Laparoscopy-assisted distal gastrectomy for gastric cancer

Advances in the surgical management of gastric and gastroesophageal junction cancer

Since Theodore Billroth and Cesar Roux perfected the methods of post-gastrectomy reconstruction in the late 19^th century, surgical management of gastric and gastroesophageal cancer has made incremental progress. The majority of patients with localized disease are treated with perioperative combination chemotherapy or neoadjuvant chemoradiation. Staging laparoscopy before initiation of treatment or before surgical resection has improved staging accuracy and can drastically inform treatment decisions. The longstanding and contentious debate on the optimal extent of lymph node dissection for gastric cancer appears to have settled in favor of D2 dissection with the recently published 15-year follow-up of the Dutch randomized trial. Minimally invasive gastric and gastroesophageal resections are performed routinely in most centers affording faster recovery and equivalent oncologic outcomes. Pylorus-preserving distal (central) gastrectomy has emerged as a less invasive, function-preserving option for T1N0 middle-third gastric cancers, while randomized data on its oncologic adequacy are pending. Multi-visceral resections and cytoreductive surgery with hyperthermic intraperitoneal chemotherapy has been utilized selectively for patients with locally advanced tumors who have demonstrated disease control on preoperative chemotherapy. This review summarizes the current standard of surgical care for gastroesophageal junction and gastric cancer as well as highlights recent and upcoming advances to the field.

Comparison of laparoscopic versus open gastrectomy for advanced gastric cancer: an updated meta-analysis

BACKGROUND

Laparoscopic gastrectomy (LG) has been used as an alternative to open gastrectomy (OG) to treat early gastric cancer. However, the use of LG for advanced gastric cancer (AGC) has been in debate.

METHODS

Literature retrieval was performed by searching PubMed, EMBASE, and the Cochrane library up to July 2014. Potential studies comparing the surgical effects between LG with OG were evaluated and data were extracted accordingly. Meta-analysis was carried out using RevMan. The pooled risk ratio and weighted mean difference (WMD) with 95 % confidence interval (95 % CI) were calculated.

RESULTS

Overall, 26 studies were included in this meta-analysis. LG had some advantages over OG, including shorter hospitalization (WMD, -3.63, 95 % CI, -4.66 to -2.60; P < 0.01), less blood loss (WMD, -161.37, 95 % CI, -192.55 to -130.18; P < 0.01), faster bowel recovery (WMD, -0.78, 95 % CI, -1.05 to -0.50; P < 0.01), and earlier ambulation (WMD, -0.95, 95 % CI, -1.47 to -0.44; P < 0.01). In terms of surgical and oncological safety, LG could achieve similar lymph nodes (WMD, -0.49, 95 % CI, -1.78 to 0.81; P = 0.46), a lower complication rate [odds ratio (OR), 0.71, 95 % CI, 0.59 to 0.87; P < 0.01], and overall survival (OS) and disease-free survival (DFS) comparable to OG.

CONCLUSIONS

For AGCs, LG appeared comparable with OG in short- and long-term results. Although more time was needed to perform LG, it had some advantages over OG in achieving faster postoperative recovery. Ongoing trials and future studies could help to clarify this controversial issue.

Laparoscopic versus open distal gastrectomy for gastric cancer: a meta-analysis of randomized controlled trials and high-quality nonrandomized studies

OBJECTIVE

To perform a meta-analysis of high-quality published trials, randomized and observational, comparing laparoscopic distal gastrectomy (LDG) and open distal gastrectomy (ODG) for gastric cancer.

BACKGROUND

Controversy persists about the clinical utility of minimally invasive techniques for the treatment of gastric cancer. Prospective data is limited to a few small randomized trails.

METHODS

: Studies published from January 1992 to March 2010 that compare LDG and ODG were identified. No restrictions in pathologic stage were applied. All randomized controlled trials (RCTs) were included. Selection of high-quality, nonrandomized comparative studies (NRCTs) was based on a validated tool (Methodological Index for Nonrandomized Studies). Mortality, complications, harvested lymph nodes, operative time, blood loss, and hospital stay were compared using weighted mean differences (WMDs) and odds ratios (ORs).

RESULTS

Twenty-five studies were included in the analyses, 6 RCTs and 19 NRCTs, compromising 3055 patients (1658 LDG, 1397 ODG). LDG was associated with longer operative times (WMD 48.3 minutes; P < 0.001) and lower overall complications (OR 0.59; P < 0.001), medical complications (OR 0.49; P = 0.002), minor surgical complications (OR 0.62; P = 0.001), estimated blood loss (WMD -118.9 mL; P < 0.001), and hospital stay (WMD -3.6 days; P < 0.001). Mortality and major complications were similar. Patients in the ODG group had a significantly higher number of lymph nodes harvested (WMD 3.9 nodes; P < 0.001), although the estimated proportion of patients with less than 15 retrieved nodes was similar (OR 1.26, P = 0.09).

CONCLUSIONS

LDG can be performed safely with a shorter hospital stay and fewer complications than open surgery. The long-term significance of a difference of less than 5 nodes in the number of harvested lymph nodes remains unclear. Lymph node staging appears to be unaffected. These results need to be validated in Western patients with advanced gastric cancer.

Subtotal gastrectomy with D2 dissection by minimally invasive surgery for distal adenocarcinoma of the stomach: results and 5-year survival

BACKGROUND

The purpose of this study is to assess outcomes and 5-year survival after subtotal gastrectomy (SG) for early and advanced distal adenocarcinoma with D2 dissection performed by minimally invasive surgery (MIS).

METHODS

From June 2000 to October 2009 a total of 70 patients with adenocarcinoma of the lower third of the stomach underwent SG with D2 nodal clearance by MIS. This series enrolled 37 patients with early gastric cancer (EGC) and 33 with advanced gastric cancer (AGC). SG was attempted by conventional laparoscopy (CL) in 52 cases and by robot-assisted (RA) technique in 18. Clinical and histopathologic results with 5-year survival were analyzed.

RESULTS

No intraoperative complication was registered. Conversion to laparotomy was required in five patients. Overall, the mean operating time for SG was 254 min (range = 145-460) and estimated mean blood loss was 146 ml (range = 45-250). Postoperative complications occurred in seven patients, including two duodenal leakages none of which required laparotomy. There were two postoperative deaths, one caused by hepatic failure and one by hemorrhagic stroke. Preoperative understaging occurred in ten cases (three were AGC). On average, 30 ± 8 lymph nodes were collected. The distance of proximal resection margin was 6.6 cm (range = 4-8.5 cm). Short-term results were equal with those of laparoscopic and RA gastrectomy. The mean hospital stay of all patients was 10 days (range = 7-24). The mean follow-up span was 53 months (range = 3-112). Relapse of disease occurred in 12 patients, 10 of whom died from the disease and their mean survival was 25 months (range = 12-38). The overall 3-year survival was 85% for CL gastrectomy and 78% for RA gastrectomy, but this difference was not significant with the log rank test (p > 0.05). The overall 5-year survival was 81% (97% for EGC and 67% for AGC).

CONCLUSION

D2 subtotal gastrectomy performed by MIS is reproducible and safe. The long-term outcomes and 5-year survival are acceptable. Extended lymphadenectomy was carried out for both EGC and AGC so as to ensure adequate nodal clearance and compensate preoperative underestimation.

Systemic and peritoneal inflammatory response after laparoscopic-assisted gastrectomy and the effect of inflammatory cytokines on adhesion of gastric cancer cells to peritoneal mesothelial cells

INTRODUCTION

There still remain concerns over the potential for peritoneal metastasis after laparoscopic surgery. We designed this trial to investigate the effects of the inflammatory cytokines interleukin-1β (IL-1β) and tumor necrosis factor-α (TNF-α) on the interaction between gastric cancer cells and mesothelial cells, and to evaluate differences in both the peritoneal and systemic cytokine (IL-1β and TNF-α) concentrations after laparoscopic and conventional surgical approaches, thus offering another possible advantage of laparoscopic procedures for treatment of gastric cancer.

EXPERIMENTAL DESIGN

A reproducible human in vitro assay was developed to study adhesion of SGC-7901 and MKN-45 human gastric cancer cells to monolayers of primary cultured human peritoneal mesothelial cells (HPMCs). Tumor cell adhesion to a mesothelial monolayer was assessed after preincubation of the monolayer with IL-1β and TNF-α using flow cytometry. Expression of adhesion molecules (ICAM-1, VCAM-1, and CD44) and their counterparts (LFA-1 and VLA-4) was investigated by real-time polymerase chain reaction (PCR) immunocytochemical staining. Furthermore, the proinflammatory cytokines IL-1β and TNF-α were measured perioperatively in peritoneal drain fluid and in serum by enzyme immunoassay.

RESULTS

Preincubation of the mesothelial monolayer with IL-1β and TNF-α resulted in enhanced tumor cell adhesion of SGC-7901 and MKN-45 cells. Mesothelial cells showed significant enhancement of expression of ICAM-1, VCAM-1, and CD44 after stimulation with IL-1β and TNF-α. Meanwhile their counterparts (LFA-1, VLA-4, and CD44) were identified in gastric cancer cells. The level of IL-1β in peritoneal drain fluid and in serum perioperatively in the laparoscopy-assisted gastrectomy group was lower than in the conventional open gastrectomy group, whereas there were no significant differences between the laparoscopic-assisted distal gastrectomy (LADG) and conventional open distal gastrectomy(CODG) groups with respect to TNF-α.

CONCLUSIONS

The presented results prove that IL-1β and TNF-α are significant stimulating factors in gastric cancer cell adhesion in vitro and may therefore partly account for local tumor recurrence and peritoneal metastasis in vivo. Owing to less impact on the postoperative abdominal regional and systemic immune responses, laparoscopic surgery not only shows clinically relevant advantages but also causes less effect of inflammatory factors on local recurrence and peritoneal metastasis of gastric cancer than conventional operations. Thus, we offer another possible advantage of laparoscopic procedures for treatment of gastric cancer.