Increased fat content and body shape have little effect on the accuracy of lymph node retrieval and blood loss in laparoscopic distal gastrectomy for gastric cancer

Obesity promotes lipid accumulation in lymph node metastasis of gastric cancer: a retrospective case‒control study

Background

The connection between obesity, lipid accumulation, and lymph node metastasis (LNM) in gastric cancer (GC) is unclear.

Methods

The association of body mass index (BMI) and serum lipid levels with LNM was measured by calculating the odds ratio (OR) and 95% confidence interval (CI) in 1,058 eligible GC patients with a mean age of 61.4 years. Meanwhile, differentially expressed genes (DEGs) were identified between lymph node metastasis-positive (N +) and -negative (N0) groups using public RNA-seq data. Neutral lipids in human GC samples were detected by Oil red O staining. The expression of cluster of differentiation 36 (CD36), fatty acid synthase (FASN), and lipoprotein lipase (LPL) was detected by immunohistochemistry (IHC) and quantitative real-time PCR.

Results

Compared with normal-weight patients, overweight (OR = 2.02, 95% CI = 1.26–3.23) and obese (OR = 1.83, 95% CI = 1.15–2.91) patients showed increased ORs for LNM. However, no significant results were obtained for serum lipids in the multivariable-adjusted model (P > 0.05). Subgroup analysis suggested that increased low-density lipoprotein cholesterol was a risk factor in females (OR = 1.27, 95% CI = 1.02–1.59). Functional enrichment analysis of DEGs revealed a connection between lipid metabolism and LNM. Meanwhile, lipid staining showed a mass of lipids in obese N + tumor samples, and IHC analysis indicated an increase in LPL and CD36 expression in N + cases, implying a crucial role for exogenous lipid supply in LNM.

Conclusions

High BMI significantly increases the risk of LNM in GC and promotes lipid accumulation in GC cells in LNM.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12944-022-01734-7.

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

Background

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

Study design

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

Results

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

Conclusion

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

A Simple Predictive Index of the Abdominal Shape for Postoperative Complications After Laparoscopy-Assisted Distal Gastrectomy for Gastric Cancer

Background: The purpose of this study was to explore the effect of abdominal shape on the short-term surgical outcomes. Methods: This was a retrospective study that included 425 patients undergoing laparoscopic distal gastrectomy plus D2 lymph node dissection (LADG) from January 2013 to January 2021. The abdominal parameters, including the shortest distance of the pancreas from the anterior abdominal skin (PAAD), the lower sternum angle (LSA), the thickness of the subcutaneous fat at the navel level (SFT), the anteroposterior diameters (APD) and the left-right diameters (LRD) at the navel level, the distance from the xiphoid process to the navel (XND) and the distance from the xiphoid process to the pubis (XBD), were calculated by preoperative abdominal computed tomography (CT) imaging. The parameters and short-term surgical outcomes were analyzed. Results: In males, the number of retrieved lymph nodes was significantly higher in patients with a lower APD group (p = 0.031). The operation time was significantly shorter in the lower body mass index (BMI) (p = 0.007), lower LSA (p = 0.035), lower PAAD (p = 0.000), lower SFT (p = 0.004), lower APD (p = 0.000) and lower LRD (p = 0.014) groups. The estimated blood loss was significantly less in the lower BMI (p = 0.035), lower LSA (p = 0.001), lower PAAD (p = 0.012), lower SFT (p = 0.003), lower APD (p = 0.000) and lower LRD (p = 0.005) groups. The complications were fewer in the lower LSA (p = 0.012), lower APD (p = 0.043) and lower LRD (p = 0.023) groups. In females, the postoperative hospital stay was shorter in the lower PAAD (p = 0.027) and lower SFT (p = 0.004) groups, and the lower SFT group had fewer complications (p = 0.020). Furthermore, in multivariate analysis, higher PAAD (p = 0.037, odds ratio = 1.030, 95% CI = 1.002-1.059) was an independent factor for predicting postoperative complications in males. Conclusion: Various abdominal shapes can affect the difficulty of LADG. Higher PAAD is a simple independent index for predicting postoperative complications in males.

Detection of sarcopenic obesity and prediction of long-term survival in patients with gastric cancer using preoperative computed tomography and machine learning

Background

Previous studies evaluating the prognostic value of computed tomography (CT)‐derived body composition data have included few patients. Thus, we assessed the prevalence and prognostic value of sarcopenic obesity in a large population of gastric cancer patients using preoperative CT, as nutritional status is a predictor of long‐term survival after gastric cancer surgery.

Methods

Preoperative CT images were analyzed for 840 gastric cancer patients who underwent gastrectomy between March 2009 and June 2018. Machine learning algorithms were used to automatically detect the third lumbar (L3) vertebral level and segment the body composition. Visceral fat area and skeletal muscle index at L3 were determined and used to classify patients into obesity, sarcopenia, or sarcopenic obesity groups.

Results

Out of 840 patients (mean age = 60.4 years; 526 [62.6%] men), 534 (63.5%) had visceral obesity, 119 (14.2%) had sarcopenia, and 48 (5.7%) patients had sarcopenic obesity. Patients with sarcopenic obesity had a poorer prognosis than those without sarcopenia (hazard ratio [HR] = 3.325; 95% confidence interval [CI] = 1.698–6.508). Multivariate analysis identified sarcopenic obesity as an independent risk factor for increased mortality (HR = 2.608; 95% CI = 1.313–5.179). Other risk factors were greater extent of gastrectomy (HR = 1.928; 95% CI = 1.260–2.950), lower prognostic nutritional index (HR = 0.934; 95% CI = 0.901–0.969), higher neutrophil count (HR = 1.101; 95% CI = 1.031–1.176), lymph node metastasis (HR = 6.291; 95% CI = 3.498–11.314), and R1/2 resection (HR = 4.817; 95% CI = 1.518–9.179).

Conclusion

Body composition analysis automated by machine learning predicted long‐term survival in patients with gastric cancer.

Body composition assessment and sarcopenia in patients with gastric cancer: a systematic review and meta-analysis

INTRODUCTION

There has recently been increased interest in the assessment of body composition in patients with gastric cancer for the purpose of prognostication. This systematic review and meta-analysis aim to evaluate the current literature on body composition assessment in patients with gastric cancer and its impact on peri-operative outcomes.

METHODS

A systematic literature search was conducted for studies reporting assessment of body composition in patients with gastric cancers. Meta-analysis of postoperative outcomes (overall and major complications, anastomotic leaks, pulmonary complications) and survival was performed using random effects models.

RESULTS

Thirty-nine studies reported the assessment of body composition in 8402 patients. Methods used to assess body composition in patients with gastric cancers were computerized tomography (n = 26), bioelectrical impedance analysis (n = 9), and dual-energy-X-ray-absorptiometry (n = 3). Only 21 studies reported the impact of pre-operative sarcopenia on post-operative outcomes. Sarcopenic patients have significantly higher rates of postoperative major complications (n = 12, OR 1.67, CI_95% 1.14-2.46, p = 0.009), and pulmonary (n = 8, OR 4.01, CI_95% 2.23-7.21, p < 0.001) complications after gastrectomy. Meta-analysis of nine studies reporting overall survival after gastrectomy identified significantly worse survival in patients with pre-operative sarcopenia (HR 2.12, CI_95% 1.89-2.38, p < 0.001).

CONCLUSIONS

Assessment of body composition has the potential to become a clinically useful tool that could support decision-making in patients with gastric cancer. However, variation in methods of assessing and reporting body composition in this patient group limits assessment of current post-operative outcomes.

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.

Prediction of the Risk of Laparoscopy-Assisted Gastrectomy by Comparing Visceral Fat Area and Body Mass Index

Propose

The purpose of this study was to compare the accuracy of visceral fat area (VFA) and body mass index (BMI) in predicting the risk of laparoscopic-assisted gastrectomy.

Methods

Clinicopathological and imaging data of 133 patients who underwent laparoscopy-assisted gastrectomy were recorded, including 17 cases of conversion to open surgery. The remaining 116 patients were retrospectively analyzed after we excluded 17 patients who had been transferred to laparotomy. The patients were divided into two groups according to BMI (≤25 kg/m²: BMI-L group; >25 kg/m²: BMI-H group) and VFA (≤100 cm²: VFA-L group; >100 cm²: VFA-H group). Clinical outcomes were compared between the BMI and VFA subgroups.

Results

There were no differences in intraoperative blood loss and the number of harvested lymph nodes between low and high patients defined by BMI and VFA (p > 0.050). However, in the comparison of patients who underwent laparoscopic resection only, it was found that the operation time and intraoperative blood loss of the VFA-H group were more than those of the VFA-L group (p < 0.050). Compared to the VFA-L group, the VFA-H group had later first exhaust time (p = 0.018), more complications (p < 0.001), and longer hospital stays (p = 0.049). However, no similar conclusion was obtained in the BMI group (p > 0.050).

Conclusion

This study demonstrates that VFA better evaluates the difficulty of laparoscopy-assisted gastrectomy and the risk of postoperative complications than BMI.

Which Factors Are Important for Successful Sentinel Node Navigation Surgery in Gastric Cancer Patients? Analysis from the SENORITA Prospective Multicenter Feasibility Quality Control Trial

Background

We investigated the results of quality control study prior to phase III trial of sentinel lymph node navigation surgery (SNNS).

Methods

Data were reviewed from 108 patients enrolled in the feasibility study of laparoscopic sentinel basin dissection (SBD) in gastric cancer. Seven steps contain tracer injection at submucosa (step 1) and at four sites (step 2) by intraoperative esophagogastroduodenoscopy (EGD), leakage of tracer (step 3), injection within 3 minutes (step 4), identification of at least one sentinel basin (SB) (step 5), evaluation of sentinel basin nodes (SBNs) by frozen biopsy (step 6), and identification of at least five SBNs at back table and frozen sections (step 7).

Results

Failure in step 7 (n = 23) was the most common followed by step 3 (n = 15) and step 6 (n = 13). We did not find any differences of clinicopathological factors between success and failure group in steps 1~6. In step 7, body mass index (BMI) was only the significant factor. The success rate was 97.1% in patients with BMI  <  23 kg/m² and 80.3% in those with BMI ≥ 23 kg/m² (P = 0.028).

Conclusions

Lower BMI group showed higher success rate in step 7. Surgeons doing SNNS should be cautious when evaluating sufficient number of SBN in obese patients.

Impact of Abdominal Shape on Short-Term Surgical Outcome of Laparoscopy-Assisted Distal Gastrectomy for Gastric Cancer

BACKGROUND

Laparoscopy-assisted distal gastrectomy (LADG) has been widely accepted for the treatment for gastric cancer. The aim of the present study was to explore the impact of abdominal shape parameters on gastric antrum cancer patients' short-term surgical outcomes of LADG with D2 lymph node dissection in both genders, including the number of lymph nodes retrieved and surgical safety index.

METHODS

This was a retrospective analysis of 177 gastric antrum cancer patients, who underwent LADG between April 2009 and January 2016. The abdominal shape parameters, including abdominal anterior-posterior diameter (APD), transverse diameter (TD), xiphoid process of the sternum-navel distance (XND), and thickness of subcutaneous fat (SCF) at the umbilicus level, were calculated by preoperative abdominal computed tomography (CT) scans. The effects of abdominal shape parameters on the short-term surgical outcomes of LADG were analyzed.

RESULTS

In male patients undergoing LADG and D2 lymph node dissection, the number of retrieved lymph nodes was significantly lower in patients with APD ≥17.3 cm (P = 0.005), TD ≥27.4 cm (P = 0.029), SCF ≥1.2 cm (P = 0.014), and BMI ≥22.2 (P = 0.008), whereas in female patients, these were statistically insignificant (P > 0.05). APD, TD, SCF, and BMI were negatively correlated with the number of retrieved lymph nodes in male patients. There was no significant difference in the number of lymph nodes retrieved between high-XND group and low-XND group in either gender. Operation time was significantly shorter in male patients with XND < 17.0 cm (P = 0.044) and in female patients with SCF < 2.15 cm (P = 0.013). Intraoperative blood loss and postoperative complication rate were not significantly different between high- and low-APD groups, high- and low-TD groups, high- and low-XND groups, and high- and low-SCF groups in either gender. Compared with male patients, SCF and TD were significantly higher in female patients. In addition, a higher incidence rate of hypertension was observed in patients of both genders with large APD and SCF, although statistically significant only in male patients.

CONCLUSIONS

LADG with D2 lymph node dissection can effectively achieve the lymph node dissection requirement of radical distal gastrectomy for patients with various abdominal shapes. It is worth noting that APD, TD, and SCF can impact on lymph node dissection of LADG in male patients. Nevertheless, in female patients, abdominal shape do not impact on lymph node dissection of LADG. Moreover, LADG with D2 lymph node dissection is proved to be safe for various abdominal shape in both genders, even for abdominal obese patients.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Early phase II study of robot-assisted distal gastrectomy with nodal dissection for clinical stage IA gastric cancer

BACKGROUND

Robot-assisted distal gastrectomy (RADG) is increasingly performed in Japan and Korea and is thought to have many advantages over laparoscopic gastrectomy. However, a prospective study investigating the safety of RADG has never been reported. The present study evaluated the safety of RADG with nodal dissection for clinical stage IA gastric cancer.

METHODS

This single-center, prospective phase II study included patients with clinical stage IA gastric cancer located within the lower two-thirds of the stomach. The primary endpoint was the incidence of postoperative intraabdominal infectious complications including anastomotic leakage, pancreas-related infection, and intraabdominal abscess. The secondary endpoints included all in-hospital adverse events, RADG completion rate, and survival outcome.

RESULTS

From May 2012 to November 2012, 18 eligible patients were enrolled for this study. The incidence of intraabdominal infectious complication was 0 % (90 % CI, 0-12.0 %). The overall incidence of in-hospital adverse events was 22.2 % (90 % CI, 8.0-43.9 %). No patient required conversion to laparoscopic or open gastrectomy; thus, the RADG completion rate was 100 %.

CONCLUSIONS

This early phase II study suggested that RADG might be a safe and feasible procedure for stage IA gastric cancer, providing experienced surgeons perform the surgery. This conclusion should be clarified in subsequent late phase II studies with a larger sample size.

Inverse association between visceral obesity and lymph node metastasis in gastric cancer

BACKGROUND

The relationship between fat distribution and lymph node metastasis has not been well studied. The goal of this study was to determine the impact of visceral obesity on lymph node metastasis in gastric cancer.

MATERIALS AND METHODS

Metastatic lymph node ratio (MLR) was defined as the number of involved nodes by tumor divided by the total number of resected lymph nodes. Visceral (VFA) and subcutaneous fat areas (SFA) were determined by measuring abdominal fat volume distribution via CT scan, and visceral obesity was defined as a VFA to total fat area ratio (V/T) >0.29.

RESULTS

With lymph node metastasis as a dependent variable, the following factors were significant in multivariate analysis among 495 patients: pathologic T stage (P < 0.001), lympho-vascular invasion (P < 0.001), and V/T (hazard ratio (HR) = 0.455, 95 % confidence interval (CI) = 0.263-0.786, P = 0.005). Similarly, when MLR was the dependent variable in multivariate analysis, MLR was significantly associated with lympho-vascular invasion (HR = 2.222, 95 % CI = 1.149-4.296, P = 0.018), and V/T (HR = 0.247, 95 % CI = 0.133-0.458, P < 0.001).

CONCLUSIONS

Visceral obesity defined by higher visceral to total fat area ratio was significantly associated with decreased MLR.

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

BACKGROUND

High body mass index (BMI) and high visceral fat area (VFA) are known to be a preoperative risk factor for laparoscopic gastrectomy (LG) for gastric cancer. However, the impact of obesity on LG still remains controversial. In the present study, we compared the operative outcomes of LG with those of OG in patients with BMI of 30 kg/m(2) or more.

METHODS

Seventy-seven patients who underwent distal or total gastrectomy for gastric cancer were enrolled. The patients were divided into two groups by approach method; an OG group (n = 19) and a LG group (n = 62). Aquarius iNtuition(®) program was used to measure VFA. The operation time, estimated blood loss, complication rate, the number of retrieved lymph nodes, and patient survival were compared between two groups.

RESULTS

The mean BMI and VFA were 31.6 kg/m(2) and 195.3 cm(2). The complication rate was 42.1 % in OG group and 14.5 % in LG group, respectively (P = 0.010). LG group showed less estimated blood loss (P = 0.030) and fast recovery of bowel movement (P < 0.001). However, there were no significant differences in operation time, the number of retrieved lymph nodes, and the length of hospital stay between two groups. In subgroup analysis, there was significant correlation between estimated blood loss and VFA (R (2) = 0.113, P = 0.014), but there was no correlation between operation time and VFA (R(2) = 0.002, P = 0.734). In stage I, the 5-year survival was not different between two groups (P = 0.220).

CONCLUSION

LG showed better operative outcomes compared with OG, in terms of less estimated blood loss, fast recovery of bowel movement, and low complication rate, in patients with BMI of ≥ 30 kg/m(2) or more.

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

BACKGROUND

Laparoscopic distal gastrectomy for gastric cancer has been firmly established in recent decades but still is a difficult procedure, especially for obese patients, as with open surgery. This study aimed to evaluate the perioperative outcome of total laparoscopic distal gastrectomy (TLDG) for early gastric cancer patients with a body mass index (BMI) exceeding 25 kg/m(2) and to consider countermeasures to this.

METHODS

Perioperative outcomes were compared between 42 patients with a BMI exceeding 25 kg/m(2) [overweight or obese group (OWG)] and 174 patients with a BMI lower than 25 kg/m(2) [normal or underweight group (NWG)] who underwent TLDG between September 2010 and December 2012.

RESULTS

The BMI was 26.0 ± 1.4 kg/m(2) in the OWG group and 22.0 ± 2.1 kg/m(2) in the NWG group (P < 0.001). The groups did not differ in terms of age, sex, American Society of Anesthesiologists score, presence of diabetes, number of retrieved lymph nodes, number of metastatic lymph nodes, or metastatic lymph node ratio. The two groups did not differ significantly with respect to the extent of lymph node dissection [OWG: D1 (11.9 %), D1+ (66.7 %), D2 (21.4 %) vs NWG: D1 (5.2 %), D1+ (51.7 %), D2 (43.1 %); P = 0.020] or tumor size (OWG: 25.5 ± 20.2 mm vs NWG: 33.0 ± 17.2 mm; P = 0.037). Differences in operation time (OWG: 212 ± 31 min vs NWG: 200 ± 35 min; P = 0.005) and estimated blood loss (OWG: 15 ± 22 ml vs NWG: 10 ± 34 ml; P = 0.013) seemed to have a minimal impact clinically. Postoperative complications including infectious complications and recovery after surgery did not differ between the two groups.

CONCLUSIONS

For overweight and obese patients, TLDG was managed safely. The procedure was considered to be difficult but sufficiently feasible.

Esophagojejunal reconstruction after total gastrectomy for gastric cancer using a transorally inserted anvil delivery system

INTRODUCTION

Total gastrectomy (TG) is commonly performed for the treatment of patients with gastric cancer. However, reconstruction of the esophagojejunal (EJ) anastomosis can be technically demanding, with reported anastomotic leak rates in the Western world still approaching 10-15%. We report our experience using the transoral anvil delivery system (OrVil™) for creation of the EJ anastomosis after TG.

METHODS

From 2007 to 2011, 48 consecutive patients with gastric cancer underwent open (n=31) or laparoscopic (n=17) TG. EJ reconstruction was performed with the transoral anvil deliver system (OrVil™) in an end-to-side fashion. Demographic, clinic, and perioperative data were obtained from a prospectively maintained database.

RESULTS

Of the 48 patients, 83% were male. Median age at resection was 64 years. Median body mass index was 27.1 kg/m2. Seventy-nine percent (n=38) of patients had at least one comorbidity. Fifteen patients (31%) had at least one perioperative complication. There was one perioperative death (2%) following a duodenal stump leak. There were four EJ leaks (8%) and two EJ stenoses (independent of leak; 4%). There was one EJ leak (6%) and one EJ stenosis (6%) following a case that was first attempted laparoscopically. There were no deaths as a consequence of an EJ leak.

CONCLUSIONS

The use of the transoral anvil delivery system during EJ reconstruction is a safe and effective option for reconstruction after open or laparoscopic TG with acceptable mortality and morbidity. The anastomotic leak rate appears to be comparable to that of other techniques.

Postoperative intra-abdominal complications assessed by the Clavien-Dindo classification following open and laparoscopy-assisted distal gastrectomy for early gastric cancer

BACKGROUND

Laparoscopy-assisted gastrectomy (LAG) has been increasingly used for the treatment of early gastric cancer, and many advantages over open gastrectomy (OG) have been reported. However, only a few reports have assessed postoperative complications following LAG using the Clavien-Dindo classification.

METHODS

A total of 265 patients who underwent distal gastrectomy or pylorus-preserving gastrectomy with D1+ lymph node dissection for clinical stage IA early gastric cancer at the Shizuoka Cancer Center between June 2009 and December 2011 were included in this study. Clinicopathological characteristics and early surgical outcomes were compared between patients who underwent LAG (LAG group, n = 129) and those who underwent OG (OG group, n = 136). The severity of postoperative morbidities was assessed according to the Clavien-Dindo classification.

RESULTS

There were no differences in sex or age between the two groups. Body mass index (21.97 vs. 23.19, P < 0.001) was lower in the LAG group than the OG group. The duration of the postoperative hospital stay was similar between the two groups (9 days each, P = 0.511). There was no difference in the overall morbidity rate (grade II or higher) between the two groups (LAG group, 7.0%; OG group, 8.1%; P = 0.818). The incidence of grade IIIa or more severe morbidities was also not significantly different between the LAG group (4.7%) and OG group (2.9%, P = 0.532).

CONCLUSIONS

There was no significant difference in postoperative complication rates between the LAG and the OG groups. The more severe Clavien-Dindo grade III complications, which required surgical interventions, were observed at similar rates between the two groups. Laparoscopic gastrectomy for early gastric cancer is therefore feasible in terms of the incidence and severity of intra-abdominal complications.

Laparoscopy-assisted versus open distal gastrectomy for early gastric cancer: evidence from randomized and nonrandomized clinical trials

OBJECTIVE

To evaluate the safety and efficacy of laparoscopy-assisted distal gastrectomy (LADG) in patients with early gastric cancer (EGC) to determine whether LADG is an acceptable alternative to open distal gastrectomy (ODG).

BACKGROUND

LADG combined with less than D2 or D2 lymphadenectomy for EGC is still a controversial surgical intervention for its uncertain oncological safety and economic benefit. We conducted this systematic review and meta-analysis that included randomized control trials (RCTs) and non-RCTs of LADG versus ODG to evaluate whether the safety and efficacy of LADG in patients with EGC are equivalent to those of ODG.

METHODS

A comprehensive search of PubMed, EMBASE, Cochrane Library, and China Knowledge Resource Integrated Database was performed. Eligible trials published between January 1, 1994, and December 31, 2010, were included in the study. Data synthesis and statistical analysis were carried out by RevMan 5.0 software. The quality of evidence was assessed by GRADEpro 3.2.2.

RESULTS

Twenty-two studies with 3411 participants were included in this study. The mean number of lymph nodes retrieved in LADG was close to that retrieved in ODG (in the less than D2 resection: weighted mean difference [WMD] = -1.79; 95% confidence interval [95% CI], -5.78 to 2.19; P = 0.38; heterogeneity: P < 0.00001, I = 98%; and in the D2 resection: WMD = -1.53; 95% CI, -3.56 to 0.51; P = 0.14; heterogeneity: P = 0.23, I = 26%). The overall postoperative morbidity was significantly less in LADG than in ODG (relative risk = 0.58; 95% CI, 0.46-0.74; P < 0.00001; heterogeneity: P = 0.94, I = 0%). LADG reduced the intraoperative blood loss, postoperative analgesic consumption, and hospital duration, without increasing the total hospitalization costs and cancer recurrence rate. The long-term survival rate of patients undergoing LADG was similar to that of patients undergoing ODG. However, LADG was still a technically dependent and time-consuming procedure. Conversion rate of LADG was 0% to 2.94%. The reported reasons for conversion were bleeding, adhesion, and safety resection margin requirement.

LIMITATIONS

: There were potential biases and significant heterogeneity in some clinical outcome measures in this study. Methodologically high-quality controlled clinical trials were sparse for this new surgical intervention. According to The Grading of Recommendations Assessment, Development and Evaluation approach, when assessing the safety and efficacy of LADG by comparing with those of ODG with the defined clinical outcomes in patients with EGC, the quality of the currently available clinical evidence was very low.

CONCLUSIONS

LADG may be a technically feasible alternative for EGC when it is performed in experienced surgical centers in which patients undergoing LADG may benefit from the faster postoperative recovery. However, the currently available evidence cannot exclude the potential clinical benefits or harms, especially in the node-positive cases. Methodologically high-quality comparative studies are needed for further evaluation.

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.

The impact of abdominal shape index of patients on laparoscopy-assisted distal gastrectomy for early gastric cancer

PURPOSE

The aim of this study was to explore the effects of the abdominal shape index on gastric cancer patients' short-term surgical outcomes of laparoscopy-assisted distal gastrectomy (LADG) in both genders.

METHODS

This retrospective study included 231 consecutive patients with early gastric cancer who underwent LADG with Billroth I anastomosis between 1998 and 2009. The abdominal shape index of patients was calculated using preoperative abdominal computed tomography scans and the Fat Scan software program.

RESULTS

In male patients, the duration of surgery was longer in patients with a body mass index ≥25 kg/m(2) (P = 0.016), with the anterior to posterior diameter ≥200 mm (P < 0.0001), with the transverse diameter (TD) ≥300 mm (P = 0.030), with the waist ≥85 cm (P = 0.039), and with the visceral fat area (VFA) ≥100 cm(2) (P = 0.029). The intraoperative blood loss was higher in the large TD group (P = 0.049), in the high waist group (P = 0.006), and in the large VFA group (P = 0.007). In female patients, the correlations between these surgical outcomes and this abdominal shape index were not found. No significant relationships between each body shape index and the number of lymph nodes retrieved were found in either gender. Postoperative complications were not associated with the fat volume and abdominal shape index.

CONCLUSIONS

Accumulation of fat did not affect short-term surgical outcomes except for the duration of surgery and intraoperative blood loss in male patients.

Minimally invasive surgery for gastric cancer: the future standard of care

Laparoscopy-assisted distal gastrectomy for gastric cancer was first reported by Kitano et al. in 1991. Laparoscopic wedge resection (LWR) and intragastric mucosal resection (IGMR) were quickly adapted for gastric cancer limited to the mucosal layer and having no risk of lymph node metastasis. Following improvements in endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), the use of LWR and IGMR for these indications decreased, and patients with gastric cancer, including those with a risk of lymph node metastases, were more likely to be managed with laparoscopic gastrectomy (LG) with lymph node dissection. Many retrospective comparative trials and randomized-controlled trials (RCT) have confirmed that LG is safe and feasible, and that short-term outcomes are better than those of open gastrectomy (OG) in patients with early gastric cancer (EGC). However, these trials did not include a satisfactory number of patients to establish clinical evidence. Thus, additional multicenter randomized-controlled trials are needed to delineate significantly quantifiable differences between LG and OG. As laparoscopic experience has accumulated, the indications for LG have been broadened to include older and overweight patients and those with advanced gastric cancer. Moreover, advanced techniques, such as laparoscopy-assisted total gastrectomy, laparoscopy-assisted proximal gastrectomy, laparoscopy-assisted pylorus-preserving gastrectomy (PPG), and extended lymph node dissection (D2) have been widely performed.In the near future, sentinel node navigation and robotic surgery will become additional options in minimally invasive surgery (MIS) involving LG. Such developments will improve the quality of life of patients following gastric cancer surgery.

Influence of visceral obesity for postoperative pulmonary complications after pancreaticoduodenectomy

BACKGROUND

We conduct this study to determine whether postoperative complications, including postoperative pulmonary complications (PPCs), are associated with BMI and visceral fat area (VFA) after pancreaticoduodenectomy.

METHODS

A total of 317 patients undergoing pancreaticoduodenectomy were enrolled. VFA was measured using a cross-sectional computed tomography (CT) scan at the level of the umbilicus by FatScan software version 3.0 (N2 systems Inc., Osaka, Japan). Clinicopathological variables, intraoperative outcomes, and postoperative courses were analyzed.

RESULTS

Of all patients, 130 (41.0%) had postoperative complications and PPCs occurred in 14 patients (4.4%). VFA were significantly higher in patients who developed postoperative pancreatic fistula (POPF), PPCs, and mortality than in those patients who did not (P = .0282, P = .0058, and P = .0173, respectively). Multivariate analysis demonstrated that high BMI and high VFA were not independent predictive risk factors for POPF grade B/C and mortality; only high VFA was an independent risk factor influencing PPCs (P = .0390, odds ratio 4.246, 95% confidence interval 1.076-16.759).

CONCLUSIONS

Visceral obesity was the independent risk factor for the incidence of PPCs after pancreaticoduodenectomy. Preoperative VFA measurement using CT scan is a useful tool for the prediction of the development of PPCs compared to BMI calculation.

Implications of overweight in gastric cancer: A multicenter study in a Western patient population

AIMS

The purpose of this study was to evaluate the effects of overweight on surgical and long-term outcomes in a Western population of patients with gastric cancer (GC).

METHODS

An electronic database of all patients with resectable GC treated between 1986 and 1998 at seven university surgical centres cooperating in the Polish Gastric Cancer Study Group was reviewed. Overweight was defined as a body mass index (BMI) of 25 kg/m(2) or higher.

RESULTS

Four hundred and ninety-two of 1992 (25%) patients were overweight. Postoperatively, higher BMI was associated with higher rates of cardiopulmonary complications (16% vs 12%, P = 0.001) and intra-abdominal abscess (6.9% vs 2.9%, P < 0.001). However, other complications and mortality rates were unaffected. The median disease-specific survival of overweight patients was significantly higher (36.7 months, 95% confidence interval (CI) 29.0-44.4) than those with BMI<25 kg/m(2) (25.7 months, 95%CI 23.2-28.1; P = 0.003). These differences were due to the lower frequencies of patients with T3 and T4 tumours, metastatic lymph nodes, distant metastases, and non-curative resections. A Cox proportional hazards model identified age, depth of infiltration, lymph node metastases, distant metastases, and residual tumour category as the independent prognostic factors.

CONCLUSIONS

Overweight is not the independent prognostic factor for long-term survival in a Western-type population of GC.