Short-term outcome of total laparoscopic distal gastrectomy for overweight and obese patients with gastric cancer

Lung ultrasound score evaluation of the effect of pressure-controlled ventilation volume-guaranteed on patients undergoing laparoscopic-assisted radical gastrectomy

BACKGROUND

Laparoscopic-assisted radical gastrectomy (LARG) is the standard treatment for early-stage gastric carcinoma (GC). However, the negative impact of this procedure on respiratory function requires the optimized intraoperative management of patients in terms of ventilation.

AIM

To investigate the influence of pressure-controlled ventilation volume-guaranteed (PCV-VG) and volume-controlled ventilation (VCV) on blood gas analysis and pulmonary ventilation in patients undergoing LARG for GC based on the lung ultrasound score (LUS).

METHODS

The study included 103 patients with GC undergoing LARG from May 2020 to May 2023, with 52 cases undergoing PCV-VG (research group) and 51 cases undergoing VCV (control group). LUS were recorded at the time of entering the operating room (T0), 20 minutes after anesthesia with endotracheal intubation (T1), 30 minutes after artificial pneumoperitoneum (PP) establishment (T2), and 15 minutes after endotracheal tube removal (T5). For blood gas analysis, arterial partial pressure of oxygen (PaO2) and partial pressure of carbon dioxide (PaCO2) were observed. Peak airway pressure (Ppeak), plateau pressure (Pplat), mean airway pressure (Pmean), and dynamic pulmonary compliance (Cdyn) were recorded at T1 and T2, 1 hour after PP establishment (T3), and at the end of the operation (T4). Postoperative pulmonary complications (PPCs) were recorded. Pre- and postoperative serum interleukin (IL)-1β, IL-6, and tumor necrosis factor-α (TNF-α) were measured by enzyme-linked immunosorbent assay.

RESULTS

Compared with those at T0, the whole, anterior, lateral, posterior, upper, lower, left, and right lung LUS of the research group were significantly reduced at T1, T2, and T5; in the control group, the LUS of the whole and partial lung regions (posterior, lower, and right lung) decreased significantly at T2, while at T5, the LUS of the whole and some regions (lateral, lower, and left lung) increased significantly. In comparison with the control group, the whole and regional LUS of the research group were reduced at T1, T2, and T5, with an increase in PaO2, decrease in PaCO2, reduction in Ppeak at T1 to T4, increase in Pmean and Cdyn, and decrease in Pplat at T4, all significant. The research group showed a significantly lower incidence of PPCs than the control group within 3 days postoperatively. Postoperative IL-1β, IL-6, and TNF-α significantly increased in both groups, with even higher levels in the control group.

CONCLUSION

LUS can indicate intraoperative non-uniformity and postural changes in pulmonary ventilation under PCV-VG and VCV. Under the lung protective ventilation strategy, the PCV-VG mode more significantly improved intraoperative lung ventilation in patients undergoing LARG for GC and reduced lung injury-related cytokine production, thereby alleviating lung injury.

Comprehensive assessment of body mass index effects on short-term and long-term outcomes in laparoscopic gastrectomy for gastric cancer: a retrospective study

To examine the influence of Body Mass Index (BMI) on laparoscopic gastrectomy (LG) short-term and long-term outcomes for gastric cancer. A retrospective analysis was conducted on gastric cancer patients undergoing LG at the Third Hospital of Nanchang City from January 2013 to January 2022. Based on WHO BMI standards, patients were categorized into normal weight, overweight, and obese groups. Factors such as operative time, intraoperative blood loss, postoperative complications, and overall survival were assessed. Across different BMI groups, it was found that an increase in BMI was associated with longer operative times (average times: 206.22 min for normal weight, 231.32 min for overweight, and 246.78 min for obese), with no significant differences noted in intraoperative blood loss, postoperative complications, or long-term survival among the groups. The impact of BMI on long-term survival following LG for gastric cancer was found to be insignificant, with no notable differences in survival outcome between different BMI groups. Although higher BMI is associated with increased operative time in LG for gastric cancer, it does not significantly affect intraoperative blood loss, postoperative complications, recovery, or long-term survival. LG is a feasible treatment choice for obese patients with gastric cancer.

Systematic review and meta-analysis of short-term outcomes: robot-assisted versus laparoscopic surgery for gastric cancer patients with visceral obesity

The objective of this meta-analysis was to assess the comparative efficacy of robot-assisted and laparoscopic surgery in treating gastric cancer among patients characterized by a high visceral fat area (VFA). In April 2024, we conducted a comprehensive literature review using major international databases, such as PubMed, Embase, and Google Scholar. We restricted our selection to articles written in English, excluding reviews, protocols without published data, conference abstracts, and irrelevant content. Our analysis focused on continuous data using 95% confidence intervals (CIs) and standard mean differences (SMDs), while dichotomous data were assessed with odds ratios (ORs) and 95% CIs. We set the threshold for statistical significance at P < 0.05. Data extraction included baseline characteristics, primary outcomes (such as operative time, major complications, lymph node yield, and anastomotic leakage), and secondary outcomes. The meta-analysis included three cohort studies totaling 970 patients. The robotic-assisted group demonstrated a significantly longer operative time compared to the laparoscopic group, with a weighted mean difference (WMD) of - 55.76 min (95% CI - 74.03 to - 37.50; P < 0.00001). This group also showed a reduction in major complications, with an odds ratio (OR) of 2.48 (95% CI 1.09-5.66; P = 0.03) and fewer occurrences of abdominal infections (OR 3.17, 95% CI 1.41-7.14; P = 0.005), abdominal abscesses (OR 3.83, 95% CI 1.53-9.57; P = 0.004), anastomotic leaks (OR 4.09, 95% CI 1.73-9.65; P = 0.001), and pancreatic leaks (OR 8.93, 95% CI 2.33-34.13; P = 0.001). However, no significant differences were observed between the groups regarding length of hospital stay, overall complications, estimated blood loss, or lymph node yield. Based on our findings, robot-assisted gastric cancer surgery in obese patients with visceral fat appears to be correlated with fewer major complications compared to laparoscopic surgery, while maintaining similar outcomes in other surgical aspects. However, it is important to note that robot-assisted procedures do tend to have longer operative times.

Laparoscopic D2+ lymph node dissection in patients with obesity and gastric cancer: A retrospective study

D2 lymph node dissection is widely used in laparoscopic radical gastrectomy for gastric cancer, and its efficacy and safety are known for patients with obesity. Currently, D2+ lymph node dissection is also applied to certain patients with gastric cancer of later stages. Due to the high difficulty of D2+ surgery, it is more challenging to perform on patients with obesity. There is currently limited research on the efficacy and safety of D2+ surgery in obese patients with gastric cancer. The present study aimed to retrospectively analyze the clinical data of patients undergoing laparoscopic radical gastrectomy for gastric cancer admitted to a single gastroenterology department. Patients with a body mass index ≥25 kg/m2 were included in the study. A total of 149 patients were selected as the research subjects and divided into two groups. The observation group comprised 74 patients who underwent D2+ lymph node dissection, while the control group comprised 75 patients who underwent standard D2 lymph node dissection. The surgical performance, postoperative recovery and postoperative complications of the two groups were compared. The results showed that the rates of conversion to open surgery in the D2+ and D2 groups were 5.4% (4/74) and 2.7% (2/75), respectively, and were not significantly different. The duration of surgery in the D2+ group (282.55±23.02 min) was significantly longer than that in the D2 group (271.45±20.05 min). The mean number of lymph node dissections in the D2+ group was 28.57±7.19, which was significantly higher than that in the D2 group (25.29±6.41). No statistically significant differences in intraoperative blood loss, time to first flatus, postoperative hospitalization days, total hospitalization expenses or postoperative complications was detected between the two groups. There were no deaths in either group within the 30-day perioperative period. In addition, there was no significant difference in the 3-year overall survival rate between the two groups, while the 5-year overall survival rate of the D2+ group was significantly higher than that of the D2 group. For obese patients with gastric cancer, D2+ surgery may increase the duration of surgery and slightly increase intraoperative blood loss compared with standard D2 radical surgery, but does not increase the incidence of postoperative complications. Moreover, D2+ surgery increases the number of lymph node dissections and improves the 5-year survival rate of patients. Therefore, it may be concluded that laparoscopic D2+ lymph node dissection is safe and feasible for obese patients with gastric cancer.

Robotic versus laparoscopic gastrectomy for gastric cancer in patients with obesity: systematic review and meta-analysis

Introduction

The number of overweight patients with gastric cancer (GC) is increasing, and no previous study has compared laparoscopic gastrectomy (LG) and robotic gastrectomy (RG) in obese patients with GC. To investigate the perioperative and oncologic outcomes of RG and LG in obese GC patients, we performed a meta-analysis of propensity matched scores and retrospective studies to compare the perioperative parameters, oncologic findings, and short-term postoperative outcomes between the two groups.

Methods

This study was performed according to the PRISMA guidelines. A search was performed on PubMed, Web of Science, EMBASE, and Cochrane Central Register to identify eligible propensity matched scores and retrospective studies conducted and published before December 2022. Data on perioperative and oncological outcomes were included in the meta-analysis.

Results

Overall, we identified 1 propensity score match study and 5 randomized control trials of RG and LG, enrolling a total of 718 patients (197 and 521 patients received RG and LG, respectively). No significant differences were observed between the two groups in terms of complications, bleeding, or lymph node dissection. Of note, RG had a longer procedure time (P = 0.03), earlier oral intake (P = 0.0010), shorter hospital stay (P = 0.0002), and shorter time to defecation (P < 0.00001).

Conclusions

This meta-analysis concluded that patients in the RG group had shorter hospital stays, earlier postoperative feeding, and earlier postoperative ventilation; however, no differences were found in blood loss, number of lymph nodes removed, or overall complications. RG is an effective, safe, and promising treatment for obese patients with GC, compensating for the shortcomings of laparoscopy and allowing for less trauma and faster recovery.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022298967.

The Impact of Overweight and Obesity on Reduced-Port Laparoscopic Distal Gastrectomy for Gastric Cancer Patients: A Propensity Score Matching Analysis of a Single-Institution Data

This study aimed to investigate the short-term postoperative outcomes of reduced-port laparoscopic distal gastrectomy and demonstrate its safety and feasibility in overweight and obese patients with gastric cancer. The medical records of 211 patients who underwent reduced-port laparoscopic distal gastrectomy, between August 2014 and April 2020, were reviewed. After propensity score matching, they were divided into a non-overweight group (n = 68) and overweight group (n = 68). Operative details and short-term surgical outcomes were compared between two groups. Reduced-port laparoscopic distal gastrectomy in overweight group showed statistically longer operation time (200.59 vs. 208.68 min, p = 0.044), higher estimated bleeding volume (40.96 vs. 58.01 mL, p = 0.001), and lesser number of harvested lymph nodes (36.81 vs. 32.13, p = 0.039). However, no significant differences were found in hospital course and other surgical outcomes. There was no mortality in either group, and the postoperative morbidity rate was not significantly different (14.7% vs. 16.2%). In the subgroup analysis, overweight and obesity did not significantly affect postoperative complication rates (16.2% vs. 16.2%, p = 1). We demonstrated comparable short-term surgical outcomes of reduced-port laparoscopic distal gastrectomy between the two groups (p = 0.412~1). Reduced-port laparoscopic distal gastrectomy was safe in overweight and obese patients with gastric cancer.

Advantages of a robotic approach compared with laparoscopy gastrectomy for patients with high visceral fat area

BACKGROUND

Gastric cancer surgery for obese patients is regarded as a technically challenging procedure. The morbidity after gastrectomy has been reported to be significantly higher in patients with high visceral fat area (VFA). Robotic gastrectomy (RG) is expected to be advantageous for complicated operations. However, whether RG is superior to conventional laparoscopic gastrectomy (LG) for patients with visceral fat obesity remains unclear. The present study aimed to clarify the impact of RG on the short- and long-term outcomes of patients with high VFAs.

METHODS

This study included 1306 patients with clinical stage I/II gastric cancer who underwent minimally invasive gastrectomy between January 2012 and December 2020. The patients were subclassified according to VFA. The short- and long-term outcomes of RG were compared with those of LG in two VFA categories.

RESULTS

This study included 394 (high-VFA, 151; low-VFA, 243) and 882 patients (high-VFA, 366; low-VFA, 516) in the RG and LG groups, respectively. RG was associated with a significantly longer operative time than LG (high-VFA, P < 0.001; low-VFA, P < 0.001). The incidence rates of overall and intra-abdominal infectious complications in the high-VFA patients were lower in the RG group than in the LG group (P = 0.019 and P = 0.048, respectively) but not significantly different from those in the low-VFA patients. In the multivariate analysis, LG was identified as the only independent risk factor of overall (odds ratio [OR] 3.281; P = 0.012) and intra-abdominal infectious complications (OR 3.462; P = 0.021) in the high-VFA patients. The overall survival of high-VFA patients was significantly better in the RG group than in the LG group (P = 0.045).

CONCLUSIONS

For patients with visceral fat obesity, RG appears to be advantageous to LG in terms of reducing the risk of complications and better long-term survival.

Reverse rolling-mat type lymph node dissection is the key step to solve the operative difficulties in hand-assisted laparoscopic D2 radical gastrectomy

Background

We have improved and named a new reverse rolling-mat type lymph node dissection, which effectively solves the dilemma faced by the traditional lymph node dissection in hand-assisted laparoscopic D2 radical gastrectomy through the optimization of the surgical procedure. However, the relevant clinical data are still scarce. The study aims to compare the clinical effects of two surgical procedure and explore the safety and feasibility of “reverse procedure”.

Study design

The clinicopathological data of 195 patients who underwent hand-assisted D2 radical total gastrectomy (HALTG) in our hospital from January 2011 to September 2017 were collected. A retrospective case–control study was used to compare the clinical outcomes of the two patterns of lymph node dissection. Among them, 89 patients underwent “cabbage type” lymph node dissection and 106 patients underwent the “reverse procedure” lymph node dissection.

Results

There were no significant differences between the two groups of patients in terms of gender, age, tumor location, incision length, postoperative hospitalization duration, pathological classification, recent complications, long-term recurrence and metastasis. The operation time of “cabbage type” group was shorter than that of “reverse procedure” group (178.35 ± 31.52 min vs 191.25 ± 32.77 min; P = 0.006). While, in the “reverse procedure” group, intraoperative blood loss was less (249.4 ± 143.12 vs 213.58 ± 101.43; P = 0.049), and there were more numbers of lymph nodes dissected (18.04 ± 7.00 vs 32.25 ± 14.23; P < 0.001).

Conclusion

The pattern of reverse rolling-mat type lymph node dissection in HALTG perform well in terms of safety and feasibility.

Feasibility of totally laparoscopic total gastrectomy in obese patients with gastric cancer

PURPOSE

This study aimed to evaluate the short- and long-term outcomes in obese patients with gastric cancer undergoing totally laparoscopic total gastrectomy (TLTG) to clarify its feasibility in this population.

METHODS

We examined 136 consecutive patients who underwent TLTG for gastric cancer (GC) between 2013 and 2018. A total of 45 patients with a body mass index (BMI) ≥ 25 kg/m² were defined as the obese group (obese and overweight patients by the WHO classification), and 91 patients with a BMI < 25 kg/m² were defined as the non-obese group. Short- and long-term outcomes were compared, and the correlation between obesity and postoperative complications was examined in patients who underwent TLTG.

RESULTS

Although the operation time (min) was significantly longer in the obese group than in the non-obese group (329 vs 307, p = 0.002), there were no significant differences in the total volume of blood loss (mL) (118 vs 60, p = 0.059) or the rate of conversion to laparotomy between the two groups (2 vs 2, p = 0.466). Moreover, there was no significant difference in the incidence of postoperative complications between the two groups (16% vs 19%, p = 0.653). In the multivariate analysis, obesity was not identified as a risk factor for postoperative complications among patients who underwent TLTG. The rate of overall survival was not significantly different between the groups (p = 0.512).

CONCLUSION

TLTG is feasible for obese Japanese patients with GC. To validate the results of the present study, it is necessary to conduct a prospective study of a large population of patients with GC.

Reduced-port laparoscopic distal gastrectomy in obese gastric cancer patients

BACKGROUND

Reduced-port laparoscopic gastrectomy is currently widely performed for patients with gastric cancer. However, its safety in obese patients has not yet been verified. This is the first study on reduced-port laparoscopic distal gastrectomy (RpLDG) in obese patients with gastric cancer. This study aimed to evaluate the short-term surgical outcomes and investigate the feasibility and safety of RpLDG in obese patients with gastric carcinoma.

MATERIAL AND METHODS

A total of 271 gastric cancer patients who underwent RpLDG at our institution were divided into two groups: non-obese [body mass index (BMI) <30 kg/m2, n = 251; NOG] and obese (BMI ≥30 kg/m2, n = 20; OG). The mean age of the enrolled patients was 64.8 ± 11.4 years, with 72.0% being men and 28.0% women. Operative details and short-term surgical outcomes, including hospital course and postoperative complications, were compared by retrospectively reviewing the medical records.

RESULTS

No significant difference in operation time was found between the NOG and OG (205.9 ± 40.0 vs. 211.3 ± 37.3 minutes, P = 0.563). Other operative outcomes in the OG, including estimated blood loss (54.1 ± 86.1 vs. 54.0 ± 39.0 mL, P = 0.995) and retrieved lymph nodes (36.2 ± 16.4 vs. 35.5 ± 18.2, P = 0.875), were not inferior to those in the NOG. There were also no statistical differences in short-term surgical outcomes, including the incidence of surgical complications (13.9% vs. 10.0%, P = 1).

CONCLUSION

RpLDG can be performed safely in obese gastric cancer patients by an experienced surgeon. It should be considered a feasible alternative to conventional port distal gastrectomy.

Association of Obesity with Worse Operative and Oncologic Outcomes for Patients Undergoing Gastric Cancer Resection

BACKGROUND

How obesity has an impact on operative and oncologic outcomes for gastric cancer patients is unclear, and the influence of obesity on response to neoadjuvant chemotherapy (NAC) has not been evaluated.

METHODS

Patients who underwent curative gastrectomy for primary gastric cancer between 2000 and 2018 were retrospectively identified. After stratification for NAC, operative morbidity, mortality, overall survival (OS), and disease-specific survival (DSS) were compared among three body mass index (BMI) categories: normal BMI (< 25 kg/m²), mild obesity (25-35 kg/m²), and severe obesity (≥ 35 kg/m²).

RESULTS

During the study period, 984 patients underwent upfront surgery, and 484 patients received NAC. Tumor stage did not differ among the BMI groups. However, the rates of pathologic response to NAC were significantly lower for the patients with severe obesity (10% vs 40%; p < 0.001). Overall complications were more frequent among the obese patients (44.3% for obese vs 24.9% for normal BMI, p < 0.001). Intraabdominal infections were also more frequent in obese patients (13.9% for obese vs 4.7% for normal BMI, p = 0.001). In the upfront surgery cohort, according to the BMI, OS and DSS did not differ, whereas in the NAC cohort, severe obesity was independently associated with worse OS [hazard ratio (HR) 1.87; 95% confidence interval (CI) 1.01-3.48; p = 0.047] and disease-specific survival (DSS) (HR 2.08; 95% CI 1.07-4.05; p = 0.031).

CONCLUSION

For the gastric cancer patients undergoing curative gastrectomy, obesity was associated with significantly lower rates of pathologic response to NAC and more postoperative complications, as well as shorter OS and DSS for the patients receiving NAC.

Laparoscopic gastrectomy reduces adverse postoperative outcomes and decreases morbidity for gastric cancer patients with visceral obesity: a propensity score-matched analysis

Background: Laparoscopic gastrectomy for gastric cancer shortens the recovery period without decreasing long-term survival. However, clinical evidence on whether laparoscopic radical gastrectomy reduces the surgical stress and improves the short- and long-term outcomes of obese patients with gastric cancer is lacking. We compared the short- and long-term outcomes of gastric cancer patients with visceral obesity (VO) who underwent laparoscopic gastrectomy (LG) or open gastrectomy (OG).

Methods: We prospectively collected data from 578 patients who underwent radical gastrectomy in two centers between January 2014 and December 2016. The visceral fat area (VFA) was measured on the umbilicus level, and VFA ≥100 cm² was defined as VO. The section bias was reduced by conducting a propensity score matching analysis. The short- and long-term outcomes were further compared between patients who underwent OG and those who underwent LG.

Results: Overall, 245 patients (42.61%) were classified as having VO, of whom 102 were included for further analysis after matching. There were no significant differences in clinical characteristics between the two groups in the matched cohort. The LG group had significantly fewer overall complications (P<0.001) and shorter postoperative hospital stays (P<0.001). Subgroup analysis of postoperative complications also showed that the incidence of surgical complications was lower in the LG group (P=0.002). Further survival analysis showed the LG group had significantly better long-term overall survival (P=0.017).

Conclusions: Compared with open radical gastrectomy, laparoscopy would reduce the rate of postoperative complications in patients with VO, as well as prolong their overall survival.

Safety of subxiphoid uniportal video-assisted thoracoscopic surgery for anterior mediastinal tumour in obese patients

Introduction

Subxiphoid uniportal video-assisted thoracoscopic surgery (VATS) has been gradually applied for the treatment of anterior mediastinal tumour (AMT). However, whether obesity is a risk factor for subxiphoid uniportal VATS for AMT is still unknown.

Aim

To explore the safety and short-term outcome of subxiphoid uniportal VATS for AMT in obese patients.

Material and methods

The clinical data of 142 patients who received VATS via subxiphoid approach for AMT were analysed. According to body mass index (BMI), the patients were divided into an obese group (BMI ≥ 28 kg/m²) and a non-obese group (BMI < 28 kg/m²). Then, the clinical and surgical characteristics between the obese group and the non-obese group were analysed to explore the effect of obesity on VATS for AMT. The pain scores were evaluated by the Numeric Rating Scale.

Results

The operative time and tracheal intubation time using subxiphoid uniportal VATS for AMT in the obese group were longer than that in the non-obese group (p < 0.05). However, there was no obvious difference in intraoperative blood loss, chest tube drainage time, chest tube drainage volume, and length of hospital stay between the obese group and the non-obese group (p > 0.05). Moreover, there was also no significant difference in postoperative complications, including pulmonary complications, wound infection, arrhythmia, and pulmonary leak, between the obese group and the non-obese group. In addition, the pain scores in the obese group were similar to those in the non-obese group.

Conclusions

Although obesity might prolong operative time of subxiphoid uniportal VAST for AMT, it does not increase the rate of postoperative complications. An experienced centre can properly conduct VAST via subxiphoid approach when treating AMT in obese patients.

The effect of the body mass index on the short-term surgical outcomes of laparoscopic total gastrectomy: A propensity score-matched study

Purpose

This study aimed to evaluate the relationship between the body mass index (BMI) and the short-term outcomes of laparoscopic total gastrectomy (LTG).

Subjects and Methods

Data of patients who underwent LTG for gastric cancer at six institutions between 2004 and 2018 were retrospectively collected. The patients were classified into three groups: low BMI (<18.5 kg/m²), normal BMI (≥18.5 and <25 kg/m²) and high BMI (≥25 kg/m²). In these patients, clinicopathological variables were analysed using propensity score matching for age, sex, the American Society of Anaesthesiologists physical state, clinical stage, surgical method, D2 lymph node dissection, combined resection of other organs, anastomosis method and jejunal pouch reconstruction. The surgical results and post-operative outcomes were compared among the three groups.

Results

A total of 82 patients were matched in the analysis of the low BMI and normal BMI groups. There were no differences in operative time (P = 0.693), blood loss (P = 0.150), post-operative complication (P = 0.762) and post-operative hospital stay (P = 0.448). In the analysis of the normal BMI and high BMI groups, 208 patients were matched. There were also no differences in blood loss (P = 0.377), post-operative complication (P = 0.249) and post-operative hospital stay (P = 0.676). However, the operative time was significantly longer in the high BMI group (P = 0.023).

Conclusions

Despite the association with a longer operative time in the high BMI group, BMI had no significant effect on the surgical outcomes of LTG. LTG could be performed safely regardless of BMI.

Effect of Standardizing the Incision Line on Delayed Gastric Emptying After Laparoscopic Gastrectomy: A Retrospective Preliminary Analysis

Background

The use of totally laparoscopic surgery with Billroth-I reconstruction (delta-shaped anastomosis) has rapidly become widespread in recent years. However, we experienced delayed gastric emptying (DGE) in the early period after introduction of this technique. To the best of our knowledge, there are no reports that mention the incision line when discussion prevention of DGE in distal gastrectomy. In the present study, we standardized the surgical techniques, including the gastric incision line, and compared the short-term results before and after standardization.

Methods

A total of 86 patients were enrolled in this study. Twenty-eight procedures were performed in the early period, 58 procedures were performed in the late period, and the 2 groups were compared retrospectively.

Results

The operation time decreased significantly after standardization from 288 to 224 minutes (P &lt; 0.001). The median value of perioperative bleeding volume decreased from 22.5 to 12.5 mL (P = 0.060). There were no postoperative complications related to the site of anastomosis in either group. Five cases of DGE (17.8%) were noted in the early period, but only 2 cases (3.4%) were noted in the late period (P = 0.022).

Conclusions

Standardization of the incision line after laparoscopic gastrectomy resulted in a decrease in the incidence of DGE.

Minimally invasive gastrectomy for cancer and anastomotic options

In this review article, we explore patient selection criteria for minimally invasive surgery (MIS) gastrectomy, present evidence on the risks and benefits of minimally invasive techniques, describe operative techniques focusing specifically on reconstruction options, and discuss the learning curve associated with these operations.

Lymph Node Noncompliance Affects the Long-Term Prognosis of Patients with Gastric Cancer after Laparoscopic Total Gastrectomy

BACKGROUND

Our study investigated the effect of lymph node (LN) noncompliance on the long-term prognosis of patients after laparoscopic total gastrectomy (LTG) and explored the risk factors of LN noncompliance.

METHODS

The clinicopathological data of gastric cancer (GC) patients who underwent LTG with D2 lymphadenectomy from June 2007 to December 2013 were prospectively collected and retrospectively analyzed. The effects of LN noncompliance on the long-term prognosis of patients with GC after LTG were explored.

RESULTS

The overall LN noncompliance rate was 51.9%. The survival rate of patients after LTG with LN compliance was significantly superior to that of patients with LN noncompliance (p = 0.013). The stratified analysis of TNM stage indicated that there was no difference between the OS of stage I patients with LN compliance and those with LN noncompliance; OS of stage II/III patients with LN compliance was significantly better than that of those with LN noncompliance. Cox regression analyses showed that LN noncompliance was an independent risk factor for OS. Logistic regression analysis showed that high BMI (≥ 25 kg/m²) was an independent risk factor for preoperative prediction of LN noncompliance in cStage II/III patients. Patients with a high BMI were more likely to have LN noncompliance during surgery, especially during the dissections of #6, #8a, and #12a LN stations.

CONCLUSIONS

LN noncompliance was an independent risk factor for poor prognosis in patients with advanced gastric cancer (AGC) after LTG. Patients with high BMI were more likely to have LN noncompliance, especially during the dissections of #6, #8a, and #12a LN stations. LN tracing was recommended for these patients to reduce the rate of LN noncompliance.

Comparison of the short-term outcomes between totally laparoscopic total gastrectomy and laparoscopic-assisted total gastrectomy for gastric cancer: a meta-analysis

BACKGROUND

Totally laparoscopic total gastrectomy (TLTG) and laparoscopic-assisted total gastrectomy (LATG) are two common surgical approaches for upper and middle gastric cancer. Which surgical approach offers more advantages is still controversial due to a lack of evidence from randomized controlled trials (RCTs). This meta-analysis was conducted to compare the short-term outcomes between the two surgical approaches.

METHODS

A systematic literature search was performed to evaluate short-term outcomes between TLTG and LATG, including overall postoperative complications, anastomosis-related complications, time for anastomosis, operation time, intraoperative blood loss, harvested lymph nodes, proximal margin, distal margin, time to first flatus, time to first diet, and postoperative hospital stay. Short-term outcomes were pooled and compared by meta-analysis using RevMan 5.3. Mean differences (MDs) or risk ratios (RRs) were calculated with 95% confidence intervals (CIs). P < .05 was considered statistically significant.

RESULTS

A total of 9 cohort studies fulfilled the selection criteria. The total sample included 1671 cases. The meta-analysis showed no significant difference between the two surgical approaches in overall postoperative complications (RR = 1.02, 95% CI = 0.82 to 1.26, P = .87),anastomosis-related complications (RR = 0.64, 95%CI = 0.39 to 1.03, P = .06),time for anastomosis (MD = -5.13, 95% CI = -10.54 to 0.27, P = .06),operation time (MD = -10.68, 95% CI = -23.62 to 2.26, P = .11), intraoperative blood loss (MD = -25.58, 95% CI = -61.71 to 10.54, P = .17), harvested lymph nodes (MD = 1.61, 95% CI = -2.09 to 5.31, P = .39), proximal margin (MD = -0.37, 95% CI = -0.78 to 0.05, P = .09), distal margin (MD = 0.79, 95% CI = -0.57 to 2.14, P = .25), time to first flatus (MD = 0.01, 95% CI = -0.13 to 0.15, P = .87), time to first diet (MD = -0.22, 95% CI = -0.45 to 0.02, P = .07), and postoperative hospital stay (MD = -0.51, 95% CI = -1.10 to 0.07, P = .09).

CONCLUSIONS

TLTG is a safe and feasible surgical approach for upper and middle gastric cancer, with short-term outcomes that are similar to LATG. Nevertheless, high-quality, large-sample and multicenter RCTs are still required to further verify our conclusions.

Laparoscopic total gastrectomy for upper-middle advanced gastric cancer: analysis based on lymph node noncompliance

BACKGROUND

Increasing number of clinical studies have shown that laparoscopic distal gastrectomy (LDG) with D2 lymph node (LN) dissection is an effective method for the treatment of advanced gastric cancer (AGC). However, reports on the technical feasibility and oncology efficacy of laparoscopic total gastrectomy (LTG) in the treatment of AGC are rare.

METHODS

A retrospective analysis of the clinicopathologic data of 1313 patients with clinical stage of cT2-4aN0-3M0 undergoing laparoscopic radical gastrectomy with D2 LN dissection from June 2007 to December 2013 was performed. Noncompliance was defined as patients with more than one LN station absence as described in the protocol for D2 lymphadenectomy in the Japanese Gastric Cancer Association (JGCA). According to the literature, it was subdivided into LN compliance group (all LN stations were detected), minor LN noncompliance group (1-2 LN stations were not detected), major LN noncompliance group (more than 2 LN stations were not detected). Based on the LN noncompliance, the surgical indications of LTG were analyzed with LDG as control.

RESULTS

Among the 1313 patients, 197 (39.20%) patients and 321(39.71%) patients in the LDG group and the LTG group had minor LN noncompliance, 59(11.70%) patients and 163(20.10%) patients had major LN noncompliance. The difference in the extent of LN noncompliance between the two groups was statistically significant (p < 0.001). COX proportional hazards regression analysis elucidated that the LN noncompliance was an independent prognostic factor for overall survival (OS). BMI ≥ 25 kg/m² and the history of previous abdominal surgery (PAS) were independent risk factors for major LN noncompliance in LTG group (p < 0.05), with which patients were defined as a LN noncompliance high-risk group. With the exception of LN noncompliance high-risk group, the difference in the extent of LN noncompliance between LTG group and LDG group was still statistically significant (p = 0.008). Tumor diameter > 60 mm is a preoperative risk factor for station #5 LN noncompliance, and no preoperative risk factors for station #6 LN noncompliance were found, with which patients were defined as LN noncompliance middle-risk group.

CONCLUSION

LN noncompliance is an independent prognostic factor for poor prognosis in patients after LTG. Based on this finding, patients with BMI ≥ 25 kg/m², history of PAS and tumor diameter > 60 mm in the advanced stage of upper-middle gastric cancer represent high/middle-risk groups with LN noncompliance in LTG surgery, which should be carefully selected.

Safety and efficacy of laparoscopic gastrectomy in obese patients with gastric cancer

The present study aimed to investigate the safety and short-term outcome of laparoscopy-assisted distal radical gastrectomy in treating gastric cancer among obese patients.Perioperative outcomes were compared between 67 gastric cancer patients with a body mass index (BMI) ≥25 kg/m (obese group) and 198 ones with BMI <25 kg/m (non-obese group). All the cases underwent laparoscopic radical resection between April 2009 and October 2013.The value of BMI was 27.3 ± 2.67 kg/m in the obese group and 21.3 ± 2.64 kg/m in non-obese group. There were no significant differences between 2 groups in age, sex, presence of diabetes, tumor size, number of metastatic lymph nodes, or metastatic lymph node ratio. Postoperative complications did not differ between the 2 groups (P > .05). There were significant differences between the 2 groups in operation time (non-obese: [234.2 ± 67.1] minutes vs obese group: [259.4 ± 78.5]; P = .017), postoperative hospital stay (obese group [19.7 ± 14.8] day vs non-obese [15.4 ± 7.1], P = .002), and retrieved lymph nodes ([27.6 ± 11.0] day vs non-obese [31.9 ± 12.5] day, P = .002).Obesity may prolong operation time and postoperative hospital stay, and cause less retrieved lymph nodes, but does not increase the incidence of postoperative complications. The experienced center can properly conduct laparoscopic assisted radical gastrectomy in obese patients.

An overview on 3D printing for abdominal surgery

BACKGROUND

Three-dimensional (3D) printing is a disruptive technology that is quickly spreading to many fields, including healthcare. In this context, it allows the creation of graspable, patient-specific, anatomical models generated from medical images. The ability to hold and show a physical object speeds up and facilitates the understanding of anatomical details, eases patient counseling and contributes to the education and training of students and residents. Several medical specialties are currently exploring the potential of this technology, including general surgery.

METHODS

In this review, we provide an overview on the available 3D printing technologies, together with a systematic analysis of the medical literature dedicated to its application for abdominal surgery. Our experience with the first clinical laboratory for 3D printing in Italy is also reported.

RESULTS

There was a tenfold increase in the number of publications per year over the last decade. About 70% of these papers focused on kidney and liver models, produced primarily for pre-interventional planning, as well as for educational and training purposes. The most used printing technologies are material jetting and material extrusion. Seventy-three percent of publications reported on fewer than ten clinical cases.

CONCLUSION

The increasing application of 3D printing in abdominal surgery reflects the dawn of a new technology, although it is still in its infancy. The potential benefit of this technology is clear, however, and it may soon lead to the development of new hospital facilities to improve surgical training, research, and patient care.

Difference in the short-term outcomes of laparoscopic gastrectomy for gastric carcinoma between the east and west: a retrospective study from the IMIGASTRIC trial

Purpose: To compare the clinicopathologic data and short-term surgical outcomes of laparoscopic gastrectomy (LG) for gastric cancer (GC) between the east and west. Methods: Patient demographics, surgical procedures, pathological information, and postoperative recovery were compared among gastric cancer patients who underwent LG in the clinical trial of IMIGASTRIC (NCT02325453) between 2009 and 2016. Results: More younger males, higher BMI, lower ASA score and less neoadjvant chemotherapy were evident in east patient cohort. Eastern patients had a higher proportion of proximal, differentiated and advanced gastric cancers. More total gastrectomies, larger extent of lymph node (LN) dissection, and higher number of retrieved LNs were found in the eastern patients. However, more Roux-en-Y anastomosis procedures during distal gastrectomy and intra-corporeal anastomosis were performed in the western patients. The west patients showed faster postoperative recovery than the eastern patients. The mortality rates of the western patients were comparable to those of the eastern patients. However, fewer III-IV complications were evident in the eastern centers. Multivariate analyses revealed that an elderly age, higher ASA score, and more blood loss were the significant independent risk factors of postoperative complications for eastern patients. However, for the western patients, the independent risk factors were neoadjuvant therapy, more retrieval LNs, and pT3-4 stage. Conclusions: The selections and short-term surgical outcomes of LG for GC were widely different between East and West. To obtain more objective and accurate results, these differences should be considered in future international prospective studies.

Feasibility of laparoscopy gastrectomy for gastric cancer in the patients with high body mass index: A systematic review and meta-analysis

The aim of this study was to evaluate the impact of high body mass index (BMI) on surgical outcome of laparoscopic gastrectomy for gastric cancer (GC). Systematic literature search was performed using PubMed and Embase databases. The relevant data were extracted, and surgical outcomes and postoperative complications were compared between BMI≥25 kg/m² and BMI<25 kg/m² group using a fixed effect model or random effect model. 16 studies, with a total of 9572 GC patients, were included in this meta-analysis. The results indicated that operation time was significantly longer (WMD:16.22, 95% CI: 14.10-18.34, P < 0.001; I² = 0%) and the number of lymph nodes retrieved was significantly fewer (WMD:-2.11, 95%CI: -3.14, -1.07, P < 0.001; I² = 64.0%) in high BMI patients than in other patients. In addition, the amount of intraoperative blood loss was significantly larger in high BMI patients (WMD: 23.43, 95%CI: 20.05-26.81, P < 0.001; I² = 40.3%). Compared with non-high BMI patients, overweight and obese patients had a higher risk of postoperative complications (RR:1.26, 95%CI: 1.11-1.43, P < 0.001; I² = 39.1%), especially for wound infection (RR:1.62, 95%CI: 1.15-2.29, P < 0.01; I² = 18.8%) and postoperative ileus (RR:1.80, 95% CI: 1.05-3.09, P < 0.05; I² = 0%). However, there was no significant difference between two patient groups for postoperative recovery, major surgery-related complications (eg: anastomotic leakage, pancreatic fistula and intra-abdominal bleeding) and postoperative mortality. Despite increased technical challenge and risk of postoperative complications, the majority of these complications may be minor and cured. Laparoscopic gastrectomy for GC was a feasible and safe procedure even for high BMI patients.

Preoperative weight loss program involving a 20-day very low-calorie diet for obesity before laparoscopic gastrectomy for gastric cancer

INTRODUCTION

The increased visceral fat in patients with obesity can increase the technical difficulty of surgery. This study was performed to evaluate a preoperative 20-day very low-calorie diet for obesity before laparoscopic gastrectomy for gastric cancer.

METHODS

This prospective single-center study involved patients with obesity who were planning to undergo laparoscopic gastrectomy for gastric cancer. Obesity was defined according to the Japanese criteria: BMI ≥25 kg/m² or waist circumference ≥85 cm in men and ≥90 cm in women. The patients underwent a preoperative 20-day very low-calorie diet and received nutritional counseling. Weight loss, body composition, visceral fat mass, and operative outcomes were evaluated.

RESULTS

Thirty-three patients were enrolled from September 2013 to August 2015. Their median age was 71 years, and 78.8% were men. Their median bodyweight and BMI were 72.3 kg (range, 53.8-82.5 kg) and 26.0 kg/m² (range, 23.5-31.0 kg/m² ), respectively. The patients achieved a mean weight loss of 4.5% (95% confidence interval [CI]: 3.8-5.1), corresponding to 3.2 kg (95%CI: 2.7-3.7 kg). Body fat mass was significantly decreased by a mean of 2.5 kg (95%CI: 1.9-3.1), whereas skeletal muscle mass was unaffected (mean: -0.20 kg [95%CI: -0.55-0.15]). The visceral fat mass reduction rate was high as 16.8% (range, 11.6%-22.0%). All patients underwent laparoscopic gastrectomy as planned. Severe postoperative morbidity (Clavien-Dindo grade ≥III) was seen in only one patient (3.0%).

CONCLUSION

The preoperative 20-day very low-calorie diet weight loss program is promising for the treatment of obesity before laparoscopic gastrectomy for gastric cancer.

Feasibility of laparoscopic total gastrectomy in overweight patients: Implications of less impact of overweight on laparoscopic versus open approach

AIM

To investigate safety and oncological feasibility of laparoscopic total gastrectomy (LTG) in overweight (OW) patients.

METHODS

Patients who underwent total gastrectomy (110 laparoscopic, 211 open) for gastric cancer between January 1999 and July 2016 were included. Propensity score matching selected 152 patients (76 laparoscopic, 76 open), which were subsequently divided into the OW (≥ 25) or non-OW (< 25) group by body mass index. Postoperative outcomes of laparoscopic versus open approaches were compared between OW and non-OW groups.

RESULTS

In the propensity-matched population, baseline characteristics were comparable between the OW and non-OW groups for the laparoscopy and open groups. In the laparoscopy group, operative time was longer (P = 0.01) in the OW group, however, other perioperative results including complication rates were comparable between the non-OW and OW groups. In the open group, number of retrieved lymph nodes were less (P = 0.03) and local complication rate was more frequent (P = 0.03) in the OW group.

CONCLUSION

LTG in OW patients remains technically challenging but can be performed safely. Our findings imply that OW has a lesser effect on the laparoscopic versus open approach to total gastrectomy.

Does high body mass index negatively affect the surgical outcome and long-term survival of gastric cancer patients who underwent gastrectomy: A systematic review and meta-analysis

BACKGROUND

Whether high body mass index (BMI) was associated with increased postoperative complications and unfavorable prognosis of gastric cancer (GC) patients remain controversial. In the present study, we performed a systematic review and meta-analysis to evaluate the impact of high BMI on surgical outcome, postoperative complications and long-term survival of GC patients.

METHODS

The related studies were identified by searching PubMed and Embase databases. According to the BMI, all GC patients were classified into BMI ≥25 kg/m² group and BMI <25 kg/m² group. The relevant data was extracted and pooled effect size was assessed using a fixed effect model or random effect model.

RESULTS

A total of 36 relevant studies involving 30,642 GC patients were included in this meta-analysis. The results indicated that high BMI patients had longer operation time, fewer number of retrieved lymph nodes and larger amount of intraoperative blood loss than other patients, regardless of open gastrectomy or laparoscopic gastrectomy. In addition, the risk of postoperative complications was significantly higher in the patients with BMI ≥25 kg/m² than in those with BMI <25 kg/m², especially for infectious complications. However, high BMI had no negative impact on postoperative mortality and long-term survival of GC patients.

CONCLUSION

Despite the increased surgical difficulty and postoperative complications, high BMI was not associated with the prognosis of GC patients. To reduce the risk of postoperative complications, more meticulous operation technique and improved perioperative management should be necessary for high BMI patients.

A comparative study of totally laparoscopic distal gastrectomy versus laparoscopic-assisted distal gastrectomy in gastric cancer patients: Short-term operative outcomes at a high-volume center

Objective

Laparoscopic gastrectomy has been established as a standard treatment for early gastric cancer, and its use is increasing recently. Compared with the conventional laparoscopy-assisted distal gastrectomy (LADG), totally laparoscopic distal gastrectomy (TLDG) involves intracorporeal reconstruction, which can avoid the additional incision, resulting in pain reduction and early recovery. This study aimed to compare the short-term postoperative outcomes of TLDG vs. LADG in gastric cancer in a high-volume center.

Methods

A retrospective cohort study was conducted on 1,322 patients who underwent laparoscopic distal gastrectomy from June 2012 to June 2017 at the National Cancer Center, Korea. LADG was performed in the early period before July 2015, and TLDG was applied in the later period. Postoperative short-term outcomes were compared in terms of complication and clinical course between the two groups. Pain score was measured by rating the pain intensity from 0 to 10 points on postoperative day (POD) 1 and 3.

Results

A total of 667 patients underwent LADG and 655 patients underwent TLDG. Clinicopathologic characteristics were not different in both groups. Intraoperative estimated blood loss (EBL) was significantly lower in the TLDG group (P<0.001). Postoperative pain scores were significantly lower in the TLDG group than in the LADG group on POD 1 (5.1±1.5vs. 4.8±1.4, P=0.015). First flatus passage after operation was significantly earlier in the TLDG group (3.4±0.8 d vs. 3.2±0.6 d, P<0.001). There were no differences in postoperative complications and hospital stay between the two groups.

Conclusions

Based on the reported short-term postoperative outcomes, TLDG is safe and feasible as well as LADG. Moreover, compared with LADG, TLDG can reduce intraoperative EBL and postoperative pain and enhance the bowel motility in gastric cancer surgery.

Application of Laparoscopic Gastrectomy in Obese Patients (BMI≥30 kg/m2) with Gastric Cancer: A Comparison With Open Gastrectomy Regarding Short-term Outcomes

OBJECTIVE

Few studies have compared the surgical outcomes of laparoscopic (LG) and open (OG) gastrectomy in obese patients (BMI≥30 kg/m) with gastric cancer. The current study aimed to investigate the short-term outcomes of LG in this group of patients.

METHODS

A total of 33 LG cases and 23 OG cases (BMI≥30 kg/m) were identified from our gastric cancer database. Clinicopathologic features, operative details, laboratory examination, and postoperative outcomes were compared between both groups. Regression analysis was used to determine the effects of BMI on intraoperative outcomes.

RESULTS

The 2 groups had comparable clinicopathologic characteristics. LG was associated with significantly lesser blood loss, whereas both also groups had a similar operative time, and number of harvested lymph nodes. However, regression analysis indicated that increased BMI affected the operative time and blood loss in patients that underwent OG but had little effect on patients who received LG. The elevation of inflammatory factors (WBC, CRP) was lower in LG than in OG, postoperatively. Postoperative hepatic (alanine aminotransferase, total bilirubin, albumin) and renal (creatinine, blood urea nitrogen) functions in the LG group were not worse than in the OG group. The time to first flatus, initiation of diet, hospitalization, and postoperative complications seemed superior in LG than in OG, but these differences were not statistically significant.

CONCLUSION

LG can be safely performed in obese gastric cancer patients. Compared with conventional OG, LG is less invasive and is characterized by less blood loss and milder surgical trauma. LG is also less adversely affected by increased BMI.

The Advances of Laparoscopic Gastrectomy for Gastric Cancer

Laparoscopic gastrectomy is evolving. With the increasing expertise and experience of oncologic surgeons in the minimally invasive surgery for gastric cancer, the indication for laparoscopic gastrectomy is expanding to advanced cases. Many studies have demonstrated the benefits of minimally invasive surgery, including reduced risk of surgery-related injury, reduced blood loss, less pain, and earlier recovery. In order to establish concrete evidence for the suitability of minimal invasive surgery for gastric cancer, many multicenter RCTs, comparing the short- and long-term outcomes of laparoscopic versus open surgery, are in progress. Advances in laparoscopic gastrectomy are moving toward increasingly minimally invasive approaches that enable the improvement of the quality of life of patients, without compromising on oncologic safety.

Robotic versus laparoscopic Gastrectomy for gastric cancer: a systematic review and updated meta-analysis

Background

Advanced minimally invasive techniques including robotic surgery are being employed with increasing frequency around the world, primarily in order to improve the surgical outcomes of laparoscopic gastrectomy (LG). We conducted a systematic review and meta-analysis to evaluate the feasibility, safety and efficacy of robotic gastrectomy (RG).

Methods

Studies, which compared surgical outcomes between LG and RG, were retrieved from medical databases before May 2017. Outcomes of interest were estimated as weighted mean difference (WMD) or risk ratio (RR) using the random-effects model. The software Review Manage version 5.1 was used for all calculations.

Results

Nineteen comparative studies with 5953 patients were included in this analysis. Compared with LG, RG was associated with longer operation time (WMD = −49.05 min; 95% CI: -58.18 ~ −39.91, P < 0.01), less intraoperative blood loss (WMD = 24.38 ml; 95% CI: 12.32 ~ 36.43, P < 0.01), earlier time to oral intake (WMD = 0.23 days; 95% CI: 0.13 ~ 0.34, P < 0.01), and a higher expense (WMD = −3944.8 USD; 95% CI: -4943.5 ~ −2946.2, P < 0.01). There was no significant difference between RG and LG regarding time to flatus, hospitalization, morbidity, mortality, harvested lymph nodes, and cancer recurrence.

Conclusions

RG can be performed as safely as LG. However, it will take more effort to decrease operation time and expense.

Laparoscopic gastrectomy in obese gastric cancer patients: a comparative study with non-obese patients and evaluation of difference in laparoscopic methods

Background

Obesity is a growing epidemic around the world, and obese patients are generally regarded as high risk for surgery compared with normal weight patients. The purpose of this study was to evaluate the influence of obesity on the surgical outcomes of laparoscopic gastrectomy (LG) for gastric cancer.

Methods

We reviewed data for all patients undergoing LG for gastric cancer at our institute between October 2004 and December 2016. Patients were divided into non-obese and obese groups and the perioperative outcomes were compared. Furthermore, a subgroup analysis was conducted to evaluate which of the two commonly used methods of LG, laparoscopic-assisted gastrectomy (LAG) and totally laparoscopic gastrectomy (TLG), is more suitable for obese patients.

Results

A total of 1691 patients, 1255 non-obese and 436 obese or overweight patients, underwent LG during the study period. The mean operation time was significantly longer in the obese group than in the non-obese group (209.9 ± 29.7 vs. 227.2 ± 25.7 min, P < 0.01), and intraoperative blood loss was significantly lower in the non-obese group (113.4 ± 34.1 vs. 136.9 ± 36.7 ml, P < 0.01). Time to first flatus, time to oral intake, and postoperative hospital stay were significantly shorter in the non-obese group than in the obese group (3.3 ± 0.8 vs. 3.6 ± 0.9 days; 4.3 ± 1.0 vs. 4.6 ± 1.0 days; and 9.0 ± 2.2 vs. 9.6 ± 2.2 days, respectively; P < 0.01). 119 (9.5%) of the non-obese patients had postoperative complications as compared to 44 (10.1%) of the obese patients (P = 0.71). In the subgroup analysis of all patients, TLG showed improved results for early surgical outcomes compared to LAG, mainly due to its advantages in obese patients.

Conclusions

Obesity is associated with long operation time, increased blood loss, and slow recovery after laparoscopic gastric resection but does not affect intraoperative security or effectiveness. TLG may have less negative results in obese patients than LAG due to a variety of reasons. Our analysis shows that TLG is more advantageous, with regard to early surgical outcomes, for obese patients.

Comparison of the cost and outcomes following totally laparoscopic and laparoscopy-assisted distal gastrectomies for gastric cancer: a single-institution comparison

OBJECTIVE

This study aimed to compare the short-term surgical outcomes and cost-benefits following totally laparoscopic distal gastrectomy (TLDG) and laparoscopy-assisted distal gastrectomy (LADG) for the treatment of gastric cancer.

METHODS

Between April 2007 and December 2013, a total of 100 patients with gastric cancer underwent laparoscopic distal gastrectomy. The patients were classified into two groups according to whether intracorporeal anastomosis or extracorporeal anastomosis had been performed. The comparison between the groups was based on clinicopathological characteristics and surgical and economic outcomes.

RESULTS

There were 57 and 43 patients who underwent TLDG and LADG, respectively. The patients' demographics and tumor characteristics did not show any statistically significant differences with the exception for tumor location. In the LADG group, tumors were localized to relatively higher positions (p = 0.024) and received Roux-en-Y reconstruction more frequently (p < 0.001). There were no differences in the incidence of morbidity. Anastomotic leakage was not recorded in either group, although anastomotic stenosis occurred in one patient (1.8 %) after TLDG and in two patients (4.7 %) after LADG. Compared with the LADG group, the TLDG group was associated with significantly less operative blood loss (p < 0.001), a shorter time to oral intake (p = 0.012), and hospital stay (p = 0.018). The median operation costs were greater in the TLDG group than in the LADG group (¥982,000 in TLDG vs. ¥879,830 in LADG; p < 0.001), whereas the median total hospital costs were similar between the two groups (¥1302,665 in LADG vs. ¥1383,322 in TLDG: p = 0.119).

CONCLUSION

This study suggests that TLDG is as technically feasible, safe, and effective as LADG for treating patients with gastric cancer. Furthermore, TLDG is associated with equivalent total hospital costs compared with LADG. The increased operation cost is offset by the decreased costs associated with longer periods of hospitalization.

Comparison of short-term outcomes and acute inflammatory response between laparoscopy-assisted and totally laparoscopic distal gastrectomy for early gastric cancer

Purpose

Laparoscopic gastrectomy is widely used to treat early gastric cancer. The advantages of totally laparoscopic distal gastrectomy (TLDG) are unproven, and some concerns remain regarding the early surgical outcomes due to its technical difficulty. We compared the early surgical outcomes and acute inflammatory response between patients undergoing TLDG and laparoscopy-assisted distal gastrectomy (LADG) for treatment of early gastric cancer.

Methods

We performed a retrospective study on 212 consecutive patients who underwent laparoscopic distal gastrectomy for gastric cancer between January 2008 and June 2014. A total of 179 LADG cases and 33 TLDG cases were included. After age, sex, body mass index, and American Society of Anesthesiologists physical status score were matched using propensity score matching (PSM), we compared the short-term surgical outcomes between the LADG and TLDG groups.

Results

The TLDG group had a shorter hospital stay (9.5 days vs. 11.0 days, P = 0.046) and less blood loss (116.6 mL vs. 141.5 mL, P = 0.031) than those in the LADG group. There were no differences in the preoperative WBC count and CRP level and the other clinical data between the two groups after PSM. Postoperative WBC count, serum CRP level, and decrease rate of WBC count in the TLDG group were significantly lower than those in the LADG group.

Conclusion

The short-term outcomes of TLDG revealed better than that of LADG in this study. Therefore, TLDG is one of the safe and feasible procedure for the treatment of early gastric cancer.

Surgical outcomes of 2041 consecutive laparoscopic gastrectomy procedures for gastric cancer: a large-scale case control study

Background

Laparoscopic gastrectomy (LG) for gastric cancer has increased in popularity due to advances in surgical techniques. The aim of this study is to validate the efficacy and safety of laparoscopic gastrectomy for gastric cancer compared with open gastrectomy (OG).

Methods

The study comprised 3,580 patients who were treated with curative intent either by laparoscopic gastrectomy (2,041 patients) or open gastrectomy (1,539 patents) between January 2005 and October 2013. The surgical outcomes were compared between the two groups.

Results

Laparoscopic gastrectomy was associated with significantly less blood loss, transfused patient number, time to ground activities, and post-operative hospital stay, but with similar operation time, time to first flatus, and time to resumption of diet, compared with the open gastrectomy. No significant difference in the number of lymph nodes dissected was observed between these two groups. The morbidity and mortality rates of the LG group were comparable to those of the OG group (13.6% vs. 14.4%, P = 0.526, and 0.3% vs. 0.2%, P = 0.740). The 3-year disease-free and overall survival rates between the two groups were statistically significant (P<0.05). According to the UICC TNM classification of gastric cancer, the 3-year disease-free and overall survival rates were not statistically different at each stage.

Conclusions

Our single-center study of a large patient series revealed that LG for gastric cancer yields comparable surgical outcomes. This result was also true of local advanced gastric cancer (AGC). A well-designed randomized controlled trial comparing surgical outcomes between LG and OG in a larger number of patients for AGC can be carried out.

Three-step hand-assisted laparoscopic d2 radical gastrectomy for chinese obese patients: a highly efficient and feasible surgical approach

Three-step hand-assisted laparoscopic D2 radical gastrectomy (HALG) is a modified surgical procedure that has achieved satisfactory results for obese patients in our surgical center. To fully elucidate the advantages of this procedure, in this study, comprehensive and in-depth comparative analyses were performed to assess clinical data from obese gastric cancer patients who underwent HALG, laparoscopic-assisted D2 radical gastrectomy (LAG), and open D2 radical gastrectomy (OG) in our surgical center during a specific time period. For the 3 groups, incision length was 1.25 cm longer for the HALG group than for the LAG group but was significantly shorter for the HALG group than for the OG group (P =0.00). The rate of conversion to laparotomy , the pneumoperitoneum time and the number of recovered lymph nodes were significantly better for the HALG group than for the LAG group (P <0.05). The pain score at day 2 after surgery, intestinal function recovery time, and duration of postoperative hospital stay were not significantly different for the HALG and LAG groups ( P >0.05) but were significantly better for the HALG group than for the OG group (P <0.05). There were significantly fewer postoperative complications for the HALG group than for the LAG and OG groups (P =0.049). According to the results, the “three-step HALG method” incorporates both the thoroughness of the radical OG approach and the minimal invasiveness of the LAG approach for obese patients. Thus, the HALG approach is a relatively safe and extremely feasible surgical procedure for the treatment of these patients.

Totally laparoscopic gastrectomy for gastric cancer: A systematic review and meta-analysis of outcomes compared with open surgery

AIM: To systematically review the surgical outcomes of totally laparoscopic gastrectomy (TLG) vs open gastrectomy (OG) for gastric cancer.

METHODS: A systematic search of PubMed, Embase, Cochrane Library, and Web of Science was conducted. All original studies comparing TLG with OG were included for critical appraisal. Data synthesis and statistical analysis were carried out using RevMan 5.1 software.

RESULTS: One RCT and 13 observational studies involving 1532 patients were included (721 TLG and 811 OG). TLG was associated with longer operation time [weighted mean difference (WMD) = 58.04 min, 95%CI: 37.77-78.32, P < 0.001], less blood loss [WMD = -167.57 min, 95%CI: -208.79-(-126.34), P < 0.001], shorter hospital stay [WMD = -3.75 d, 95%CI: -4.88-(-2.63), P < 0.001] and fewer postoperative complications (RR = 0.71, 95%CI: 0.58-0.86, P < 0.001). The number of harvested lymph nodes, surgical margin, mortality and cancer recurrence rate were similar between the two groups.

CONCLUSION: TLG may be a technically safe, feasible and favorable approach in terms of better cosmesis, less blood loss and faster recovery compared with OG.

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.

Race/Ethnicity is predictive of lymph node status in patients with early gastric cancer

BACKGROUND

Race/ethnicity has long been suspected to affect survival in patients with gastric adenocarcinoma. However, the clinicohistopathological impact of race or ethnicity on early gastric cancer (EGC) is not known.

METHODS

From 2000 to 2013, 286 patients underwent gastrectomy and 104 patients had pathological confirmation of EGC. A retrospective analysis of pathological and clinical prognostic indicators was performed.

RESULTS

The study population consisted of 38 (37%) Asian Americans and 66 (63%) non-Asian Americans. Of these, 2 (5.3%) Asian Americans and 19 (28.8%) non-Asian Americans had pathological confirmation of lymph node metastasis (LNM) (p = 0.004). Univariate analysis comparing the clinicohistopathological characteristics in each group did not reveal significant difference regarding histotype, tumor size, grade, location, morphology, or lymphovascular invasion, except for the LNM rate and mean body mass index (23.2 versus 26.6, p < 0.001). Multivariate analysis showed that non-Asian race/ethnicity (odds ratio (OR), 9.09; 95% confidence interval (CI), 1.12-71.43; p = 0.038), younger age (OR, 1.11; 95% CI, 1.01-1.12; p = 0.046), and lymphovascular invasion (OR, 13.9; 95% CI, 2.40-79.99; p = 0.003) were significant predictors for LNM.

CONCLUSIONS

This study demonstrated that Asian American race in EGC is associated with a significantly decreased rate of LNM in comparison to non-Asian Americans, despite similar histopathological characteristics of each group.