Minimally invasive surgery for gastric cancer: the American experience

Impact of Minimally Invasive Surgery on Early and Late Outcomes of Patients With Gastric Cancer Treated Using Neoadjuvant Chemotherapy

BACKGROUND

Gastric cancer is the fifth most common neoplasm and the third leading cause of cancer-related death worldwide. Neoadjuvant chemotherapy is recommended for Stages II-III resectable tumors, but the comparative effectiveness of minimally invasive surgery (MIS) versus open gastrectomy (OG) post-neoadjuvant therapy has not been adequately investigated.

METHODS

A retrospective cohort analysis was performed on patients with clinical Stage II and III gastric adenocarcinoma who underwent neoadjuvant chemotherapy followed by either MIS or OG between 2007 and 2020. Propensity score matching was utilized to compare the clinical and surgical outcomes, morbidity, and mortality, and the influence of MIS on 3-year survival rates was evaluated.

RESULTS

After matching, no statistical differences in clinical aspects were noted between the two groups. MIS was associated with increased D2 lymphadenectomy, curative intent, and complete neoadjuvant therapy. Furthermore, this therapeutic approach resulted in reduced transfusion rates and shorter hospital stays. Nonetheless, no significant differences were observed in global, clinical, or surgical complications or mortality between the two groups. Weight loss emerged as a significant risk factor for complications, but MIS did not independently affect survival rates. Extended resection and higher American Society of Anesthesiology scores were independent predictors of reduced survival.

CONCLUSION

MIS after neoadjuvant chemotherapy for gastric cancer appears to be a viable option, with oncological outcomes comparable to those of OG, less blood loss, and shorter hospital stays. Although MIS did not independently affect long-term survival, it offered potential benefits in terms of postoperative recovery and morbidity. Further studies are needed to validate these findings, especially across diverse populations.

Trends of Oncological Quality of Robotic Gastrectomy for Gastric Cancer in the United States

Background

Robotic gastrectomy (RG) has been increasingly used for treatment of gastric cancer in the United States. However, it is unknown if there has been a nationwide improvement of short-term safety outcomes and oncological quality metrics over time.

Methods

We used the National Cancer Database to identify patients who underwent major gastrectomy from 2010 through 2018. The short-term safety outcomes and oncological metrics were compared between cases of open gastrectomy (OG), laparoscopic gastrectomy (LG), and RG. We also compared the indications and outcomes of RG between the three periods (2010 - 2012, 2013 - 2015, and 2016 - 2018).

Results

Of the 22,445 patients included, 1,867 (8%) underwent RG. Number of RG continued to increase from only 37 cases performed in 2010 to 412 cases performed in 2018. The number of lymph nodes (LNs) examined (OG, 16; LG, 17; and RG, 19) and the R0 rate (OG, 88%; LG, 92%; and RG 94%) were better for RG than for OG or LG (P < 0.001). In the RG group, the number of LNs examined (first period, 15; third period, 18; P < 0.001), R0 rate (first period, 88.6%; third period, 91.1%; P < 0.001), length of hospital stay (first period, 9 days; third period, 8 days; P < 0.001), 30-day readmission rate (first period, 10.1%; third period, 7.9%; P < 0.001), and 90-day mortality (first period, 7.3%; third period, 6.0%; P = 0.003) continued to improve cohort over time. The ratio of the robotic cases performed in academic institutions gradually increased (first period, 48.6%; third period, 54.3%; P < 0.001). In multivariable analyses, RG was associated with more than 15 LNs being examined (OR, 1.49; 95% CI, 1.34 - 1.65; P < 0.001). The indications for RG appeared expanding to include more advanced stage, high comorbidity, and patients who underwent preoperative therapy.

Conclusions

RG has been increasingly performed in the past decade. Although its indication was expanded to include more advanced tumors, we found that the oncological quality metrics and safety outcomes of RG have improved over time and were better than those of OG or LG.

Trends and perioperative mortality in gastric cancer surgery: a nationwide population‑based cohort study

This study aimed to investigate changes and perioperative mortality over a 6-year period within the Italian Hospital Information System among patients with gastric cancer (GC) who underwent gastrectomies and to identify risk factors associated with 90-day mortality. Additionally, nationwide differences between high and low-volume hospitals were evaluated. A nationwide retrospective study was conducted using patient hospital discharge records (HDRs) based on the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) classification. The HDRs were linked to the National Tax Registry records using deterministic record linkage. The data were obtained from the Italian National Outcomes Evaluation Programme (PNE). Multivariate logistic regression was used to examine risk factors for 90-day mortality among patients with GC who underwent partial or total gastrectomies over the period from 2018 to 2020 with adjustment for comorbidities. Overall, the number of patients with GC who underwent total or partial gastrectomies steadily decreased in Italy from 5765 in 2015 to 4291 in 2020 (p < 0.001). The use of the laparoscopic approach more than doubled from 2015 (10.8%) to 2020 (26.3%), with a concomitant conversion rate from laparoscopy to open surgery decreasing from 7.7 to 5.8%. The 30 and 90-day mortality rates remained stable over time (p > 0.05). Low-volume hospitals had higher inpatient, early, and late mortality compared to high-volume hospitals (5.9% vs 3.8%, 6.3% vs 3.8%, and 11.8% vs 7.9%, respectively; p < 0.001). Multivariate logistic regression analysis showed that an advanced age (adjusted odds ratio: 3.72; 95% [CI]: 3.15-4.39; p < 0.001), an open approach (adjusted-OR: 1.69, 95% CI: 1.43-1.99, p < 0.001) and a total gastrectomy (adjusted-OR: 1.44, 95% CI: 1.27-1.64, p < 0.001) were independent risk factors for 90-day mortality. Additionally, patients with GC who referred to high-volume hospitals were 26% less likely to die within 90 days after a gastrectomy than those who underwent surgery in low-volume hospitals. During the 6-year period, surgeons implemented a minimally invasive approach to reduce the conversion over time. Centralisation was associated with better outcomes while advanced age, an open approach, and total gastrectomy were identified as risk factors for 90-day mortality.

Application of laparoscopic surgery in gallbladder carcinoma

Gallbladder carcinoma (GC) is a rare type of cancer of the digestive system, with an incidence that varies by region. Surgery plays a primary role in the comprehensive treatment of GC and is the only known cure. Compared with traditional open surgery, laparoscopic surgery has the advantages of convenient operation and magnified field of view. Laparoscopic surgery has been successful in many fields, including gastrointestinal medicine and gynecology. The gallbladder was one of the first organs to be treated by laparoscopic surgery, and laparoscopic cholecystectomy has become the gold standard surgical treatment for benign gallbladder diseases. However, the safety and feasibility of laparoscopic surgery for patients with GC remain controversial. Over the past several decades, research has focused on laparoscopic surgery for GC. The disadvantages of laparoscopic surgery include a high incidence of gallbladder perforation, possible port site metastasis, and potential tumor seeding. The advantages of laparoscopic surgery include less intraoperative blood loss, shorter postoperative hospital stay, and fewer complications. Nevertheless, studies have provided contrasting conclusions over time. In general, recent research has tended to support laparoscopic surgery. However, the application of laparoscopic surgery in GC is still in the exploratory stage. Here, we provide an overview of previous studies, with the aim of introducing the application of laparoscopy in GC.

Comparison of short-term efficacy and safety between total robotic and total 3D laparoscopic distal radical gastrectomy for gastric cancer in Enhanced Recovery After Surgery (ERAS) protocol: a propensity score matching study

BACKGROUND

The application of Enhanced Recovery After Surgery (ERAS) protocol in gastrointestinal surgery has been widely accepted. The aim of this study was to compare the effect of ERAS in total robotic distal gastrectomy (TRDG) versus 3D total laparoscopic distal gastrectomy (3D-TLDG) for gastric cancer.

METHODS

We retrospectively evaluated 73 patients underwent TRDG and 163 patients who received 3D-TLDG. The propensity score was used for matching analysis according to a 1:1 ratio, so that there was no significant difference in the baseline data between the two groups. The short-term effect and safety of the two groups were compared.

RESULTS

The TRDG group had a less intraoperative bleeding (30.21 ± 13.78 vs. 41.44 ± 17.41 ml, P < 0.001), longer intraoperative preparation time (31.05 ± 4.93 vs. 15.48 ± 2.43 min, P < 0.001), shorter digestive tract reconstruction time (32.67 ± 4.41 vs. 39.78 ± 4.95 min, P < 0.001), shorter postoperative ambulation time (14.07 ± 8.97 vs. 17.49 ± 5.98 h, P = 0.007), shorter postoperative anal exhaust time (1.78 ± 0.79 vs. 2.18 ± 0.79 days, P = 0.003), shorter postoperative hospital stay (7.74 ± 3.15 vs. 9.97 ± 3.23 days, P < 0.001), lower postoperative pain score (P = 0.006) and higher hospitalization cost (89,907.15 ± 17,147.19 vs. 125,615.82 ± 11,900.80 RMB, P < 0.001) than the 3D-TLDG group.

CONCLUSION

TRDG and 3D-TLDG under ERAS protocol are safe and feasible. Compared with 3D-TLDG, the TRDG has better intraoperative bleeding control effect and greater advantages in digestive tract reconstruction. After the combination of ERAS protocol, TRDG also has certain advantages in the recovery process of patients after surgery.

Disturbed passage of jejunal limb near esophageal hiatus after overlapped esophagojejunostomy following laparoscopic total gastrectomy

BACKGROUND

Overlapped esophagojejunostomy (OEJ) is a secure purely laparoscopic reconstruction after laparoscopic total gastrectomy (LTG). However, long-term surgical results have not been documented well.

AIM

In this paper, we report unusual patients who manifested jejunal limb stricture near the esophageal hiatus without anastomotic stenosis during long-term observation after surgery.

METHODS

From April 2009 until May 2020, we retrospectively reviewed 211 patients underwent LTG following by OEJ for gastric carcinoma and took a standard surveillance program. We aimed to characterize a novel complicated disorder observed in these patients to assist treatment and prevention.

RESULTS

Five patients (2.4%) had unusual jejunal limb stricture after LTG and OEJ, occurring at a mean of 10 mo after initial radical LTG. All five patients had disturbed oral intake and marked weight loss, and two had aspiration pneumonia. Various diagnostic modalities and intraoperative findings in each patient revealed an intact anastomosis, bent or tortuous jejunal limb resulting from loose fibrous adhesions on the left crus at the esophageal hiatus and no cancer recurrence. All five patients were successfully treated by reoperation for adhesiolysis, division of the left crus and rearrangement of the jejunal limb.

CONCLUSION

Disturbed passage through the jejunal limb near the hiatus can occur after some types of OEJ following LTG. We speculate that it may result from a short remnant esophagus, excessive mobilization of the jejunal limb that permits bending or tortuosity and adhesions on the left crus at the hiatus. Prevention for this complication is possible during the original LTG procedure.

Disparities in Utilization and Outcomes of Minimally Invasive Techniques for Gastric Cancer Surgery in the United States

Background

This study investigated national implementation patterns and perioperative outcomes of minimally invasive gastrectomy (MIG) in gastric cancer surgery in the United States.

Methods

The National Inpatient Sample (NIS) was queried for patients who underwent elective gastrectomy for gastric cancer from 2008-2018. The MIG versus open gastrectomy approach was correlated with hospital factors, patient characteristics, and complications.

Results

There was more than a fivefold increase in MIG from 5.8% in 2008 to 32.9% in 2018 (nptrend < 0.001). Patients undergoing MIG had a lower Elixhauser Comorbidity Index (p = 0.001). On risk adjusted analysis, black patients (AOR = 0.77, p = 0.024) and patients with income below 25th percentile (AOR = 0.80, p = 0.018) were less likely to undergo MIG. When these analyses were limited to minimally invasive capable centers only, these differences were not observed. Hospitals in the upper tertile of gastrectomy case volume, Northeast, and urban teaching centers were more likely to perform MIG. Overall, MIG was associated with a 0.7-day decrease in length of stay, reduced risk adjusted mortality rates (AOR = 0.58, p = 0.05), and a $4,700 increase in total cost.

Conclusions

In this national retrospective study, we observe socioeconomic differences in patients undergoing MIG, which is explained by hospital level factors in MIG utilization. We demonstrate that MIG is associated with a lower mortality compared with open gastrectomy. Establishing MIG as a safe approach to gastric cancers and understanding regional differences in implementation patterns can inform delivery of equitable high-quality health care.

Impact of neoadjuvant therapy followed by laparoscopic radical gastrectomy with D2 lymph node dissection in Western population: A multi-institutional propensity score-matched study

BACKGROUND AND OBJECTIVES

In the setting of a minimally invasive approach, we aimed to compare short and long-term postoperative outcomes of patients treated with neoadjuvant therapy (NAT) + surgery or upfront surgery in Western population.

METHODS

All consecutive patients from six Italian and one Serbian center with locally advanced gastric cancer who had undergone laparoscopic gastrectomy with D2 lymph node dissection were selected between 2005 and 2019. After propensity score-matching, postoperative morbidity and oncologic outcomes were investigated.

RESULTS

After matching, 97 patients were allocated in each cohort with a mean age of 69.4 and 70.5 years. The two groups showed no difference in operative details except for a higher conversion rate in the NAT group (p = 0.038). The overall postoperative complications rate significantly differed between NAT + surgery (38.1%) and US (21.6%) group (p = 0.019). NAT was found to be related to a higher risk of postoperative morbidity in patients older than 60 years old (p = 0.013) but not in patients younger (p = 0.620). Conversely, no difference in overall survival (p = 0.41) and disease-free-survival (p = 0.34) was found between groups.

CONCLUSIONS

NAT appears to be related to a higher postoperative complication rate and equivalent oncological outcomes when compared with surgery alone. However, poor short-term outcomes are more evident in patients over 60 years old receiving NAT.

Laparoscopic vs Open Distal Gastrectomy for Locally Advanced Gastric Cancer: Five-Year Outcomes From the CLASS-01 Randomized Clinical Trial

Importance

It is not clear whether laparoscopic and open distal gastrectomy produce similar outcomes among patients with locally advanced gastric cancer. Data from a multicenter, randomized clinical trial (Chinese Laparoscopic Gastrointestinal Surgical Study [CLASS]-01) showed that laparoscopic distal gastrectomy did not result in inferior disease-free survival at 3 years compared with open distal gastrectomy.

Objective

To report 5-year overall survival data from the CLASS-01 trial of laparoscopic vs open distal gastrectomy among patients with locally advanced gastric cancer.

Design, Setting, and Patients

This was a noninferiority, open-label, randomized clinical trial conducted at 14 centers in China. A total of 1056 eligible patients with clinical stage T2, T3, or T4a gastric cancer without bulky nodes or distant metastases were enrolled from September 12, 2012, to December 3, 2014. Final follow-up was on December 31, 2019.

Interventions

Participants were randomized in a 1:1 ratio after stratification by site, age, cancer stage, and histologic features to undergo either laparoscopic distal gastrectomy (n = 528) or open distal gastrectomy (n = 528) with D2 lymphadenectomy.

Main Outcomes and Measures

The 5-year overall survival rates were updated to compare laparoscopic distal gastrectomy with open distal gastrectomy. All analyses were performed on an intention-to-treat basis. In addition, per-protocol and as-treated analyses were performed for overall survival.

Results

Data from 1039 patients (726 men [69.9%]; mean [SD] age, 56.2 [10.7] years) who received curative therapy were analyzed. At 5 years, the overall survival rates were 72.6% in the laparoscopic distal gastrectomy group and 76.3% in the open distal gastrectomy group (log-rank P = .19; hazard ratio, 1.17; 95% CI, 0.93-1.48; P = .19). After comparison for competing risk events, gastric cancer-related deaths (hazard ratio, 1.14; 95% CI, 0.87-1.49; P = .34) and deaths from other causes (hazard ratio, 1.23; 95% CI, 0.74-2.05; P = .42) did not differ significantly between groups. Overall rates of survival did not differ significantly between groups with each tumor stage.

Conclusions and Relevance

This study found that laparoscopic distal gastrectomy with D2 lymphadenectomy performed by experienced surgeons in high-volume specialized institutions resulted in similar 5-year overall survival compared with open distal gastrectomy among patients with locally advanced gastric cancer.

Trial Registration

ClinicalTrials.gov Identifier: NCT01609309.

Surgical Treatment for Gastric Cancer

Surgery is an essential component of curative-intent treatment strategies for gastric cancer. However, the care of each patient with gastric cancer must be individualized based on patient and tumor characteristics. It is important that all physicians who will be caring for patient with gastric cancer understand the current best practices of surgical management to provide patients with the highest quality of care. This article aims to provide this information while acknowledging areas of surgical management that are still controversial.

Reduction in postoperative complications by robotic surgery: a case-control study of robotic versus conventional laparoscopic surgery for gastric cancer

Background

Robotic gastrectomy (RG) is being increasingly performed globally; it is considered an evolved type of conventional laparoscopic surgery with excellent dexterity and precision, but higher costs and longer operation time. Thus, there is a need to identify the benefits from RG and its specific candidates.

Methods

This retrospective study analyzed data from a prospectively collected clinical database at our center. Data of patients with primary gastric cancer undergoing either robotic or laparoscopic radical gastrectomy from June 2014 to June 2020 were reviewed. Surgical outcomes were compared between the two groups, and multivariable analyses were performed to elucidate the relevant factors for postoperative complications in several subgroups.

Results

A total of 1172 patients were divided into those who underwent RG (n = 152) and those who underwent laparoscopic gastrectomy (LG) (n = 1020). Baseline characteristics were similar in the two groups, except the RG group included more patients undergoing total/proximal gastrectomy (TG/PG) and patients at clinical stage III. Compared with the LG group, the RG group had lower incidences of postoperative complications ≥ Clavien-Dindo grade III (2/152 (1.3%) versus 72/1020 (7.1%); P = 0.004), and intraabdominal complications ≥ grade II (6/152 (3.9%) versus 119/1020 (11.7%); P = 0.004). Multivariable analysis revealed that RG was a significant relevant factor for reducing overall postoperative complications (≥ grade III) (odds ratio (OR) 0.16, P = 0.013), and intraabdominal complications (≥ grade II) (OR 0.29, P = 0.002). Subgroup analyses demonstrated that this tendency was enhanced in patients undergoing TG/PG (OR 0.29, P = 0.021) or at clinical stage II/III (OR 0.10, P = 0.027).

Conclusions

RG reduces the incidence of postoperative complications compared with conventional LG and this tendency may be enhanced in technically complicated procedures with demanding anastomosis or D2 lymphadenectomy. Patients requiring such procedures would most benefit from RG.

Effect of Surgical Approach on Node Harvest in Gastrectomy: Analysis of the National Cancer Database

BACKGROUND

Gastrectomy is the cornerstone of treatment for gastric cancer. Recent studies demonstrated significant surgical outcome advantages for patients undergoing minimally invasive versus open gastrectomy. Lymph node harvest is an indicator of adequate surgical resection, and greater harvest is associated with improved staging and patient outcomes. This study evaluated lymph node harvest based on surgical approach.

METHODS

Gastric adenocarcinoma patients were identified from NCDB who underwent gastrectomy between 2010 and 2016. Patients were classified by surgical approach into three cohorts: robotic, laparoscopic, or open gastrectomy. Clinical and demographic data were collected. Lymph node harvest was compared with univariate analysis and multivariable generalized linear mixed model. Univariate analysis with propensity matching was also performed to control for differences in patient population across cohorts.

RESULTS

We identified 10,690 patients that underwent gastrectomy for gastric adenocarcinoma, with 68% males and median age of 66 (IQR 5774) years. 7161 (67%) underwent open, 2841 (26.6%) laparoscopic, and 688 (6.4%) robotic gastrectomy. Multivariable analysis revealed robotic was associated with a significantly higher median node harvest (18, IQR 1326) compared to laparoscopic (17, IQR 1125) and open gastrectomy (16, IQR 1023). Laparoscopic was also associated with significantly higher node harvest then open gastrectomy. Propensity-matched analysis (6950 patients) showed robotic gastrectomy was still associated with significantly higher node harvest (18, IQR 1226) compared to laparoscopic (17, IQR 1125) and open (17, IQR 1124); however, laparoscopic and open were not significantly different.

CONCLUSION

Robotic approach is associated with increased node harvest compared to laparoscopic and open approach in gastrectomy patients.

Short- and long-term comparison of robotic and laparoscopic gastrectomy for gastric cancer by the same surgical team: a propensity score matching analysis

BACKGROUND

Research on short-term outcomes and oncology results after robotic gastrectomy (RG) is still limited, especially from a single surgical team. The purpose of this study was to compare the short-term and long-term outcomes of robotic and laparoscopic gastrectomy (LG).

METHODS

Between October 2014 and September 2019, 1686 consecutive patients who underwent MIS gastrectomy were enrolled. The patients were divided into RG and LG groups according to surgical type. Groups were matched at a 1:1 ratio using propensity scores based on the following variables: age, sex, ASA score, primary tumor location, histologic type, pathological stage, and neoadjuvant chemotherapy. The primary outcomes were 3-year overall survival (OS) and relapse-free survival (RFS). The secondary outcomes were postoperative short-term outcomes.

RESULTS

Demographic and baseline characteristics were similar between the two groups after matching. Compared to the LG group, the RG group had a significantly higher retrieved lymph node (LN) number (32.15 vs 30.82, P = 0.040), more retrieved supra-pancreatic LNs (12.45 vs 11.61, P = 0.028), lower estimated blood loss (73.67 vs 98.08 ml, P < 0.001), but longer operation time (205.18 vs 185.27 min, P < 0.001) and higher hospitalization costs ($13,607 vs $10,928, P < 0.001) in the matched cohort. In the subgroup analysis, we observed that compared with LG, patients with advanced gastric cancer benefitted more from RG surgery. The matched cohort analysis demonstrated no statistically significant differences for 3-year OS or RFS (log-rank, P = 0.648 and P = 0.951, respectively): 80.3% and 77.0% in LG vs. 81.2% and 76.6% in RG, respectively.

CONCLUSION

RG has certain technical advantages over LG, especially in patients with advanced gastric cancer. However, RG does not improve long-term oncology outcomes.

Comparison of laparoscopic versus open gastrectomy for gastric cancer

BACKGROUND

This study aimed to compare the short-term and long-term outcomes of laparoscopic gastrectomy (LG) and open gastrectomy (OG) for gastric cancer in a tertiary referral center in Hong Kong.

METHODS

Two hundred and ninety-four consecutive patients with gastric cancer who underwent radical gastrectomy with curative intent between January 2008 and December 2015 were analyzed. Data was prospectively collected and reviewed. Propensity score matching was applied at a ratio of 1:1 to compare the OG and LG groups.

RESULTS

After propensity score matching, operation duration (294.7 vs 231.8min, P < 0.01) was significantly longer while estimated blood loss (191.6 vs 351.0 ml, P = 0.01) was significantly less in LG group compared with OG. There were no significant differences in postoperative complications and mortality between LG and OG groups (postoperative complication rate, 35.2% vs 40.7%, P = 0.69; 90-day mortality rate, 1.9% vs 3.7%, P = 1.00). Three-year OS and 3-yr DFS of patients who underwent LG was not inferior to that of patients who had OG (P = 0.34; P = 0.51). However, there were significantly more peritoneal recurrences among the OG group than LG group (P < 0.01).

CONCLUSIONS

LG has comparable outcomes for gastric cancer, even in advanced tumors. We could appropriately increase the proportion of laparoscopic gastrectomy for gastric cancer.

The Impact of Minimally Invasive Gastrectomy on Survival in the USA

BACKGROUND

Minimally invasive surgical approaches for gastric adenocarcinoma are increasing in prevalence. Although recent studies suggest such approaches are associated with improvements in short-term outcomes, long-term outcomes have not been well studied. This study aimed to evaluate the impact of minimally invasive gastrectomy on long-term survival.

METHODS

The National Cancer Database (NCDB) was used to identify patients who underwent gastrectomy for adenocarcinoma between 2010 and 2015. Patient characteristics were stratified by open and minimally invasive approaches and compared using chi-square and t tests. Unadjusted survival functions were estimated using Kaplan-Meier methodology. Multivariable modeling of risks factors for survival was analyzed with Cox proportional hazard models. Covariate imbalance was controlled using propensity score matching.

RESULTS

The study included 17,449 patients who underwent gastrectomy. Cox proportional hazard modeling demonstrated that minimally invasive surgery improved survival (hazard ratio = 0.86, P < 0.0001). Predictors of worsened survival included community facility type, comorbidities, tumor size, extent of gastrectomy, clinical T and N staging (P < 0.0060 for all). After propensity score matching, minimally invasive surgery had a significantly improved survival at 5 years compared to an open approach, 51.9% versus 47.7% (P < 0.0001). Survival was not significantly different between propensity score-matched patients who received laparoscopic and robotic approaches (P = 0.2611).

CONCLUSIONS

Minimally invasive approaches for gastric carcinoma are associated with improved long-term survival. There was no significant difference in survival when comparing laparoscopic to robotic gastrectomy. The mechanisms that drive these improvements deserve further investigation.

Liver-first approach to stage IV colon cancer with synchronous isolated liver metastases

Background

The only possibility for cure in patients with colon adenocarcinoma (CAC) with isolated liver metastases (ILM) is resection of both primary and metastatic tumors. Little is known about the implication of the sequence in which a colectomy and hepatectomy are performed on outcomes. This study analyzes whether resection sequence impacts clinical outcomes.

Methods

The National Cancer Database was queried for CAC cases with hepatic metastases from 2010-2015 with exclusion of extrahepatic metastases. We compared patients treated with a liver-first approach (LFA) to those treated with a colectomy-first or simultaneous approach using Kaplan Meier and multivariable Cox proportional hazards analysis.

Results

In 21,788 CAC patients identified, the LFA was uncommon (2%), but was associated with higher rates of completion resection of remaining tumor (41% vs. 22%, P<0.001). Patients selected for LFA were younger, less comorbid, and more commonly received upfront chemotherapy (P<0.05). The LFA was associated with increased median survival [34 months, 95% CI (30.5-39.6 months) vs. 24 months, 95% CI (23.7-24.6 months), logrank P<0.001] and decreased risk of death [HR 0.783; 95% CI (0.67-0.89), P=0.001].

Conclusions

The LFA to CAC with synchronous ILM is uncommon but is associated with greater likelihood of receiving chemotherapy prior to surgery and increased survival in selected candidates.

Impact of minimally invasive gastrectomy on use of and time to adjuvant chemotherapy for gastric adenocarcinoma

BACKGROUND

Chemotherapy improves outcomes in patients with resectable gastric cancer. Minimally invasive gastrectomy (MIS) rates are increasing, though the impact of MIS on postoperative chemotherapy remains uncertain. This study examines the impact of MIS vs open gastrectomy (OG) on utilization of adjuvant chemotherapy for high-risk gastric cancer.

METHODS

Patients in the National Cancer Database who underwent resection for high-risk gastric adenocarcinoma between 2010 and 2015 were included. Patients were stratified by surgical approach (MIS vs OG) and analyzed using multivariable regression modeling. Primary endpoints were utilization of and time to initiation of adjuvant chemotherapy.

RESULTS

Overall, 23 071 patients were included; 16 595 (71.9%) underwent OG and 6476 (28.1%) underwent MIS. After adjusting for patient and tumor characteristics, MIS was not associated with increased use of adjuvant chemotherapy (odds ratio [OR]: 1.027, 95% confidence interval [CI]: 0.95 to 1.11, P = .50), and time to initiation of chemotherapy was similar (-2% change, 95% CI: -5% to +1%, P = .27). MIS was associated with shorter hospital stays (-1 day). Thirty-day readmission rates, 90-day mortality, and overall survival were similar between groups.

CONCLUSIONS

In this study, while MIS for gastric adenocarcinoma was associated with shorter hospital stays and comparable survival, it was not associated with improved utilization or time to initiation of adjuvant chemotherapy.

Advancements and challenges in treating advanced gastric cancer in the West

Gastric cancer is a leading cause of cancer incidence and death worldwide. Patients with advanced gastric cancer benefit from a multi-modality treatment regimen. Sound oncologic resection with negative margins and complete lymphadenectomy plays a crucial role in long-term survival for patients with resectable disease. The utilization of minimally invasive techniques for gastric cancer has been slowly increasing and is proving to be both technically and oncologically safe. Perioperative chemotherapy is the current standard of care for advanced gastric cancer. A variety of chemotherapy regimens have been used with the combination of docetaxel, oxaliplatin, 5-fluorouracil, and leucovorin being the current recommendation given its superior ability to induce a complete pathologic response and prolong survival. The use of radiation has been more controversial with its optimal place in the treatment sequence being unclear. There are current ongoing studies assessing the impact of radiation as an adjunct or in place of chemotherapy. Targeted treatments (e.g., trastuzumab for human epidermal growth factor receptor 2 positive tumors and pembrolizumab for programmed death-ligand 1 positive tumors) are showing promise and are part of a continued emphasis on individualized care. Intraperitoneal chemotherapy may also play a role in preventing peritoneal recurrences for patients with high risk lesions. The treatment of patients with advanced gastric cancer in the West continues to advance and improve with a better understanding of optimal treatment sequences and the utilization of personalized treatment regimens.

Should robotic gastrectomy become a standard surgical treatment option for gastric cancer?

Robotic gastrectomy (RG) using the da Vinci Surgical System for gastric cancer was approved for national medical insurance coverage in Japan in April, 2018, and has been used increasingly since. We reviewed the current evidence on RG, open gastrectomy (OG), and conventional laparoscopic gastrectomy (LG) to identify differences in surgical outcomes between Japan and other countries. Briefly, three independent reviewers systematically reviewed the data collected from a comprehensive literature search by an independent organization and focused on the following nine endpoints: mortality, morbidity, operative time, estimated volume of blood loss, length of postoperative hospital stay, long-term oncologic outcome, quality of life, learning curve, and cost. Overall, the mortality rate of the three approaches did not differ, but RG and LG had less intraoperative blood loss and resulted in a shorter postoperative hospital stay than OG. RG had longer operative times and incurred higher costs than LG and OG. However, in Japan, RG may be more effective than LG and OG for decreasing morbidity. Further studies are needed to establish the specific indications for RG, optimal robotic setup, and dissection methods to best utilize the surgical robot.

SURVIVAL AND PERIOPERATIVE MORBIDITY OF TOTALLY LAPAROSCOPIC VERSUS OPEN GASTRECTOMY FOR EARLY GASTRIC CANCER: ANALYSIS FROM A SINGLE LATIN AMERICAN CENTRE

BACKGROUND

Laparoscopic gastrectomy has numerous perioperative advantages, but the long-term survival of patients after this procedure has been less studied.

AIM

To compare survival, oncologic and perioperative outcomes between completely laparoscopic vs. open gastrectomy for early gastric cancer.

METHODS

This study was retrospective, and our main outcomes were the overall and disease-specific 5-year survival, lymph node count and R0 resection rate. Our secondary outcome was postoperative morbidity.

RESULTS

Were included 116 patients (59% men, age 68 years, comorbidities 73%, BMI 25) who underwent 50 laparoscopic gastrectomies and 66 open gastrectomies. The demographic characteristics, tumour location, type of surgery, extent of lymph node dissection and stage did not significantly differ between groups. The overall complication rate was similar in both groups (40% vs. 28%, p=ns), and complications graded at least Clavien 2 (36% vs. 18%, p=0.03), respiratory (9% vs. 0%, p=0.03) and wound-abdominal wall complications (12% vs. 0%, p=0.009) were significantly lower after laparoscopic gastrectomy. The lymph node count (21 vs. 23 nodes; p=ns) and R0 resection rate (100% vs. 96%; p=ns) did not significantly differ between groups. The 5-year overall survival (84% vs. 87%, p=0.31) and disease-specific survival (93% vs. 98%, p=0.20) did not significantly differ between the laparoscopic and open gastrectomy groups.

CONCLUSION

The results of this study support similar oncologic outcome and long-term survival for patients with early gastric cancer after laparoscopic gastrectomy and open gastrectomy. In addition, the laparoscopic approach is associated with less severe morbidity and a lower occurrence of respiratory and wound-abdominal wall complications.

Effects of siRNA-mediated silencing of Bmi-1 gene expression on proliferation of gastric cancer cells

This study was designed to investigate the effects of siRNA-mediated silencing of Bmi-1 gene expression on proliferation of AGS gastric cancer cell. siRNA Bmi-1 was transfected into human AGS gastric cancer cells by liposome (as siRNA Bmi-1 group) with negative control (as control group); the expressions of Bmi-1 and apoptosis-related genes like P21, Bax, and Bcl-2 in AGS cells were determined by Western blot method; the apoptosis of AGS cells was detected by flow cytometry double staining and Hoechst staining; and cell cycle was measured by flow cytometry. Compared with the control group, the expression of Bmi-1 in the siRNA Bmi-1 group was significantly decreased ( P < 0.05), the apoptosis rate was increased ( P < 0.05), and cell cycles were arrested at G1 phase (P < 0.05); the expression level of P21 and Bax in cells was significantly up-regulated while that of Bcl-2 down-regulated ( P < 0.05). The down regulation of Bmi-1 can inhibit the proliferation of AGS gastric cancer cell and promote its apoptosis, which takes such effects mainly by up-regulating P21 as well as Bax and down-regulating Bcl-2.

Curative effect of Da Vinci robot assisted radical gastrectomy for gastric cancer

AIM

To assess the value of Da Vinci robot in radical gastrec-tomy for gastric cancer.

METHODS

The information of patients who underwent Da Vinci robot assisted radical gastrectomy for gastric cancer at the Department of General Surgery, Lanzhou General Hospital of the Chinese People's Liberation Army from December 2016 to April 2017 was collected. The information of patients who received laparoscopic radical gastrectomy for gastric cancer was also obtained. The information on surgical treatment, postoperative recovery, hospital expenses, and prognosis was statistically analyzed between the two groups.

RESULTS

Compared with the laparoscopic group, the Da Vinci group had less bleeding during operation (P < 0.05), more complete lymph node dissection (P < 0.05), and safer incision margin (P < 0.05), but the operative time was increased (P < 0.05). In the postoperative recovery of patients of the two groups, the time to first food intake, the time to the recovery of the digestive tract, and the incidence of complications were not significantly different between the two groups (P > 0.05), but surgical cost was significantly increased (P < 0.05). The hospital stay was significantly shorter in patients who received Da Vinci robot assisted radical gastrectomy than in the laparoscopy group (P < 0.05), but this difference was not found in patients who underwent distal radical gastrectomy (P > 0.05). There was no significant difference in long-term survival between the two groups (P > 0.05).

CONCLUSION

Da Vinci robot assisted radical gastrectomy has certain advantages over laparoscopic radical gastrectomy in the treatment of gastric cancer, but it is still necessary for practitioners to improve their skills and be cautious.

Minimally invasive surgery for gastric cancer in UK: current status and future perspectives

The aim of this study is to review the literature and report the various minimally invasive methods used to treat gastric cancer in the UK and compare it with worldwide practice. Published randomised studies, non-randomised studies and case series reporting the use of minimal invasive approach to treat gastric cancer were retrieved from the search of standard medical electronic databases and their outcomes were highlighted suggesting their effectiveness. Several randomised, controlled trials and meta-analyses have proven the clinical and oncological safety of the laparoscopic gastrectomy for gastric cancer. Similarly, robot-assisted gastrectomy, EMR (endoscopic mucosal resection) and ESD (endoscopic sub-mucosal dissection) have also been proven feasible and safe to treat gastric cancer of various stages in prospective and retrospective comparative studies. However, UK based studies on minimally invasive surgery to treat gastric cancer is scarce and the paucity of trials led to uncertain outcomes. Laparoscopic gastrectomy, robot-assisted gastrectomy, EMR and ESD are feasible procedures in terms of clinical and oncological safety but mainly being practiced in Asian countries with high prevalence of stomach cancer. The UK based practice is still small and limited but the introduction of MIGOCS and STOMACH trial might help to widen the application of this technique.

Robotic gastrectomy for gastric cancer

The number of robotic gastrectomy (RG) performed per year has been increasing, particularly in East Asia where the incidence of gastric cancer is high and approximately half of the cases are diagnosed as early gastric cancer. With articulated devices of RG, surgeons are able to perform every procedure more meticulously, which can result in less bleeding and damage to organs. There are many single arm and comparative studies, and these study showed similar trends, which included relatively less estimated blood loss and longer operation time following RG than laparoscopic gastrectomy (LG), equivalent number of harvested lymph nodes and similar length of postoperative hospital stay between RG and LG. Considering the results of these retrospective comparative studies, RG seems to be as feasible as LG in terms of early surgical outcomes. However, medical expense of RG is approximately twice as much as that of LG. Lack of solid evidence in terms of long-term outcomes is another problem. Considering the higher medical expenses associated with RG, its superiority in terms of long-term survival outcomes needs to be confirmed in the future for it to be accepted more widely.

Current status and future perspectives of laparoscopic radical surgery for advanced gastric cancer

Laparoscopic radical gastrectomy with lymph node dissection has widely penetrated to East Asian countries, where incidence of gastric cancer occurrence is higher than the rest of the world. Laparoscopic distal gastrectomy for cStageI disease is regarded as one of the option in daily practice in the latest Japanese guidelines; however its applicability to more advanced disease (Stage II/III) is still under debate. Actually, operative techniques of laparoscopic D2 dissection is being matured, but still, necessity of total omentectomy, splenic hilar dissection, management of bulky nodes or large primary tumor, high-level anastomosis in esophageal invasion cases, and extensive peritoneal lavage can be raised as technical limitations. In the future perspective, further technological innovation, including next generation surgical robot, may help surgeons overcome these difficulties. Currently, three large-scaled randomized phase-III clinical trials are ongoing in East Asia, in which patients' accruals have been already completed. With coming long-term outcomes of these well-designed studies, oncological validity of laparoscopic approach will be adequately elucidated.