Laparoscopic gastrectomy versus open gastrectomy for gastric cancer in patients with body mass index of 30 kg/m2 or more

Positive impact of laparoscopic hepatectomy versus open hepatectomy on body size-corrected bleeding in obese patients

PURPOSE

Laparoscopic hepatectomy (LH) is reported to cause less bleeding than open hepatectomy (OH) in obese patients; however, there are no reports addressing this issue in terms of body size-corrected bleeding.

METHODS

The subjects of this study were 31 obese and 149 non-obese patients who underwent LH and 32 obese and 245 non-obese patients who underwent OH. Bleeding corrected for body surface area (C-BL) was compared between the obese and non-obese patients who underwent each procedure. A multivariate analysis for increased C-BL was performed using the median C-BL for each procedure.

RESULTS

The median C-BL tended to be higher in the obese patients than in the non-obese patients who underwent LH, but there was no significant difference (72 vs. 42 mL/m2, P = 0.050). However, it was significantly higher in the obese patients than in the non-obese patients who underwent OH (542 vs. 333 mL/m2, P = 0.002). In a multivariate analysis, for OH, sectionectomy or more (OR 3.20, P < 0.001) and a high BMI (OR 2.76, P = 0.018) were found to be independent risk factors, whereas for LH, a high BMI was not (OR 1.58, P = 0.301).

CONCLUSIONS

Obesity was identified as a risk factor for increased bleeding with body size correction for OH, but the risk was reduced for LH.

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.

Minimally invasive approaches increase postoperative complications in obese patients undergoing pancreaticoduodenectomy during the initial development period: a propensity score matching study

BACKGROUND

Obesity increases surgical risks in various abdominal surgeries and its impact on open pancreaticoduodenectomy (OPD) and minimally invasive pancreaticoduodenectomy (MIPD) remains unknown. This study aimed to compare the surgical outcomes of OPD and MIPD in obese and non-obese patients by propensity score matching (PSM) analysis during the implementation of MIPD.

METHODS

We retrospectively reviewed all pancreaticoduodenectomies from December 2014 to May 2021. Obesity was defined as body mass index > 25 kg/m² according to World Health Organization International Obesity Task Force. PSM was used to minimize the selection bias of MIPD.

RESULTS

Among 462 pancreaticoduodenectomies (339 OPDs, 123 MIPDs), there were 313 patients in the non-obese group (MIPD: 78, OPD: 235) and 149 patients in the obese group (MIPD: 45, OPD: 104). After PSM, there were 70 MIPD/106 OPD patients in the non-obese group and 38 MIPD/54 OPD patients in the obese group. The obese MIPD patients had more fluid collection (36.8% vs 9.8%, p = 0.002), a higher Clavien-Dindo (CD) grade (p = 0.007), more major complications (42.1% vs 14.8%, p = 0.004), and longer operative times (306 min vs 264 min, p < 0.001) than the obese OPD patients. The non-obese MIPD patients had lower CD grades (p = 0.02), longer operative times (294 vs 264 min, p < 0.001), and less blood loss (100 mL vs 200 mL) than the non-obese OPD patients. MIPD was a strong predictor of major complication (CD ≥ 3) in obese patients (odds ratio 3.11, 95% CI: 1.40-6.95, p = 0.005).

CONCLUSIONS

Minimally invasive approaches deteriorate the CD grade, fluid collection, and major complications in obese patients undergoing pancreaticoduodenectomy during the initial development period. Non-obese patients may benefit from MIPD over OPD in terms of less blood loss and lower CD grades. The impact of BMI on MIPD should be considered when assessing the surgical risks.

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

Background

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

Methods

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

Results

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

Conclusions

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

Supplementary Information

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

Effects of a high body mass index on the short-term outcomes and prognosis after radical gastrectomy

PURPOSE

This study aimed to investigate the effects of a high body mass index (BMI) on the outcomes of radical gastrectomy for gastric cancer.

METHODS

We conducted a retrospective cohort study of 1729 patients with stage I to III gastric cancer who received open radical gastrectomy from February 2003 to August 2011. The patients were divided into 3 groups according to their BMI: a low BMI group (BMI < 18.5 kg/m²), normal BMI group (18.5 ≤ BMI < 25 kg/m²), and high BMI group (BMI ≥ 25 kg/m²).

RESULTS

A total of 871 patients were included in the final analysis, of which the median BMI was 22.7 kg/m² (range 13.6-44.9 kg/m²). A high BMI increased the risk of postoperative intestinal fistula but not the risk of a reduced number of examined lymph nodes or hospital death. Furthermore, a high BMI did not negatively affect the overall survival (OS) of gastric cancer patients.

CONCLUSIONS

A high BMI increased the operative morbidity after radical gastrectomy for gastric cancer. However, a high BMI did not negatively affect the quality of lymphadenectomy or the OS of gastric cancer patients in experienced high-volume centers. A careful approach during operation and meticulous perioperative management are required for gastric cancer patients with a high BMI.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Impact of obesity on short- and long-term outcomes of laparoscopy assisted distal gastrectomy for gastric cancer

BACKGROUND

Laparoscopy assisted distal gastrectomy (LADG) for gastric cancer has been rapidly adopted for the treatment of both early and advanced gastric cancers which need lymph node dissection, but remains difficult procedure, especially in patients with obesity. We evaluated the impact of obesity on short- and long-term outcomes of LADG for gastric cancer.

METHODS

We retrospectively investigated 243 patients who underwent LADG for gastric cancer between January 2007 and December 2014. The patients were classified based on their body mass index (BMI) into the Obese (BMI ≥ 25) and Non-Obese (BMI < 25) Groups. Patient characteristics, clinicopathologic and operative findings, and short- and long-term outcomes were investigated and compared between the groups.

RESULTS

The groups did not differ in age, sex, American Society of Anesthesiologists score, the presence of comorbidities, or pathologic stage. Operative time (265 ± 46.6 vs. 244 ± 55.6 min; P = 0.007) and estimated blood loss (113 ± 101.4 vs. 66.5 ± 95.2 ml; P = 0.007) were greater in the Obese Group. Fewer lymph nodes were retrieved in the Obese Group (38 ± 23.7 vs. 47.5 ± 24.3; P = 0.004). No differences were evident in postoperative complication rate (20% vs. 17%; P = 0.688) or the duration of postoperative hospital stay (9 ± 8.5 vs. 9 ± 5.1 days; P = 0.283) between the two groups. In the Obese Group, the 5-year overall survival rate was significantly lower than in the Non-Obese Group (67.6% vs. 90.3%; P = 0.036). Furthermore, 5-year disease-specific survival was significantly lower in the Obese Group than in the Non-Obese Group (72.7% vs. 94.9%; P = 0.015).

CONCLUSIONS

LADG in patients with obesity could be performed as safe as in patients without obesity, with comparable postoperative results. But obesity may be a poor prognostic factor in gastric cancer.

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

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

Is There any Role of Visceral Fat Area for Predicting Difficulty of Laparoscopic Gastrectomy for Gastric Cancer?

PURPOSE

Obesity is associated with morbidity following gastric cancer surgery, but whether obesity influences morbidity after laparoscopic gastrectomy (LG) remains controversial. The present study evaluated whether body mass index (BMI) and visceral fat area (VFA) predict postoperative complications.

MATERIALS AND METHODS

A total of 217 consecutive patients who had undergone LG for gastric cancer between May 2003 and December 2005 were included in the present study. We divided the patients into two groups ('before learning curve' and 'after learning curve') based on the learning curve effect of the surgeon. Each of these groups was sub-classified according to BMI (<25 kg/m(2) and ≥25 kg/m(2)) and VFA (<100 cm(2) and ≥100 cm(2)). Surgical outcomes, including operative time, quantity of blood loss, and postoperative complications, were compared between BMI and VFA subgroups.

RESULTS

The mean operative time, length of hospital stay, and complication rate were significantly higher in the before learning curve group than in the after learning curve group. In the subgroup analysis, complication rate and length of hospital stay did not differ according to BMI or VFA; however, for the before learning curve group, mean operative time and blood loss were significantly higher in the high VFA subgroup than in the low VFA subgroup (P=0.047 and P=0.028, respectively).

CONCLUSIONS

VFA may be a better predictive marker than BMI for selecting candidates for LG, which may help to get a better surgical outcome for inexperienced surgeons.