Totally laparoscopic vs. laparoscopically assisted distal gastrectomy for gastric cancer

Totally laparoscopic verse laparoscopic assisted distal gastrostomy for gastric cancer: an update meta-analysis

Totally laparoscopic distal gastrostomy (TLDG) and laparoscopic- assisted distal gastrostomy (LADG) are the minimally invasive surgical technology for gastric cancer. This study aimed to compare the surgical outcomes of these two methods. Relevant studies were selected through electronic searches of EMBASE, PubMed and Web of Science. In total, 21 non-randomized controlled studies containing 2475 patients in the totally laparoscopic distal gastrostomy and 1889 patients in the laparoscopic-assisted distal gastrostomy were included in this study. And operative time, operative blood loss, retrieved lymph nodes, time to liquid diet (days), postoperative hospital stay and overall complications were pooled and compared using meta-analysis. There were no significant differences between operative time (WMD = 0.38, 95% CI –10.43 –11.18, P = 0.95) and overall complications (RR = 1.09, 95% CI 0.91–1.30, P = 0.36). But totally laparoscopic distal gastrostomy had more advantages in aspects of intraoperative blood loss (WMD = 24.4, 95% CI 12.45–36.36, P < 0.0001), time to liquid diet (days) (WMD = 0.21, 95% CI 0.03–0.40, P = 0.03) and postoperative hospital stay (WMD = 0.72, 95% CI 0.31–1.13, P = 0.0006). Moreover, totally laparoscopic distal gastrostomy had more retrieved lymph nodes (WMD = –1.24, 95% CI–1.90 to–0.58, P = 0.0002). This meta-analysis indicates that totally laparoscopic distal gastrostomy may be a safe, feasible, and favorable surgical technology in terms of less blood loss, faster liquid diet, shorter postoperative hospital stay and more lymph nodes retrieved.

Systematic review and meta-analysis of totally laparoscopic versus laparoscopic assisted distal gastrectomy for gastric cancer

BACKGROUND

Totally laparoscopic distal gastrectomy (TLDG) has been developed in the hope of improving surgical quality and overcoming the limitations of conventional laparoscopic assisted distal gastrectomy (LADG) for gastric cancer. The aim of this study was to determine the extent of evidence in support of these ideals.

METHODS

A systematic review of the two operation types (LADG and TLDG) was carried out to evaluate short-term outcomes including duration of operation, retrieved lymph nodes, estimated blood loss, resection margin status, technical postoperative complications, and hospital stay.

RESULTS

Twelve non-randomized observational clinical studies involving 2,255 patients satisfied the eligibility criteria. Operative time was not statistically different between groups (P > 0.05). The number of retrieved lymph nodes and the resection margin length in TLDG were comparable with those in LADG. Estimated blood loss was significantly less in TLDG than that in LAG (P < 0.01). Compared to LADG, TLDG also involved lesser postoperative hospital stay (P < 0.01) and earlier time to soft diet intake (P < 0.05). Time to flatus and postoperative complications were similar for those two operative approaches.

CONCLUSIONS

TLDG may be a technically safe, feasible, and favorable approach in terms of better cosmesis, less blood loss, and faster recovery compared with LADG.

Does the Difference of Invasiveness between Totally Laparoscopic Distal Gastrectomy and Laparoscopy-Assisted Distal Gastrectomy Lead to a Difference in Early Surgical Outcomes? A Prospective Randomized Trial

BACKGROUND

Resection and anastomosis in laparoscopic distal gastrectomy can be performed extracorporeally or intracorporeally. Most surgeons have performed laparoscopy-assisted distal gastrectomy (LADG) because of technical difficulties of intracorporeal anastomosis. However, totally laparoscopic distal gastrectomy (TLDG) has recently been attempted and is expected to be feasible and less invasive compared with LADG. In this study, we tried to evaluate the clinical effect of the difference of invasiveness between TLDG and LADG, by way of a randomized prospective trial.

METHODS

From February 2011 to September 2013, a total of 110 patients with primary gastric cancer were randomly assigned to either TLDG or LADG. Clinicopathologic features, operative details, postoperative course, and quality of life (QoL) were compared between the two groups. QoL was assessed using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-C30 and gastric module STO22 at 2 weeks and 3 months after surgery.

RESULTS

The two groups were comparable in clinical and pathological characteristics. The proximal resection margin was significantly longer and the length of wound was shorter in the TLDG group. We could not find any significant difference in postoperative inflammatory parameters, postoperative pulmonary function, postoperative recovery, and QoL scores at 2 weeks and 3 months after surgery. There were no significant differences in complication rates.

CONCLUSIONS

This study suggests that TLDG is as safe and feasible as LADG in gastric cancer. The parameters used routinely in the clinical field to evaluate early surgical outcomes could not reflect the delicate difference in surgical invasiveness between TLDG and LADG.

Comparison of short-term surgical outcomes between totally laparoscopic and laparoscopic-assisted distal gastrectomy for gastric cancer: a 10-y single-center experience with meta-analysis

BACKGROUND

Laparoscopic-assisted distal gastrectomy (LADG) and totally laparoscopic distal gastrectomy (TLDG) are two commonly used methods of laparoscopic gastrectomy for gastric cancer. This study aimed to compare the short-term surgical outcomes of these two methods.

METHODS

A prospectively maintained gastric cancer database between October 2004 and February 2014 was reviewed and 115 patients underwent LADG and 198 patients underwent TLDG were included. The clinical characteristics and perioperative clinical outcomes of two groups were compared. Moreover, a systematic review and meta-analysis were conducted.

RESULTS

The mean operation time and blood loss were similar in two groups, as was the number of retrieved lymph nodes. There was no significant difference in time to first flatus, the time to restart oral intake, the length of the hospital stay after surgery, and postoperative complications. The meta-analysis revealed no significant differences in the operative time, surgical margin, time to first flatus, length of hospital stay, mortality, overall, and anastomosis-related complications among the groups. However, the intraoperative blood loss was lower in TLDG (weighted mean difference = 21.50 mL; 95% confidence interval: 9.79-33.22; P < 0.01), and number of retrieved lymph nodes was higher in TLDG (weighted mean difference = -1.56; 95% confidence interval: -2.69 to -0.44; P < 0.01).

CONCLUSIONS

TLDG is safe and feasible compared with LADG. However, it is difficult to identify the clinical advantages of TLDG over LADG based on our study. Thus, the choice of surgical approach mainly depends on the patient conditions and the preference of the patients or surgeons.

Comparison between totally laparoscopic and laparoscopically assisted distal gastrectomy for gastric cancer with a short follow-up: a meta-analysis

Laparoscopic surgery has become common in the treatment of gastric cancer because of improvements of both surgical techniques and devices. The aim of this study was to compare totally laparoscopic distal gastrectomy (TLDG) with laparoscopically assisted distal gastrectomy (LADG) implemented by experienced laparoscopic surgeons. Studies and relevant literature regarding LADG versus TLDG were searched for in the PubMed and Embase databases. Operative time, volume of bleeding, number of retrieved lymph nodes, time to first flatus, duration of postoperative hospitalization, and postoperative complications in LADG and TLDG were pooled and compared by meta-analysis. Odds ratios (ORs) and weighted mean differences (WMDs) were calculated with 95% confidence intervals (CIs) to evaluate the effect of TLDG. Six recent studies of 1644 patients were included in the meta-analysis. Compared with LADG, TLDG had advantages of less bleeding (WMD -17.79, 95% CI -32.57 to -3.02, P=.02), shorter time to first flatus (WMD -0.14, 95% CI -0.23 to -0.06, P=.001), and shorter postoperative hospitalization (WMD -0.32, 95% CI -0.53 to -0.12, P=.002). Operative time, mean number of lymph nodes retrieved, and postoperative complication rate were not statistically different (P>.05). Compared with LADG, TLDG significantly reduced bleeding, time to first flatus, and postoperative hospital stay and can be considered a useful technique for patients with gastric cancer.

Progression from laparoscopic-assisted to totally laparoscopic distal gastrectomy: comparison of circular stapler (i-DST) and linear stapler (BBT) for intracorporeal anastomosis

BACKGROUND

Billroth I (B-I) gastroduodenostomy is an anastomotic procedure that is widely performed after gastric resection for distal gastric cancer. A circular stapler often is used for B-I gastroduodenostomy in open and laparoscopic-assisted distal gastrectomy. Recently, totally laparoscopic distal gastrectomy (TLDG) has been considered less invasive than laparoscopic-assisted gastrectomy, and many institutions performing laparoscopic-assisted distal gastrectomy are trying to progress to TLDG without markedly changing the anastomosis method. The purpose of this report is to introduce the technical details of new methods of intracorporeal gastroduodenostomy using either a circular or linear stapler and to evaluate their technical feasibility and safety.

METHODS

Seventeen patients who underwent TLDG with the intracorporeal double-stapling technique using a circular stapler (n = 7) or the book-binding technique (BBT) using a linear stapler (n = 10) between February 2010 and April 2011 were enrolled in the study. Clinicopathological data, surgical data, and postoperative outcomes were analyzed.

RESULTS

There were no intraoperative complications or conversions to open surgery in any of the 17 patients. The usual postoperative complications following gastroduodenostomy, such as anastomotic leakage and stenosis, were not observed. Anastomosis took significantly longer to complete with DST (64 ± 24 min) than with BBT (34 ± 7 min), but more stapler cartridges were needed with BBT than with DST.

CONCLUSIONS

TLDG using a circular or linear stapler is feasible and safe to perform. DST will enable institutions performing laparoscopic-assisted distal gastrectomy with circular staplers to progress to TLDG without problems, and this progression may be more economical because fewer stapler cartridges are used during surgery. However, if an institution has already been performing δ anastomosis in TLDG but has been experiencing certain issues with δ anastomosis, converting from δ anastomosis to BBT should be beneficial.

Impact of carbon dioxide pneumoperitoneum on the expression of nuclear factor kappa B p65, TNF-α, and IL-6 in human gastric cancer xenografts in a nude mouse model

AIM: To assess the impact of carbon dioxide (CO₂) pneumoperitoneum versus laparotomy on the expression of tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), and nuclear factor kappa B (NF-κB) in human gastric cancer xenografts in a nude mouse model.

METHODS: Nude mice were inoculated intraperitoneally with human gastric cancer cells (MKN45) to generate a xenograft mouse model of human gastric cancer. The model mice were randomly divided into three groups to undergo laparotomy, CO₂ pneumoperitoneum, and anesthesia alone, respectively. Tumor growth and expression of TNF-α, IL-6 expression and NF-κB in tumor xenografts were determined.

RESULTS: Total tumor weight was higher in mice undergoing laparotomy than in those undergoing CO₂ pneumoperitoneum (0.72 ± 0.02 vs 0.43 ± 0.06, P < 0.05). The mRNA expression levels of NF-κB p65, TNF-α, and IL-6 were significantly higher at 24 h after laparotomy than after CO₂ pneumoperitoneum (1.09 ± 0.12 vs 0.63 ± 0.07; 1.14 ± 0.11 vs 0.31 ± 0.05; 0.65 ± 0.08 vs 0.42 ± 0.04, all P < 0.05).

CONCLUSION: In a xenograft mouse model of human gastric cancer, CO₂ pneumoperitoneum resulted in slower tumor growth and lower expression levels of TNF-α, IL-6 and NF-κB p65 in tumor tissue than laparotomy, suggesting that laparoscopy is a minimally invasive technique in gastrointestinal oncologic surgery.