recommended in older adults undergoing major abdominal surgery, with evidence supporting use in colorectal surgery. Though expert opinion supported prehabilitation, there is insufficient evidence supporting use. This work has identified evidence gaps for further studies to optimize older adults undergoing major abdominal surgery.

Chinese national clinical practice guidelines on the prevention, diagnosis, and treatment of early gastric cancer

BACKGROUND

Gastric cancer is one of the most common malignant tumors in the digestive system in China. Few comprehensive practice guidelines for early gastric cancer in China are currently available. Therefore, we created the Chinese national clinical practice guideline for the prevention, diagnosis, and treatment of early gastric cancer.

METHODS

This clinical practice guideline (CPG) was developed in accordance with the World Health Organization's recommended process and with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) in assessing evidence quality. We used the Evidence to Decision framework to formulate clinical recommendations to minimize bias and increase transparency in the CPG development process. We used the Reporting Items for practice Guidelines in HealThcare (RIGHT) statement and the Appraisal of Guidelines for Research and Evaluation II (AGREE II) as reporting and conduct guidelines to ensure completeness and transparency of the CPG.

RESULTS

This CPG contains 40 recommendations regarding the prevention, screening, diagnosis, treatment, and follow-up of early gastric cancer based on available clinical studies and guidelines. We provide recommendations for the timing of Helicobacter pylori eradication, screening populations for early gastric cancer, indications for endoscopic resection and surgical gastrectomy, follow-up interval after treatment, and other recommendations.

CONCLUSIONS

This CPG can lead to optimum care for patients and populations by providing up-to-date medical information. We intend this CPG for widespread adoption to increase the standard of prevention, screening, diagnosis, treatment, and follow-up of early gastric cancer; thereby, contributing to improving national health care and patient quality of life.

Advantages of Function-Preserving Gastrectomy for Older Patients With Upper-Third Early Gastric Cancer: Maintenance of Nutritional Status and Favorable Survival

PURPOSE

The incidence of early gastric cancer is increasing in older patients alongside life expectancy. For early gastric cancer of the upper third of the stomach, laparoscopic function-preserving gastrectomy (LFPG), including laparoscopic proximal gastrectomy (LPG) and laparoscopic subtotal gastrectomy (LSTG), is expected to be an alternative to laparoscopic total gastrectomy (LTG). However, whether LFPG has advantages over LTG in older patients remains unknown.

MATERIALS AND METHODS

We retrospectively analyzed data of consecutive patients aged ≥75 years who underwent LTG, LPG, or LSTG for cT1N0M0 gastric cancer between 2005 and 2019. Surgical and nutritional outcomes, including blood parameters, percentage body weight (%BW) and percentage skeletal muscle index (%SMI) were compared between LTG and LPG or LSTG. Survival outcomes were also compared between LTG and LFPG groups.

RESULTS

A total of 111 patients who underwent LTG (n=39), LPG (n=48), and LSTG (n=24) were enrolled in this study. To match the surgical indications, LTG was further categorized into "LTG for LPG" (LTG-P) and "LTG for LSTG" (LTG-S). No significant differences were identified in the incidence of postoperative complications among the procedures. Postoperative nutritional parameters, %BW and %SMI were better after LPG and LSTG than after LTG-P and LTG-S, respectively. The survival outcomes of LFPG were better than those of LTG.

CONCLUSIONS

LFPG is safe for older patients and has advantages over LTG in terms of postoperative nutritional parameters, body weight, skeletal muscle-sparing, and survival. Therefore, LFPG for upper early gastric cancer should be considered in older patients.

Prognosis after curative resection for stage IA gastric cancer in elderly patients: endoscopic submucosal dissection versus surgery

PURPOSE

To establish whether gastrectomy for early gastric cancer (EGC) in elderly patients is related to poor survival.

METHODS

The subjects of this retrospective study were patients aged ≥ 75 years with primary stage IA EGC, who underwent curative resection with endoscopic submucosal dissection (ESD) or surgery.

RESULTS

We analyzed data on 365 patients who underwent ESD and 170 patients who underwent surgery. Overall survival (OS) was not significantly different for the ESD group vs. the surgery group (5-year cumulative rates, 81.5% vs. 79.7%; log-rank test, P = 0.506). Multivariate analysis revealed that treatments; namely, ESD or surgery, were not associated with OS (hazard ratio 1.09, 95% confidence interval 0.77-1.51). Similar results were observed even in the subgroups with worse conditions, such as age > 80 years, Eastern Cooperative Oncology Group performance status 2-3, Charlson comorbidity index ≥ 2, and prognostic nutritional index ≤ 46.7. Using propensity score matching, we selected 88 pairs of patients who underwent ESD or surgery with baseline characteristics matched and found that OS was not different between the two groups (log-rank test, P = 0.829).

CONCLUSION

OS was comparable for elderly patients who underwent ESD and those who underwent surgery for EGC. Surgical invasiveness did not worsen the prognosis, even for elderly patients.

Evaluation of Peroperative and Oncological Results in Laparoscopic Surgery of Gastric Cancer in Elderly Patients: Single-Center Study

Introduction: Laparoscopic treatment of gastric cancer in elderly patients is still controversial. The aim of this retrospective study is to evaluate the safety and feasibility of laparoscopic gastrectomy in elderly gastric cancer patients based on the long- and short-term results of laparoscopic surgery. Materials and Methods: The data of 163 patients who underwent laparoscopic gastrectomy for gastric cancer. Patients were categorized into two groups by age based on World Health Organization (WHO) criteria: elderly (≥65 years, 80 cases) and nonelderly (<65 years, 83 cases). Patient characteristics and clinicopathological findings, surgical findings, short- and long-term results were compared between the two groups. Results: The patients in the study group were in the age range of 22-87 years and 80 (49%) patients were found out to be 65 years old or older. When all complications were categorized according to Clavien-Dindo (C-D) classification, >3 serious complication rates were similar between groups (P = .421). Although the length of hospital stay and the need for intensive care were higher in the elderly group, the difference was not significant (P = .066; P = .072). There was no significant difference between the two in terms of in-hospital mortality (P = .364). No statistically significant differences were found in the rates of overall survival (nonelderly group; 61.17 ± 3.34, 95% confidence interval [CI]: 54.61-67.74 versus elderly group; 56.48 ± 3.80, 95% CI: 49.03-63.93; P = .176) and disease-specific survival (nonelderly group; 64.24 ± 3.15, 95% CI: 58.06-70.40 versus elderly group; 61.93 ± 3.57, 95% CI: 54.93-68.93; P = .363) between the age groups. Conclusion: In conclusion, although laparoscopic gastrectomy is a feasible and safe method in elderly gastric cancer patients, further randomized prospective studies are needed.

Impact of Age and Comorbidity on the Short-Term Surgical Outcome after Laparoscopy-Assisted Distal Gastrectomy for Adenocarcinoma

The aim of this study was to determine whether age and comorbidity are valuable risk factors of the short-term surgical outcome after laparoscopy-assisted distal gastrectomy (LADG) in patients with adenocarcinoma. A series of 387 patients who underwent LADG at three university hospitals between March 2006 and December 2010 were retrospectively studied. To compare the short-term surgical outcomes of LADG of elderly patients with those of younger patients, patients were categorized into an elderly group (older than 70 years of age) and a younger group (70 years of age or younger). For another comparative analysis to identify risk factors of postoperative complications after LADG, patients were categorized into two groups: those with complications and those without complications. With the exception of sex ratio and comorbidity rate, two age groups were nonsignificantly different in terms of demographic, operative, pathologic, and short-term surgical outcome data. Our data support the safety and feasibility of LADG in elderly patients. However, our data show that comorbidity is an important predictor of postoperative systemic complications after LADG. Patients with an age-adjusted Charlson comorbidity index (CCI) of 3 or greater were found to be at a greater risk of developing systemic complications, which suggests that age-adjusted CCI is a useful predictor of systemic complications after LADG and that it could be used routinely for the perioperative care of aged patients with comorbidity. We recommend age-adjusted CCI be used in comparative clinical research studies on the surgical outcomes across surgeons and hospitals.

Short- and Long-Term Outcomes after Laparoscopic Versus Open Gastrectomy for Elderly Gastric Cancer Patients: A Systematic Review and Meta-Analysis

Background: With the rapid aging of global population, the number of elderly patients with gastric cancer is increasing. This study aimed to evaluate short- and long-term outcomes after laparoscopic gastrectomy (LG) versus open gastrectomy (OG) in elderly gastric cancer patients. Materials and Methods: We searched PubMed, EMBASE, and the Cochrane library databases from January 1994 to May 2019. Surgical safety, postoperative complications, number of harvested lymph nodes, and overall survival rate were included and analyzed. The qualities of the included studies were evaluated by Newcastle-Ottawa Quality Assessment Scale. The evidence of outcomes was evaluated using the GRADE approach. The Review Manager^® 5.3 (Cochrane, London, UK) and Stata^® 14.0 (StataCorp., College Station, Texas) were used to analyze the outcomes. Results: Thirteen studies containing 4768 elderly patients with gastric cancer were included in this meta-analysis. LG was more favorable than OG in terms of overall postoperative morbidity (odds ratio [OR]: 0.56; 95% confidence interval [CI]: 0.44 to 0.70; P < .00001), the postoperative stay (standardized mean difference [SMD]: -0.56; 95% CI: -0.76 to (-0.37); P < .00001), and the number of harvested lymph nodes (SMD: 0.19; 95% CI: 0.09 to 0.29; P = .0003). No significant difference was found in anastomotic leakage rate (OR: 0.82; 95% CI: 0.59 to 1.12; P = .21), mental disease (OR: 0.79; 95% CI: 0.44 to 1.44; P = .44), or overall survival rate (P = .62) between two groups. However, in the subgroup with a cutoff age of 80 years, the anastomotic leakage rate was higher in LG (OR: 10.27; 95% CI: 1.31 to 80.35; P = .03). Conclusions: LG was more favorable than OG in the elderly patients <80 years old with gastric cancer.

Laparoscopic versus open gastrectomy for high-risk patients with gastric cancer: A systematic review and meta-analysis

BACKGROUND

It is still remains unclear whether high-risk patients with gastric cancer can benefit from the application of laparoscopic gastrectomy (LG). The aim of this systematic review was to evaluate the surgical and long-term outcomes after LG and open gastrectomy (OG) for high-risk patients with gastric cancer.

METHODS

We performed a systematic literature search in various databases from January 1994 to June 2018. Patients who had≥1 of the following conditions were defined as high-risk patients: (1) age≥70 years; (2) BMI≥30 kg/m²; (3) ASA (American Society of Anesthesiologists) grade≥3; or (4) clinical T4 stage (cT4). The results were analyzed according to predefined criteria.

RESULTS

In the present meta-analysis, the outcomes of 12 non-randomized controlled studies enrolling 1651 patients (873 in the LG group and 778 in the OG group) were pooled. The estimated blood loss was significantly lower in the LG group than those in the OG group (P < 0.01). There was no significant difference between two groups in operative time (P = 0.17) and number of harvested lymph nodes (P = 0.21). In the LG group, the time to flatus (P < 0.01), time to food intake (P < 0.01), and postoperative hospital stay (P < 0.01) were significantly shorter than those in the OG group. A lower overall postoperative complication rate was observed in the LG group (P < 0.01). The incidence of surgical (P < 0.01) and non-surgical (P < 0.01) complication was significantly lower in the LG group than that in the OG group. The pooled analysis showed no significant difference in overall survival (OS) between LG and OG groups (P = 0.98).

CONCLUSIONS

LG can be a safe and feasible procedure for high-risk patients with gastric cancer.

Comparison of Outcomes for Elderly Gastric Cancer Patients at Least 80 Years of Age Following Gastrectomy in the United States and China

OBJECTIVE

The aim of this study was to compare gastric cancer (GC) patients aged 80 years or older undergoing gastrectomy at two high-volume cancer centers in the US and China.

METHODS

Patients aged ≥ 80 years who underwent R0 resection at Memorial Sloan Kettering Cancer Center (MSKCC) in New York, USA (n = 159), and Fujian Medical University Union Hospital (FMUUH) in Fujian, China (n = 118) from January 2000 to December 2013 were included. Demographic, surgical, and pathologic variables were compared, and factors associated with survival were determined via multivariate analysis.

RESULTS

The number of patients increased annually in the FMUUH cohort but not in the MSKCC cohort. Patients at MSKCC were slightly older (mean age 83.7 vs. 82.7 years), more commonly female (38 vs. 19%), and had higher average body mass index (BMI; 26 vs. 23). Treatment at FMUUH more frequently employed total gastrectomy (59 vs. 20%) and laparoscopic surgery (65 vs. 7%), and less frequently included adjuvant therapy (11 vs. 18%). In addition, FMUUH patients had larger tumors of more advanced T, N, and TNM stage. Morbidity (35 vs. 25%, p = 0.08) and 30-day mortality (2.5 vs. 3.3%, p = 0.67) were similar between the cohorts. For each TNM stage, there was no significant difference between MSKCC and FMUUH patients in 5-year overall survival and disease-specific survival (DSS). TNM stage was the only independent predictor of DSS for both cohorts.

CONCLUSIONS

Patients ≥ 80 years of age selected for gastrectomy for GC at MSKCC and FMUUH had acceptable morbidity and mortality, and DSS was primarily dependent on TNM stage.

Comparison of Open and Laparoscopic Gastrectomy in Elderly Patients

PURPOSE

The purpose of this study was to estimate surgical outcomes of elderly patients older than 80 years who received laparoscopic or open gastrectomy for gastric cancer and to identify risk factors for postoperative complications.

METHODS

Two hundred forty-two elderly patients older than 80 years underwent gastric cancer surgery between January 2010 and December 2016 in three tertiary hospitals. They were divided into two groups: laparoscopic gastrectomy (N = 59) and open gastrectomy (N = 183). The surgical outcomes and risk factors for postoperative complication were evaluated.

RESULTS

Among the elderly patients, 24.4% showed an ASA score of 3 or 4, and 20.7% showed a Charlson comorbidity index (CCI) score of 2 or more. 46.3% of patients had hypertension and 15.3% had diabetes. The laparoscopic gastrectomy group showed similar operation time, less intraoperative blood loss, and faster postoperative gastrointestinal recovery compared to the open gastrectomy group. The incidence of postoperative complications was 30.1% in the open group and 22.0% in the laparoscopic group (P = 0.249). One patient died for pulmonary complication in the open gastrectomy group. In multivariate analysis, older age, male, higher CCI score, and open approach were found to be correlated with increased risk for postoperative complications.

CONCLUSIONS

Although elderly patients over 80 years had a high incidence of comorbidity, gastric cancer surgery can be safely performed. The laparoscopic approach might be feasible for open surgery in improving quality of life in these patients, given a faster postoperative intestinal recovery period, with similar risk for postoperative complications.

Laparoscopic gastrectomy for elderly patients with gastric cancer: A systematic review with meta-analysis

BACKGROUND

Laparoscopic gastrectomy (LG) has been widely applied in patients with gastric cancer (GC). However, the safety and application value of LG in elderly patients with GC was still unclear. In this study, we aimed to evaluate the feasibility and safety of LG for elderly patients with GC using the meta-analysis.

METHODS

Studies comparing elderly patients and nonelderly patients who underwent LG for GC were reviewed and collected from the PubMed, EBSCO, Cochrane Library, and EMBASE. Outcomes such as operative results, postoperative recovery, and morbidity were compared and analyzed. The Review Manager 5.3 was used to portray the weighted mean difference (WMD) and odds ratio (OR) with a 95% confidence interval (CI).

RESULTS

Eleven observational studies with a total of 3275 patients were included. Compared with nonelderly patients, elderly patients had shorter operation time (WMD -10.46; 95% CI -17.06 to -3.86; P = .002), less retrieved lymph nodes (WMD -2.34; 95% CI -3.77 to -0.92; P = .001), delayed time to first flatus (WMD 0.31; 95% CI 0.10-0.51; P = .003), longer postoperative hospital stays (WMD 1.06; 95% CI 0.07-2.05; P = .04), higher risk for overall postoperative complication (OR 1.34; 95% CI 1.08-1.67; P = .009), nonsurgical postoperative complication (OR 1.98; 95% CI 1.24-3.15; P = .004), and postoperative pulmonary complication (OR: 3.09; 95% CI 1.68-5.68; P < .001). There was no significance between nonelderly patients and elderly patients regarding the estimated blood loss, incidences of surgical postoperative complication, surgical site infection, and ileus (P > .05).

CONCLUSION

Outcomes of LG for elderly patients were comparable to those in nonelderly patients. Age alone should not preclude LG in elderly patients.

Laparoscopy-assisted gastrectomy in the elderly: experience from a UK centre

BACKGROUND Gastric cancer has a high incidence in the elderly in the UK, with a significant number of patients aged 75 years or more. While surgery forms the mainstay of treatment, evidence pertaining to the management of gastric cancer in the Western population in this age group is scarce. METHODS We retrospectively reviewed the outcomes of laparoscopy-assisted total and distal gastrectomies at our centre from 2005 to 2015. Patients aged 70 years or above were included in the elderly group. RESULTS A total of 60 patients underwent laparoscopy-assisted gastrectomy over a 10-year period, with a predominance of male patients. There was no significant difference in the rate of overall surgical and non-surgical complications, in-hospital mortality, operation time and length of hospital stay, between the elderly and non-elderly groups. Univariate analysis, performed for risk factors relating to anastomotic leak and surgical complications, showed that age over 70 years and higher American Association of Anesthesiologists grades are associated with a higher, though not statistically significant, number of anastomotic leaks (P = 1.000 and P = 0.442, respectively) and surgical complications (P = 0.469 and P = 0.162, respectively). The recurrence rate within the first 3 years of surgery was significantly higher in the non-elderly group compared with the elderly group (Log Rank test, P = 0.002). There was no significant difference in survival between the two groups (Log Rank test, P = 0.619). CONCLUSIONS Laparoscopy-assisted gastrectomy is safe and feasible in an elderly population. There is a need for well-designed, prospective, randomised studies with quality of life data to inform our practice in future.

Feasibility of laparoscopic gastrectomy for elderly gastric cancer patients: meta-analysis of non-randomized controlled studies

The aim of this meta-analysis was to determine the feasibility of laparoscopic gastrectomy (LG) for elderly gastric cancer patients by comparing laparoscopic and conventional open gastrectomies (OG). Comprehensive search of the PubMed, EMBASE, and Cochrane Library databases revealed nine non-randomized controlled studies that compared LG and OG in elderly gastric cancer patients We then analyzed dichotomous or continuous parameters using odds ratios (ORs) or weighted mean differences (WMDs). Overall survival was estimated using hazard ratios (HRs) with a fixed effects or random effects model. We observed that the age distribution was similar between the LG and OG patient groups (WMD -0.22 95% CI, -1.26-0.82). LG patients experienced less blood loss (WMD -119.14 95% CI, -204.17--34.11) and had shorter hospital stays (WMD -3.48 95% CI, -5.41--1.56), but endured longer operation times (WMD 10.87 95% CI, 2.50-19.24). Postoperatively, LG patients exhibited lower incidences of postoperative morbidities (OR 0.59 95% CI, 0.43-0.79), surgery related morbidities (OR 0.58 95% CI, 0.41-0.81) and systemic morbidities (OR 0.56 95% CI, 0.38-0.82). We observed no differences between the LG and OG patient groups regarding anastomotic leakage (OR 0.69 95% CI, 0.34-1.41), mental disease (OR 0.72 95% CI, 0.37-1.41) and long term effects (HR 0.98 95% CI, 0.74-1.32). We therefore conclude that laparoscopic gastrectomy might be technically feasible for elderly gastric cancer patients.

Robotic gastrectomy for elderly gastric cancer patients: comparisons with robotic gastrectomy in younger patients and laparoscopic gastrectomy in the elderly

BACKGROUND

Robotic surgery for gastric cancer has been adopted to overcome technical difficulties in performing laparoscopic gastrectomy. This study aimed to investigate the feasibility and safety of robotic gastrectomy in elderly gastric cancer patients.

METHODS

Patients who underwent laparoscopic or robotic gastrectomy from 2003 to 2010 in a single high-volume center were included in this study. We retrospectively compared preoperative characteristics, perioperative factors, and oncological parameters among an elderly (≥70 years old) robotic gastrectomy group (n = 49), a younger (<70 years old) robotic gastrectomy group (n = 321), and an elderly laparoscopic gastrectomy group (n = 132).

RESULTS

The elderly robotic group presented with more comorbidities than the younger robotic group. Except for number of retrieved lymph nodes (36.5 vs. 41.5; P = 0.007), short-term operative outcomes including complications and pathological parameters were comparable between the two robotic groups. The elderly robotic group showed comparable disease-specific survival to the younger robotic group although overall survival was worse. Compared to their laparoscopic counterparts, the elderly robotic group showed longer mean operation time (227 vs. 174 min). Nevertheless, the incidence and severity of postoperative complications was not different between the two elderly groups. Overall and disease-specific survival were also comparable between the elderly groups. In multivariate analysis, age and surgical approach were not risk factors for overall and major complications.

CONCLUSIONS

The outcomes of robotic gastrectomy in the elderly did not differ from those in younger robotic gastrectomy patients and were comparable to those in elderly patients who underwent laparoscopic gastrectomy. Thus, robotic gastrectomy could be a safe and feasible approach in elderly patients.

Laparoscopy-assisted distal gastrectomy for early gastric cancer poses few limitations for selected elderly patients: a single-center experience

Background

The safety and efficacy of laparoscopy-assisted distal gastrectomy (LADG) for early gastric cancer have been demonstrated in clinical studies. The aim of this study was to clarify the safety and efficacy of LADG in patients ≥80 years of age with early gastric cancer, an American Society of Anesthesiologists (ASA) classification of 1–2, and a performance status (PS) of 0–1.

Case presentation

From April 2009 to July 2011, 12 elderly patients aged ≥80 years and 43 younger patients underwent LADG for early gastric cancer. Seven of the 55 patients underwent LADG and simultaneous surgery including surgery for colorectal cancer, cholecystectomy, or other conditions. Forty-eight of the 55 patients who underwent only LADG were studied. Demographics and postoperative outcomes were compared.

Results

The postoperative complication rate, time to first ambulation, time to first flatus, time to first fluid intake, and postoperative hospital stay were similar in these two groups. Nutritional status as assessed by body weight, serum albumin, and total protein at 1 and 3 months after surgery was also similar in these two groups.

Conclusions

Postoperative outcomes were acceptable in the elderly patients included in the study. LADG for early gastric cancer is a safe and effective treatment in elderly patients aged ≥80 years with an ASA status of 1–2 and PS of 0–1.

Laparoscopic gastrectomy versus open gastrectomy for elderly patients with gastric cancer: a systematic review and meta-analysis

Background

The objective of this study was to evaluate the feasibility, safety, and potential benefits of laparoscopic gastrectomy (LG) comparing with open gastrectomy (OG) in elderly population.

Methods

Studies comparing LG with OG for elderly population with gastric cancer, published between January 1994 and July 2015, were identified in the PubMed, Embase, and ISI Web of Science databases. Operative outcomes (intraoperative blood loss, operative time, and the number of lymph nodes harvested) and postoperative outcomes (time to first ambulation, time to first flatus, time to first oral intake, postoperative hospital stay, postoperative morbidity) were included and analyzed. The Newcastle-Ottawa Scale was used to assess the quality of the pooled study. A funnel plot was used to evaluate the publication bias.

Results

Seven studies totaling 845 patients were included in the meta-analysis. LG in comparison to OG showed less intraoperative blood loss (weighted mean difference (WMD) −127.47; 95 % confidence interval (CI) −202.79 to −52.16; P < 0.01), earlier time to first ambulation (WMD −2.07; 95 % CI −2.84 to −1.30; P < 0.01), first flatus (WMD −1.04; 95 % CI −1.45 to −0.63; P < 0.01), and oral intake (WMD −0.94; 95 % CI −1.11 to −0.77; P < 0.01), postoperative hospital stay (WMD −5.26; 95 % CI −7.58 to −2.93; P < 0.01), lower overall postoperative complication rate (odd ratio (OR) 0.39; 95 % CI 0.28 to 0.55; P < 0.01), less surgical complications (OR 0.47; 95 % CI 0.32 to 0.69; P < 0.01), medical complication (OR 0.35; 95 % CI 0.22 to 0.56; P < 0.01), incisional complication (OR 0.40; 95 % CI 0.19 to 0.85; P = 0.02), and pulmonary infection (OR 0.49; 95 % CI 0.26 to 0.93; P = 0.03). No significant differences were observed between LG and OG for the number of harvested lymph nodes. However, LG had longer operative times (WMD 15.73; 95 % CI 6.23 to 25.23; P < 0.01).

Conclusions

LG is a feasible and safe approach for elderly patients with gastric cancer. Compared with OG, LG has less blood loss, faster postoperative recovery, and reduced postoperative morbidity.

Current status of surgical treatment of gastric cancer in the era of minimally invasive surgery in China: Opportunity and challenge

Gastric cancer is one of the most common cancers in China. In the past decade, with the developments in surgical instruments and technologies, minimally invasive surgery has rapidly become an accepted treatment for gastric cancer in China. Many Chinese surgeons and researchers have contributed to the rapid evolution of minimally invasive surgery for gastric cancer. Their efforts have transformed into unique laparoscopic technique, workshops, academic communications, education and international communications in China. Meanwhile, many retrospective comparative trials and randomized controlled trials have revealed the advantages in minimally invasive surgery for gastric cancer. However, multicenter randomized controlled trials are still needed to delineate significantly quantifiable differences between laparoscopic and open gastrectomy. With more and more experience has accumulated, laparoscopic gastrectomy has been performed on older and overweight patients. Moreover, advanced minimally invasive techniques, such as modified laparoscopic spleen-preserving splenic hilum lymphadenectomy, various laparoscopic gastric reconstruction methods and robotic gastrectomy have been developed. It seems that China owns the potential to keep up with her neighbor, Japan and Korea, to become one of leading countries utilizing minimally invasive surgery for gastric cancer.

Short- and Long-Term Outcomes After Laparoscopic Versus Open Total Gastrectomy for Elderly Gastric Cancer Patients: a Propensity Score-Matched Analysis

BACKGROUND

To date, it has been unclear whether laparoscopic-assisted total gastrectomy (LTG) was a suitable treatment for elderly patients (aged 65 years and older) with gastric cancer. The aim of the present study was to clarify the value of LTG in the elderly using a propensity score matching method.

METHODS

We prospectively collected data from 675 elderly gastric cancer patients who underwent total gastrectomies at our institution between January 2002 and February 2012. Propensity score matching was applied at a ratio of 1:1 to compare the LTG and open total gastrectomy (OTG) groups. The operation results, hospital courses, and survival rates were compared between the matched groups.

RESULTS

The LTG group had a significantly shorter mean operating time (194 vs. 267 min, P < 0.001) and significantly less intraoperative blood loss (92 vs. 204 ml, P < 0.001). The total number of collected lymph nodes was similar in the two groups. Postoperatively, the length of hospital stay was shorter in the LTG group than in the OTG group (median 14.4 vs. 16.6 days; P = 0.001); however, no significant intergroup differences were found in morbidity or mortality. Furthermore, the 3-year overall survival (OS) rate was similar between the two groups (P = 0.517).

CONCLUSIONS

LTG for elderly gastric cancer is feasible and safe with acceptable oncologic outcomes. Therefore, patient age alone should not be considered a contraindication in the decision between LTG and OTG treatment options. A high-volume prospective study is needed to confirm this rationale.

Laparoscopic gastrectomy for gastric cancer in the elderly patients

BACKGROUND

This study aimed to investigate the short-term surgical outcomes of laparoscopic gastrectomy for gastric cancer in elderly patients in order to determine the safety, feasibility, and risk factors for postoperative complications associated with this procedure.

METHODS

We retrospectively investigated 208 patients who underwent laparoscopic gastrectomy for gastric cancer between January 2007 and September 2014. After excluding 15 patients with unusual medical histories or surgical treatments, 193 were selected for this cohort study. We divided the patients into two cohorts: elderly patients (≥75 years old) and non-elderly patients (<74 years old). We compared these cohorts with respect to clinicopathological characteristics and intraoperative and postoperative parameters.

RESULTS

The overall complication rates were 11.4% (8 of 70 patients) in the elderly cohort and 8.1% (10 of 123 patients) in the non-elderly cohort (P = 0.449). In a univariate analysis, Charlson comorbidity index (CCI) of ≥3, American Society of Anesthesiologists (ASA) score of 3, operative time of ≥330 min, and intraoperative blood loss of ≥50 ml were found to correlate significantly with postoperative complications. In a multivariate analysis, CCI of ≥3 (P = 0.034), ASA score of 3 (P = 0.019), and intraoperative blood loss of ≥50 ml (P = 0.016) were found to be independent risk factors of postoperative complications. In contrast, age was not found to significantly affect the risk of postoperative complications.

CONCLUSIONS

Laparoscopic gastrectomy for gastric cancer can be successfully performed in elderly patients with an acceptable complication rate. This study suggested that high CCI, ASA score, and intraoperative blood loss volume were identified as independent predictors of postoperative complications after laparoscopic gastrectomy for gastric cancer.

The outcome of surgical treatment for elderly patients with gastric carcinoma

BACKGROUND

The aim of this study was to clarify the operative mortality and long-term survival of gastrectomy for elderly patients with gastric cancer.

METHODS

A total of 461 patients who underwent gastrectomy for gastric cancer in our hospital were classified as elderly group (≥80 years-old, 95 patients) and control group (60-69 years-old, 366 patients).

RESULTS

The frequency of comorbidities was significantly (P < 0.05) higher in elderly group (74.7%) than that in the control group (49.5%). No significant difference of the postoperative complication rate was found between the elderly group (23.2%) and the control group (23.2%). Adjuvant chemotherapy was 9.5% in the elderly group, which was significantly less than 29.0% of the control group (P < 0.05). Stage II and III elderly patients had worse disease specific survival (DSS) than controls did. In the elderly, overall survival (OS) was significantly worse than DSS in stage I patients (P < 0.05).

CONCLUSIONS

The operative complication rate of elderly patients was comparable to the control group. Comorbidity and occurrence of secondary malignant disease should be followed for elderly patients at stage I. For stage II and III disease patients, a novel drug which is acceptable for the elderly is needed as a postoperative therapy.

Potentially fatal complications for elderly patients after laparoscopy-assisted distal gastrectomy

BACKGROUND

The safety of surgery for gastric cancer in the elderly has been shown previously. However, potentially fatal complications based on an established severity grading system were not well described, and associated risk factors have not been assessed. The present study sought to examine severity-dependent postoperative complications after laparoscopy-assisted distal gastrectomy (LADG) in elderly patients and risk factors of potentially fatal postoperative complications.

METHODS

The study included 189 patients aged 70 years or older and who underwent LADG for early gastric cancer. Patient characteristics, perioperative outcomes, postoperative complications including severity assessment using the Clavien-Dindo classification, and risk factors related to postoperative complications were analyzed.

RESULTS

The overall complication rate was 24.9 % (47/189). The most frequent complication was abdominal fluid collection (9 cases, 4.8 %). Severe complications classified as grade III or above in the Clavien-Dindo grading system were found in 20 (10.6 %) patients. Multivariate analysis identified preoperative serum albumin concentration (odds ratio, 5.200; 95 % CI, 1.706-15.850), Roux-en-Y reconstruction (odds ratio, 3.611; 95 % CI, 1.103-11.817), and simultaneous cholecystectomy (odds ratio, 5.008; 95 % CI, 1.378-18.201) as independent predictors of a higher rate of severe postoperative complications after LADG in elderly patients.

CONCLUSION

The incidence of severe complications after LADG in the elderly was quite acceptable considering the risks associated with radical surgery with extensive lymphadenectomy. Preoperative serum concentrations of albumin (<4.0 g/dl), Roux-en-Y reconstruction, and simultaneous cholecystectomy are independent risk factors for severe postoperative complications in these patients.

Minimally invasive surgery as a treatment option for gastric cancer in the elderly: comparison with open surgery for patients 80 years and older

BACKGROUND

As life expectancy is increasing, the use of minimally invasive surgery (MIS) in the elderly is gaining interest. The aim of this study was to identify the impact of minimally invasive gastrectomy by comparing the procedure to open surgery in octogenarians. In addition, we also evaluated the role of gastrectomy in elderly gastric cancer patients by assessing long-term outcomes.

METHODS

We retrospectively analyzed data from 99 gastric cancer patients aged 80 years or older, who underwent gastrectomy by either MIS or open surgery from 2005 to 2010. Patient characteristics, operative outcomes, pathologic results, morbidity, mortality, and follow-up data (including survival) were compared.

RESULTS

Thirty patients underwent gastrectomy with MIS (19 laparoscopic and 11 robotic) and 69 patients underwent open gastrectomy. MIS demonstrated significantly less blood loss, lower analgesic consumption, faster time to first flatus and soft diet, and a shorter post-operative hospital stay. Multivariate analysis revealed that the type of operation had no effect on the occurrence of complications. There were two postoperative mortalities, both in the open group. Excluding these patients, the overall and disease-specific 5-year survival rates were 57.4 and 70.0 %, respectively. The overall (MIS 70.0 %; open 52.0 %) and disease-specific (MIS 81.8 %; open 65.1 %) 5-year survival rates were similar for the two groups. When we analyzed the 85 patients underwent curative resection only, the overall (MIS 71.4 %; open 58.4 %) and disease-specific (MIS 84.1 %; open 73.6 %) 5-year survival rates were similar for the two groups.

CONCLUSIONS

MIS for gastric cancer may be performed safely and maintains the advantages of minimal invasiveness, even in extremely old patients. Furthermore, gastrectomy by either by MIS or open surgery can reduce gastric cancer-related deaths, even in patients 80 years or older.

Short- and long-term outcomes of laparoscopic gastrectomy in elderly patients with gastric cancer

BACKGROUND

Elderly patients are regarded as being at increased risk during major abdominal surgery because of a lack of functional reserve and an increased number of comorbidities. The aim of this study was to compare short- and long-term outcomes of laparoscopic gastrectomy between elderly and young gastric cancer patients.

METHODS

Two-hundred ten patients who underwent laparoscopic gastrectomy for gastric cancer at our institution between January 2001 and December 2011 were included in this retrospective study. Patients were divided into two age groups (younger than 70 years and older than 70 years) and were evaluated with respect to postoperative morbidity, quality of life (QOL), and survival.

RESULTS

Postoperative morbidity was similar in elderly and young groups (18.3 vs. 21.6 %; P = 0.718). Overall survival of the elderly group was significantly worse than that of the young group (P < 0.001). However, disease-specific survival was not significantly different between the two groups. Longitudinal postoperative change in QOL in the elderly group showed a recovery similar to that in the young group.

CONCLUSIONS

Laparoscopic gastrectomy can be performed as safely in elderly patients as in young patients, with comparable postoperative results and long-term outcomes, including QOL, although the life expectancy of elderly patients is shorter.

Laparoscopic versus open liver resection for elderly patients with malignant liver tumors: a single-center experience

BACKGROUND

Laparoscopic liver resection is associated with less perioperative blood loss, shorter hospital stay, and fewer postoperative complications in younger patients. However, it remains unclear if these short-term benefits could also be applicable to elderly patients with medical comorbidities.

AIM

To evaluate the perioperative outcomes of laparoscopic liver resection in patients with advanced age.

MATERIALS AND METHODS

Patients aged ≥ 70 years old who received liver resections for malignant liver tumors between January 2002 and December 2012 were included. The perioperative outcomes of 17 patients with laparoscopic approach were matched and compared with 34 patients with conventional open approach in a 1:2 ratio.

RESULTS

There was no significant difference with regard to age, gender, incidence of comorbid illness, hepatitis B positivity, and Child grading of liver function. The median tumor size was 3 cm for both groups. The types of liver resection were similar between the two groups with no significant difference in the duration of operation (laparoscopic: 195 min vs open: 210 min, P = 0.436). The perioperative blood loss was 150 mL in the laparoscopic group and 330 mL in the open group (P = 0.046) with no significant difference in the number of patients with blood transfusion. The duration of hospital stay was 6 days (3-15 days) for the laparoscopic group and 8 days (5-105 days) for the open group (P = 0.005).

CONCLUSION

Laparoscopic liver resection is safe and feasible for elderly patients. The short-term benefits of laparoscopic approach continued to be evident for geriatric oncological liver surgery.

Is the rate of postoperative complications following laparoscopy-assisted gastrectomy higher in elderly patients than in younger patients?

Background

With an increase in life expectancy, very elderly patients are presenting with gastric cancer more commonly than ever. The present study retrospectively analyzed the surgical outcomes of laparoscopy-assisted gastrectomy for gastric cancer in the young, elderly, and very elderly age groups.

Methods

The study group consisted of 1,055 patients who underwent laparoscopy-assisted gastrectomy between February 2002 and December 2012. We divided these patients into three groups; group 1 (young age, <65 years), group 2 (elderly age, 65–74 years), and group 3 (very elderly age, ≥75 years).

Results

There were statistical differences in the rates of postoperative complications among the three groups (P = 0.008). However, when assessed according to the severity of postoperative complications based on the Clavien-Dindo classification, there was no statistical difference among the three groups (P = 0.562).

Conclusions

Laparoscopy-assisted gastrectomy for gastric cancer can be performed in very elderly patients. In analyzing studies of elderly patients with postoperative complications following the procedure, not only should the rate of postoperative complications be taken into consideration, but also the severity of any postoperative complications.

Laparoscopy-assisted distal gastrectomy for early gastric cancer in the elderly

PURPOSE

With an increase in life expectancy, more elderly patients are presenting with gastric cancer. As a result it is yet be resolved whether laparoscopy assisted distal gastrectomy is a suitable treatment for elderly patients with early gastric cancer. This study retrospectively compared surgical outcomes of laparoscopy assisted distal gastrectomy between elderly and nonelderly patients with gastric cancer.

MATERIALS AND METHODS

The study group was comprised of 316 patients who underwent laparoscopy assisted distal gastrectomy between April 2005 and December 2010. Of these patients, 93 patients whose ages were 65 years or more were compared with 223 patients who were younger.

RESULTS

There were no differences in the short term outcome or minor complication rate between the elderly patients and the nonelderly patients. The hospital stay was significantly longer and the major complication rate was significantly higher for the elderly patients compared with nonelderly patients.

CONCLUSIONS

Laparoscopy assisted distal gastrectomy for early gastric cancer in the elderly patients had comparable operation time and blood loss with the nonelderly group. However, the safety and advantage of laparoscopy assisted distal gastrectomy in the elderly patients need to be further studied in higher volume trials.

The impact of obesity on the use of a totally laparoscopic distal gastrectomy in patients with gastric cancer

PURPOSE

Since a patient's obesity can affect the mortality and morbidity of the surgery, less drastic surgeries may have a major benefit for obese individuals. This study evaluated the feasibility of performing a totally laparoscopic distal gastrectomy, with intracorporeal anastomosis, in obese patients suffering from gastric cancer.

MATERIALS AND METHODS

This was a retrospective analysis of the 138 patients, who underwent a totally laparoscopic distal gastrectomy from April 2005 to March 2009, at the National Kyushu Cancer Center. The body mass index of 20 patients was ≥25, and in 118 patients, it was <25 kg/m(2).

RESULTS

The mean values of body mass index in the 2 groups were 27.3±2.2 and 21.4±2.3. Hypertension was significantly more frequent in the obese patients than in the non-obese patients. The intraoperative blood loss, duration of surgery, post-operative complication rate, post-operative hospital stay, and a number of retrieved lymph nodes were not significantly different between the two groups.

CONCLUSIONS

Intracorporeal anastomosis seemed to have a benefit for obese individuals. Totally laparoscopic gastrectomy is, therefore, considered to be a safe and an effective modality for obese patients.

The role of laparoscopic surgery in gastric cancer

The laparoscopic surgery in gastric cancer is applied with increasing frequency nowadays; noticeable reports come mainly from Korea and Japan with satisfactory results. This review presents briefly the issue by evaluating its role. A PubMed search of relevant articles published up to 2010 was performed to identify current information. Most data come from Far East, where gastric cancer occurs more often, and the proportion of early gastric cancer is high. Laparoscopic approach includes both the diagnostic laparoscopy and laparoscopic resection. Laparoscopic gastrectomy has currently limited application for gastric cancer in the West; it is not widely accepted and raises important considerations necessitating the planning of multicentre randomised control trials based mainly on the long-term results.

Minimally invasive surgery for gastric cancer: the future standard of care

Laparoscopy-assisted distal gastrectomy for gastric cancer was first reported by Kitano et al. in 1991. Laparoscopic wedge resection (LWR) and intragastric mucosal resection (IGMR) were quickly adapted for gastric cancer limited to the mucosal layer and having no risk of lymph node metastasis. Following improvements in endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), the use of LWR and IGMR for these indications decreased, and patients with gastric cancer, including those with a risk of lymph node metastases, were more likely to be managed with laparoscopic gastrectomy (LG) with lymph node dissection. Many retrospective comparative trials and randomized-controlled trials (RCT) have confirmed that LG is safe and feasible, and that short-term outcomes are better than those of open gastrectomy (OG) in patients with early gastric cancer (EGC). However, these trials did not include a satisfactory number of patients to establish clinical evidence. Thus, additional multicenter randomized-controlled trials are needed to delineate significantly quantifiable differences between LG and OG. As laparoscopic experience has accumulated, the indications for LG have been broadened to include older and overweight patients and those with advanced gastric cancer. Moreover, advanced techniques, such as laparoscopy-assisted total gastrectomy, laparoscopy-assisted proximal gastrectomy, laparoscopy-assisted pylorus-preserving gastrectomy (PPG), and extended lymph node dissection (D2) have been widely performed.In the near future, sentinel node navigation and robotic surgery will become additional options in minimally invasive surgery (MIS) involving LG. Such developments will improve the quality of life of patients following gastric cancer surgery.

A pilot study of the technical and oncologic feasibility of thoracoscopic esophagectomy with extended lymph node dissection in the prone position for clinical stage I thoracic esophageal carcinoma

BACKGROUND

Thoracoscopic esophagectomy in the prone position (TSEP) without thoracotomy is more invasive than right transthoracic esophagectomy (TTE). However, TTE and TSEP have not been compared in terms of technical and oncological feasibility for thoracic esophageal carcinomas of the same stage.

METHODS

Fifty-nine patients with clinical stage I esophageal cancer underwent esophagectomy with three-field lymph node dissection from 2000 through 2010, 30 patients underwent right TTE through 2008, and 29 patients underwent TSEP from 2008 through 2010. TSEP was performed with four ports from 2008 through 2009 (13 patients) and with five ports--four conventional ports and a 5 mm camera port for the upper mediastinum--from 2009 (16 patients). We retrospectively evaluated the technical and oncologic feasibility of TSEP with extended lymph node dissection for clinical stage I thoracic esophageal carcinoma by comparing surgical outcomes between TTE and TSEP and examined the historical improvements and current status of TSEP, including port placement.

RESULTS

All 29 patients who underwent TSEP with three-field lymph node dissection achieved complete resection, and in the 13 patients followed up for more than 1 year, there were no surgery-related postoperative deaths and no recurrence. No significant difference was found between TTE and TSEP in the mean number of dissected mediastinal lymph nodes, amount of blood loss, incidence of postoperative complications, mean postoperative hospital stay, or rate of complete resection or locoregional control, but the mean duration of thoracic procedure was significantly longer for TSEP than for TTE. For TSEP, the incidence of complications was lower and the postoperative hospital stay was shorter with five ports than with four ports.

CONCLUSIONS

TSEP with extended lymphadenectomy is a feasible and appropriate surgical technique for clinical stage I thoracic esophageal carcinoma. We believe that its oncological feasibility for advanced esophageal carcinoma also will be demonstrated.

Outcomes of elderly patients undergoing cytoreductive surgery and perioperative intraperitoneal chemotherapy for colorectal cancer peritoneal carcinomatosis

BACKGROUND

The combined treatment of cytoreductive surgery (CRS) and perioperative chemotherapy (PIC) for colorectal peritoneal carcinomatosis (PC) is a rigorous surgical treatment most suited for fit and young patients. With technical maturity and improved perioperative care, we examined the outcomes of elderly patients undergoing CRS and PIC for colorectal PC.

METHODS

All consecutive patients treated in two tertiary centers for PC of colorectal cancer who were 70 years of age or older at the time of surgery were included. Data on patient characteristics, concomitant diseases, operation details, perioperative course, and follow-up were retrieved from medical charts. Primary outcomes were perioperative morbidity and mortality. Secondary outcomes were disease-free and overall survival.

RESULTS

Twenty-four patients (11 male) were included in this study (mean age 73.5 years). In eight patients major complications occurred. In six patients the postoperative course was complicated by minor adverse events. There was no perioperative mortality. Median overall survival was 35 months with a 6, 12, and 18 months survival rate of 94%, 83%, and 68%, respectively.

CONCLUSIONS

CRS and PIC for colorectal PC may be safely performed with acceptable morbidity in selected elderly patients. When considering patients for surgery, performance status, and the disease extent should be used as eligibility criteria rather than age.

Intensive versus conventional insulin therapy in type 2 diabetes patients undergoing D2 gastrectomy for gastric cancer: a randomized controlled trial

BACKGROUND

This study was to compare the effect of intensive insulin therapy (IIT) to conventional insulin therapy (CIT) on postoperative outcomes among type 2 diabetes mellitus (DM) patients who underwent D2 gastrectomy for gastric cancer.

METHODS

We randomly assigned gastric cancer patients with type 2 DM who underwent radical gastrectomy to receive IIT (maintenance of blood glucose at a level between 4.4 and 6.1 mmol/l) with insulin infusion or CIT (maintenance of blood glucose at a level between 10 and 11.1 mmol/l) during the postoperative period.

RESULTS

Of the 179 eligible patients, 92 patients were assigned to receive IIT and 87 patients to receive CIT. Mean blood glucose concentrations were lower in the intensive group (IG) than in the conventional group (CG) (5.5 ± 0.8 vs. 9.9 ± 1.0 mmol/l, P < 0.001). Hypoglycemia occurred in 6 patients (6.5%) in the IG (P = 0.029) versus in 1 patient (1.1%) in the CG. Hospital mortality did not differ significantly between two groups (4.3% vs. 5.7%, P = 0.742). However, IIT significantly reduced morbidity (from 18.4 to 7.6%, P = 0.031). Also, IIT shortened the days to suture removal, postoperative hospital stay, and postoperative duration of antibiotic use. The HOMA-IR score was lower at all time points in IG. Moreover, IIT increased the postoperative HLA-DR expression on monocytes on postoperative days 3 and 5.

CONCLUSIONS

IIT significantly reduced short-term morbidity but not mortality among type 2 DM patients who underwent D2 gastrectomy for gastric cancer. Furthermore, a possible mechanism of suppression of the insulin resistance and improvement of HLA-DR expression may partially explain the benefits of IIT.

The benefits of laparoscopically assisted distal gastrectomy for obese patients

BACKGROUND

In Japan, the number of obese patients with gastric cancer is increasing. This study aimed to evaluate the advantages of laparoscopically assisted distal gastrectomy (LADG) for obese patients relative to those of conventional distal gastrectomy (DG).

METHODS

Between January 2004 and June 2009, a total of 197 consecutive patients with gastric carcinoma underwent curative distal gastrectomy with Billroth 1 reconstruction in the Gunma University Hospital. The patients were assigned to undergo LADG (n = 120) or DG (n = 77) according to the depth of tumor invasion and lymph node status. A body mass (BMI) of 25 kg/m(2) or higher was defined as obesity, and the amounts of blood loss, the operating time, the number of lymph nodes dissected, and the postoperative complications experienced by obese and nonobese patients were compared.

RESULTS

None of the patients in the LADG group required conversion to laparotomy. In the DG group, significantly fewer lymph nodes were retrieved from the obese patients (22.5 ± 3.4) than from the nonobese patients (31.9 ± 2.0; P < 0.05). However, among the obese patients, the number of lymph nodes retrieved did not differ significantly between the LADG and DG groups. In the LADG group, the obese patients had a longer operating time (206.6 ± 6.3 vs. 192.0 ± 3.1 min; P < 0.05) and a greater estimated blood loss (158.2 ± 24.7 vs. 101.9 ± 10.4 ml; P < 0.05) than the nonobese patients. The estimated blood loss correlated the surgical procedures and BMI. No significant difference in postoperative complications was noted between the obese and nonobese groups after each procedure.

CONCLUSIONS

Relative to DG, LADG did not affect the radicality of the procedure for the obese patients, and there is no significant difference in the operating time. The estimated blood loss was significantly less for LADG than for DG. Surgeons should elect to perform LADG for obese patients with gastric cancer.

Multicentre study of the safety of laparoscopic subtotal gastrectomy for gastric cancer in the elderly

BACKGROUND

The aim of this study was to assess the safety and short-term value of laparoscopic gastrectomy in the elderly with gastric cancer compared with a younger cohort.

METHODS

Data on all patients with gastric cancer undergoing laparoscopic gastrectomy at ten institutions in Korea between May 1998 and December 2005 were collected. Patients under the age of 45 years and those undergoing total gastrectomy, proximal gastrectomy and pylorus-preserving gastrectomy were excluded. An analysis of clinicopathological data for patients aged 45-69 years (average-age group) and those aged 70 years or more (elderly group) was undertaken.

RESULTS

Co-morbidity was more common and postoperative hospital stay was longer in elderly patients. Pre-existing pulmonary and cardiovascular disease in the elderly contributed to respiratory dysfunction and intraperitoneal complications respectively. Tumour size and location, stage, methods of reconstruction and the number of combined operations were similar in the two groups. There were no significant differences in postoperative morbidity or mortality.

CONCLUSION

Although elderly patients had greater co-morbidity, laparoscopic gastrectomy was a safe treatment for gastric cancer in this age group.

Laparoscopy-assisted gastrectomy in patients older than 80

BACKGROUND

With the changing age distribution, the number of elderly patients with gastric cancer is anticipated to increase. This study evaluated the morbidity and mortality of laparoscopy-assisted gastrectomy (LAG) in patients older than 80.

METHODS AND METHODS

A total of 74 patients who underwent LAG for gastric cancer were assigned to two groups: an elderly group (70-79 y; n=56) and a very elderly group (older than 80; n=18). Preoperative comorbidity, operative results, and postoperative outcome were retrospectively analyzed.

RESULTS

In terms of concurrent illness, cardiovascular disease was significantly more frequent in the very elderly group than in the elderly group (P=0.042). Percent vital capacity (%VC) and forced expiratory volume in 1 s/forced vital capacity (FEV1/FVC) ratio were lower in the very elderly group than in the elderly group (%VC; 97.9% +/- 18.8% versus 109.0% +/- 18.0%, P=0.035, FEV(1)/FVC ratio; 68.0% +/- 7.8% versus 73.5% +/- 8.7%, P=0.026). Preoperative hemoglobin was significantly lower in the very elderly group than in the elderly group (11.8+/-2.0 versus 13.1+/-2.0, P=0.026). Incidence of postoperative complications and postoperative hospital stay were similar in both groups. No significant differences in time to first flatus or time to fever resolution (<37 degrees C) were noted between the two groups.

CONCLUSION

Our analysis revealed that LAG can be safely performed in patients older than 80, with complication rates and operation outcomes similar to those for patients aged 70-79.

Does age matter in the indication for laparoscopy-assisted gastrectomy?

BACKGROUND

Laparoscopy-assisted gastrectomy (LAG) is being increasingly performed in Japan. However, the indication of LAG in elderly patients who usually have preoperative morbidities and reduced functional capacities still remains unclear.

MATERIALS AND METHODS

Two hundred eighty-nine patients who underwent LAG at the Cancer Institute Hospital were included in this study. Among them, 240 cases were younger than 75 years old (Y-LAG group), and 49 cases were 75 years old or older (E-LAG group). Early surgical outcomes between the two groups were compared to clarify the feasibility of performing LAG in elderly patients.

RESULTS

The E-LAG group had a higher incidence of preoperative morbidities; however, the frequency of intraoperative and postoperative complications in this group was not significantly different from the Y-LAG group (9% vs 11%). The operation time was significantly shorter, and the number of retrieved lymph nodes was significantly smaller in the E-LAG group compared to the Y-LAG group. However, other early surgical outcomes were not significantly different between two groups.

CONCLUSIONS

LAG proved to be a feasible and safe procedure in elderly patients provided that the patients were selected carefully.

Efficacy of laparoscopy-assisted distal gastrectomy for gastric cancer in the elderly

BACKGROUND

To date, it has been unclear whether laparoscopy-assisted distal gastrectomy (LADG) is a suitable treatment for elderly patients with early gastric cancer. This study retrospectively compared surgical outcomes between elderly and nonelderly patients with gastric cancer.

METHODS

The study group was comprised of 211 patients who underwent distal gastrectomy between April 2000 and March 2007. Of these, 130 patients (26 aged >or=75 years and 104 aged <75 years) underwent LADG, and the remaining 81 patients underwent conventional open distal gastrectomy (ODG). Short- and long-term patient outcomes were evaluated.

RESULTS

The operation time was significantly longer in the LADG group than in the ODG group (262.6 versus 234.3 min, p = 0.005), but the other short-term outcomes did not differ between the two groups. When performed by an experienced surgeon, blood loss was significantly reduced, while operation time for LADG was similar to that for ODG. Within the LADG group, incidences of comorbid disease and lymph-node metastasis were significantly greater, the histological tumor type was significantly more differentiated, and the macroscopically depressed tumor type was less common in elderly patients. However, the incidence of postoperative morbidity did not differ between the elderly and nonelderly groups (11.5% versus 3.8%, p = 0.1201), and there was no significant difference in postoperative course. Logistic regression analysis showed that body mass index, but not chronological age, was an independent predictive factor of postoperative morbidity (odds ratio = 3.674, p = 0.045). There were no significant differences in overall or disease-specific survival between elderly and nonelderly patients.

CONCLUSION

LADG is an effective treatment for elderly patients with early gastric cancer if it is performed by an experienced surgeon. A high-volume study is needed to confirm this rationale.

Laparoscopic gastrectomy for gastric cancer: early experience among the elderly

BACKGROUND

The data are scarce on the outcome for elderly patients presenting with resectable gastric cancer in the West who have been treated with minimally invasive surgery. This report presents the authors' early experience with totally laparoscopic gastric resections for cancer in elderly patients.

METHODS

A total of 20 patients underwent laparoscopic gastrectomy procedures: 14 distal, 5 subtotal, and 1 total gastrectomy. The male-to-female ratio was 15 to 5. The ages ranged from 75 to 88 years (mean, 80 years).

RESULTS

All cases were managed laparoscopically with R0 resection. Four patients needed high-dependency unit care postoperatively. There were no perioperative deaths. The median time required for the procedure was 212 min, and time to diet was 4 days. The hospital stay was 8 days. Four patients experienced significant complications, with two patients requiring reoperation. The pathology was adenocarcinoma for 17 patients and high-grade dysplasia for 3 patients.

CONCLUSION

Among elderly patients for whom conventional gastric surgery carries a high morbidity and mortality risk, minimal access surgery may offer equivalent oncologic integrity but with superior safety and economy. The primary aim is to remove the tumor with at least a D1 lymphadenectomy.