Evaluation of laparoscopic total gastrectomy for advanced gastric cancer: results of a comparison with laparoscopic distal gastrectomy

A meta-analysis evaluating wound infections and other complications following distal versus complete gastrectomy for gastric cancer

A meta-analysis investigation was carried out to measure the wound infections (WIs) and other postoperative problems (PPs) of distal gastrectomy (DG) compared with total gastrectomy (TG) for gastric cancer (GC). A comprehensive literature investigation till February 2023 was used and 1247 interrelated investigations were reviewed. The 12 chosen investigations enclosed 2896 individuals with GC in the chosen investigations' starting point, 1375 of them were TG, and 1521 were DG. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were utilized to compute the value of the WIs and other PPs of DG compared with TG for GC by the dichotomous approaches and a fixed or random model. TG had significantly higher overall PP (OR, 1.58; 95% CI, 1.15-2.18, p = 0.005), WIs (OR, 1.69; 95% CI, 1.07-2.67, p = 0.02), peritoneal abscess (PA) (OR, 2.99; 95% CI, 1.67-5.36, p < 0.001), anastomotic leakage (AL) (OR, 1.90; 95% CI, 1.21-2.97, p = 0.005) and death (OR, 2.26; 95% CI, 1.17-4.37, p = 0.02) compared to those with DG in individuals with GC. TG had significantly higher overall PP, WIs, PA, AL and death compared to those with DG in individuals with GC. However, care must be exercised when dealing with its values because of the low sample size of some of the nominated investigations for the meta-analysis.

Indocyanine green fluorescence imaging-guided versus conventional laparoscopic lymphadenectomy for gastric cancer: long-term outcomes of a phase 3 randomised clinical trial

Indocyanine green (ICG) fluorescence imaging-guided lymphadenectomy has been demonstrated to be effective in increasing the number of lymph nodes (LNs) retrieved in laparoscopic gastrectomy for gastric cancer (GC). Previously, we reported the primary outcomes and short-term secondary outcomes of a phase 3, open-label, randomized clinical trial (NCT03050879) investigating the use of ICG for image-guided lymphadenectomy in patients with potentially resectable GC. Patients were randomly (1:1 ratio) assigned to either the ICG or non-ICG group. The primary outcome was the number of LNs retrieved and has been reported. Here, we report the primary outcome and long-term secondary outcomes including three-year overall survival (OS), three-year disease-free survival (DFS), and recurrence patterns. The per-protocol analysis set population is used for all analyses (258 patients, ICG [n = 129] vs. non-ICG group [n = 129]). The mean total LNs retrieved in the ICG group significantly exceeds that in the non-ICG group (50.5 ± 15.9 vs 42.0 ± 10.3, P < 0.001). Both OS and DFS in the ICG group are significantly better than that in the non-ICG group (log-rank P = 0.015; log-rank P = 0.012, respectively). There is a difference in the overall recurrence rates between the ICG and non-ICG groups (17.8% vs 31.0%). Compared with conventional lymphadenectomy, ICG guided laparoscopic lymphadenectomy is safe and effective in prolonging survival among patients with resectable GC.

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.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Comparison of submucosal and subserosal approaches toward optimized indocyanine green tracer-guided laparoscopic lymphadenectomy for patients with gastric cancer (FUGES-019): a randomized controlled trial

BACKGROUND

Application of indocyanine green (ICG) fluorescence imaging is effective in guiding laparoscopic radical lymphadenectomy for gastric cancer. However, the optimal approach for indocyanine green injection is controversial. Therefore, the objective of this study was aimed to compare the efficacy and ICG injection between the preoperative submucosal and intraoperative subserosal approaches for lymph node (LN) tracing during laparoscopic gastrectomy.

METHOD

This randomized controlled trial (ClinicalTrials.gov, NCT04219332) included 266 patients with potentially resectable gastric cancer (cT1-T4a, N0/+, M0) enrolled from a tertiary teaching center between December 2019 and October 2020. The primary endpoint was total number of retrieved LNs.

RESULTS

In total, 259 patients (n = 130 and n = 129 in the submucosal and subserosal groups, respectively) were included in the per-protocol analysis. There are no significant differences in total number of retrieved LNs between the two groups (49.8 vs. 49.2, P = 0.713). The rate of LN noncompliance in the submucosal group was comparable to that in the subserosal group (32.3% vs. 33.3%, P = 0.860). No significant difference was found between the submucosal and subserosal groups in terms of the incidence (17.7% vs. 16.3%; P = 0.762) or severity of postoperative complications. The mean fluorescence cost in the submucosal group was higher than that in the subserosal group ($335.3 vs. $182.4; P < 0.001). The overall treatment satisfaction score was lower in the submucosal group than in the subserosal group (70.5 vs. 76.1%, P = 0.048).

CONCLUSION

ICG administered by subserosal injection was comparable to that administered by submucosal injection for lymph node tracing in gastric cancer. However, the former approach imposed a lower economic and mental burden on patients undergoing laparoscopic D2 lymphadenectomy.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04219332 .

Safety and Efficacy of Indocyanine Green Tracer-Guided Lymph Node Dissection During Laparoscopic Radical Gastrectomy in Patients With Gastric Cancer: A Randomized Clinical Trial

Importance

The application of indocyanine green (ICG) imaging in laparoscopic radical gastrectomy is in the preliminary stages of clinical practice, and its safety and efficacy remain controversial.

Objective

To investigate the safety and efficacy of ICG near-infrared tracer-guided imaging during laparoscopic D2 lymphadenectomy in patients with gastric cancer.

Design, Setting, and Participants

Patients with potentially resectable gastric adenocarcinoma (clinical tumor stage cT1-cT4a, N0/+, M0) were enrolled in a prospective randomized clinical trial at a tertiary referral teaching hospital between November 2018 and July 2019. Patients were randomly assigned to the ICG group or the non-ICG group. The number of retrieved lymph nodes, rate of lymph node noncompliance, and postoperative recovery data were compared between the groups in a modified intention-to-treat analysis. Statistical analysis was performed from August to September 2019.

Interventions

The ICG group underwent laparoscopic gastrectomy using near-infrared imaging after receiving an endoscopic peritumoral injection of ICG to the submucosa 1 day before surgery.

Main Outcomes and Measures

Total number of retrieved lymph nodes.

Results

Of 266 participants randomized, 133 underwent ICG tracer-guided laparoscopic gastrectomy, and 133 underwent conventional laparoscopic gastrectomy. After postsurgical exclusions, 258 patients were included in the modified intention-to-treat analysis, which comprised 129 patients (86 men and 43 women; mean [SD] age, 57.8 [10.7] years) in the ICG group and 129 patients (87 men and 42 women; mean [SD] age, 60.1 [9.1] years) in the non-ICG group. The mean number of lymph nodes retrieved in the ICG group was significantly more than the mean number retrieved in the non-ICG group (mean [SD], 50.5 [15.9] lymph nodes vs 42.0 [10.3] lymph nodes, respectively; P < .001). Significantly more perigastric and extraperigastric lymph nodes were retrieved in the ICG group than in the non-ICG group. In addition, the mean total number of lymph nodes retrieved in the ICG group within the scope of D2 lymphadenectomy was also significantly greater than the mean number retrieved in the non-ICG group (mean [SD], 49.6 [15.0] lymph nodes vs 41.7 [10.2] lymph nodes, respectively; P < .001). The lymph node noncompliance rate of the ICG group (41 of 129 patients [31.8%]) was lower than that of the non-ICG group (74 of 129 patients [57.4%]; P < .001). The postoperative recovery process was comparable, and no significant difference was found between the ICG and non-ICG groups in the incidence (20 of 129 patients [15.5%] vs 21 of 129 [16.3%], respectively; P = .86) or severity of complications within 30 days after surgery.

Conclusions and Relevance

Indocyanine green can noticeably improve the number of lymph node dissections and reduce lymph node noncompliance without increased complications in patients undergoing D2 lymphadenectomy. Indocyanine green fluorescence imaging can be performed for routine lymphatic mapping during laparoscopic gastrectomy, especially total gastrectomy.

Trial Registration

ClinicalTrials.gov Identifier: NCT03050879.

Comparative study between total and subtotal gastrectomy for distal gastric cancer: Meta-analysis of prospective and retrospective studies

There is no clear agreement on the type of gastrectomy to be used (either total [TG] or distal [DG]) in middle or distal gastric cancer, especially when it is undifferentiated or Lauren diffuse type. In this meta-analysis, we intend to define which of the 2techniques should be recommended, based on survival, morbidity and mortality rates. Prospective and retrospective studies comparing both techniques have been included for a total of 6303 patients (3,641 DG and 2,662 TG). DG was significantly associated with fewer complications, fewer anastomotic fistulae, and less perioperative mortality. The number of lymph nodes in DG was significantly lower, but always above 15. Finally, even the 5-year survival of DG was also higher. Therefore, DG, as long as a safety margin is obtained and regardless of the histological type, should be performed in surgery for distal stomach cancer.

Impact of anastomotic leak on long-term survival in patients undergoing gastrectomy for gastric cancer

BACKGROUND

The impact of anastomotic leak (AL) on long-term outcomes after gastrectomy for gastric adenocarcinoma is poorly understood. This study determined whether AL contributes to poor overall survival.

METHODS

Consecutive patients undergoing gastrectomy in a single high-volume unit between 1997 and 2016 were evaluated. Clinicopathological characteristics, oncological and postoperative outcomes were stratified according to whether patients had no AL, non-severe AL or severe AL. Severe AL was defined as anastomotic leakage associated with Clavien-Dindo Grade III-IV complications.

RESULTS

The study included 969 patients, of whom 58 (6·0 per cent) developed AL; 15 of the 58 patients developed severe leakage. Severe AL was associated with prolonged hospital stay (median 50, 30 and 13 days for patients with severe AL, non-severe AL and no AL respectively; P < 0·001) and critical care stay (median 11, 0 and 0 days; P < 0·001). There were no significant differences between groups in number of lymph nodes harvested (median 29, 30 and 28; P = 0·528) and R1 resection rates (7, 5 and 6·5 per cent; P = 0·891). Cox multivariable regression analysis showed that severe AL was independently associated with overall survival (hazard ratio 3·96, 95 per cent c.i. 2·11 to 7·44; P < 0·001) but not recurrence-free survival. In sensitivity analysis, the results for patients who had neoadjuvant therapy then gastrectomy were similar to those for the entire cohort.

CONCLUSION

AL prolongs hospital stay and is associated with compromised long-term overall survival.

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.

Clinicopathological Evaluation of Gastric Signet Ring Cell Carcinoma: Our Experience

Aim

Gastric cancer is one of the most common cancers worldwide. In Turkey, stomach cancer is ranked 5th among men and 8th among women in all cancers and is located in the forefront in cancer-related deaths. Signet ring cell adenocarcinoma, which is the histopathological subtype of gastric cancer, has a poor prognosis. The incidence of signet ring cell adenocarcinoma is rising. In the present study, we aimed to describe the clinicopathologic features of signet ring cell adenocarcinoma.

Materials and Methods

A total of 79 patients with 30 being female (38%) and 49 male (62%) who were diagnosed with gastric signet ring cell adenocarcinoma in the Medical Oncology Department of Ankara Numune Training and Research Hospital between January 2004 and October 2015 were retrospectively evaluated.

Results

The baseline demographic characteristics of the patients, such as tumor localization, tumor stage, preoperative serum tumor markers, and treatment type (surgery and chemotherapy regimen), and the effects of these variables on survival and mortality were evaluated. Total surgery, stage III disease, moderate to poor grade, preoperative serum CA 19-9 and CEA levels were found as independent predictors of progression risk (p < 0.05). Each 1 ng/mL increase in preoperative serum CEA level was found to increase the risk of progression by 1.20 folds. Again, each 1 U/mL in preoperative serum CA 19-9 level was found to increase the risk of progression and mortality by 1.06 folds.

Conclusion

The clinicopathologic features of signet ring cell stomach cancer were described. Tumor localization and disease, CA 19-9 and CEA levels, and treatment type (surgery and chemotherapy regimen) were effective on survival and mortality. However, further studies with larger patient groups are needed on this issue.

How to cite this article

Altay SB, Akkurt G, Yılmaz N, et al. Clinicopathological Evaluation of Gastric Signet Ring Cell Carcinoma: Our Experience. Euroasian J Hepato-Gastroenterol 2020;10(2):76–84.

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.

Postoperative dynamic survival of gastric cancer patients: A multi-institutional, international analysis of 22 265 patients

BACKGROUND

How to best evaluate the disease-specific survival (DSS) of gastric cancer (GC) survivors over time is unclear.

METHODS

Clinicopathological data from 22 265 patients who underwent curative intend resection for GC were retrospectively analyzed. Changes in the patients' 3-year conditional disease-specific survival (CS3) were analyzed. We used time-dependent Cox regression to analyze which variables had long-term effects on DSS and devised a dynamic predictive model based on the length of survival.

RESULTS

Based on 1-, 3-, and 5-year survivorships, the CS3 of the population increased gradually from 62% to 68.1%, 83.7%, and 90.6%, respectively. Subgroup analysis showed that the CS3 of patients who had poor prognostic factors initially demonstrated the greatest increase in postoperative survival time (eg, N3b: 26.6%-84.1%, Δ57.5% vs N0: 84.1%-93.3%, Δ9.2%). Time-dependent Cox regression analysis showed the following predictor variables constantly affecting DSS: age, the number of examined lymph nodes (LNs), T stage, N stage, and site (P < .05). These variables served as the basis for a dynamic prediction model.

CONCLUSIONS

The influence of prognostic factors on DSS and CS3 changed dramatically over time. We developed an effective model for predicting the DSS of patients with GC based on the length of survival time.

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.

Does Noncompliance in Lymph Node Dissection Affect Oncological Efficacy in Gastric Cancer Patients Undergoing Radical Gastrectomy?

BACKGROUND

Few reports have examined the prognosis of or possible remedial treatments for patients with noncompliant D2 lymphadenectomy. We investigated the effect of noncompliance in lymph node (LN) dissection on long-term survival in gastric cancer (GC) patients after radical gastrectomy and explored intervention measures.

METHODS

Clinicopathological data were retrospectively analyzed in 2401 patients who underwent radical gastrectomy for GC. Noncompliance was defined as patients with more than one empty LN station, as described in the protocol of the Japanese GC Association.

RESULTS

The overall noncompliance rate was 49.1%. The 3-year overall survival (OS) rate was significantly better in compliant than noncompliant patients (74.0% vs. 60.1%, P < 0.001). Univariate and multivariate analyses revealed that noncompliance was an independent risk factor for OS. Logistic regression analysis demonstrated that extent of gastrectomy, primary tumor site, history of intraperitoneal surgery, body mass index, and open gastrectomy were independent preoperative predictive factors for noncompliance. Cox analysis demonstrated that age, pT, pN, and extent of gastrectomy independently affected OS in patients with noncompliant lymphadenectomy. However, OS was significantly better in the compliant than noncompliant group regardless of the recommendation for chemotherapy. Stratified analysis demonstrated that OS was significantly better in chemotherapy patients than in patients without chemotherapy and stage II patients (pT1N2/N3M0 and pT3N0M0) in whom chemotherapy was not recommended.

CONCLUSIONS

Noncompliance is an independent risk factor after radical gastrectomy for GC. Adjuvant chemotherapy improved the prognosis of patients with pT1N2/N3M0 and pT3N0M0 disease who underwent noncompliant D2 lymphadenectomy.

Severity and incidence of complications assessed by the Clavien-Dindo classification following robotic and laparoscopic gastrectomy for advanced gastric cancer: a retrospective and propensity score-matched study

BACKGROUND

Robot-assisted gastrectomy (RAG) has been increasingly used for the treatment of advanced gastric cancer (AGC), and many advantages over laparoscopy-assisted gastrectomy (LAG) have been reported. However, its postgastrectomy complications still under investigation and the results remain controversial. This study aimed to objectively assess the incidence and severity of complications following RAG vs. LAG using Clavien-Dindo (C-D) classification and to identify risk factors related to complications.

METHODS

Five hundred and twenty-seven patients with AGC who underwent RAG or LAG between January 2016 and May 2018 were enrolled in this study. Complications were categorized according to the C-D classification. The complications following RAG and LAG were compared using one-to-one propensity score matching (PSM) analysis and subgroup analyses. Logistic regression analyses were performed to identify risk factors related to complications.

RESULTS

RAG was performed in 251 patients (47.6%) and LAG in 276 patients (52.4%). Before PSM, the RAG group had a smaller tumour size (P = 0.004) and less patients with previous abdominal operation (P = 0.013). After PSM, a well-balanced cohort of 446 patients (223 in each group) was further analyzed. Of interest, the incidence of overall and severe complications (C-D grade ≥ IIIa) following the RAG group were significantly fewer than the LAG group (overall, 24.5% vs. 18.8%, P < 0.001; severe, 8.9% vs. 17.5%, P = 0.002). Subgroup analyses showed statistically significant difference were also observed in most stratified parameters. Multivariable analysis identified age ≥ 65 years, total gastrectomy, stage T3-T4a, stage II-III, and operation time ≥ 250 min as independent predictors of overall complications. Additionally, age ≥ 65 years, stage II-III, and operation time ≥ 250 min were confirmed as independent risk factors for severe complications.

CONCLUSIONS

RAG with D2 lymphadenectomy is feasible and safe for the treatment of AGC in terms of the lower incidence and severity of complications.

Impact of body mass index on short-term outcomes of laparoscopic gastrectomy in Asian patients: A meta-analysis

AIM

To perform a meta-analysis to investigate the correlation between body mass index (BMI) and the short-term outcomes of laparoscopic gastrectomy (LG) for gastric cancer (GC) in Asian patients.

METHODS

The PubMed, Cochrane, EMBASE, and Web of Science databases were searched for studies that focused on the impact of obesity on the short-term outcomes of LG for GC in Asian patients who were classified into a high BMI (BMI ≥ 25 kg/m²) or low BMI group (BMI < 25 kg/m²). The results are expressed using the pooled odds ratio (OR) for binary variables and standard mean difference (SMD) for continuous variables with 95% confidence interval (CI), and were calculated according to the fixed-effects model while heterogeneity was not apparent or a random-effects model while heterogeneity was apparent.

RESULTS

Nine studies, with a total sample size of 6077, were included in this meta-analysis. Compared with the low BMI group, the high BMI group had longer operative time (SMD = 0.26, 95%CI: 0.21 to 0.32, P < 0.001), greater blood loss (SMD = 0.19, 95%CI: 0.12 to 0.25, P < 0.001), and fewer retrieved lymph nodes (SMD = -0.13, 95%CI: 0.18 to 0.07, P < 0.001). There was no significant difference between the high and low BMI groups in postoperative complications (OR = 1.12, 95%CI: 0.95 to 1.33, P = 0.169), the duration of postoperative hospital stay (SMD = 0.681, 95%CI: -0.05 to 0.07, P = 0.681), postoperative mortality (OR = 1.95, 95%CI: 0.78 to 4.89, P = 0.153), or time to resuming food intake (SMD = 0.00, 95%CI: -0.06 to 0.06, P = 0.973).

CONCLUSION

Our meta-analysis provides strong evidence that despite being associated with longer operative time, greater blood loss, and fewer retrieved lymph nodes, BMI has no significant impact on the short-term outcomes of LG for GC in Asian patients, including postoperative complications, the duration of postoperative hospital stay, postoperative mortality, and time to resuming food intake. BMI may be a poor risk factor for short-term outcomes of LG. Other indices should be taken into account.

Comparison of Outcomes for Elderly Gastric Cancer Patients at Least 80 Years of Age Following Gastrectomy in the United States and China

OBJECTIVE

The aim of this study was to compare gastric cancer (GC) patients aged 80 years or older undergoing gastrectomy at two high-volume cancer centers in the US and China.

METHODS

Patients aged ≥ 80 years who underwent R0 resection at Memorial Sloan Kettering Cancer Center (MSKCC) in New York, USA (n = 159), and Fujian Medical University Union Hospital (FMUUH) in Fujian, China (n = 118) from January 2000 to December 2013 were included. Demographic, surgical, and pathologic variables were compared, and factors associated with survival were determined via multivariate analysis.

RESULTS

The number of patients increased annually in the FMUUH cohort but not in the MSKCC cohort. Patients at MSKCC were slightly older (mean age 83.7 vs. 82.7 years), more commonly female (38 vs. 19%), and had higher average body mass index (BMI; 26 vs. 23). Treatment at FMUUH more frequently employed total gastrectomy (59 vs. 20%) and laparoscopic surgery (65 vs. 7%), and less frequently included adjuvant therapy (11 vs. 18%). In addition, FMUUH patients had larger tumors of more advanced T, N, and TNM stage. Morbidity (35 vs. 25%, p = 0.08) and 30-day mortality (2.5 vs. 3.3%, p = 0.67) were similar between the cohorts. For each TNM stage, there was no significant difference between MSKCC and FMUUH patients in 5-year overall survival and disease-specific survival (DSS). TNM stage was the only independent predictor of DSS for both cohorts.

CONCLUSIONS

Patients ≥ 80 years of age selected for gastrectomy for GC at MSKCC and FMUUH had acceptable morbidity and mortality, and DSS was primarily dependent on TNM stage.

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.

Impact of Various Types of Comorbidities on the Outcomes of Laparoscopic Total Gastrectomy in Patients with Gastric Carcinoma

Purpose

With increasing life expectancy, the presence of comorbidities has become a major concern in elderly patients who require surgery. However, little is known about the impact of different comorbidities on the outcomes of laparoscopic total gastrectomy (LTG). In this study, we investigated the impact of comorbidities on postoperative complications in patients undergoing LTG for gastric carcinoma.

Materials and Methods

We retrospectively reviewed the cases of 303 consecutive patients who underwent LTG for gastric carcinoma between 2005 and 2016. The associations between each comorbidity and postoperative complications were assessed using univariate and multivariate analyses.

Results

A total of 189 patients (62.4%) had one or more comorbidities. Hypertension was the most common comorbidity (37.0%), followed by diabetes mellitus (17.8%), chronic viral hepatitis (2.6%), liver cirrhosis (2.6%), and pulmonary (27.1%), ischemic heart (3.3%), and cerebrovascular diseases (2.3%). The overall postoperative morbidity and mortality rates were 20.1% and 1.0%, respectively. Patients with pulmonary disease significantly showed higher complication rates than those without comorbidities (32.9% vs. 14.9%, respectively, P=0.003); patient with other comorbidities showed no significant difference in the incidence of LTG-related complications. During univariate and multivariate analyses, pulmonary disease was found to be an independent predictive factor for postoperative complications (odds ratio, 2.14; 95% confidence interval, 1.03-4.64), along with old age and intraoperative bleeding.

Conclusions

Among the various comorbidities investigated, patients with pulmonary disease had a significantly higher risk of postoperative complications after LTG. Proper perioperative care for optimizing pulmonary function may be required for patients with pulmonary disease.

Severity of complications and long-term survival after laparoscopic total gastrectomy with D2 lymph node dissection for advanced gastric cancer: A propensity score-matched, case-control study

BACKGROUND

Increasing numbers of studies have shown that postoperative complication is a negative predictor of long-term survival outcomes in various malignancies. However, the impact of severity of complications on long-term survival for patients with gastric cancer still remains unclear. This study aimed to explore the relationship between the severity of complications and long-term survival outcomes after laparoscopic total gastrectomy (LTG) for advanced gastric cancer (AGC).

METHODS

The study analyzed 571 patients with AGC who underwent LTG in a single institution between April 2008 and June 2015. Patients were divided into two groups based on the occurrence or absence of postoperative complications which were recorded using the Clavien-Dindo (C-D) classification. Long-term survival outcomes were compared between groups in the propensity score-matched cohort.

RESULTS

The groups were well balanced after the propensity score matched. The complication (C) group was associated with decreased 5-year cancer-specific survival (CSS) (65.1% vs. 76.2%, P=0.049). Subgroup analysis showed that the severe complication (C-D grade > II) group was associated with decreased 5-year overall survival (OS) (46.3% vs. 65.9%, P = 0.042) and cancer-specific survival (CSS) (53.7% vs. 74.4%, P = 0.030). However, a comparative analysis of 5-year OS and CCS showed no significant differences between the minor complication (C-D grade II) group and matched NC group (68.9% vs. 72.2%, P = 0.578; 75.6% vs. 77.8%, P = 0.649; respectively). Multivariate analysis confirmed severe complication was an independent risk factor for decreased OS. Further analysis showed that older age, lower body mass index (BMI), and combined resection were independent risk factor for the occurrence of severe complications.

CONCLUSIONS

Severe complications adversely affected long-term survival outcomes after LTG with D2 lymph node dissection for AGC. More attention should be paid to patients at high risk for severe complications in preoperative assessment and postoperative management.

Prediction of Conditional Probability of Survival After Surgery for Gastric Cancer: A Study Based on Eastern and Western Large Data Sets

BACKGROUND

The dynamic prognosis of patients who have undergone curative surgery for gastric cancer has yet to be reported. Our objective was to devise an accurate tool for predicting the conditional probability of survival for these patients.

METHODS

We analyzed 11,551 gastric cancer patients from the Surveillance, Epidemiology, and End Results database. Two-thirds of the patients were selected randomly for the development set and one-third for the validation set. Two nomograms were constructed to predict the conditional probability of overall survival and the conditional probability of disease-specific survival, using conditional survival methods. We then applied these nomograms to the 4,001 patients in the database from Fujian Medical University Union Hospital, Fuzhou, China, one of the most active Chinese institutes.

RESULTS

The 5-year conditional probability of overall survival of the patients was 41.6% immediately after resection and increased to 52.8%, 68.2%, and 80.4% at 1, 2, and 3 years after gastrectomy. The 5-year conditional probability of disease-specific survival "increased" from 48.9% at the time of gastrectomy to 59.8%, 74.7%, and 85.5% for patients surviving 1, 2, and 3 years, respectively. Sex; race; age; depth of tumor invasion; lymph node metastasis; and tumor size, site, and grade were associated with overall survival and disease-specific survival (P <.05). Within the Surveillance, Epidemiology, and End Results validation set, the accuracy of the conditional probability of overall survival nomogram was 0.77, 0.81, 0.82, and 0.82 at 1, 3, 5, and 10 years after gastrectomy, respectively. Within the other validation set from the Fujian Medical University Union Hospital (n = 4,001), the accuracy of the conditional probability of overall survival nomogram was 0.76, 0.79, 0.77, and 0.77 at 1, 3, 5, and 10 years, respectively. The accuracy of the conditional probability of disease-specific survival model was also favorable. The calibration curve demonstrated good agreement between the predicted and observed survival rates.

CONCLUSION

Based on the large Eastern and Western data sets, we developed and validated the first conditional nomogram for prediction of conditional probability of survival for patients with gastric cancer to allow consideration of the duration of survivorship.

Laparoscopy-assisted distal gastrectomy versus laparoscopy-assisted total gastrectomy with D2 lymph node dissection for middle-third advanced gastric cancer

BACKGROUND

There still remains controversy for the choice of resection extent for gastric cancer involving the middle-third of the stomach. The aim of this study was to compare the technical feasibility and long-term outcomes of laparoscopy-assisted distal gastrectomy (LADG) versus laparoscopy-assisted total gastrectomy (LATG) for middle-third advanced gastric cancer (AGC) and to determine which is the optimal surgical procedure.

METHODS

For this study, clinical data for 379 patients who underwent LADG or LATG with D2 lymph node dissection between April 2005 and June 2014 were analyzed retrospectively. The short- and long-term outcomes were compared between the propensity score-matched groups.

RESULTS

The LADG group had a significantly shorter operating time (212.74 vs. 241.79 min, P < 0.001), less estimated blood loss (114.38 vs. 181.51 ml, P = 0.000), shorter first flatus and postoperative hospital stay. Additionally, the total cost of hospitalization was significantly higher in the LATG group than LADG group (71187.58 vs. 65783.25 RMB, P = 0.000). There were no significant differences in postoperative complications rate between the LADG group and the LATG group. The 5-year overall survival (OS) rates were 64.4% in the LADG group and 61.0% in the LATG group (P = 0.548). The resection extent was not an independent prognostic factor for the OS.

CONCLUSIONS

LADG with D2 nodal dissection is a feasible treatment strategy for middle-third AGC with better short-term outcomes and similar long-term survival rates compared with LATG. We recommended that DG should be the optimal surgical procedure for middle one-third AGC under the premise of negative proximal resection margin.

Survey on laparoscopic total gastrectomy at the 11th China-Korea-Japan Laparoscopic Gastrectomy Joint Seminar

INTRODUCTION

Laparoscopic total gastrectomy (LTG) has been widely performed for gastric cancer in China, Korea, and Japan. The current status of this surgical approach needs to be investigated.

METHODS

During the 11th China-Korea-Japan Laparoscopic Gastrectomy Joint Seminar in Shanghai, China, on 5 March 2016, a questionnaire was completed by 65 experts in LTG. The survey included questions on surgical indication, operation team, laparoscopic instruments, and operative procedures.

RESULTS

Of the 65 respondents, 35 (53.8%) were from China, 18 (27.7%) were from Korea, and 12 (18.5%) were from Japan. Surgeons have various indications for LTG. Among respondents, stage II gastric cancer (42.9%) was the most acceptable indication, but Japanese surgeons were more cautious on this issue (P = 0.005). Using a flexible scope was more popular with Japanese surgeons than with others (P = 0.003). A goose-neck curved grasper was used more often in China and Korea than in Japan (P = 0.006). Chinese surgeons preferred vertical subxiphoid mini-laparotomy rather than vertical transumbilical laparotomy. Intracorporeal reconstruction (73.0%) was most frequently adopted for LTG. Linear staplers (53.8%) and circular staplers (42.1%) were both popular for esophagojejunostomy. However, jejunojejunostomy was more often conducted extracorporeally (67.7%), in which case a linear stapler (86.4%) was usually selected. Significant differences were observed between the three countries with regard to reinforcement of the duodenal stump (P = 0.018) and closure of Peterson's space (P < 0.001).

CONCLUSION

This survey on LTG involving surgeons from China, Korea, and Japan clearly informed the current practice of this surgical approach and will likely aid future research studies as well as clinical treatment for gastric cancer.

Negative lymph node count is a significant prognostic factor in patient with stage IV gastric cancer after palliative gastrectomy

Negative lymph node (NLN) count has been validated as a protective predictor in various cancers after radical resection. However, the prognostic value of NLN count in the setting of stage IV gastric cancer patients who have received palliative resection has not been investigated. Surveillance, Epidemiology, and End Results Program (SEER)-registered gastric cancer patients were used for analysis in this study. Kaplan-Meier survival curves and multivariate Cox proportional hazards model were used to assess the risk factors for patients’ survivals. The results showed that NLN count and N stage were independently prognostic factors in patients with stage IV gastric cancer after palliative surgery (P< 0.001). X-tile plots identified 2 and 11 as the optimal cutoff values to divide the patients into high, middle and low risk subsets in term of cause-specific survival (CSS). And NLN count was proved to be an independently prognostic factor in multivariate Cox analysis (P< 0.001). The risk score of NLN counts demonstrated that the plot of hazard ratios (HRs) for NLN counts sharply increased when the number of NLN counts decreased. Collectively, our present study revealed that NLN count was an independent prognostic predictor in stage IV gastric cancer after palliative resection. Standard lymph node dissection, such as D2 lymphadectomy maybe still necessary during palliative resection for patients with metastatic gastric cancer.

Does Total Gastrectomy Provide Better Outcomes than Distal Subtotal Gastrectomy for Distal Gastric Cancer? A Systematic Review and Meta-Analysis

Background/Aims

Total gastrectomy (TG) has shown to be superior regarding low risk of recurrence and readmission to distal subtotal gastrectomy (DG) for treatment of distal stomach cancer, but the incidence of postoperative morbidity and mortality in TG cannot be ignored. Therefore, we performed a meta-analysis to compare the effectiveness between TG and DG for distal stomach cancer.

Methodology

A search in PubMed, EMBASE, the Cochrane Library, Web of Science, Chinese Biomedical Database through January 2016 was performed. Eligible studies in comparing of TG and DG for distal gastric cancer were included in this meta-analysis. Review Manager 5.2 software from the Cochrane Collaboration was used for the performance of meta-analysis and STATA 12.0 software for meta-regression analysis.

Results

Ten retrospective cohort studies and one randomized control trial involving 5447 patients were included. The meta-analysis showed no significant difference of postoperative mortality (RR = 1.48, 95%CI = 0. 90–2.44,p = 0.12), intraoperative blood loss (MD = 24.34, 95%CI = -3.31–51.99, p = 0.08) and length of hospital stay(MD = 0.76, 95%CI:-0.26–1.79, p = 0.15). TG procedure could retrieve more lymph nodes than DG(MD = 4.33, 95% CI = 2.34–6.31, p<0.0001). According to different postoperative complications, we performed subgroup analysis, subgroup analysis revealed that patients in TG group tended to have a higher rate of postoperative intra-abdominal abscess than DG procedure (RR = 3.41, 95% CI = 1.21–9.63,p<0.05). No statistical differences were found in leakage, intestinal obstruction, postoperative bleeding, anastomotic stricture and wound infection between the two groups (p>0.05). We pooled the data together, the accumulated 5-year Overall Survival rates of TG and DG groups were 49.6% (919/1852) vs.55.9%(721/1290) respectively. Meta-analysis revealed a favoring trend to DG procedure and there was a statistical difference between the two groups (RR = 0.91,95% CI = 0.85–0.97,p = 0.006).

Conclusion

Based on current retrospective evidences, we found that in spite of similar postoperative mortality, TG for distal gastric cancer provided a high risk of five-year Overall Survival rate. DG procedure can be a recommendation for distal gastric cancer, whereas due to lack of high quality RCTs in multicenter and the relatively small sample size of long-term outcomes, further comparative studies are still needed.

Influence of Total Lymph Node Count on Staging and Survival After Gastrectomy for Gastric Cancer: An Analysis From a Two-Institution Database in China

BACKGROUND

Although current guidelines suggest that 16 or more lymph nodes (LNs) are required for the appropriate staging of gastric cancer, the effect that the minimum number of examined LNs (eLNs) in the different types of gastrectomy has on survival remains unclear.

METHODS

This study retrospectively analyzed 2662 patients who underwent curative gastrectomy with D2 lymphadenectomy for gastric cancer at Fujian Medical University Union Hospital from January 2000 to December 2010 and randomly divided them into development (70 %, n = 1863) and validation (30 %, n = 799) data sets. An additional external validation was performed using the data set (n = 285) collected during the same period from the Sun Yat-sen University Cancer Center in Guangzhou, China. A hypothetical tumor-node-metastasis (TNM) classification (hTNM) was proposed based on eLNs and survival.

RESULTS

The mean numbers of nodes removed during radical distal and total gastrectomy were respectively 26 ± 9.6 and 29 ± 10.7 (p < 0.01). The optimal LN-count thresholds were determined to be 16 for patients who underwent curative distal gastrectomy and 21 for patients who underwent total gastrectomy. The hTNM staging system had higher linear trend and likelihood ratio χ ² scores and lower Akaike information criterion (AIC) values than the seventh American Joint Committee on Cancer (AJCC) TNM classification. Thus, the hTNM staging system exhibited superior prognostic stratification. Similar results were found in the two validation data sets.

CONCLUSION

A harvest of at least 21 LNs may represent a superior threshold for radical total gastrectomy (RTG) and could yield a better prognosis. For patients undergoing RTG, the hTNM staging system may predict survival more accurately and discriminatively. However, a validation from a Western institution is warranted.