Comparison of invasiveness between laparoscopy-assisted total gastrectomy and open total gastrectomy. World J Surg. 2009;33:2389-2395. [PMID: 19760315 DOI: 10.1007/s00268-009-0208-y]

Outcomes of laparoscopic versus open total gastrectomy with D2 lymphadenectomy for gastric cancer: a systematic review and meta-analysis

Background

The effectiveness of laparoscopic total gastrectomy with D2 lymphadenectomy (LTGD2) remains controversial. This meta-analysis compares surgical and survival outcomes of LTGD2 and open total gastrectomy with D2 lymphadenectomy (OTGD2) for gastric cancer.

Methods

Controlled studies comparing LTGD2 and OTGD2 published before November 2021 were retrieved via database searches. We compared intraoperative outcomes, pathological data, postoperative outcomes, 5-year disease-free survival (DFS), and overall survival (OS).

Results

17 studies were included, containing 4742 patients. Compared with OTGD2, the LTGD2 group had less blood loss (mean difference [MD] = − 122.48; 95% CI: − 187.60, − 57.37; P = 0.0002), fewer analgesic medication (MD = -2.48; 95% CI: − 2.69, − 2.27; P < 0.00001), earlier first flatus (MD = − 1.03; 95% CI: − 1.80, − 0.26; P = 0.009), earlier initial food intake (MD = − 0.89; 95% CI: − 1.09, − 0.68; P < 0.00001) and shorter hospital stay (MD = − 3.24; 95% CI: − 3.75, − 2.73; P < 0.00001). The LTGD2 group had lower postoperative total complication ratio (OR = 0.76; 95% CI: 0.62, 0.92; P = 0.006), incision (OR = 0.50; 95% CI:0.31, 0.79; P = 0.003) and pulmonary (OR = 0.57; 95% CI: 0.34, 0.96; P = 0.03) complication rates, but similar rates of other complications and mortality. Total number of dissected lymph nodes were similar, but the number of No. 10 dissected nodes was less with LTGD2 (MD = − 0.31; 95% CI: − 0.46, − 0.16; P < 0.0001). There was no difference in 5-year OS (P = 0.19) and DFS (P = 0.34) between LTGD2 and OTGD2 groups.

Conclusions

LTGD2 produces small trauma, fast postoperative recovery and small length of hospital stays than OTGD2, and had similar long-term clinical efficacy as OTGD2. However, these results still need further high-quality prospective randomized controlled trials confirmation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40001-022-00748-2.

Laparoscopic vs open total gastrectomy for advanced gastric cancer following neoadjuvant therapy: A propensity score matching analysis

BACKGROUND

Laparoscopic total gastrectomy (LTG) has drawn increasing attention over the years. Although LTG has shown surgical benefits compared to open TG (OTG) in early stage gastric cancer (GC), little is known about the surgical and oncological outcomes of LTG for advanced GC following neoadjuvant therapy (NAT).

AIM

To compare the long- and short-term outcomes of advanced GC patients who underwent LTG vs OTG following NAT.

METHODS

Advanced GC patients who underwent TG following NAT between April 2011 and May 2018 at the Cancer Hospital of the Chinese Academy of Medical Sciences were enrolled and stratified into two groups: LTG and OTG. Propensity score matching analysis was performed at a 1:1 ratio to overcome possible bias.

RESULTS

In total, 185 patients were enrolled (LTG: 78; OTG: 109). Of these, 138 were paired after propensity score matching. After adjustment for propensity score matching, baseline parameters were similar between the two groups. Compared to OTG, LTG was associated with a significantly shorter length of hospital stay (P = 0.012). The rates of R0 resection, lymph node harvest, and postoperative morbidity did not significantly differ between the two groups. Overall survival (OS) outcomes were comparable between the two groups. Pathological T and N stages were found to be independent risk factors for OS.

CONCLUSION

LTG can be a feasible method for advanced GC patients following NAT, as it appears to be associated with better short- and comparable long-term outcomes compared to OTG.

The Role of Minimally Invasive Surgery in Gastric Cancer

Objective: This study aims to investigate the efficacy and safety of minimally invasive surgery (MIS) in gastric cancer and to compare MIS versus open gastrectomy (OG) in terms of early mortality and morbidity, long-term oncological outcomes, and recurrence rates.

Methods: A total of 75 patients who underwent MIS or OG for gastric cancer at Koç University School of Medicine between December 2014 and December 2019 were retrospectively analyzed. Postoperative complications and disease-specific survival were compared between surgical approaches.

Results: Of the patients, 44 were treated with MIS and 31 with OG. In the MIS group, 33 patients underwent laparoscopic surgery, and 11 patients underwent robotic gastrectomy. Duration of operation was significantly longer in the MIS group than in the OG group (p<0.0001). The median amount of blood loss was 142.5 (range, 110 to 180) mL in the MIS group and 180.4 (range, 145 to 230) mL in the OG group (p<0.706). The median number of lymph node dissection was 38.9 (range, 15 to 66) and 38.7 (range, 12 to 70) in the MIS and OG groups, respectively (p<0.736). The median length of hospitalization, twelve days in the OG group and nine days in the MIS group. Median follow-up was 19.1 (range, 2 to 61) months in the MIS group and 22.1 (range, 2 to 58) months in the OG group. The median OS and DFS rates were 56.8 months and 39.6 months in the MIS group, respectively (log-rank; p=0.004) and 31.6 months and 23.1 months in the OG group, respectively (log-rank; p=0.003).

Conclusion: Our study results suggest that, despite its technical challenges, MIS is an effective and safe method in treating gastric cancer with favorable early mortality and morbidity rates and long-term oncological outcomes, and acceptable recurrence rates.

[Evidence in minimally invasive oncological gastric surgery]

BACKGROUND

The aim of this study was to systematically review the current evidence on laparoscopic and robotic distal and total gastrectomy in comparison to open surgery.

MATERIAL AND METHODS

A systematic search of EMBASE and PubMed was conducted and 197 randomized (RCT) and non-randomized (non-RCT) studies were identified. An evaluation of early gastric cancer (EGC) and advanced (AGC) gastric cancer was carried out.

RESULTS

For EGC and laparoscopic distal resection (LDG) and total gastrectomy (LTG) a total of 10 RCT and 6 non-RCT, including 4329 patients (laparoscopic 2010 vs. open 2319) were identified. At a high evidence level (1+, 1++) there was no significant difference in terms of feasibility, intraoperative outcome and oncological quality, mortality and long-term oncological outcome compared to open gastrectomy (OG). After LDG and LTG patients showed a significantly faster early postoperative recovery and lower total morbidity. In contrast, the operation times were significant longer compared to ODG and OTG. For distal AGC and LDG in 6 RCT, including 2806 patients (LDG 1410 vs. ODG 1369) comparable results could be found also with a high evidence level (1++). The evidence for LTG in cases of AGC was lower (2-, 2+). Currently ,only 6 non-RCT with a total of 1090 patients (LTG 539 vs. OTG 551) are available, which showed comparable results to LDG but further high-quality RCTs are necessary. Robotic gastrectomy (RG) is currently being evaluated. According to the first studies RG for EGC seems to be equivalent to LDG; however, the evidence is currently low (3 to 2-).

Short-term outcomes of laparoscopic versus open total gastrectomy after neoadjuvant chemotherapy: a cohort study using the propensity score matching method

Background

Until now, little is known about the benefit of laparoscopic total gastrectomy (LTG) after neoadjuvant chemotherapy (NACT). This study was designed to compare the safety and efficacy of the LTG versus the open total gastrectomy (OTG) approach after NACT treatment in patients with advanced gastric cancer (AGC).

Methods

This study involved a cohort of 145 patients with AGC who underwent total gastrectomy after NACT at our centre between April 2013 and August 2018 including 24 cases of LTG and 121 OTG. The baseline characteristics were matched based on 1:2 balanced propensity score-matching method.

Results

Sixty-nine marched cases were finally analysed (23 LTG vs. 46 OTG). All patients underwent R0 resection. Compared to the OTG group, the LTG group had a longer surgery duration (P<0.001), but a shorter incision length (P<0.001) and less intravenous patient-controlled analgesia (IV-PCA) time after surgery (P=0.027). No statistical differences were observed in terms of blood loss, retrieved lymph nodes (LNs), resection margin, length of stay, postoperative pain intensity, and complications (P>0.05).

Conclusions

LTG had comparable safety and histological findings to OTG after NACT in the perioperative period; however, LTG is less invasive and patients can benefit from less IV-PCA use. Further research is needed to investigate long-term effects.

Keywords

Gastric cancer (GC); neoadjuvant chemotherapy (NACT); safety; laparoscopic technique.

Laparoscopic versus open approach in gastrectomy for advanced gastric cancer: a systematic review

BACKGROUND

Additional studies comparing laparoscopic gastrectomy (LG) versus open gastrectomy (OG) for advanced gastric cancer (AGC) have been published, and it is necessary to update the systematic review of this subject.

OBJECTIVE

We conducted the meta-analysis to find some proof for the use of LG in AGC and evaluate whether LG is an alternative treatment for AGC.

METHOD

Randomized controlled trials (RCT) and high-quality retrospective studies (NRCT) compared LG and OG for AGC, which were published in English between January 2010 and May 2019, were search in PubMed, Embase, and Web of Knowledge by three authors independently and thoroughly. Some primary endpoints were compared between the two groups, including intraoperative time, intraoperative blood loss, harvested lymph nodes, first flatus, first oral intake, first out of bed, post-operative hospital stay, postoperative morbidity and mortality, rate of disease recurrence, and 5-year over survival (5-y OS). Besides, considering for this 10-year dramatical surgical material development between 2010 and 2019, we furtherly make the same analysis based on recent studies published between 2016 and 2019.

RESULT

Thirty-six studies were enrolled in this systematic review and meta-analysis, including 5714 cases in LAG and 6094 cases in OG. LG showed longer intraoperative time, less intraoperative blood loss, and quicker recovery after operations. The number of harvested lymph nodes, hospital mortality, and tumor recurrence were similar. Postoperative morbidity and 5-y OS favored LG. Furthermore, the systemic analysis of recent studies published between 2016 and 2019 revealed similar result.

CONCLUSION

A positive trend was indicated towards LG. LG can be performed as an alternative to OG for AGC.

Short-term and Long-term Outcomes Following Laparoscopic Gastrectomy for Advanced Gastric Cancer Compared With Open Gastrectomy

INTRODUCTION

To investigate the oncological feasibility and technical safety of laparoscopic gastrectomy with D2 lymphadenectomy for advanced gastric cancer.

METHODS

A total of 186 advanced gastric cancer patients treated by gastrectomy with D2 lymphadenectomy were eligible for inclusion including those with invasion into the muscularis propria, subserosa, and serosa without involvement of other organs, and stages N0-2 and M0. We retrospectively compared the short-term and long-term outcomes between laparoscopic gastrectomy and open gastrectomy.

RESULTS

We analyzed short-term outcomes by comparing distal with total gastrectomy results. We found no significant difference for distal gastrectomy for postoperative morbidity [laparoscopic vs. open: n=4 (4.6%) vs. n=1 (3.6%); P=1.00]. We also found no significant difference in postoperative morbidity for total gastrectomy [laparoscopic vs. open: n=2 (4.0%) vs. n=1 (4.0%); P=1.00]. No deaths occurred in any group.The entire cohort analysis revealed no statistically significant differences in overall-free or recurrence-free survival between the laparoscopic and open groups. For overall survival, there were no significant differences between open and laparoscopic groups for clinical stage II or III (P=0.29 and 0.27, respectively), and for pathologic stage II or III (P=0.88 and 0.86, respectively). For recurrence-free survival, there were no significant differences between open and laparoscopic groups for clinical stage II or III (P=0.63 and 0.60, respectively), and for pathologic stage II or III (P=0.98 and 0.72, respectively).

CONCLUSION

Laparscopic gastrectomy for advanced gastric cancer compared favorably with open gastrectomy regarding short-term and long-term outcomes.

Linear or circular stapler? A propensity score-matched, multicenter analysis of intracorporeal esophagojejunostomy following totally laparoscopic total gastrectomy

BACKGROUND

Presently, there is no consensus as to what procedure of intracorporeal esophagojejunostomy (EJS) in totally laparoscopic total gastrectomy (TLTG) is best to reduce postoperative complications. The aim of this study was to demonstrate the superiority of linear stapled reconstruction in terms of anastomotic-related complications for EJS in TLTG.

METHODS

We collected data on 829 consecutive gastric cancer patients who underwent TLTG reconstructed by the Roux-en-Y method with radical lymphadenectomy between January 2010 and December 2016 in 13 hospitals. The patients were divided into two groups according to reconstruction method and matched by propensity score. Postoperative EJS-related complications were compared between the linear stapler (LS) and the circular stapler (CS) groups.

RESULTS

After matching, data from 196 patients in each group were analyzed. The overall incidence of EJS-related complications was significantly lower in the LS group than in the CS group (4.1% vs. 11.7%, p = 0.008). The incidence of EJS anastomotic stenosis during the first year after surgery was significantly lower in the LS group than in the CS group (1.5% vs. 7.1%, p = 0.011). The incidence of EJS bleeding did not differ significantly between the groups, although no bleeding was observed in the LS group (0% vs. 2.0%, p = 0.123). The incidence of EJS leakage did not differ significantly between the groups (2.6% vs. 3.6%, p = 0.771).

CONCLUSION

The use of linear stapled reconstruction is safer than the use of circular stapled reconstruction for intracorporeal EJS in TLTG because of its lower risks of stenosis.

A feasibility study of laparoscopic total gastrectomy for clinical stage I gastric cancer: a prospective multi-center phase II clinical trial, KLASS 03

BACKGROUND

With improved short-term surgical outcomes, laparoscopic distal gastrectomy has rapidly gained popularity. However, the safety and feasibility of laparoscopic total gastrectomy (LTG) has not yet been proven due to the difficulty of the technique. This single-arm prospective multi-center study was conducted to evaluate the use of LTG for clinical stage I gastric cancer.

METHODS

Between October 2012 and January 2014, 170 patients with pathologically proven, clinical stage I gastric adenocarcinoma located at the proximal stomach were enrolled. Twenty-two experienced surgeons from 19 institutions participated in this clinical trial. The primary end point was the incidence of postoperative morbidity and mortality at postoperative 30 days. The severity of postoperative complications was categorized according to Clavien-Dindo classification, and the incidence of postoperative morbidity and mortality was compared with that in a historical control.

RESULTS

Of the enrolled patients, 160 met criteria for inclusion in the full analysis set. Postoperative morbidity and mortality rates reached 20.6% (33/160) and 0.6% (1/160), respectively. Fifteen patients (9.4%) had grade III or higher complications, and three reoperations (1.9%) were performed. The incidence of morbidity after LTG in this trial did not significantly differ from that reported in a previous study for open total gastrectomy (18%).

CONCLUSIONS

LTG performed by experienced surgeons showed acceptable postoperative morbidity and mortality for patients with clinical stage I gastric cancer.

The Feasibility of Laparoscopic Gastrectomy for Remnant Gastric Cancer

We compared laparoscopic gastrectomy for remnant gastric cancer (LRG) with open gastrectomy for remnant gastric cancer (ORG) to assess the safety and invasive nature of LRG. This study was a retrospective study. The study population consisted of 27 consecutive patients who underwent gastrectomy for remnant gastric cancer. Of these, 15 underwent ORG between January 2003 and April 2007, and 12 underwent LRG between May 2007 and January 2013. The operation time was not significantly different between the 2 groups. However, blood loss was significantly less in the LRG group than in the ORG group. No intraoperative blood transfusion was required. There was no significant difference in morbidity rate between the LRG (1/12, 8.3%) and ORG (4/15, 26.7%) groups, and no patients died in either group. Body temperature on postoperative day (POD) 7 (P = 0.034); systolic blood pressure on PODs 6 (P = 0.042) and 7 (P = 0.035); and heart rate on POD 7 (P = 0.049) were significantly lower in the LRG group than in the ORG group. No significant differences were observed in white blood cell count, or C-reactive protein and serum albumin levels between the groups. Serum total protein levels were significantly higher on POD 1 (P = 0.020), and the number of lymphocytes was significantly higher on POD 7 in the LRG group than in the ORG group (P = 0.036). Pain scores on POD 7 were significantly lower in the LRG group than in the ORG group (P = 0.033). LRG is a technically feasible and safe procedure.

Total and Subtotal Laparoscopic Gastrectomy for the Treatment of Advanced Gastric Cancer: Morbidity and Oncological Outcomes

BACKGROUND

A debate is still surrounding the use of laparoscopic surgery for advanced gastric cancer (AGC) related to doubts about the requirements to satisfy oncologic criteria. The aim of this study is to analyze the oncological results, the intraoperative complications, and the short- and medium-term morbidity and mortality in patients with AGC who underwent subtotal laparoscopic gastrectomy (SLG) or total laparoscopic gastrectomy (TLG) with extended lymphadenectomy.

MATERIALS AND METHODS

We reviewed medical records of patients who underwent radical gastrectomy for AGC started laparoscopically with the intent of curative surgery, between July 2007 and October 2015. We recruited 74 patients and studied demographics, American Society of Anesthesiologists (ASA) score, pTNM stage, histologic pattern of the tumor, duration of surgery, conversion rate, estimated blood loss, number of resected lymph nodes, type of gastrointestinal reconstruction, postoperative complication, mortality rate, length of stay, time to canalization and resumption of food intake, and overall and disease-free survival rate.

RESULTS

We performed 74 interventions, with a conversion rate of 14.9% (11/74). Sixty-three were performed totally as laparoscopic: 43 (68.25%) SLGs and 20 (31.75%) TLGs, all with an extended lymphadenectomy (D2 or more). Operative time was 150 ± 34 minutes (range 75-225 minutes), the mean number of resected lymph nodes 21.4 ± 6.2, global morbidity rate 25.39%, rate of reoperation 9.52%, and perioperative mortality at 30 days 0%. We performed an average follow-up of 48.7 months (range 18-60), and we observed 5-year overall and disease-free survival, respectively, of 48.6% and 42.7%.

CONCLUSIONS

LG with extended lymphadenectomy for AGC is a feasible procedure with good results in terms of postoperative course, complications, and mortality. Thanks to the use of extremely precise and safe technologies the extended lymphadenectomy can be performed laparoscopically. The laparoscopic approach, when performed by experienced surgeons, ensures a correct oncological treatment in combination with the benefits of the laparoscopic technique.

Postoperative Complications of Laparoscopic Total Gastrectomy versus Open Total Gastrectomy for Gastric Cancer in a Meta-Analysis of High-Quality Case-Controlled Studies

Background. Some meta-analyses of case-controlled studies (CCSs) have shown that laparoscopic or laparoscopy-assisted total gastrectomy (LTG) had some short-term advantages over open total gastrectomy (OTG). However, postoperative complications differed somewhat among the meta-analyses, and some CCSs included in the meta-analyses had mismatched factors between LTG and OTG. Methods. CCSs comparing postoperative complications between LTG and OTG were identified in PubMed and Embase. Studies matched for patients' status, tumor stage, and the extents of lymph-node dissection were included. Outcomes of interest, such as anastomotic, other intra-abdominal, wound, and pulmonary complications, were evaluated in a meta-analysis performed using Review Manager version 5.3 software. Result. This meta-analysis included a total of 2,560 patients (LTG, 1,073 patients; OTG, 1,487 patients) from 15 CCSs. Wound complications were significantly less frequent in LTG than in OTG (n = 2,430; odds ratio [OR] 0.30, 95% confidence interval [CI] 0.29-0.85, P = 0.01, I2 = 0%, and OR 0.46, 95% CI 0.17-0.52, P < 0.0001, I2 = 0%). However, the incidence of anastomotic complications was slightly but not significantly higher in LTG than in OTG (n = 2,560; OR 1.44, 95% CI 0.96-2.16, P = 0.08, I2 = 0%). Conclusion. LTG was associated with a lower incidence of wound-related postoperative complications than was OTG in this meta-analysis of CCSs; however, some concern remains about anastomotic problems associated with LTG.

Extracorporeal Hand-Sewn Anastomosis Through a Minilaparotomy in Laparoscopic Distal Gastrectomy

BACKGROUND

Various methods of reconstruction after laparoscopic distal gastrectomy (LDG) have been developed and reported. In open gastrectomy, gastroduodenostomy or gastroenterostomy is often performed with the hand-sewn technique. Therefore, hand-sewn anastomosis was performed through a small incision in LDG. The aim of this study was to evaluate the feasibility and safety of LDG with hand-sewn anastomosis.

METHODS

Between June 2009 and December 2015, we assessed 263 consecutive patients who underwent LDG in our institution. In all patients, the reconstruction procedures were performed extracorporeally with the hand-sewn technique. The clinical characteristics, surgical outcomes, and operation cost related to anastomosis were evaluated and compared with the other methods.

RESULTS

The average operation time was 157.5 minutes, and average blood loss was 38.8 mL. The types of reconstruction were Billroth I, 95 cases (36.1%); Billroth II, 165 cases (62.7%); and Roux-en-Y, 3 cases (1.1%). The overall incidence of postoperative complications (Clavien-Dindo classification≧Grade II) was 8.0%. Anastomotic leakage was observed in 1 patient (0.4%) and anastomotic bleeding and anastomotic stenosis in 2 patients each (0.8%). There was no postoperative mortality. The cost of the absorbable threads used in anastomosis is less than the cost of a linear or circular stapler, which is often used in intracorporeal anastomosis.

CONCLUSION

This procedure is similar to conventional open surgery, and it is feasible, safe, and cost-effective. In addition, in an institution that plans to introduce LDG, the use of our method during the introductory phase of LDG has many advantages.

Feasibility of laparoscopy-assisted gastrectomy for patients with poor physical status: A propensity-score matching study

BACKGROUND

Laparoscopically-assisted gastrectomy (LAG) has been established to be a minimally invasive treatment for early gastric cancer. However, few studies have shown the feasibility of LAG in patients with risky comorbidities according to the American Society of Anesthesiologists physical status (ASA-PS) classification. We performed this retrospective cohort study to assess the feasibility of LG in patients with an ASA-PS class of 3 or higher.

METHODS

We retrospectively identified 214 patients with an ASA-PS class of 3 or 4 among 1192 patients who underwent radical gastrectomy with lymph-node dissection between 1999 and 2014 in our hospital. Finally, 106 patients were generated by propensity-score matching between LAG and open gastrectomy (OG). Postoperative complications were compared between LAG and OG.

RESULT

The overall incidence of complications was the same in LAG (30%) and OG (30%). Surgical complications were similar in LAG and OG (19% and 17%, p = 0.80). Medical complications also did not differ significantly between LAG and OG (21% and 15%, p = 0.45).

CONCLUSION

LAG was a feasible procedure for patients with gastric cancer who had an ASA-PS class of 3 or 4 and could undergo general anesthesia. LAG can become an optional treatment for such risky patients.

Minimally invasive surgery for stomach cancer

Laparoscopic surgery for gastric cancer has become extremely widespread in recent years especially in Asian countries due to its low invasiveness. As to evidence of indication for laparoscopic surgery for gastric cancer, laparoscopic surgery for gastric cancer often appears to be indicated for early gastric cancer at many institutions, while evidence was considered to be insufficient to recommend laparoscopic surgery for gastric cancer at Stage II and above. There are also problems with indications for cases other than tumour factors. No meta-analyses and prospective studies have been reported, but outcomes of laparoscopic surgery for gastric cancer in gastric cancer patients with co-morbid and/or existing diseases have been reported in retrospective studies. Indications in the elderly appear to be favourable in terms of post-operative ambulation considering factors such as the degree of dissection in accordance with the status of the patient. Meta-analyses, randomized controlled trials and several retrospective studies have compared the short-term usefulness of laparoscopic surgery for gastric cancer with that of conventional gastrectomy. The superiority of laparoscopic surgery for gastric cancer has been reported in terms of the reduced amount of bleeding, a reduction in the administration frequency and period of analgesic doses, a reduction in the duration of fever, early recovery of intestinal movement and early return to oral intake. A small-scale randomized controlled trial and several retrospective studies have demonstrated no significant differences in survival rate, recurrence rate and type of recurrence between laparoscopic surgery for gastric cancer and conventional gastrectomy. The results of the aforementioned trials in early gastric cancer in Japan and Korea for which enrolment is complete remain to be published.

A comparison between fentanyl plus celecoxib therapy and epidural anesthesia for postoperative pain management following laparoscopic gastrectomy

PURPOSE

To clarify the efficacy of postoperative pain management following laparoscopic gastrectomy (LG), we retrospectively compared pain assessments in patients who received fentanyl plus celecoxib with those who received epidural anesthesia.

METHODS

From 2011 to 2012, 55 consecutive LG patients at our institution received 48 h of epidural anesthesia for postoperative pain management (group-E). Since September 2013, epidural anesthesia was replaced with 24 h of intravenous fentanyl and 4 days of oral celecoxib. Thirty-three consecutive LG patients who received this analgesic method (group-FC) were included in this analysis. The severity of postoperative pain as assessed by the FACES Pain Rating Scale and the frequency of rescue pain medication were retrospectively compared between the two groups.

RESULTS

No significant difference in the severity of postoperative pain on postoperative day (POD) 0 or 1 was observed between the two groups. In contrast, pain was significantly lower in group-FC than group-E on PODs 2, 3, 4, and 7. The total use of rescue pain medications during the first 7 days following LG did not differ between the two groups.

CONCLUSION

Pain management using 24 h of intravenous fentanyl and 4 days of oral celecoxib is comparable to epidural anesthesia following LG.

Systemic analysis on laparoscope-assisted gastrectomy for patients with gastric cancer

BACKGROUND

Laparoscope-assisted gastrectomy in treating patients with gastric cancers developed with a background of highly invasive traditional surgery and is being increasingly performed in the Asian Pacific area. This study systemically investigated the technique and clinical results for comparison with traditional radical subtotal gastrectomy for gastric cancers.

METHODS

Clinical studies evaluating the effectiveness and side effects of laparoscope-assisted gastrectomy in treating patients with gastric cancers were identified using a predefined search strategy. Summary rates of effectiveness and side effects of laparoscope-assisted gastrectomy were calculated.

RESULTS

Thirteen clinical studies which including 1,412 patients with gastric cancer treated by laparoscope-assisted gastrectomy were considered eligible for inclusion. Systemic analysis showed that, for all patients, the pooled resection rate was 100%. Major adverse effects were anastomotic stenosis, abdominal abscess, abdominal bleeding, postoperative ileus. Treatment related death occurred in 0. 71% (10/1412).

CONCLUSION

This systemic analysis suggests that laparoscope-assisted gastrectomy in treating patients with gastric cancers is associated with good curative rate and acceptable complications.

Systematic review of anastomotic complications of esophagojejunostomy after laparoscopic total gastrectomy

AIM: To investigate the anastomotic complications of esophagojejunostomy (EJS) after laparoscopic total gastrectomy (LTG), we reviewed retrospective studies.

METHODS: A literature search was conducted in PubMed for studies published from January 1, 1994 through January 31, 2015. The search terms included “laparoscopic,”“total gastrectomy,” and “gastric cancer.” First, we selected 16 non-randomized controlled trials (RCTs) comparing LTG with open total gastrectomy (OTG) and conducted an updated meta-analysis of anastomotic complications after total gastrectomy. The Newcastle-Ottawa scoring system (NOS) was used to assess the quality of the non-RCTs included in this study. Next, we reviewed anastomotic complications in 46 case studies of LTG to compare the various procedures for EJS.

RESULTS: The overall incidence of anastomotic leakage associated with EJS was 3.0% (30 of 984 patients) among LTG procedures and 2.1% (31 of 1500 patients) among OTG procedures in the 16 non-RCTs. The incidence of anastomotic leakage did not differ significantly between LTG and OTG (odds OR = 1.42, 95%CI: 0.86-2.33, P = 0.17, I² = 0%). Anastomotic stenosis related to EJS was reported in 72 (2.9%) of 2484 patients, and the incidence was 3.2% among LTG procedures and 2.7% among OTG procedures. The incidence of anastomotic stenosis related to EJS was slightly, but not significantly, higher in LTG than in OTG (OR = 1.55, 95%CI: 0.94-2.54, P = 0.08, I² = 0%). The various procedures for LTG were classified into six categories in the review of case studies of LTG. The incidence of EJS leakage was similar (1.1% to 3.2%), although the incidence of EJS stenosis was relatively high when the OrVil^TM device was used (8.8%) compared with other procedures (1.0% to 3.6%).

CONCLUSION: The incidence of anastomotic complications associated with EJS was not different between LTG and OTG. Anastomotic stenosis was relatively common when the OrVil^TM device was used.

Outcome of laparoscopic gastrectomy with D1 plus lymph node dissection in gastric cancer patients postoperatively diagnosed with locally advanced disease or lymph node metastasis

BACKGROUND

Some laparoscopic gastrectomy (LG) patients are postoperatively diagnosed with locally advanced disease or lymph node metastasis. Few reports have reviewed the outcomes or validity of LG in such patients.

METHODS

We retrospectively compared the outcomes of LG for gastric cancer patients postoperatively diagnosed with T3 (subserosal invasion) or higher or N1 (metastasis in 1-2 regional lymph nodes), or higher disease (n = 36), with open gastrectomy (OG) for c-stage I gastric cancer patients (n = 62).

RESULTS

D1 plus lymph node dissection was performed in all patients in the LG group. Blood loss was significantly lower in the LG group than in the OG group (P < 0.0010). The mean postoperative hospital stay duration was significantly shorter in the LG group than in the OG group (P = 0.0016). In the LG group, lymph node metastasis occurred in 1 patient, peritoneal dissemination in 2 patients, and liver metastasis in 1 patient. The 5-year survival rate did not significantly differ between the LG and OG groups (90.00 vs. 94.52 %; P = 0.6517).

CONCLUSIONS

Given the similarity in long-term outcomes between the LG and OG groups, LG is an appropriate indication for gastric cancer patients postoperatively diagnosed with locally advanced disease or lymph node metastasis.

Current status of randomized controlled trials for laparoscopic gastric surgery for gastric cancer in Korea

Laparoscopic gastrectomy for gastric cancer has rapidly gained popularity as a result of the increased incidence of early gastric cancer in Korea. Although laparoscopic gastrectomy has been considered as an investigational treatment because of the lack of solid evidence of efficacy and safety, it is increasingly regarded as a standard treatment for early gastric cancer. Moreover, solid evidence is anticipated from two studies in Korea, KLASS 01 and KLASS 02, the latter of which examines the suitability of laparoscopic gastrectomy for advanced gastric cancer. The use of cutting-edge techniques for laparoscopic gastrectomy enables surgeons to deliver various treatment options that offer the best possible quality of life after gastrectomy. In this review, we summarize the current status of clinical trials on laparoscopic gastrectomy in Korea and examine future perspectives regarding laparoscopic gastrectomy for the treatment of gastric cancer.

Routine clinical markers of the magnitude of the systemic inflammatory response after elective operation: a systematic review

BACKGROUND

Operative injury to the body from all procedures causes a stereotypical cascade of neuroendocrine, cytokine, myeloid, and acute phase responses. This response has been examined commonly by the use of cortisol, interleukin-6 (IL-6), white cell count, and C-reactive protein (CRP). We aimed to determine which markers of the systemic inflammatory response were useful in determining the magnitude of injury after elective operations.

METHODS

A systematic review of the literature was performed using surgery, endocrine response, systemic inflammatory response, cortisol, IL-6, white cell count, and CRP. For each analyte the studies were grouped according to whether the operative injury was considered to be minor, moderate, or major and then by the operative procedure.

RESULTS

A total of 164 studies were included involving 14,362 patients. The IL-6 and CRP responses clearly were associated with the magnitude of operative injury and the invasiveness of the operative procedure. For example, the peak CRP response increased from 52 mg/L with cholecystectomy to 123 mg/L with colorectal cancer resection, 145 mg/L with hip replacement, 163 mg/L after abdominal aortic aneurysm repair, and 189 mg/L after open cardiac surgery. There also appeared to be a difference between minimally invasive/laparoscopic and open procedures such as cholecystectomy (27 vs 80 mg/L), colorectal cancer resection (97 vs 133 mg/L), and aortic aneurysm repair (132 vs 180 mg/L).

CONCLUSION

Peak IL-6 and CRP concentrations consistently were associated with the magnitude of operative injury and operative procedure. These markers may be useful in the objective assessment of which components of Enhanced Recovery after Surgery are likely to improve patient outcome and to assess the possible impact of operative injury on immune function.

A systematic review of laparoscopic total gastrectomy for gastric cancer

BACKGROUND

Laparoscopic total gastrectomy (LTG) has been performed since 1999. Although surgical outcomes have been reported from Japan, Korea, China, and many Western countries, the effectiveness of this technique has not been conclusively established. This study therefore aimed to review the literature systematically.

METHODS

Our search of the research literature identified 150 studies, which were mostly retrospective and from single institutions.

RESULTS

There has recently been a remarkable increase in the number of studies from Korea, and the number of patients included in studies has increased since 2009. In most studies, the surgical procedures were longer, blood loss was reduced, and the number of retrieved lymph nodes was the same in the LTG group as in the open total gastrectomy group. The incidence of postoperative complications and that of inflammation during postoperative recovery were the same in these two groups.

CONCLUSIONS

During LTG, the method used for esophagojejunostomy is important for surgical reliability and to reduce postoperative complications. There has been rapid development of new techniques from the level of esophagojejunostomy through a small skin incision to the high level of intracorporeal esophagojejunostomy using various techniques. A nationwide prospective phase II study is urgently needed to establish the value of LTG.

Totally laparoscopic total gastrectomy for gastric cancer: literature review and comparison of the procedure of esophagojejunostomy

There has been a recent increase in the use of totally laparoscopic total gastrectomy (TLTG) for gastric cancer. However, there is no scientific evidence to determine which esophagojejunostomy (EJS) technique is the best. In addition, both short- and long-term oncological results of TLTG are inconsistent. We reviewed 25 articles about TLTG for gastric cancer in which at least 10 cases were included. We analyzed the short-term results, relationships between EJS techniques and complications, long-term oncological results, and comparative study results of TLTG. TLTG was performed in a total of 1170 patients. The mortality rate was 0.7%, and the short-term results were satisfactory. Regarding EJS techniques and complications, circular staplers (CSs) methods were significantly associated with leakage (4.7% vs. 1.1%, p < 0.001) and stenosis (8.3% vs. 1.8%, p < 0.001) of the EJS as compared with the linear stapler method. The long-term oncological prognosis was acceptable in patients with early gastric cancers and without metastases to lymph nodes. Although TLTG tended to increase surgical time compared with open total gastrectomy and laparoscopy-assisted total gastrectomy, it reduced intraoperative blood loss and was expected to shorten postoperative hospital stay. TLTG is found to be safer and more feasible than open total gastrectomy and laparoscopy-assisted total gastrectomy. At present, there is no evidence to encourage performing TLTG for patients with advanced gastric cancer from the viewpoint of long-term oncological prognosis. Although the current major EJS techniques are CS and linear stapler methods, in this review, CS methods are significantly associated with leakage and stenosis of the EJS.

Preoperative C-reactive protein and operative blood loss predict poor prognosis in patients with gastric cancer after laparoscopy-assisted gastrectomy

INTRODUCTION

The aim of this study was to clarify the factors associated with postoperative complications and prognoses following laparoscopy-assisted gastrectomy for gastric cancer.

METHODS

A total of 214 patients who underwent laparoscopy-assisted gastrectomy for gastric cancer were enrolled in this retrospective study. Factors that were potentially associated with postoperative complications and prognosis were assessed using the following clinical and perioperative parameters: the Estimation of Physiologic Ability and Surgical Stress scoring system, the Prognostic Nutritional Index, and the Clavien-Dindo classification.

RESULTS

Postoperative complications developed in 18.7% of patients. Blood loss ≥ 1% of body weight was significantly correlated with anastomotic leakage (P = 0.0108). Severe complications, based on the Clavien-Dindo classification, were more frequent in patients with proximal or total gastrectomies (P = 0.0324). A preoperative C-reactive protein level > 0.5 mg/dL, blood loss > 1% of body weight, age ≥ 70 years at the time of operation, and an Estimation of Physiologic Ability and Surgical Stress score ≥ 0.2 were significantly correlated with poor prognosis. Multivariate analysis revealed that two of these factors, preoperative C-reactive protein level ≥ 0.5 mg/dL and operative blood loss ≥ 1% of body weight, were independent prognostic factors (P = 0.0376 and P = 0.0112, respectively). The Prognostic Nutritional Index had no significant correlation with prognosis or the occurrence of postoperative complications.

CONCLUSION

Operative blood loss ≥ 1% of body weight and type of resection were associated with an increased frequency of postoperative complications, while preoperative C-reactive protein levels and operative blood loss may be prognostic predictors for gastric cancer patients following laparoscopy-assisted gastrectomy.

Laparoscopic versus open total gastrectomy for gastric cancer: an updated meta-analysis

Objective

To expand the current knowledge on the feasibility and safety of laparoscopic total gastrectomy (LTG) for gastric cancer in comparison with open total gastrectomy (OTG).

Background

Additional studies comparing laparoscopic versus open total gastric resection have been published, and it is necessary to update the meta-analysis of this subject.

Methods

Original articles compared LTG and OTG for gastric cancer, which published in English from January 1990 to July 2013 were searched in PubMed, Embase, and Web of Knowledge by two reviewers independently. Operative time, blood loss, harvested lymph nodes, proximal resection margin, analgesic medication, first flatus day, first oral intake, postoperative hospital stay, postoperative complications, hospital mortality, 5-year overall survival (OS) and disease-free survival (DFS) were compared using STATA version 10.1.

Results

17 studies were selected in this analysis, which included a total of 2313 patients (955 in LTG and 1358 in OTG). LTG showed longer operative time, less blood loss, fewer analgesic uses, earlier passage of flatus, quicker resumption of oral intake, earlier hospital discharge, and reduced postoperative morbidity. The number of harvested lymph nodes, proximal resection margin, hospital mortality, 5-year OS and DFS were similar.

Conclusion

LTG had the benefits of less blood loss, less postoperative pain, quicker bowel function recovery, shorter hospital stay and lower postoperative morbidity, at the price of longer operative time. There were no statistical differences in lymph node dissection, resection margin, hospital mortality, and long-term outcomes, which indicated the similar oncological safety with OTG. A positive trend was indicated towards LTG. So LTG can be performed as an alternative to OTG by the experienced surgeons in high-volume centers. Whereas, due to the relative small sample size of long-term outcomes and lack of randomized control trials, more studies are required.

Laparoscopic vs open total gastrectomy for gastric cancer: A meta-analysis

AIM: To conduct a meta-analysis comparing laparoscopic total gastrectomy (LTG) with open total gastrectomy (OTG) for the treatment of gastric cancer.

METHODS: Major databases such as Medline (PubMed), Embase, Academic Search Premier (EBSCO), Science Citation Index Expanded and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library were searched for studies comparing LTG and OTG from January 1994 to May 2013. Evaluated endpoints were operative, postoperative and oncological outcomes. Operative outcomes included operative time and intraoperative blood loss. Postoperative recovery included time to first flatus, time to first oral intake, hospital stay and analgesics use. Postoperative complications comprised morbidity, anastomotic leakage, anastomotic stenosis, ileus, bleeding, abdominal abscess, wound problems and mortality. Oncological outcomes included positive resection margins, number of retrieved lymph nodes, and proximal and distal resection margins. The pooled effect was calculated using either a fixed effects or a random effects model.

RESULTS: Fifteen non-randomized comparative studies with 2022 patients were included (LTG - 811, OTG - 1211). Both groups had similar short-term oncological outcomes, analgesic use (WMD -0.09; 95%CI: -2.39-2.20; P = 0.94) and mortality (OR = 0.74; 95%CI: 0.24-2.31; P = 0.61). However, LTG was associated with a lower intraoperative blood loss (WMD -201.19 mL; 95%CI: -296.50--105.87 mL; P < 0.0001) and overall complication rate (OR = 0.73; 95%CI: 0.57-0.92; P = 0.009); fewer wound-related complications (OR = 0.39; 95%CI: 0.21-0.72; P = 0.002); a quicker recovery of gastrointestinal motility with shorter time to first flatus (WMD -0.82; 95%CI: -1.18--0.45; P < 0.0001) and oral intake (WMD -1.30; 95%CI: -1.84--0.75; P < 0.00001); and a shorter hospital stay (WMD -3.55; 95%CI: -5.13--1.96; P < 0.0001), albeit with a longer operation time (WMD 48.25 min; 95%CI: 31.15-65.35; P < 0.00001), as compared with OTG.

CONCLUSION: LTG is safe and effective, and may offer some advantages over OTG in the treatment of gastric cancer.

Outcomes of minimally invasive surgery for early gastric cancer are comparable with those for open surgery: analysis of 1,013 minimally invasive surgeries at a single institution

BACKGROUND

This study aimed to compare the short- and long-term results of minimally invasive surgery (MIS) and open surgery for primary early gastric cancer (EGC) at a single high-volume institution.

METHODS

The clinicopathologic and survival data of primary gastric cancer patients who underwent a minimally invasive radical gastrectomy at Seoul National University Hospital from December 2003 to January 2012 were retrospectively analyzed. For comparison of short-term outcomes, the data for 1,112 patients who underwent a radical open gastrectomy from 2007 to 2011 were collected. For long-term outcome analysis, the data for 962 patients who underwent a radical open gastrectomy from 2004 to 2006 were collected. Because the application of MIS was limited to suspected EGC, the control groups were similarly limited to patients deemed to have EGC as shown by preoperative endoscopy, endoscopic ultrasound, or both.

RESULTS

The review of our database identified 1,013 patients who had undergone MIS for gastric cancer. In the short-term outcome analysis, the MIS group showed statistically better results than the open surgery group in terms of postoperative hospital stay (8.7 vs. 11.3 days; p < 0.001), estimated blood loss (75.4 vs. 142.3 ml; p < 0.001), and overall complication rate (17.5 vs. 24.4 %; p < 0.001). In the subset analysis of total gastrectomy, the local complication rate was much higher in the MIS group than in the open surgery group. Both uni- and multivariate analyses showed that not only the surgical approach but also age, chronic liver disease, chronic renal disease, and additional organ resection had significant effects on complications. In the long-term outcome analysis, the two groups showed comparable disease-free survival rates.

CONCLUSIONS

The use of MIS for EGC showed a shorter operation time, a shorter postoperative hospital stay, and a lower overall complication rate than open surgery but a comparable disease-free survival rate. Total gastrectomy in the MIS group was associated with a higher complication rate than in the open group. Therefore, a new stable surgical technique needs to be established.

Is laparoscopy-assisted total gastrectomy feasible for the treatment of gastric cancer? A case-matched study

BACKGROUND

The aim of this study was to clarify the short- and long-term outcomes of laparoscopy-assisted total gastrectomy (LATG) for gastric cancer compared to conventional open total gastrectomy (COTG) with a case-control study.

METHODS

Between January 2002 and December 2010, a series of 264 patients with gastric cancer underwent R0 total gastrectomy (61 LATG patients and 203 COTG patients). Age, gender, and pathological stage were matched by propensity scoring, and 120 patients (60 LATG and 60 COTG) were selected for analysis.

RESULTS

There were no significant differences in the clinicopathological features between the two groups. Regarding postoperative outcomes, first flatus time was significantly shorter in the LATG group than in the COTG group (p < 0.001), while operation time was significantly longer in the LATG group than in the COTG group (p < 0.001). Postoperative complications occurred in 5 cases (8.3%) of the LATG group and in 11 cases (18.3%) of the COTG group (p = 0.178). There were two recurrences in the LATG group and three recurrences in the COTG group. There was no significant difference in the 5-year survival rate between the two groups (p = 0.667).

CONCLUSIONS

LATG for gastric cancer may be both feasible and efficient compared to COTG for experienced laparoscopic surgeons. This study is valuable for a prospective randomized controlled trial of LATG for gastric cancer in a larger number of patients.

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

OBJECTIVE

To elucidate the feasibility and safety of laparoscopic total gastrectomy with D2 dissection (LTGD2) for gastric cancer in comparison with open total gastrectomy with D2 dissection (OTGD2).

BACKGROUND

More surgeons have chosen laparoscopic total gastrectomy as an alternative to open total gastrectomy. But no meta-analysis has been performed to evaluate the value of LTGD2.

METHODS

Original articles compared LTGD2 and OTGD2 for gastric cancer, which published in English from January 1990 to March 2013 were searched in PubMed, Embase, and Web of Knowledge by two reviewers independently. Operative time, blood loss, harvested lymph nodes, analgesic medication, first flatus day, postoperative hospital stay, postoperative complications, and hospital mortality were compared using STATA version 10.1.

RESULTS

8 studies were selected in this analysis. A total of 1,498 patients were included (559 in LTG and 939 in OTG). LTGD2 showed longer operative time (WMD 39.29; 95 % CI 20.52, 58.06; P < 0.001), less blood loss (WMD -157.94; 95 % CI -245.25 -70.62; P < 0.001), fewer analgesic requirements (WMD -2.01; 95 % CI -3.10, -0.93; P < 0.001), earlier passage of flatus (WMD -0.73; 95 % CI -1.19, -0.27; P = 0.002), earlier hospital discharge (WMD -2.69; 95 % CI -3.42, -1.97; P < 0.001), and reduced postoperative morbidity (RR 0.70; 95 % CI 0.50, 0.98; P = 0.035). The number of harvested lymph nodes (WMD 0.27; 95 % CI -1.43, 1.98; P = 0.752) and hospital mortality rate (RR 0.57; 95 % CI 0.11, 3.09; P = 0.513) were similar.

CONCLUSION

LTGD2 was associated with less blood loss, less postoperative pain, quicker bowel function recovery, shorter hospital stay, and reduced postoperative morbidity, at the expense of longer operative time. No statistical differences were observed in lymph node dissection, and hospital mortality, which indicated the similar ability of lymph nodes clearance and short-term outcomes with OTGD2. A positive trend was indicated toward LTGD2. So we encourage the experienced surgeons to achieve LTGD2 instead of OTGD2. Whereas, due to non-randomized control trails and lack of long-term outcomes, more studies are required.

Systematic review and meta-analysis of laparoscopy-assisted and open total gastrectomy for gastric cancer

AIM: To evaluate the safety and efficacy of laparoscopy-assisted total gastrectomy (LATG) and open total gastrectomy (OTG) for gastric cancer.

METHODS: A comprehensive search of PubMed, Cochrane Library, Web of Science and BIOSIS Previews was performed to identify studies that compared LATG and OTG. The following factors were checked: operating time, blood loss, harvested lymph nodes, flatus time, hospital stay, mortality and morbidity. Data synthesis and statistical analysis were carried out using RevMan 5.1 software.

RESULTS: Nine studies with 1221 participants were included (436 LATG and 785 OTG). Compared to OTG, LATG involved a longer operating time [weighted mean difference (WMD) = 57.68 min, 95%CI: 30.48-84.88; P < 0.001]; less blood loss [standard mean difference (SMD) = -1.71; 95%CI: -2.48 - -0.49; P < 0.001]; earlier time to flatus (WMD= -0.76 d; 95%CI: -1.22 - -0.30; P < 0.001); shorter hospital stay (WMD = -2.67 d; 95%CI: -3.96 - -1.38, P < 0.001); and a decrease in medical complications (RR = 0.41, 95%CI: 0.19-0.90, P = 0.03). The number of harvested lymph nodes, mortality, surgical complications, cancer recurrence rate and long-term survival rate of patients undergoing LATG were similar to those in patients undergoing OTG.

CONCLUSION: Despite a longer operation, LATG can be performed safely in experienced surgical centers with a shorter hospital stay and fewer complications than open surgery.

Laparoscopy-assisted versus open total gastrectomy for gastric cancer: a meta-analysis

BACKGROUND

It remains controversial whether laparoscopy-assisted total gastrectomy (LATG) is a safe or better alternative to open total gastrectomy (OTG) for the treatment of gastric cancer. We aimed to evaluate the safety and efficacy of LATG by pooling comparative studies of LATG and OTG in a meta-analysis.

MATERIALS AND METHODS

Original articles comparing LATG and OTG for gastric cancer, published in the English language since 1990, were searched for in PubMed, Embase, Medline, and the Cochrane Library. The outcome variables analyzed were number of harvested lymph nodes, postoperative complications, postoperative mortality, 5-year survival, operative time, blood loss, time of analgesic use, first flatus day, and postoperative hospital stay.

RESULTS

Eight studies were considered suitable for the meta-analysis, for a total of 1161 patients (409 LATG and 752 OTG). Compared with OTG, LATG showed a similar number of lymph nodes harvested, morbidity, and postoperative mortality. There was also no difference in 5-year overall and disease-specific survival between groups, according to two enrolled studies where such data were available. LATG required longer operative times than OTG but also resulted in significantly less blood loss, earlier return of bowel function, less time of analgesics use, and shorter postoperative hospital stay.

CONCLUSIONS

This meta-analysis suggests that LATG in the treatment of gastric cancer is similar in safety and efficacy to OTG. LATG has the advantages of less blood loss and faster postoperative recovery, at the expense of a longer operative time.

Laparoscopy-assisted total gastrectomy with trans-orally inserted anvil (OrVilTM): A single institution experience

AIM: To investigate the feasibility of laparoscopy-assisted total gastrectomy (LATG) using trans-orally inserted anvil (OrVil^TM) in terms of operative characteristics and short term outcomes.

RESULTS: Characteristics of 27 patients with gastric cancer who underwent LATG from October 2009 to October 2012 in the Foshan Affiliated Hospital of South Medical University were retrospectively reviewed. Among these patients, six were reconstructed by mini-laparotomy and 21 by OrVil^TM. The clinicopathological characteristics, total operation time, total blood loss, abdominal incision and complications of anastomosis including stenosis and leakage, were compared between the groups undergoing LATG with OrVil^TM and the group undergoing mini-laparotomy.

RESULTS: The operations were successfully performed on all the patients without intraoperative complications or conversion to open surgery. Two (10%) patients received palliative procedure under laparoscope who were prepared for LATG preoperatively. One case had hepatic metastatic carcinoma and 1 case had tumor recurrence near the anastomosis 8 mo after surgery. The mean follow-up duration was 10 mo (range, 2-24 mo). Operation time was significantly reduced by the use of OrVil^TM (198.42 ± 30.28 min vs 240.83 ± 8.23 min). The postoperative course with regard to occurrence of stenosis and leakage was not different between the two groups. There were no significant differences in estimated blood loss. The upper abdominal incision was smaller in OrVil^TM group than in mini-laparotomy group (4.31 ± 0.45 cm vs 6.43 ± 0.38 cm).

CONCLUSION: LATG using OrVil^TM is a technically feasible surgical procedure with sufficient lymph node dissection, less operation time and acceptable morbidity.

Laparoscopic total gastrectomy versus open total gastrectomy for cancer: a systematic review and meta-analysis

BACKGROUND

The possible advantages of laparoscopic (assisted) total gastrectomy (LTG) versus open total gastrectomy (OTG) have not been reviewed systematically. The aim of this study was to systematically review the short-term outcomes of LTG versus OTG in the treatment of gastric cancer.

METHODS

A systematic search of PubMed, Cochrane, CINAHL, and Embase was conducted. All original studies comparing LTG with OTG were included for critical appraisal. Data describing short-term outcomes were pooled and analyzed.

RESULTS

A total of eight original studies that compared LTG (n = 314) with OTG (n = 384) in patients with gastric cancer fulfilled quality criteria and were selected for review and meta-analysis. LTG compared with OTG was associated with a significant reduction of intraoperative blood loss (weighted mean difference = 227.6 ml; 95 % CI 144.3-310.9; p < 0.001), a reduced risk of postoperative complications (risk ratio = 0.51; 95 % CI 0.33-0.77), and shorter hospital stay (weighted mean difference 4.0 = days; 95 % CI 1.4-6.5; p < 0.001). These benefits were at the cost of longer operative time (weighted mean difference = 55.5 min; 95 % CI 24.8-86.2; p < 0.001). In-hospital mortality rates were comparable for LTG (0.9 %) and OTG (1.8 %) (risk ratio = 0.68; 95 % CI 0.20-2.36).

CONCLUSION

LTG shows better short term outcomes compared with OTG in eligible patients with gastric cancer. Future studies should evaluate 30- and 60-day mortality, radicality of resection, and long-term follow-up in LTG versus OTG, preferably in randomized trials.

Comparison of short-term surgical outcomes between laparoscopic and open total gastrectomy for gastric carcinoma: case-control study using propensity score matching method

BACKGROUND

To evaluate the technical feasibility and safety of laparoscopic total gastrectomy (LTG) for gastric carcinoma, this study compared short-term surgical outcomes between LTG and open total gastrectomy (OTG) using the propensity score matching method.

STUDY DESIGN

After generating propensity scores given the covariates of age, sex, body mass index, comorbidity, American Society of Anesthesiologists (ASA) score, operators, and tumor stage, 122 patients with LTG were matched to 122 OTG patients using the nearest available score matching. Operative outcomes and hospital courses were compared in the matched groups and in the subgroups by the extent of lymph node dissection (LND).

RESULTS

The 2 study groups were well balanced with respect to the baseline characteristics of the propensity score derivation model. In the analysis of overall patients, the LTG group showed significantly longer operating time (289 vs 203 min, p < 0.001), but postoperative outcomes, including hospital stay, morbidity, and mortality, were similar in the 2 groups. In the subgroup with D1 + ß LND (perigastric nodes + Nos. 7, 8a, 9, 11p), the LTG group showed no significant differences in hospital stay, morbidity, and mortality from the OTG group. However, in the subgroup with D2 LND (perigastric nodes + Nos. 7, 8a, 9, 10, 11p, 11d, 12a), the LTG group showed significantly increased morbidity (52.6% vs 21.0%, p = 0.007) and tendency toward increased length of hospital stay and mortality as compared with the OTG group.

CONCLUSIONS

Laparoscopic total gastrectomy is a safe and feasible technique for treatment of upper gastric carcinoma. However, LTG with D2 LND for upper gastric cancer may increase the operative risk and requires considerable experience in laparoscopic surgery.

Totally laparoscopic Billroth II gastrectomy with a novel, safe, simple, and time-saving anastomosis by only stapling devices

BACKGROUND

Totally laparoscopic gastrectomy represents the evolution of laparoscopy-assisted gastrectomy. Most surgeons prefer laparoscopy-assisted gastrectomy rather than totally laparoscopic procedures because of technical difficulties of intracorporeal anastomosis. We created one novel stapling anastomosis without hand-sewn technique in totally laparoscopic Billroth II gastrectomy. The feasibility and early surgical outcomes of totally laparoscopic Billroth II gastrectomy with stapling anastomosis and with hand-sewn anastomosis were introduced in this study.

METHODS

We retrospectively analyzed early surgical outcomes in 70 patients who underwent totally laparoscopic Billroth II distal gastrectomy for gastric cancer between January 2010 and July 2011. The patients were divided into hand-sewn and device groups according to whether intracorporeal anastomosis was performed by only hand-sewn technique (n = 36) or only stapling devices (n = 34). In the device group, the gastrojejunostomy was performed using a circular stapler, and an additional side-to-side jejunojejunostomy was made at the site of jejunal enterotomy.

RESULTS

There was no difference in the mean number of lymph nodes retrieved in both groups. The blood loss (hand-sewn group 205.8 ± 37.4 vs. device group 201.2 ± 51.2 ml, p > 0.05) and hospital stay (hand-sewn group 6.5 ± 3.7 vs. device group 5.9 ± 4.1 days, p > 0.05) were similar in both groups. We found that intracorporeal anastomosis by totally stapling devices was associated with decreased operative time (hand-sewn group 239.0 ± 40.1 vs. device group 203.6 ± 27.9 min, p < 0.05).

CONCLUSION

We suggest that intracorporeal anastomosis using only stapling devices in the described method was as safe and feasible as by hand-sewn technique. Moreover, it is a simple and time-saving method without any difficult hand-sewn procedures.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Endoscopy-assisted anastomosis: a modified technique for laparoscopic side-to-side esophagojejunostomy following a total gastrectomy

INTRODUCTION

Esophagojejunostomy with a circular stapling device is sometimes difficult to perform in a laparoscopic setting. On the other hand, a side-to-side anastomosis with a linear stapling device is technically challenging.

METHODS

Between June 2002 and March 2008, 10 consecutive patients underwent a laparoscopy-assisted total gastrectomy using a side-to-side anastomosis technique. Of these patients, four underwent a laparoscopy-assisted total gastrectomy with a modified anastomosis technique. A small wound was created on the antimesenteric side of the jejunum 5 cm distal to the resected portion and then in the lower esophagus. A peroral endoscope was advanced to the hole, and the cartridge fork was introduced into the lower esophagus under endoscopic guidance. The device (45 mm, blue) was fired to create an antiperistaltic side-to-side anastomosis. The common entry hole was closed by transecting the jejunum and the esophagus with another linear stapler and by using an endoscope as a stent.

RESULTS

Four patients underwent the modified procedure and did not require an open procedure. One patient developed a pancreatic fistula, which was treated conservatively. The average operative time, reconstruction time and blood loss were 483 ± 133 minutes, 139 ± 31 minutes, and 199 ± 121 mL, respectively. An introduction of the stapler into the lower esophagus and a closure of the common entry hole were performed safely without any stress.

CONCLUSION

Although several techniques must be compared to determine the ideal procedure for laparoscopic esophagojejunostomy, the modified side-to-side anastomosis technique may be useful in clinical settings.

Safety and application of laparoscopic gastrectomy for benign gastric disease and gastric cancer

INTRODUCTION

Laparoscopic gastrectomy is rapidly expanding despite reservations by some surgeons regarding its safety and radicality. The aim of this study was to evaluate patients undergoing laparoscopic gastrectomy for both benign and malignant disease with particular emphasis on technical feasibility, safety, effectiveness and complications.

PATIENTS AND METHODS

Review of prospectively collected data of patients who underwent laparoscopic gastrectomy from May 2005 to September 2009 under the care of one consultant surgeon.

RESULTS

A total of 61 laparoscopic gastrectomies were performed (35 men and 26 women) with a median age of 68 years (range, 41-90 years). There were 39 distal gastrectomies (19 adenocarcinoma, 6 gastrointestinal stromal tumour [GIST], 4 benign gastric outlet obstruction, 4 high-grade dysplasia in gastric adenomas, 4 non-healing ulcers, 2 gastric antral vascular ectasia [GAVE]); 15 sub-total gastrectomies (13 adenocarcinomas, 2 GIST); and 7 total gastrectomies (5 adenocarcinomas, 1 GIST, 1 carcinoid). Median follow-up was for 48 months (range, 1-72 months). There was one death, two major and six minor complications. All patients with complications made a satisfactory recovery.

CONCLUSIONS

Laparoscopic gastrectomy is associated with a low mortality (1.75%) and major morbidity (3.50%). Although technically demanding, especially when a D2 lymphadenectomy is performed, our results have shown that tailored laparoscopic resection based on tumour characteristics with either D1 or D2 lymphadenectomy results in good surgical and oncological outcomes.