Laparoscopy versus open distal gastrectomy by expert surgeons for early gastric cancer in Japanese patients: short-term clinical outcomes of a randomized clinical trial

Short-Term Outcomes Analysis Comparing Open, Laparoscopic, Laparoscopic-Assisted, and Robotic Distal Gastrectomy for Locally Advanced Gastric Cancer: A Randomized Trials Network Analysis

BACKGROUND

Minimally invasive surgery for the treatment of locally advanced gastric cancer (AGC) is debated. The aim of this study was to execute a comprehensive assessment of principal surgical treatments for resectable distal gastric cancer.

METHODS

Systematic review and randomized controlled trials (RCTs) network meta-analysis. Open (Op-DG), laparoscopic-assisted (LapAs-DG), totally laparoscopic (Lap-DG), and robotic distal gastrectomy (Rob-DG) were compared. Pooled effect-size measures were the risk ratio (RR), the weighted mean difference (WMD), and the 95% credible intervals (CrIs).

RESULTS

Ten RCTs (3823 patients) were included. Overall, 1012 (26.5%) underwent Lap-DG, 902 (23.6%) LapAs-DG, 1768 (46.2%) Op-DG, and 141 (3.7%) Rob-DG. Anastomotic leak, severe complications (Clavien-Dindo > 3), and in-hospital mortality were comparable. No differences were observed for reoperation rate, pulmonary complications, postoperative bleeding requiring transfusion, surgical-site infection, cardiovascular complications, number of harvested lymph nodes, and tumor-free resection margins. Compared to Op-DG, Lap-DG and LapAs-DG showed a significantly reduced intraoperative blood loss with a trend toward shorter time to first flatus and reduced length of stay.

CONCLUSIONS

LapAs-DG, Lap-DG, and Rob-DG performed in referral centers by dedicated surgeons have comparable short-term outcomes to Op-DG for locally AGC.

[Technique and Study Results of Laparoscopic Gastrectomy for Gastric Cancer]

The aim of this paper was to describe the technique of laparoscopic gastrectomy for gastric carcinoma and to present a review of current international studies on this topic.The first part describes and documents a standard laparoscopic gastrectomy for carcinoma. In the second part, after an EMBASE and PubMed search, a total of 123 quality-relevant randomised (RCT) and non-randomised (non-RCT) studies on laparoscopic gastrectomy are identified from a primary total of 3,042 hits by systematic narrowing. The study results are then summarised conclusively for the target criteria of feasibility, outcome, oncological quality, morbidity and mortality.Both, laparoscopic subtotal resection for distal gastric carcinomas and laparoscopic gastrectomy can now be performed safely and with few complications. In a recent literature review of a total of 15 RCTs with 5,576 patients (laparoscopic 2,793 vs. open 2,756), there were no significant differences in terms of feasibility, intraoperative outcome and oncological quality (R0 and lymph node harvest). Surgical morbidity and mortality were comparable. Patients after laparoscopic surgery showed a significantly faster early postoperative recovery with a lower overall morbidity. In contrast, the operating time was significantly longer - by a mean of 45 min - compared to the open technique. The advantages of the laparoscopic technique were equally evident in studies on early gastric carcinoma and advanced carcinomas (>T2).Laparoscopic gastrectomy for gastric carcinoma is safe to perform and shows better early postoperative recovery. Complication rates, morbidity and mortality as well as long-term oncological results are comparable with open surgery.

Impact of treatment guidelines and pivotal clinical trial results on a surgeon's decision regarding treatment for gastric cancer: a retrospective cohort study using the National Clinical Database

PURPOSES

The present study evaluated the impact of clinical guidelines for gastric cancer surgery on surgeons' choice of procedure in real-world practice. We focused on the 2014 guideline revision recommending laparoscopic surgery and the evidence concerning splenectomy for prophylactic lymphadenectomy reported in 2015 using the National Clinical Database, which is the most comprehensive database in Japan.

METHODS

We investigated the monthly percentages of laparoscopic distal gastrectomies performed for stage I gastric cancer (LDG%) and splenectomies performed during total gastrectomy for advanced cancer (TGS%) between 2014 and 2017. We evaluated the descriptive statistics of the time-series changes in the LDG%, TGS%, and annual trends of outcomes.

RESULTS

In total, 124,787 patients were enrolled. The mean LDG% and TGS% were 69.8% and 9.2%, respectively. The LDG% and TGS% were 66.4% and 16.7%, respectively, in January 2014 and 73.1% and 5.9%, respectively, in December 2017. LDG% consistently increased, and TGS% showed a consistent downward trend throughout the observation period. There was no significant change in this trend after the publication of the guideline recommendations or clinical trial results.

CONCLUSION

No significant changes in surgical procedures were observed after publication of the guidelines or results of clinical trials.

Comparison of the effects of open and laparoscopic approach on body composition in gastrectomy for gastric cancer: A propensity score-matched study

Aim

To compare the effects of open (OG) and laparoscopic gastrectomy (LG) on body composition and muscle strength.

Methods

This study performed a propensity score matching analysis using cases from a large-scale, multicenter, phase III randomized controlled trial concerning oral nutritional supplements after gastrectomy and analyzed both the whole and matched cohorts. Measurements of body composition and hand grip strength (HGS) were performed at baseline (preoperatively) and at 1, 2, 3, 6, and 12 months after gastrectomy.

Results

Of 835 patients, 275 and 560 underwent OG and LG, respectively. Skeletal muscle mass (SMM) and HGS loss were significantly lesser in the LG group than in the OG group. The propensity score-matched analysis, including 120 pairs of patients, confirmed that the % SMM loss values at 1, 2, 3, 6, and 12 POM were -4.5%, -4.0%, -4.7%, -4.6%, and -5.8% in the OG group and -3.0%, -1.9%, -2.4%, -2.2%, and -2.7% in the LG group, respectively. The % SMM loss was significantly lesser in the LG group than in the OG group (repeated measures ANOVA p < 0.001). The HGS loss was non-significantly smaller in the LG group than in the OG group.

Conclusion

Skeletal muscle mass loss was significantly lesser in the LG group than in the OG group in both cohorts, indicating that LG may be more effective than OG for maintaining muscle mass.

Efficacy and safety of patient-controlled thoracic epidural analgesia alone versus patient-controlled intravenous analgesia with acetaminophen after laparoscopic distal gastrectomy for gastric cancer: a propensity score-matched analysis

BACKGROUND

Laparoscopic gastrectomy is a common procedure for early gastric cancer treatment. Improving postoperative pain control enhances patient recovery after surgery. The use of multimodal analgesia can potentially enhance the analgesic effect, minimize side effects, and change the postoperative management. The purpose of this study was to evaluate and compare the efficacies of the use of patient-controlled intravenous analgesia with regular acetaminophen (PCIA + Ace) and patient-controlled thoracic epidural analgesia (PCEA) for postoperative pain control.

METHODS

We retrospectively collected the data of 226 patients who underwent laparoscopic distal gastrectomy (LDG) with delta-shaped anastomosis between 2016 and 2019. After 1:1 propensity-score matching, we compared 83 patients who used PCEA alone (PCEA group) with 83 patients who used PCIA + Ace (PCIA + Ace group). Postoperative pain was assessed using a numeric rating scale (NRS) with scores ranging from 0 to 10. An NRS score ≥ 4 was considered the threshold for additional intravenous rescue medication administration.

RESULTS

Although NRS scores at rest were comparable between the PCEA and PCIA + Ace groups, NRS scores of patients in the PCIA + Ace group during coughing or movement were significantly better than those of patients in the PCEA group on postoperative days 2 and 3. The frequency of additional rescue analgesic use was significantly lower in the PCIA + Ace group than in the PCEA group (1.1 vs. 2.7, respectively, p < 0.001). The rate of reduction or interruption of the patient-controlled analgesic dose was higher in the PCEA group than in the PCIA + Ace group (74.6% vs. 95.1%, respectively, p = 0.0002), mainly due to hypotension occurrence in the PCEA group. Physical recovery time, postoperative complication occurrence, and liver enzyme elevation incidence were not significantly different between groups.

CONCLUSIONS

PCIA + Ace can be safely applied without an increase in complications or deterioration in gastrointestinal function; moreover, PCIA + Ace use may provide better pain control than PCEA use in patients following LDG.

Minimally Invasive and Open Gastrectomy for Gastric Cancer: A Systematic Review and Network Meta-Analysis of Randomized Clinical Trials

BACKGROUND AND OBJECTIVES

Optimal surgical management for gastric cancer remains controversial. We aimed to perform a network meta-analysis (NMA) of randomized clinical trials (RCTs) comparing outcomes after open gastrectomy (OG), laparoscopic-assisted gastrectomy (LAG), and robotic gastrectomy (RG) for gastric cancer.

METHODS

A systematic search of electronic databases was undertaken. An NMA was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-NMA guidelines. Statistical analysis was performed using R and Shiny.

RESULTS

Twenty-two RCTs including 6890 patients were included. Overall, 49.6% of patients underwent LAG (3420/6890), 46.6% underwent OG (3212/6890), and 3.7% underwent RG (258/6890). At NMA, there was a no significant difference in recurrence rates following LAG (odds ratio [OR] 1.09, 95% confidence interval [CI] 0.77-1.49) compared with OG. Similarly, overall survival (OS) outcomes were identical following OG and LAG (OS: OG, 87.0% [1652/1898] vs. LAG: OG, 87.0% [1650/1896]), with no differences in OS in meta-analysis (OR 1.02, 95% CI 0.77-1.52). Importantly, patients undergoing LAG experienced reduced intraoperative blood loss, surgical incisions, distance from proximal margins, postoperative hospital stays, and morbidity post-resection.

CONCLUSIONS

LAG was associated with non-inferior oncological and surgical outcomes compared with OG. Surgical outcomes following LAG and RG superseded OG, with similar outcomes observed for both LAG and RG. Given these findings, minimally invasive approaches should be considered for the resection of local gastric cancer, once surgeon and institutional expertise allows.

Laparoscopic vs. open distal gastrectomy for locally advanced gastric cancer: A systematic review and meta-analysis of randomized controlled trials

Objective

The aim of this systematic review and meta-analysis is to compare the short- and long-term outcomes of laparoscopic distal gastrectomy (LDG) with those of open distal gastrectomy (ODG) for patients with advanced gastric cancer (AGC) who exclusively underwent distal gastrectomy and D2 lymphadenectomy in randomized controlled trials (RCTs).

Background

Data in published meta-analyses that included different gastrectomy types and mixed tumor stages prevented an accurate comparison between LDG and ODG. Recently, several RCTs that compared LDG with ODG included AGC patients specifically for distal gastrectomy, with D2 lymphadenectomy being reported and updated with the long-term outcomes.

Methods

PubMed, Embase, and Cochrane databases were searched to identify RCTs for comparing LDG with ODG for advanced distal gastric cancer. Short-term surgical outcomes and mortality, morbidity, and long-term survival were compared. The Cochrane tool and GRADE approach were used for evaluating the quality of evidence (Prospero registration ID: CRD42022301155).

Results

Five RCTs consisting of a total of 2,746 patients were included. Meta-analyses showed no significant differences in terms of intraoperative complications, overall morbidity, severe postoperative complications, R0 resection, D2 lymphadenectomy, recurrence, 3-year disease-free survival, intraoperative blood transfusion, time to first liquid diet, time to first ambulation, distal margin, reoperation, mortality, or readmission between LDG and ODG. Operative times were significantly longer for LDG [weighted mean difference (WMD) 49.2 min, p < 0.05], whereas harvested lymph nodes, intraoperative blood loss, postoperative hospital stay, time to first flatus, and proximal margin were lower for LDG (WMD -1.3, p < 0.05; WMD -33.6 mL, p < 0.05; WMD -0.7 day, p < 0.05; WMD -0.2 day, p < 0.05; WMD -0.4 mm, p < 0.05). Intra-abdominal fluid collection and bleeding were found to be less after LDG. Certainty of evidence ranged from moderate to very low.

Conclusions

Data from five RCTs suggest that LDG with D2 lymphadenectomy for AGC has similar short-term surgical outcomes and long-term survival to ODG when performed by experienced surgeons in hospitals contending with high patient volumes. It can be concluded that RCTs should highlight the potential advantages of LDG for AGC.

Systematic Review Registration

PROSPERO, registration number CRD42022301155.

Short-and long-term outcomes of laparoscopic versus open gastrectomy in patients with gastric cancer: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Laparoscopic gastrectomy (LG) for gastric cancer has rapidly developed and become more popular in recent decades. Additional high-quality randomized controlled trial (RCT) studies comparing LG versus open gastrectomy (OG) for gastric cancer (GC) have been published in recent years. An updated systematic review is warranted. The aim of our meta-analysis was to comprehensively evaluate the short- and long-term outcomes of LG versus OG for GC.

MATERIALS AND METHODS

The PubMed, Embase, Web of Science, and Cochrane Center Register of Controlled Trials databases were comprehensively searched to identify RCTs comparing LG versus OG for GC published between January 1994 and December 7, 2021. This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Cochrane Collaboration and the Quality of Reporting of Meta-analyses (QUORUM) guidelines. All RCTs comparing the short- and long-term outcomes of LG with those of OG were included. A random effects model was adopted with significant heterogeneity (I² > 50%), while a fixed effects model was employed in all other cases (I² ≤ 50%).

RESULTS

A total of 26 RCTs with 8301 patients were included in this meta-analysis. The results indicated that the intraoperative complication rate was comparable between the LG group and the OG group (OR=1.14, 95% CI [0.76, 1.70], I²=0%, p=0.53). The LG group had fewer postoperative complications than the OG group (OR=0.65, 95% CI [0.57, 0.74], I²=26%, p<0.00001). However, the severe postoperative complication rate and perioperative mortality were comparable between the two groups (OR=0.83, 95% CI [0.67, 1.04], I²=10%, p=0.10; OR=1.11, 95% CI [0.59, 2.09], I²=0%, p=0.74, respectively). The number of lymph nodes retrieved by the LG group was less than that of the OG group (MD=-1.51, 95% CI [-2.29, -0.74], I²=0%, p<0.0001). The proximal resection margin distance in the LG group was shorter than that in the OG group (MD=-0.34, 95% CI [-0.57, -0.12], I²=23%, p=0.003), but the distal resection margin distance in the two groups was comparable (MD=-0.21, 95% CI [-0.47, 0.04], I²=0%, p=0.10). The time to first ambulation was shorter in the LG group than in the OG group (MD=-0.14, 95% CI [-.26, -0.01], I²=40%, p=0.03). The time to first flatus was also shorter in the LG group than in the OG group (MD=-0.15, 95% CI [-0.23, -0.07], I²=4%, p=0.0001). However, the first time on a liquid diet was comparable between the two groups (MD=-0.30, 95% CI [-0.64, 0.04], I²=88%, p=0.09). Furthermore, the postoperative length of stay was shorter in the LG group than in the OG group (MD=-1.26, 95% CI [-1.99, -0.53], I²=90%, p=0.0007). The 5-year overall survival (OS) was comparable between the two groups (HR=0.97, 95% CI [0.80, 1.17], I²=0%, p=0.73), and the 5-year disease-free survival (DFS) was also similar between the LG group and OG group (HR=1.08, 95% CI [0.77, 1.52], I²=0%, p=0.64).

CONCLUSION

LG is a technically safe and feasible alternative to OG with the advantages of a fewer postoperative complication rate, faster recovery of gastrointestinal function, and greater cosmetic benefit for patients with GC. Meanwhile, LG has comparable long-term outcomes to OG for GC.

Optimizing laparoscopic training efficacy by 'deconstruction into key steps': a randomized controlled trial with novice medical students

BACKGROUND

Simulator training is an effective way of acquiring laparoscopic skills but there remains a need to optimize teaching methods to accelerate learning. We evaluated the effect of the mental exercise 'deconstruction into key steps' (DIKS) on the time required to acquire laparoscopic skills.

METHODS

A randomized controlled trial with undergraduate medical students was implemented into a structured curricular laparoscopic training course. The intervention group (IG) was trained using the DIKS approach, while the control group (CG) underwent the standard course. Laparoscopic performance of all participants was video-recorded at baseline (t0), after the first session (t1) and after the second session (t2) nine days later. Two double-blinded raters assessed the videos. The Impact of potential covariates on performance (gender, age, prior laparoscopic experience, self-assessed motivation and self-assessed dexterity) was evaluated with a self-report questionnaire.

RESULTS

Both the IG (n = 58) and the CG (n = 68) improved their performance after each training session (p < 0.001) but with notable differences between sessions. Whereas the CG significantly improved their performance from t0 -t1 (p < 0.05), DIKS shortened practical exercise time by 58% so that the IG outperformed the CG from t1 -t2, (p < 0.05). High self-assessed motivation and dexterity associated with significantly better performance (p < 0.05). Male participants demonstrated significantly higher overall performance (p < 0.05).

CONCLUSION

Mental exercises like DIKS can improve laparoscopic performance and shorten practice times. Given the limited exposure of surgical residents to simulator training, implementation of mental exercises like DIKS is highly recommended. Gender, self-assessed dexterity, and motivation all appreciably influence performance in laparoscopic training.

The Role of Surgery in the Management of Gastric Cancer: State of the Art

Surgery still represents the mainstay of treatment of all stages of gastric cancer (GC). Surgical resections represent potentially curative options in the case of early GC with a low risk of node metastasis. Sentinel lymph node biopsy and indocyanine green fluorescence are novel techniques which may improve the employment of stomach-sparing procedures, ameliorating quality of life without compromising oncological radicality. Nonetheless, the diffusion of these techniques is limited in Western countries. Conversely, radical gastrectomy with extensive lymphadenectomy and multimodal treatment represents a valid option in the case of advanced GC. Differences between Eastern and Western recommendations still exist, and the optimal multimodal strategy is still a matter of investigation. Recent chemotherapy protocols have made surgery available for patients with oligometastatic disease. In this context, intraperitoneal administration of chemotherapy via HIPEC or PIPAC has emerged as an alternative weapon for patients with peritoneal carcinomatosis. In conclusion, the surgical management of GC is still evolving together with the multimodal strategy. It is mandatory for surgeons to be conscious of the current evolution of the surgical management of GC in the era of multidisciplinary and tailored medicine.

The Incidence, Characteristics and Outcomes of Vertebral Artery Injury Associated with Cervical Spine Trauma: A Systematic Review

STUDY DESIGN

Systematic Review.

OBJECTIVES

Vertebral Artery Injury (VAI) is a potentially serious complication of cervical spine fractures. As many patients can be asymptomatic at the time of injury, the identification and diagnosis of VAI can often prove difficult. Due to the high rates of morbidity and mortality associated with VAI, high clinical suspicion is paramount. The purpose of this review is to elucidate incidence, diagnosis, treatment and outcomes of VAI associated with cervical spine injuries.

METHODS

A systematic search of electronic databases was performed using 'PUBMED', 'EMBASE','Medline (OVID)', and 'Web of Science, for articles pertaining to traumatic cervical fractures with associated VAI.

RESULTS

24 studies were included in this systematic review. Data was included from 48 744 patients. In regards to the demographics of the focus groups that highlighted information on VAI, the mean average age was 46.6 (32.1-62.6). 75.1% (169/225) were male and 24.9% (56/225) were female. Overall incidence of VAI was 596/11 479 (5.19%). 190/420 (45.2%) of patients with VAI had fractures involving the transverse foramina. The right vertebral artery was the most commonly injured 114/234 (48.7%). V3 was the most common section injured (16/36 (44.4%)). Grade I was the most common (103/218 (47.2%)) injury noted. Collective acute hospital mortality rate was 32/226 (14.2%), ranging from 0-26.2% across studies.

CONCLUSION

VAI secondary to cervical spine trauma has a notable incidence and high associated mortality rates. The current available literature is limited by a low quality of evidence. In order to optimise diagnostic protocols and treatment strategies, in addition to reducing mortality rates associated with VAI, robust quantitative and qualitative studies are needed.

Patients with gastroenteric tumor after upper abdominal surgery were more likely to require rescue analgesia than lower abdominal surgery

OBJECTIVES

To find out the reasons why patients still need to use rescue analgesics frequently after gastrointestinal tumor surgery under the patient-controlled intravenous analgesia (IV-PCA), and the different abdominal surgery patients using the difference of analgesics.

METHODS

A total of 970 patients underwent abdominal operation for gastrointestinal tumors were included. According whether patients used dezocine frequently for rescue analgesics within 2 days after surgery, they assigned into two groups: RAN group (Patients who did not frequently use rescue analgesia, 406 cases) and RAY group (Patients who frequently used rescue analgesia, 564 cases). The data collected included patient's characteristics, postoperative visual analogue scale (VAS), nausea and vomiting (PONV), and postoperative activity recovery time.

RESULTS

No differences were observed in the baseline characteristics. Compared with the RAN group, patients in the RAY group had a higher proportion of open surgery, upper abdominal surgery, VAS score at rest on the first 2 days after surgery and PONV, and a slower recovery of most postoperative activities. Under the current use of IV-PCA background, the proportion of rescue analgesics used by patients undergoing laparotomy and upper abdominal surgery was as high as 64.33% and 72.8%, respectively. Regression analysis showed that open surgery (vs laparoscopic surgery: OR: 2.288, 95% CI: 1.650-3.172) and the location of the tumor in the upper abdomen (vs lower abdominal tumor: OR: 2.738, 95% CI: 2.034-3.686) were influential factors for frequent salvage administration.

CONCLUSIONS

In our patient population, with our IV-PCA prescription for postoperative pain control, patient who underwent open upper abdominal surgery required more rescue postoperative analgesia.

Laparoscopic versus open gastrectomy for gastric cancer: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Laparoscopic gastrectomy (LG) has been widely used for advanced gastric cancer (GC), and its resection extent is not limited to distal gastrectomy. However, the superiority of this minimally invasive approach remains controversial. This study aimed to evaluate the benefits and risks of LG on the short- and long-term outcomes compared with open gastrectomy (OG) for GC.

MATERIALS AND METHODS

A systematic literature search was performed to identify randomized controlled trials (RCTs) comparing LG and OG for treatment of GC. The primary outcomes were adverse events, recurrence, mortality, and the quality of life. The secondary outcomes included operation-relevant outcomes and postoperative recovery outcomes. We employed random-effects meta-analyses to pool results with Hartung-Knapp adjustment. The prediction interval (PI) was used to quantify the between-study heterogeneity. Meta-regression and subgroup analyses were performed to examine the potential sources of heterogeneity.

RESULTS

Twenty-eight studies involving 7643 patients were included. Most studies (22 out of 28) reported results from experienced surgeons. Compared to OG, LG was found to have the advantages of less blood loss, fewer postoperative complications, and faster recovery, but at the expense of lesser proximal resection margin length, longer operation time, and fewer retrieved lymph nodes. There were no significant differences for anastomosis-related complications, recurrence and survival and other outcomes between LG and OG. Significant between-study heterogeneity was observed. Body mass index (BMI) and age were two major sources of heterogeneity.

CONCLUSIONS

For experienced surgeons, LG is an alternative approach to OG for patients with GC. Patients with lower BMI and older age may benefit most from LG. Future studies are needed to confirm our findings in low-volume hospitals and for less-experienced surgeons. Future trials focusing on patient-important outcomes are warranted for clinical decision-making.

The Comparison of Short- and Long-Term Outcomes for Laparoscopic Versus Open Gastrectomy for Patients With Advanced Gastric Cancer: A Meta-Analysis of Randomized Controlled Trials

Objectives

The effect of laparoscopic gastrectomy (LG) for the treatment of advanced gastric cancer (AGC) is still controversial. The aim of this meta-analysis was to contrast the short- and long-term outcomes of laparoscopic versus conventional open gastrectomy (OG) for patients with AGC.

Methods

Databases including PubMed, Embase, Scopus, and Cochrane Library were systematically searched until December 2021 for randomized controlled trial-enrolled patients undergoing LG or OG for the treatment of AGC. Short-term outcomes were overall postoperative complications, anastomotic leakage, number of retrieved lymph node, surgical time, blood loss, length of hospital stay, and short-term mortality. Long-term outcomes were survival rates at 1, 3, and 5 years.

Results

A total of 12 trials involving 4,101 patients (2,059 in LG group, 2,042 in OG group) were included. No effect on overall postoperative complications (OR 0.84, 95% CI 0.67 to 1.05, p = 0.12, I² = 34%) and anastomotic leakage (OR 1.26, 95% CI 0.82 to 1.95, p = 0.30, I² = 0%) was found. Compared with the open approach, patients receiving LG had fewer blood loss (MD -54.38, 95% CI -78.09 to -30.67, p < 0.00001, I² = 90%) and shorter length of hospital stay (MD -1.25, 95% CI -2.08 to -0.42, p = 0.003, I² = 86%). However, the LG was associated with a lower number of retrieved lymph nodes (MD -1.02, 95% CI -1.77 to -0.27, p = 0.008, I² = 0%) and longer surgical time (MD 40.87, 95% CI 20.37 to 54.44, p < 0.00001, I² = 94%). Furthermore, there were no differences between LG and OG groups in short-term mortality and survival rate at 1, 3, and 5 years.

Conclusions

LG offers improved short-term outcomes including shorter hospital stays and fewer blood loss, with comparable postoperative complications, short-term mortality, and survival rate at 1, 3, and 5 years when compared to the open approach. Our results support the implementation of LG in patients with AGC.

Systematic Review Registration

PROSPERO (CRD 42021297141).

Laparoscopic vs. Open Gastrectomy for Locally Advanced Gastric Cancer: A Propensity Score-Matched Retrospective Case-Control Study

Introduction: Minimally invasive surgery has been increasingly used in the treatment of gastric cancer. While laparoscopic gastrectomy has become standard therapy for early-stage gastric cancer, especially in Asian countries, the use of minimally invasive techniques has not attained the same widespread acceptance for the treatment of more advanced tumours, principally due to existing concerns about its feasibility and oncological adequacy. We aimed to examine the safety and oncological effectiveness of laparoscopic technique with radical intent for the treatment of patients with locally advanced gastric cancer by comparing short-term surgical and oncologic outcomes of laparoscopic versus open gastrectomy with D2 lymphadenectomy at two Western regional institutions. Methods: The trial was designed as a retrospective comparative matched case-control study for postoperative pathological diagnoses of locally advanced gastric carcinoma. Between January 2015 and September 2021, 120 consecutive patients who underwent curative-intent laparoscopic gastrectomy with D2 lymph node dissection were retrospectively recruited and compared with 120 patients who received open gastrectomy. In order to obtain a comparison that was as homogeneous as possible, the equal control group of pairing (1:1) patients submitted to open gastrectomy who matched those of the laparoscopic group was statistically generated by using a propensity matched score method. The following potential confounder factors were aligned: age, gender, Body Mass Index (BMI), comorbidity, ASA, adjuvant therapy, tumour location, type of gastrectomy, and pT stage. Patient demographics, operative findings, pathologic characteristics, and short-term outcomes were analyzed. Results: In the case-control study, the two groups were clearly comparable with respect to matched variables, as was expected given the intentional primary selective criteria. No statistically significant differences were revealed in overall complications (16.7% vs. 20.8%, p = 0.489), rate of reoperation (3.3% vs. 2.5%, p = 0.714), and mortality (4.2% vs. 3.3%, p = 0.987) within 30 days. Pulmonary infection and wound complications were observed more frequently in the OG group (0.8% vs. 4.2%, p < 0.01, for each of these two categories). Anastomotic and duodenal stump leakage occurred in 5.8% of the patients after laparoscopic gastrectomy and in 3.3% after open procedure (p = 0.072). The laparoscopic approach was associated with a significantly longer operative time (212 vs. 192 min, p < 0.05) but shorter postoperative length of stay (9.1 vs. 11.6 days, p < 0.001). The mean number of resected lymph nodes after D2 dissection (31.4 vs. 33.3, p = 0.134) and clearance of surgical margins (97.5% vs. 95.8%, p = 0.432) were equivalent between the groups. Conclusion: Laparoscopic gastrectomy with D2 nodal dissection appears to be safe and feasible in terms of perioperative morbidity for locally advanced gastric cancer, with comparable oncological equivalency with respect to traditional open surgery.

Pancreas-contactless gastrectomy for gastric cancer prevents postoperative inflammation

BACKGROUND

Pancreas-related complications after laparoscopic gastrectomy (LG) for gastric cancer can be fatal. We developed a gastrectomy procedure with no pancreas contact to prevent such complications and herein report the surgical outcomes.

METHODS

We retrospectively reviewed 182 consecutive patients with gastric cancer who underwent LG at Kitasato University Hospital from January 2017 to January 2020. These patients were divided into a pancreas-contact group (C group) and pancreas-contactless group (CL group) for comparison of postoperative complications, and inflammatory parameters such as body temperature (BT) and C-reactive protein (CRP).

RESULTS

Postoperative complications of CDc grade ≧ IIIa were significantly fewer in the CL group than in the C group [0/76 (0%) vs. 6/106 (5.7%), P = 0.035]. The median drain amylase (drain-AMY) on postoperative day 1 (POD1) was significantly lower in the CL group than in the C group (641 vs. 1162 IU/L, P = 0.02), as was BT at POD1 (37.4 °C vs. 37.7 °C, P = 0.04), the patient group with a BT above 37.5 °C at POD3 [5/76 (6.5%) vs. 18/106 (17%), P = 0.037], and those showing a CRP above 20.0 mg/dL at POD3 [5/76 (6.5%) vs. 20/106 (19%), P = 0.018].

CONCLUSIONS

Our technique to prevent pancreas contact during supra-pancreatic lymph node dissection during LG could minimize the inflammatory response and prevent further postoperative complications. Further large-scale, prospective studies are now required.

Laparoscopic gastrectomy for gastric cancer: has the time come for considered it a standard procedure?

Radical gastrectomy with an adequate lymphadenectomy is the main procedure which makes it possible to cure patients with resectable gastric cancer. A number of randomized controlled trials and meta-analysis provide phase III evidence that laparoscopic gastrectomy is technically safe and that it yields better short-term outcomes than conventional open gastrectomy for early-stage gastric cancer. At present, laparoscopic gastrectomy is considered a standard procedure for early-stage gastric cancer, especially in Asian countries. On the other hand, the use of minimally invasive techniques is still controversial for the treatment of more advanced tumours, principally due to existing concerns about its oncological adequacy and capacity to carry out an adequately extended lymphadenectomy. Additional high-quality studies comparing laparoscopic gastrectomy versus open gastrectomy for gastric cancer have been recently published, in particular concerning the latest results obtained by laparoscopic approach to advanced gastric cancer. It seems very useful to update the review of literature in light of these new evidences for this subject and draw some considerations.

Impact of laparoscopic gastrectomy on relapse-free survival for locally advanced gastric cancer patients with sarcopenia: a propensity score matching analysis

BACKGROUND

Recent gastric cancer reports have shown that preoperative sarcopenia worsens long-term prognosis after gastrectomy. We investigated the impact of laparoscopic surgery on the long-term prognosis of locally advanced gastric cancer patients with sarcopenia.

METHODS

This retrospective study included consecutive patients who underwent radical gastrectomy for primary c-stage II or III advanced gastric cancer, between April 2008 and April 2017, with computed tomography records of skeletal muscle mass. The skeletal muscle mass index was calculated, and sarcopenia was defined when values were below the cut-off. The patients were divided into a laparoscopy group and open group, in which the background was adjusted using propensity score matching; the relapse-free survival and overall survival were compared between them. The prognostic factors for relapse-free survival and overall survival were investigated by multivariate analyses.

RESULTS

This study included 141 patients with sarcopenia (laparoscopy group, n = 69 [48.9%]; open group, n = 72 [51.1%]). After matching, there were 50 patients in both groups, with no significant differences in patient background. The median follow-up period was 38 months. Relapse-free survival was worse in the open group (hazard ratio: 1.662, 95% confidence interval: 0.910-3.034; P = 0.098), but there was no difference in the overall survival (P = 0.181). Multivariate analysis concluded that open surgery is an independent prognostic factor of relapse-free survival (hazard ratio: 3.219, 95% confidence interval: 1.381-7.502; P = 0.007) but not of OS.

CONCLUSION

Compared with the open surgery group, the laparoscopy group had a better RFS, although the difference was not statistically significant.

Systematic review and updated network meta-analysis of randomized controlled trials comparing open, laparoscopic-assisted, and robotic distal gastrectomy for early and locally advanced gastric cancer

BACKGROUND

The role of minimally invasive surgery for the treatment of early and locally advanced gastric cancer remains controversial. The purpose of this study was to perform a comprehensive evaluation of major surgical approaches for operable distal gastric cancer.

METHODS

Systematic review and network meta-analyses of randomized controlled trials were performed to compare open distal gastrectomy, laparoscopic-assisted distal gastrectomy, and robotic distal gastrectomy. Risk ratio, weighted mean difference, and 95% credible intervals were used as pooled effect size measures.

RESULTS

Seventeen randomized controlled trials (5,909 patients) were included. Overall, 2,776 (46.8%) underwent open distal gastrectomy, 2,964 (50.1%) laparoscopic-assisted distal gastrectomy, and 141 (3.1%) robotic distal gastrectomy. Among these 3 groups, there were no significant differences in 30-day mortality, anastomotic leak, and overall complications. Compared to open distal gastrectomy, laparoscopic-assisted distal gastrectomy was associated with significantly reduced intraoperative blood loss, early postoperative pain, time to first flatus, and hospital length of stay. Similarly, robotic distal gastrectomy was associated with significantly reduced blood loss and time to first flatus compared to open distal gastrectomy. No differences were found in the total number of harvested lymph nodes, tumor-free resection margins, 5-year overall, and disease-free survival. The subgroup analysis in locally advanced gastric cancer showed trends toward reduced blood loss, time to first flatus, and hospital length of stay with minimally invasive approaches but similar overall and disease-free survival.

CONCLUSION

Laparoscopic-assisted distal gastrectomy and robotic distal gastrectomy performed by well-trained experienced surgeons, even in the setting of locally advanced gastric cancer, seem associated with improved short-term outcomes with similar overall and disease-free survival compared with open distal gastrectomy.

[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-).

Surgical and oncological efficacy of laparoscopic-assisted total gastrectomy versus open total gastrectomy for gastric cancer by propensity score matching: a retrospective comparative study

Purpose

The application of laparoscopic-assisted total gastrectomy (LATG) for resectable gastric cancer (GC) remains controversial compared with open total gastrectomy (OTG), especially for advanced gastric cancer (AGC) patients according to the inconsistent results demonstrated in the previous studies. The aim of this study was to evaluate the short-term and long-term outcomes between LATG and OTG in a population with more than 80% AGC patients by applying propensity score matching (PSM) method.

Methods

The data of 365 clinical stage I–III GC cases who underwent total gastrectomy with D2 lymphadenectomy were retrospectively collected from January 2011 to April 2018 in the Department of Gastrointestinal Surgery IV of Peking University Cancer Hospital. Propensity scores were generated through taking all covariates into consideration and 131 pairs of patients receiving either LATG or OTG were matched. Intraoperative, postoperative, and survival parameters were compared in the matched groups accordingly. Risk factors for postoperative complications and overall survival were further analyzed.

Results

Patient characteristics in the LATG and OTG groups were well balanced after PSM. LATG showed advantages with respect to shorter time to ambulation, first flatus, and first whole liquid diet intake. No significant differences were found between the two groups with regard to postoperative complications as well as overall survival in terms of different pathological stage. Older age was found as an independent risk factor for postoperative complications, and pathological stage for overall survival as well.

Conclusion

LATG appears to have comparable surgical and oncological safety with OTG by experienced surgeons.

Comparisons of Postoperative Complications and Nutritional Status After Proximal Laparoscopic Gastrectomy with Esophagogastrostomy and Double-Tract Reconstruction

Background

The purpose of this study was to compare postoperative complications and nutritional status between esophagogastrostomy and double-tract reconstruction in patients who underwent laparoscopic proximal gastrectomy, and assess the advantages of both surgical procedures.

Methods

Between 2010 and 2018, 47 cases underwent proximal gastrectomy with esophagogastrostomy (n = 23) or double-tract reconstruction (n = 24) at our institution for the treatment of clinical T1N0 adenocarcinoma located in the upper third of the stomach. Patient clinical characteristics, short-term outcomes, nutrition status, and skeletal muscle index were compared among the two groups.

Results

There was no significant difference between esophagogastrostomy and double-tract reconstruction in terms of operation time, blood loss, and length of postoperative hospital stay. Reflux symptoms and anastomotic stenosis were significantly higher in the esophagogastrostomy group compared with the double-tract reconstruction group (P < 0.001 and P = 0.004, respectively). There was no significant difference in anastomotic leakage, surgical site infection, and pancreatic fistula. For the nutritional status, the decrease rate of cholinesterase was significantly higher in the esophagogastrostomy group compared with the double-tract reconstruction group at 6 months (P = 0.008) There was no significant difference in the decrease rate of skeletal muscle mass index at 1 year after surgery.

Conclusion

Compared with esophagogastrostomy, double-tract reconstruction tends to have better short-term nutritional status and postoperative outcomes in terms of preventing the occurrence of gastroesophageal reflux and anastomosis stenosis. These findings suggest that double-tract reconstruction may be a useful method in laparoscopic proximal gastrectomy.

A Comparison of the Short-Term Clinical Effects Between Totally Laparoscopic Radical Gastrectomy With Modified Roux-en-Y Anastomosis and Laparoscopic-Assisted Radical Gastrectomy With Roux-en-Y Anastomosis

Objective:

To compare the short-term clinical effects between totally laparoscopic radical gastrectomy with modified Roux-en-Y anastomosis, and laparoscopic-assisted radical gastrectomy with Roux-en-Y anastomosis; to explore the safety, feasibility and short-term effect of totally laparoscopic radical gastrectomy with modified Roux-en-Y anastomosis.

Methods:

Data of 75 patients who underwent totally laparoscopic radical gastrectomy with modified Roux-en-Y anastomosis, and 95 patients who underwent laparoscopic-assisted radical gastrectomy with Roux-en-Y anastomosis by the same surgical team were analyzed. During the modified Roux-en-Y anastomosis, the stomach separation and regional lymph node dissection were completed under a laparoscope; the specimen was placed in a bag; gastrojejunostomy was completed; the subumbilicus hole was enlarged to 3 cm; the specimen was taken out; then, the proximal and distal ends of the small intestine were moved outside of the abdominal wall to complete the small intestine-small intestine end-to-side anastomosis.

Results:

All 170 operations were successful. The differences in the time of anastomosis and the number of dissected lymph nodes between the 2 groups were not statistically significant (P > 0.05), but in the totally-MA group the amount of bleeding and the length of incision significantly decreased (P < 0.05). The recovery time as measured by breathing unassisted, drinking fluids and getting out of bed was significantly shorter than those in the laparoscopic-assisted group (P < 0.05), and the pain score 1 day after surgery was significantly lower than that of the laparoscopic-assisted group (P < 0.05). One case of duodenal stump leakage and 1 case of esophagojejunostomy leakage were found in the laparoscopic-assisted group. In the totally-MA group, there were no complications such as anastomotic leakage, anastomotic stenosis or anastomotic bleeding, but 2 patients with double primary carcinoma underwent joint radical resection.

Conclusion:

Compared with laparoscopic-assisted surgery, totally laparoscopic radical gastrectomy with modified Roux-en-Y anastomosis has the advantages of being safer and less traumatic, with associated reductions in bleeding and pain.

Laparoscopic versus open subtotal gastrectomy for gastric adenocarcinoma: cost-effectiveness analysis

Background

Laparoscopic subtotal gastrectomy (LSG) for cancer is associated with good perioperative outcomes and superior quality of life compared with the open approach, albeit at higher cost. An economic evaluation was conducted to compare the two approaches.

Methods

A cost–effectiveness analysis between LSG and open subtotal gastrectomy (OSG) for gastric cancer was performed using a decision‐tree cohort model with a healthcare system perspective and a 12‐month time horizon. Model inputs were informed by a meta‐analysis of relevant literature, with costs represented in 2016 Canadian dollars (CAD) and outcomes measured in quality‐adjusted life‐years (QALYs). A secondary analysis was conducted using inputs extracted solely from European and North American studies. Deterministic (DSA) and probabilistic (PSA) sensitivity analyses were performed.

Results

In the base‐case model, costs of LSG were $935 (€565) greater than those of OSG, with an incremental gain of 0·050 QALYs, resulting in an incremental cost–effectiveness ratio of $18 846 (€11 398) per additional QALY gained from LSG. In the DSA, results were most sensitive to changes in postoperative utility, operating theatre and equipment costs, as well as duration of surgery and hospital stay. PSA showed that the likelihood of LSG being cost‐effective at willingness‐to‐pay thresholds of $50 000 (€30 240) per QALY and $100 000 (€60 480) per QALY was 64 and 68 per cent respectively. Secondary analysis using European and North American clinical inputs resulted in LSG being dominant (cheaper and more effective) over OSG, largely due to reduced length of stay after LSG.

Conclusion

In this decision analysis model, LSG was cost‐effective compared with OSG for gastric cancer.

Clinical Outcomes of Laparoscopic Versus Laparotomic Distal Gastrectomy in Gastric Cancer Patients: A Multilevel Analysis Based on a Nationwide Administrative Database in Japan

BACKGROUND

The present study compared the short-term outcomes and costs of laparoscopic distal gastrectomy (LDG) with those of open distal gastrectomy (ODG) for gastric cancer using a nationwide administrative database in Japan.

METHOD

Overall, 37,752 patients with gastric cancer who underwent distal gastrectomy at 1074 hospitals in the fiscal year 2012-2013 were evaluated using a diagnosis procedure combination database in Japan. We performed a retrospective analysis via a multilevel analysis (MLA) of the short-term surgical results and costs of the LDG and ODG groups. The models included the age, sex, comorbid complications, smoking, body mass index (BMI), activity of daily living (ADL), stage, and the number of cases of gastrectomy per facility for adjustment. The in-hospital mortality relative to the hospital volume was also compared.

RESULTS

The LDG group required postoperative blood transfusion less frequently and had fewer postoperative complications, shorter hospitalization, and lower operative mortality than the ODG group. While this stage did not correlate with the in-hospital mortality, the surgical method, age, sex, ADL, BMI, comorbidity, and yearly volume showed a correlation. A significant association in the in-hospital mortality was observed between low- and very-high-volume hospitals.

CONCLUSION

In this large nationwide cohort of patients with gastric cancer using an MLA, LDG was shown to be safer with lower mortality and postoperative complication rates than ODG.

Comparison of short-term surgical outcome between 3D and 2D laparoscopy surgery for gastrointestinal cancer: a systematic review and meta-analysis

BACKGROUND

Three-dimensional (3D) laparoscopic surgery is becoming more popular with the development of laparoscopic devices. The objective of this study was to explore whether the 3D imaging system could improve surgical outcomes of laparoscopic surgery for gastrointestinal cancer compared with the 2D imaging system.

METHODS

Systematic literature search was performed using PubMed and Embase databases and relevant data were extracted. Surgical quality, postoperative complications, and postoperative recovery between 3D and 2D laparoscopic surgery groups were compared using a fixed or random effect model.

RESULTS

A total of 12 studies involving 1456 patients (3D group 683 patients and 2D group 773 patients) were included in this meta-analysis. The results indicated that mean operation time was significantly shorter in 3D group than in 2D group (WMD, - 9.08; 95% CI, - 14.77, - 3.40; P = 0.002; I² = 70.3%), especially for gastric cancer patients (WMD, - 14.61; 95% CI, - 26.00, - 3.23, P = 0.012; I² = 74.1%). In addition, 3D laparoscopic surgery for gastric cancer had an advantage than 2D group in reducing the amount of intraoperative blood loss (WMD, - 13.60, 95% CI, - 21.48, - 5.72; P = 0.001; I² = 0%). The number of retrieved lymph nodes in 3D group was not significantly different from that in 2D group, regardless of laparoscopic gastrectomy (WMD, 1.10; 95% CI, - 0.67, 2.88; P = 0.222; I² = 18.8%) and laparoscopic colorectal surgery (WMD, 0.55, 95% CI; - 1.99, 3.09; P = 0.671; I² = 76.9%). In addition, there was no significant difference between 3D and 2D laparoscopic surgery for postoperative complications and postoperative recovery.

CONCLUSION

Main advantages of 3D laparoscopic gastrectomy for gastric cancer were that it could shorten the operation time and reduce the amount of intraoperative blood loss. However, 3D laparoscopic surgery had no obvious advantage over 2D laparoscopic surgery for colorectal cancer patients.

Long-term Outcomes of Laparoscopic Versus Open Surgery for Clinical Stage II/III Gastric Cancer: A Multicenter Cohort Study in Japan (LOC-A Study)

OBJECTIVE

A large-scale multicenter historical cohort study was conducted to investigate the efficacy of laparoscopic gastrectomy (LG) in comparison to open gastrectomy (OG) for locally advanced gastric cancer.

BACKGROUND

LG is now practiced widely, but its applicability for advanced gastric cancer is still controversial. As oncologic outcomes of randomized trials are still pending, there is an urgent need for information that would be relevant to current practice.

METHODS

Through a consensus meeting involving surgeons and biostatisticians, 30 preoperative variables possibly influencing the choice of surgical approach and associated with outcome were identified to enable rigorous estimation of propensity scores. A total of 1948 consecutive patients who underwent gastrectomy for clinical stage II/III gastric adenocarcinoma between 2008 and 2014 were identified, and their clinical data were collected from 8 participating hospitals. After propensity score matching, 610 cases (OG = 305, LG = 305) were finally selected for comparison of long-term outcomes.

RESULTS

In the propensity-matched OG and LG populations, the mean observation period was 3.5 and 3.4 years, and the 5-year overall survival was 53.0% and 54.2%, respectively. The hazard ratio (LG/OG) for overall survival was 1.01 (95% confidence interval, 0.80-1.29), and noninferiority of LG was demonstrated statistically as the upper 95% confidence limit was less than the prespecified margin (1.33). The recurrence rate was 30.8% and 29.8% for OG and LG, respectively, and the hazard ratio for recurrence was 0.98 (95% confidence interval, 0.74-1.31). The patterns of recurrence in the 2 groups were similar.

CONCLUSIONS

This observational study strictly adjusted for confounding factors has provided evidence to suggest that LG is oncologically comparable to OG for locally advanced gastric cancer. The validity of this result will be examined in ongoing randomized trials.

Skeletal muscle loss after laparoscopic gastrectomy assessed by measuring the total psoas area

PURPOSE

Skeletal muscle loss after gastrectomy can worsen patients' quality of life and prognosis. Laparoscopic gastrectomy is less invasive than open gastrectomy and has become commonly performed. However, the degree of skeletal muscle loss after laparoscopic procedures remains unclear. We herein report the degree and risk factors of psoas muscle loss after laparoscopic gastrectomy for gastric cancer.

METHODS

The total psoas area (TPA) on computed tomography of 50 consecutive patients who underwent laparoscopic total gastrectomy (LTG) and 167 consecutive patients who underwent laparoscopic distal gastrectomy (LDG) for gastric cancer was retrospectively evaluated at one postoperative year. The TPA loss was compared between LDG and LTG and univariate and multivariate analyses were performed to identify the risk factors for TPA loss > 10%.

RESULTS

The median TPA decrease rate was 5.9% in the LDG group and 15.6% in the LTG group. LTG and postoperative respiratory complications were independent factors associated with a severe TPA loss of > 10%. In the LTG group, no independent factors were identified in a multivariate analysis. In the LDG group, postoperative complications were identified as an independent risk factor for TPA loss > 10%.

CONCLUSIONS

Laparoscopic gastrectomy leads to postoperative TPA loss, especially in patients who underwent LTG and had postoperative respiratory complications. Postoperative complications after LDG were also a risk factor for TPA loss.

Laparoscopic Gastrectomy Using Instruments with a Minimal Diameter for Early Gastric Cancer: A Feasible Alternative to Conventional Laparoscopic Gastrectomy for Experienced Surgeons

Background: The application of laparoscopic surgery using instruments that are 3 mm or less in diameter for patients with early gastric cancer (EGC) has not yet been established. We aimed to evaluate the feasibility and safety of laparoscopic gastrectomy using instruments with minimal diameter. Methods: We retrospectively analyzed 41 patients who underwent laparoscopic subtotal gastrectomy with D1-positive lymph node dissection for EGC. Among them, 17 patients underwent laparoscopic gastrectomy using instruments with a minimal diameter (experimental group), while 24 patients underwent conventional laparoscopic gastrectomy (control group). In the experimental group, we used two 3-mm trocars, one 5-mm trocar, and the GelPOINT^® Advanced Access Platform. We compared operative outcomes between the two groups and assessed the learning curve of laparoscopic gastrectomy using instruments with minimal diameter. Results: The operative outcomes were similar between the two groups. The preoperative-to-postoperative day 2 ratio of neutrophil count in the experimental group was significantly lower than in the control group (2.07 versus 2.65; P = .038). Morbidity was not observed in the experimental group and 3 patients experienced complications in the control group, although it was not significantly different (P = .252). The operation time according to the accumulation of cases was stable without any significant change in the experimental group. Conclusions: Laparoscopic gastrectomy using instruments with minimal diameter is technically feasible and safe for EGC and could also be a good alternative to conventional laparoscopic gastrectomy to minimize the impact of surgical invasiveness when performed by experienced surgeons.

C-reactive protein elevation ratio as an early predictor of postoperative severe complications after laparoscopic gastrectomy for gastric cancer: a retrospective study

Background

In gastrectomy, postoperative elevation of C-reactive protein (CRP) is thought to be useful for predicting complications. Laparoscopic gastrectomy (LG) is less invasive than laparotomy and the elevation of CRP is also mild. Postoperative complications such as anastomotic leakage not only increase the severity of the condition, but also carry a poor prognosis when treatment is delayed. Early treatment is therefore necessary.

Method

This retrospective study examined the relationship between occurrence of complications and the ratio of CRP levels on postoperative days 1 and 3 (CRP ratio) for 449 gastric cancer patients who underwent LG in the Department of Gastrointestinal Surgery at Osaka City University Hospital between 2006 and 2016.

Results

We observed that factors associated with postoperative complications were preoperative renal failure and CRP ratio. No significant associations with surgical procedure, operation time, bleeding volume, age, obesity, measured CRP concentration, or white blood cell count were evident. The optimal cut-off for CRP ratio to predict postoperative complications from the receiver operating characteristic curve was 2.13.

Conclusion

Our results suggested that the risk of severe postoperative complications after LG could be predicted using the CRP ratio.

Laparoscopy Assisted Distal Gastrectomy Versus Open Distal Gastrectomy for Patients with Gastric Cancer in A Middle Resources Country

Background:Laparoscopic surgery with a small laparotomy has several advantages over conventional open surgery, including less invasiveness, less pain, earlier recovery, and better cosmoses. The aim of this study was to compare technical feasibility and early clinical outcomes of laparoscopy-assisted distal gastrectomy in comparison with open distal gastrectomy for gastric cancer in a developing country. Patients and methods :In this retrospective study, patients with distal gastric cancer were divided into two groups (a) patients underwent laparoscopy assisted distal gastrectomy (LADG) (21 patients) and (b) open distal gastrectomy (ODG) (21 patients). For the postoperative pathologic results, the tumor-nodal-metastasis (TNM) stage, grade of tumor differentiation, distal and proximal margins, the number of harvested lymph nodes were evaluated. Staging was done according to the 7th edition of the UICC tumor, node, and metastasis (TNM) classification. D1/D2 lymphadenectomy with curative R0 intention was attempted in all cases. Perioperative mortality and morbidity were assessed. Results:The time to initiate oral intake, and postoperative hospital stay were significantly shorter in the LADG group than in the ODG group (P < 0.001). The operative time in the LADG group was significantly less than that of the ODG group (P = 0.05). Blood loss and blood transfusion frequency were significantly lower (P < 0.0001) in the LADG group in comparison to ODG group. Conclusion:Laparoscopic-assisted distal gastrectomy for distal gastric cancer could be safe and feasible technique alternative to open gastrectomy in a middle income country, with at least similar short term surgical and oncological results. However, laparoscopic gastric surgery is in need to adequate training and technical support especially in D2 lymphadenectomy.

Surgical risk and benefits of laparoscopic surgery for elderly patients with gastric cancer: a multicenter prospective cohort study

BACKGROUND

Laparoscopic gastrectomy (LG) might have greater clinical benefits for elderly patients as less invasive surgery; however, there is still little evidence to support its benefit. We evaluated the surgical outcomes of elderly patients in a nationwide prospective cohort study.

METHODS

One hundred and sixty-nine participating institutions were identified by stratified random sampling, and were adjusted for hospital volume, type and location. During 1 year from 2014 to 2015, consecutive patients who underwent gastrectomy for gastric cancer were prospectively enrolled. 'Elderly' was defined as ≥ 75 years of age, based on the prevalence of comorbidities and the activities of daily living of patients of this age. We compared the surgical outcomes of LG to those of open gastrectomy (OG) in non-elderly and elderly patients. The primary outcome was the incidence of severe morbidities (Grade ≥ 3).

RESULTS

Eight thousand nine hundred and twenty-seven patients were enrolled [non-elderly, n = 6090 (OG, n = 2602; LG, n = 3488); elderly, n = 2837 (OG, n = 1471; LG, n = 1366)]. Grade ≥ 3 complications occurred in 161 (10.9%) patients who underwent OG and 98 (7.2%) who underwent LG (p < 0.001). After adjusting for confounding factors, we confirmed that laparoscopic surgery was not an independent risk factor (odds ratio = 0.81, 0.60-1.09). OG was associated with a significantly longer median length of postoperative stay in comparison to LG (16 versus 12 days, p < 0.001). There were no significant differences in the incidence of other postoperative comorbidities.

CONCLUSION

The safety of LG in elderly patients was demonstrated. LG shortened the length of postoperative hospital stay.

Surgical and Long-Term Survival Outcomes After Laparoscopic and Open Total Gastrectomy for Locally Advanced Gastric Cancer: A Propensity Score-Matched Analysis

BACKGROUND

To compare the surgical and long-term survival outcomes of laparoscopic and open total gastrectomy (OTG) for locally advanced gastric cancer (AGC).

METHODS

We retrospectively evaluated 308 and 900 patients in pathological locally AGC who underwent laparoscopic total gastrectomy (LTG) or OTG between June 2008 and December 2014. We compared surgical and long-term outcomes between the two groups using propensity score matching method.

RESULTS

The LTG group showed a longer operation time (261.42 vs. 171.00 min, P = 0.001), less blood loss (185.47 vs. 217.84 ml, P = 0.000), earlier time to first flatus (3.47 vs. 4.12 days, P = 0.000), earlier time to start liquid diet (3.76 vs. 4.27 days, P = 0.000), and shorter postoperative hospital stay (7.56 vs. 8.22 days, P = 0.007). The overall complication rate was 15.2% in the LTG group and 17.2% in the OTG (P = 0.503). No significant difference was observed in overall survival (OS) and disease-free survival (DFS) between LTG and OTG (60.5% vs. 57.1%, P = 0.337; 57.4% vs. 54.4%, P = 0.341).

CONCLUSIONS

Compared to OTG, LTG provides surgical benefits and comparable survival outcomes for patients with locally AGC.

[Surgical management for early stage gastric cancer]

BACKGROUND

In the last decade the implementation of the new technique of endoscopic submucosal dissection (ESD) and the rapid progression of laparoscopic gastric cancer (LAG) resection with an adequate lymphadenectomy (LAD) have played an increasing role in the treatment of patients with early stage gastric cancer (EGC).

OBJECTIVE

A systematic review of the currently available data in the literature was carried out to evaluate the contemporary surgical management for treatment of EGC.

RESULTS

Endoscopic resection (ER) of mucosal T1 gastric cancer (T1m) in accordance with the German guidelines on resection criteria is a widely accepted treatment option, if a definitive R0 resection can be achieved. Excellent en bloc and R0 results in more than 90% of these cases have been shown particularly for ESD. In contrast to T1m gastric carcinomas with a low risk of lymph node metastases (approximately 3%), nodal involvement reaches more than 20% for submucosal infiltrated EGC (T1sm). For this reason, a surgical resection with adequate LAD is further recommended in all cases of non-curative ER or any T1sm gastric cancer. In seven randomized controlled trials and a series of meta-analyses including high-quality non-randomized trials, significant benefits in short-term postoperative outcome have been demonstrated for LAG in comparison to open gastrectomy (OG) in the treatment of EGC. The general morbidity was also significantly lower in LAG than in OG. The 30-day mortality and long-term survival outcome were comparable between the two groups.

CONCLUSION

The use of ESD should be the standard treatment for T1m EGC within the guidelines criteria. For non-curative ESD and T1sm gastric cancer, surgical resection with LAD is recommended. The LAG is a technically safe, feasible, and favorable approach in terms of faster recovery compared to OG. The long-term survival outcome is comparable between LAG and OG for EGC.

Comparative analysis of robotic gastrectomy and laparoscopic gastrectomy for gastric cancer in terms of their long-term oncological outcomes: a meta-analysis of 3410 gastric cancer patients

BACKGROUND

Data regarding the long-term oncological outcomes of robotic gastrectomy (RG) are limited despite the increased commonality of this method as an alternative for gastric cancer treatment. Here, we conducted a meta-analysis to evaluate the long-term oncological outcomes of RG in comparison to that of laparoscopic gastrectomy (LG).

METHODS

The PubMed, ISI Web of Science, EMBASE, and Cochrane Library databases were comprehensively searched for studies that compared RG and LG in terms of their long-term survival outcomes. The hazard ratios (HRs) of overall survival (OS), disease-free survival (DFS), and relapse-free survival (RFS) were obtained, while the odds ratio (OR) was recorded for the recurrence rate. A sensitivity analysis was performed. Egger's test and Begg's test were applied to evaluate publication bias.

RESULTS

Eight studies were identified and involved 3410 gastric cancer patients (RG, 1009; LG, 2401). The two groups had no significant differences in OS (HR, 0.98; 95% CI, 0.80-1.20; P = 0.81), DFS (HR, 1.36; 95% CI, 0.33-5.59; P = 0.67), RFS (HR, 0.92; 95% CI, 0.72-1.19; P = 0.53), or recurrence rate (OR, 0.92; 95% CI, 0.71-1.19; P = 0.53). Moreover, the two techniques were comparable in length of hospital stay (LOS), postoperative complication rate, 30-day mortality rate, and rate of conversion to open surgery.

CONCLUSIONS

The long-term oncological outcomes, expressed as OS, DFS, RFS, and recurrence rate, were similar between RG and LG. However, more randomized controlled trials with rigorous study designs and patient cohorts are needed to evaluate the oncologic outcomes of RG in patients with gastric cancer.

Laparoscopic versus open gastrectomy for locally advanced gastric cancer: a systematic review and meta-analysis of randomized controlled studies

BACKGROUND

This meta-analysis sought to evaluate the potential benefits and harms of laparoscopic gastrectomy with D2 lymphadenectomy for locally advanced gastric cancer versus open surgery.

METHODS

A comprehensive search for randomized controlled studies that compared laparoscopic versus open gastrectomy with D2 lymphadenectomy for locally advanced gastric cancer published until December 31, 2018, was conducted. Operative outcomes, early postoperative outcomes, and long-term results were analyzed using a random effects model.

RESULTS

Five randomized controlled trials containing a collective total of 2157 patients were included. In comparison with open surgery, laparoscopic gastrectomy for locally advanced gastric cancer showed similar risks of short-term mortality and serious adverse events within 30 days after surgery. Regarding intraoperative outcomes, operative time was increased for the laparoscopic approach, whereas the estimated intraoperative blood loss tended to be less. However, the amount of evidence was low for most outcomes. In addition, the results for the length of hospital stay and time to first flatus did not show statistically significant differences. The number of harvested lymph nodes and compliance with D2 lymphadenectomy did not significantly differ between the two groups, indicating oncological equivalence of both approaches. However, long-term oncological results could not be evaluated due to a lack of relevant data in four of the trials.

CONCLUSION

Laparoscopic gastrectomy with D2 lymphadenectomy can be performed with equivalent overall short-term morbidity and mortality versus the open approach for locally advanced gastric cancer. However, further well-designed randomized controlled trials are necessary to assess the possible advantages and risks of the laparoscopic approach as well as the long-term results.

Comparison of double-flap and OrVil techniques of laparoscopy-assisted proximal gastrectomy in preventing gastroesophageal reflux: a retrospective cohort study

BACKGROUND

Laparoscopy-assisted proximal gastrectomy (LAPG) with esophagogastrostomy using the double-flap technique has been reported to rarely cause gastroesophageal reflux. However, quantitative evaluation of the reflux has hardly been performed. The aim of this study was to clarify the superiority of the double-flap technique of LAPG with esophagogastrostomy compared with the OrVil technique in terms of preventing gastroesophageal reflux.

METHODS

A total of 40 and 51 patients who underwent LAPG with esophagogastrostomy using the double-flap and OrVil techniques, respectively, for upper one-third gastric cancer were included in this study. Of these, 22 and 13 patients in the double-flap and OrVil groups, respectively, consented to undergo a 24-h impedance-pH monitoring test at 3 months postoperatively. Postoperative complications, including gastroesophageal reflux and anastomotic stricture, were assessed retrospectively.

RESULTS

No significant differences were observed in the patients' background between both groups, except for a higher D1+ dissection rate observed in double-flap group than in the OrVil group (93% vs 25%, P < 0.001). Operative time was significantly longer in the double-flap group than in the OrVil group (353 min vs 280 min, P < 0.001). All reflux % time was significantly lower in the double-flap group than in the OrVil group (1.29% vs 2.62%, P = 0.043). On the other hand, the proportion of anastomotic stricture requiring endoscopic balloon dilatation was lower in the double-flap group than in the OrVil group but without statistical significance (18% vs 27%; P = 0.32).

CONCLUSIONS

Despite its longer operative time and still relatively high anastomotic stricture rate, the double-flap technique would be better than the OrVil technique in terms of preventing gastroesophageal reflux in patients who underwent LAPG with esophagogastrostomy.

Reporting of outcomes in gastric cancer surgery trials: a systematic review

BACKGROUND

The development of clinical guidelines for the surgical management of gastric cancer should be based on robust evidence from well-designed trials. Being able to reliably compare and combine the outcomes of these trials is a key factor in this process.

OBJECTIVES

To examine variation in outcome reporting by surgical trials for gastric cancer and to identify outcomes for prioritisation in an international consensus study to develop a core outcome set in this field.

DATA SOURCES

Systematic literature searches (Evidence Based Medicine, MEDLINE, EMBASE, CINAHL, ClinicalTrials.gov and WHO ICTRP) and a review of study protocols of randomised controlled trials, published between 1996 and 2016.

INTERVENTION

Therapeutic surgical interventions for gastric cancer. Outcomes were listed verbatim, categorised into groups (outcome themes) and examined for definitions and measurement instruments.

RESULTS

Of 1919 abstracts screened, 32 trials (9073 participants) were identified. A total of 749 outcomes were reported of which 96 (13%) were accompanied by an attempted definition. No single outcome was reported by all trials. 'Adverse events' was the most frequently reported 'outcome theme' in which 240 unique terms were described. 12 trials (38%) classified complications according to severity, with 5 (16%) using a formal classification system (Clavien-Dindo or Accordion scale). Of 27 trials which described 'short-term' mortality, 15 (47%) used one of five different definitions. 6 out of the 32 trials (19%) described 'patient-reported outcomes'.

CONCLUSION

Reporting of outcomes in gastric cancer surgery trials is inconsistent. A consensus approach to develop a minimum set of well-defined, standardised outcomes to be used by all future trials examining therapeutic surgical interventions for gastric cancer is needed. This should consider the views of all key stakeholders, including patients.

Laparoscopic surgery for gastric cancer: where are we now and where are we going?

INTRODUCTION

Minimally-invasive surgery is gaining increasing popularity for the management of gastric cancer (GC). Areas covered: The authors hereby comprehensively and systematically reviewed the randomized and/or prospective evidence on laparoscopic gastrectomy (LG) for GC. For early GC located in the distal stomach, various randomized trials have demonstrated the superiority/non-inferiority of LG especially in reducing surgical trauma and enhancing postoperative recovery without compromising surgical safety and oncologic efficacy. For advanced GC, while multicenter large-scale randomized evidence has demonstrated the safety and feasibility of LG by experienced hands, the long-term survival which is to be clarified by several ongoing trials are crucial to determine whether a more widespread application is acceptable. Randomized evidence regarding the application of laparoscopic total or proximal gastrectomy, which is technically challenging, is scarce. Various attempts in modification of the traditional laparoscopic approach to further reduce the trauma have been evaluated, such as single-incision and totally LG. LG is becoming increasingly individualized and precise. Expert commentary: The current randomized and/or prospective evidence supports the non-inferiority of laparoscopic surgery especially for the management of early GC located in the distal stomach, while the definitive efficacy of the laparoscopic approach for more surgically challenging situations remains largely explorative and investigative.

Perioperative outcomes of laparoscopy-assisted pylorus and vagus nerve-preserving gastrectomy and distal gastrectomy for middle-third early gastric cancer

AIM

To compare the surgical safety, postoperative compli-cations and hospitalization expenses of laparoscopy-assisted pylorus and vagus nerve-preserving gastrectomy (LAPPG) and distal gastrectomy (LADG) in order to evaluate the feasibility of LAPPG in the treatment of middle-third early gastric cancer.

METHODS

The clinical and pathological data, surgical procedure, postoperative outcomes and hospitalization expenses of 112 patients with middle-third early gastric cancer treated from June 2016 to August 2017 at Department of Gastrointestinal Surgery of Renji Hospital were analyzed retrospectively. Forty-six patients received LAPPG, and 66 cases underwent LADG.

RESULTS

There were no significant differences between the two groups in age, sex, BMI, tumor differentiation, operative time, estimated blood loss, tumor diameter, resected lymph nodes, or metastatic lymph nodes (P > 0.05). Proximal and distal resection margins were significantly shorter in the LAPPG group than in the LADG group (P < 0.05). For postoperative outcomes, there were no significant differences in hospital stay, time to first flatus, time to gastric tube removal, time to first ambulation, time to first fluid diet, or postoperative complications (≥Dindo grade Ⅱ) (P > 0.05). Hospitalization expense of LAPPG was significantly lower than that of LADG [4.6 ± 0.5 vs 5.3 ± 0.4 (ten thousand yuan), P = 0.004].

CONCLUSION

On the premise of oncologic safety and efficacy, LAPPG is a cost-effective and feasible treatment for middle-third early gastric cancer.

Compliance to D2 lymphadenectomy in laparoscopic gastrectomy

The objective of this study is to describe the compliance to D2 lymphadenectomy in laparoscopic gastrectomy. Radical partial or total gastrectomy with modified D2 lymphadenectomy is the standard of care for locally advanced gastric cancer. It is unclear whether compliance to D2 lymphadenectomy in laparoscopy is comparable to that in open surgery. A review of the literature was performed and results are described in a descriptive review. Available randomized trials are mostly performed for early gastric cancer, for which formal D2 lymphadenectomy is usually not required. Most trials report no differences in number of retrieved lymph nodes between open and laparoscopic gastrectomy. Only one trial used adherence to D2 lymphadenectomy as primary outcome parameter, and found no difference between laparoscopic and open gastrectomy. Results from randomized trials in advanced gastric cancer are awaited. In the meantime, the laparoscopic approach can be used in experienced centers.

Reevaluation of laparoscopic versus open distal gastrectomy for early gastric cancer in Asia: A meta-analysis of randomized controlled trials

BACKGROUND

The benefits and risks of laparoscopic distal gastrectomy (LADG) are not yet sufficiently clear for acceptance as a standard treatment of early gastric cancer. Previous meta-analyses were not powered to reach definitive conclusions.

MATERIALS AND METHODS

Randomized controlled trials comparing LADG with open distal gastrectomy (ODG) for early gastric cancer in Asia and published between January 1994 and January 2018 were retrieved from PubMed, Embase, the Cochrane Library, and Google Scholar. Patient characteristics, oncological safety and efficacy, and surgical safety were evaluated following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Grading of Recommendations Assessment, Development and Evaluation guidelines (GRADE) guidelines. Trial Sequential Analysis (TSA) reduced random error and reinforced the reliability and strength of evidence.

RESULTS

Eight trials including 2666 participants were selected. LADG benefits were an 11.6 cm shorter incision (95% CI: -13.31 to -9.88 cm; P < 0.0001), 103.81 ml less blood loss (95% CI: -133.68 to -73.94; P < 0.0001), 1.73 times less analgesic use (95% CI: -2.21 to -1.24; P < 0.0001), 0.51 days shorter time to first flatus (95% CI: -0.88 to -0.15 days; P = 0.006), lower risk of wound dehiscence (RR = 0.24, 95% CI: 0.08-0.78; P = 0.02), lower risk of surgical adverse events (RR = 0.69, 95% CI: 0.53-0.91; P = 0.008), and lower risk of respiratory complications (RR = 0.40; 95% CI: 0.20-0.79; P = 0.009) than ODG. LADG had 2.22 fewer resected lymph nodes (95% CI: -4.33 to -0.12; P = 0.04) and 76.61 min longer procedures (76.61 min, 95% CI: 57.74-95.47 min; P < 0.0001).

CONCLUSIONS

In Asian patients, LADG had similar mortality and oncological safety, better surgical safety, less operative morbidity, less trauma, and faster recovery than ODG. It has a high role to play in node-negative cases due to better short-term outcomes but less nodal harvest. It is a recommended alternative treatment for experienced surgeons in high-volume centers.

Long-term outcomes of laparoscopic versus open D2 gastrectomy for advanced gastric cancer

BACKGROUND

Technical safety and short-term surgical outcomes of laparoscopy-assisted gastrectomy (LAG) for advanced gastric cancer (AGC) have been investigated in many clinical trials. However, studies with large sample size and sufficient follow-up comparing LAG and open gastrectomy (OG) for AGC have seldom been reported. The purpose of this study was to compare the long-term outcomes of LAG versus open OG for AGC using a propensity score matching analysis.

METHODS

We retrospectively evaluated 459 and 856 patients who underwent LG or OG with D2 lymph node dissection, respectively, for AGC between June 2007 and June 2012. One-to-one propensity score matching was performed to compensate for heterogeneity between groups. We compared long-term outcomes between the two groups after propensity score matching.

RESULTS

In the propensity score-matched cohort, no significant differences were observed in 5-year overall survival (OS) (52.0% vs. 53.4%; P = 0.805) and disease-free survival (DFS) (46.8% vs. 47.3%; P = 0.963) between the LAG group and OG group. Stratified analysis showed that the 5-year OS and DFS rates were comparable between the two groups in each tumor stage (P > 0.05). Multivariate analysis revealed that the operation method was not an independent prognostic factor for OS or DFS. Further analysis showed that the recurrence pattern was similar between the LAG group the OG group (P > 0.05).

CONCLUSION

LAG is a feasible surgical procedure for AGC in terms of long-term prognosis, although the results should be confirmed by the ongoing randomized controlled trials.