Comparison of Open and Laparoscopic Gastrectomy in Elderly Patients

Low incidence of postoperative infectious complications following laparoscopic distal gastrectomy for locally advanced gastric cancer in older adult patients above 75 years: Propensity score-matched comparison with open distal gastrectomy

INTRODUCTION

This study compared the short-term outcomes of older adult patients with locally advanced gastric cancer who underwent open distal gastrectomy (ODG) with those who underwent laparoscopic distal gastrectomy (LDG) using propensity score matching analysis.

METHODS

Overall, 341 consecutive older adult patients aged 75 years with gastric cancer who underwent ODG or LDG between January 2013 and December 2020 were retrospectively assessed. Among them, 121 patients with locally advanced gastric cancer were included. To compare short-term outcomes, a 1:1 propensity score matching analysis was performed.

RESULTS

After matching, 29 patients were included in both groups. Compared with the ODG group, the LDG group had a longer operative time (mean, 290 vs. 190 min; p < .0001) and lower estimated blood loss (mean, 39 vs. 223 mL; p < .0001). Overall postoperative complications of grade 2 and higher were observed in 2 (6.9%) and 12 (41%) patients in the LDG and ODG groups, respectively (p = .0046). Of these, the LDG group had a significantly lower incidence rate of infectious complications than the ODG group (3.4% vs. 27.6%; p = .025). Furthermore, in multivariate analysis, the laparoscopic approach was an independent protective factor against postoperative complications (p = .029).

CONCLUSIONS

LDG is safe and feasible for locally advanced gastric cancer in patients aged ≥75 years. Moreover, it may be a promising alternative to ODG with better short-term outcomes, including significantly lower incidence rates of postoperative complications.

EAES/SAGES evidence-based recommendations and expert consensus on optimization of perioperative care in older adults

BACKGROUND

As the population ages, more older adults are presenting for surgery. Age-related declines in physiological reserve and functional capacity can result in frailty and poor outcomes after surgery. Hence, optimizing perioperative care in older patients is imperative. Enhanced Recovery After Surgery (ERAS) pathways and Minimally Invasive Surgery (MIS) may influence surgical outcomes, but current use and impact on older adults patients is unknown. The aim of this study was to provide evidence-based recommendations on perioperative care of older adults undergoing major abdominal surgery.

METHODS

Expert consensus determined working definitions for key terms and metrics related to perioperative care. A systematic literature review and meta-analysis was performed using the PubMed, Embase, Cochrane Library, and Clinicaltrials.gov databases for 24 pre-defined key questions in the topic areas of prehabilitation, MIS, and ERAS in major abdominal surgery (colorectal, upper gastrointestinal (UGI), Hernia, and hepatopancreatic biliary (HPB)) to generate evidence-based recommendations following the GRADE methodology.

RESULT

Older adults were defined as 65 years and older. Over 20,000 articles were initially retrieved from search parameters. Evidence synthesis was performed across the three topic areas from 172 studies, with meta-analyses conducted for MIS and ERAS topics. The use of MIS and ERAS was recommended for older adult patients particularly when undergoing colorectal surgery. Expert opinion recommended prehabilitation, cessation of smoking and alcohol, and correction of anemia in all colorectal, UGI, Hernia, and HPB procedures in older adults. All recommendations were conditional, with low to very low certainty of evidence, with the exception of ERAS program in colorectal surgery.

CONCLUSIONS

MIS and ERAS are recommended in older adults undergoing major abdominal surgery, with evidence supporting use in colorectal surgery. Though expert opinion supported prehabilitation, there is insufficient evidence supporting use. This work has identified evidence gaps for further studies to optimize older adults undergoing major abdominal surgery.

Comorbidity assessment methods and their significance in predicting the results of treatment of older patients undergoing elective abdominal surgeries for cancer - A scoping review

INTRODUCTION

The scoping review was performed to identify methods of comorbidity assessment and to evaluate their significance in predicting the results of treatment of older patients undergoing elective abdominal surgeries for cancer.

MATERIALS AND METHODS

Ovid MEDLINE, Embase, CENTRAL, Web of Science, ClinicalTrials.gov and European Trials Register were searched for eligible studies investigating the impact of comorbidity on various postoperative outcomes of patients aged ≥65. Findings were narratively reported.

RESULTS

The review identified 40 studies with a total population of 59,612 patients, using eight different methods of comorbidity assessment. The most used was Charlson Comorbidity Index (60 % of studies) and presence of specific comorbid conditions (38 %). No study provided rationale for the choice of specific comorbidity measure. Most of the included studies reported short-term results (75 %), such as postoperative complications (43 %) and mortality (18 %) as main clinical endpoint. The results were inconsistent across the studies.

DISCUSSION

There is still no consensus regarding the choice of comorbidity measures and their role in postoperative outcome prediction. Further efforts are needed to develop new, well-designed, more effective comorbidity assessments tools.

Laparoscopic gastrectomy versus open gastrectomy for gastric cancer in patients among octogenarians: a meta-analysis

PURPOSE

Currently, there is no consensus regarding whether super-elderly (aged > 80 years) patients are suitable candidates for laparoscopic surgery. This study aimed to analyse the short-term outcomes and oncological prognosis of laparoscopic gastrectomy in super-elderly patients with gastric cancer (GC).

METHODS

Following PRISMA and AMSTAR-2 guidelines, we searched the Web of Science, Embase, Cochrane Library, and Pubmed databases from inception until May 2024 and performed a meta-analysis. All published studies exploring the surgical outcomes and oncological prognosis of laparoscopic versus open gastrectomy in super-elderly patients with GC were reviewed. Statistical analyses were performed using RevMan 5.3.

RESULTS

A total of 1,085 studies were retrieved, eight of which were included in the meta-analysis, comprising 807 patients > 80 years of age with GC. The meta-analysis showed that compared with open gastrectomy, patients with GC > 80 years old who underwent laparoscopic gastrectomy had a longer operative time (weighted mean difference [WMD] = 30.48, p < 0.001), less intraoperative blood loss (WMD = -166.96, P < 0.001), shorter postoperative exhaust time (WMD =-0.83, p < 0.001), shorter length of stay (WMD = -0.78, p < 0.001), fewer overall complications (Odds ratio [OR] = 0.54, p = 0.003), higher 5-year overall survival rate (OR = 1.66, p = 0.03) and disease-specific survival rate (OR = 3.23, p < 0.001). Furthermore, laparoscopic gastrectomy did not significantly affect the number of lymph node dissections, the rate of D2 radical gastrectomy, major postoperative complications, or postoperative pneumonia.

CONCLUSIONS

Compared to open gastrectomy, patients with GC aged > 80 years who underwent laparoscopic gastrectomy may have better short-term outcomes. Age should not be a contraindication for minimally invasive surgery.

Does surgery cause anxiety, stress and fear in geriatric patients?

BACKGROUND

Because of physiological changes in geriatric patients, their surgical process differs from that of young adults. In this regard, the perioperative period is an extremely risky time for geriatric patients. The present study examined preoperative fear, anxiety, and perceived stress levels as well as the factors affecting them in elderly patients prior to surgical intervention.

METHODS

This study adopted a cross-sectional descriptive design. The study sample consisted of geriatric patients (n = 407) scheduled for elective laparoscopic cholecystectomy in a research and training hospital in northeast Turkey. Data were collected by the researchers using the personal information form, Perceived Stress Scale (PSS-10), Surgical Fear Questionnaire (SFQ) and Anxiety Specific to Surgery Questionnaire (ASSQ). In the data analysis, descriptive statistics, the t-test in independent groups, one-way analysis of variance (ANOVA), correlation analysis and Bonferroni tests for post hoc analyses were used.

RESULTS

On the PSS-10, the mean score was higher for the 75-and-older age group, single patients, patients with a disease requiring medication, and those who had previously undergone surgery (P < 0.05). On the ASSQ, the mean score was lower for patients aged 65-69, university graduates, patients without children, and those without a disease requiring medication (P < 0.05). On the SFQ, the mean score was higher for the 75-and-older age group, primary school graduates, and single patients (P < 0.05).

CONCLUSION

It was determined that being single, having a chronic disability, and advancing age had an effect on the patients' surgery-specific anxiety, perceived stress, and fear of surgery. Long-standing chronic diseases can negatively affect both stress and anxiety levels of individuals.

Outcomes of Gastrectomy for Gastric Cancer in Patients Aged >80 Years: A Systematic Literature Review and Meta-Analysis

This meta-analysis examined the surgical management of older patients (>80 years) with gastric cancer, who were often excluded from randomized controlled trials. We analyzed 23 retrospective cohort studies involving 18,372 patients and found that older patients had a higher in-hospital mortality rate (relative risk [RR], 3.23; 95% confidence interval [CI], 1.46-7.17; P<0.01) and more post-operative complications (RR, 1.36; 95% CI, 1.19-1.56; P<0.01) than did younger patients. However, the surgical complications were similar between the two groups. Older patients were more likely to undergo less extensive lymph node dissection and longer hospital stays. Although older patients had statistically significant post-operative medical complications, they were not deprived of surgery for gastric cancer. The comorbidities and potential risks of post-operative complications should be carefully evaluated in older patients, highlighting the importance of careful patient selection. Overall, this meta-analysis provides recommendations for the surgical management of older patients with gastric cancer. Careful patient selection and evaluation of comorbidities should be performed to minimize the risk of post-operative complications in older patients, while recognizing that they should not be deprived of surgery for gastric cancer.

Validity and reliability study of the quality of recovery scale in Turkish

Background/aim

The aim of this study was to adapt the "Quality of Recovery-15 Scale", developed to measure the postoperative recovery quality of individuals, into Turkish by carrying out validity and reliability studies.

Materials and methods

This methodological study was conducted with a total of 150 patients who underwent surgery under general anesthesia between November 2021 and January 2022 in a training and research hospital in the Black Sea region. Data was collected from the patients through the face-to-face interview method before the operation, on the 24th and the 48th hour postoperatively. First, the linguistic validity of the scale and then the validity and reliability analyses were carried out. Construct validity, confirmatory factor, and reliability analyses were then performed.

Results

The Cronbach's alpha coefficient of the scale was 0.851. The Kaiser-Meyer-Olkin test for goodness of fit of the one-dimensional 14-item scale was 0.853 and Bartlett's test was significant. The goodness of fit values of the scale were found to be RMSEA = 0.149, CFI = 0.769, and GFI = 0.745, and they were considered acceptable levels. The eighth item was removed from the scale, which had originally consisted of 15 items, because the item correlation coefficient of this item was <0.200.

Conclusion

The "Quality of Recovery Scale" was found to be a reliable and valid scale that can be used to measure the quality of recovery after surgery in Turkish society.

Laparoscopic versus open distal gastrectomy for elderly patients with advanced gastric cancer: a retrospective comparative study

BACKGROUND

Laparoscopic radical distal gastrectomy (LDG) has been more frequently performed for locally advanced distal gastric cancer (AGC) than open distal gastrectomy (ODG). However, the benefits of LDG for elderly AGC patients (AGC-lap) remain unclear.

METHODS

Patients aged ≥ 70 years who underwent D2 distal gastrectomy from July 2014 to July 2021 were enrolled consecutively. Perioperative parameters, pathological features, and oncological outcomes of AGC-lap patients (n = 39) were compared with those of elderly AGC patients receiving ODG (AGC-open; n = 37) and elderly early gastric cancer patients receiving LDG (EGC-lap; n = 41) respectively.

RESULTS

The median age of all AGC patients was 77 years, and 28% of them had an Eastern Cooperative Oncology Group score ≥ 2. Most of the perioperative and pathological features (including the number of lymph nodes harvested) were similar between the AGC-lap and AGC-open groups. AGC-lap patients had longer median operative times (215 min versus 192 min) but significantly less surgical complications (10.3% versus 37.8%) and shorter median hospital stays (11 days versus 13 days) than did AGC-open patients (all p < 0.05). The 3-year recurrence-free and overall survival was 66.2% and 88.8% in the AGC-lap group and 51% and 66.3% in the AGC-open group (both p = 0.1). The perioperative features, including operative time, number of lymph nodes harvested, hospital stay, and complication rates, were similar between the AGC- and EGC-lap groups.

CONCLUSIONS

LDG was safely and effectively performed in elderly AGC patients, resulting in faster recovery and a lower complication rate than ODG, without compromising oncological outcomes.

Comparison of Deep and Moderate Neuromuscular Blockade on Intestinal Mucosal Barrier in Laparoscopic Gastrectomy: A Prospective, Randomized, Double-Blind Clinical Trial

Deep neuromuscular blockade (NMB) improves the surgical conditions and is benefit for the postoperative recovery after laparoscopic surgery. However, the mechanisms of deep NMB in promoting the recovery of intestinal function have not been completely investigated. The objective of our study was to determine the impact of the deep NMB and moderate NMB strategy on the intestinal barrier function after laparoscopic gastrectomy. We collected patients undergoing elective laparoscopic gastrectomy. Patients were randomized to deep NMB (post-tetanic count 1–2) vs. moderate NMB (train-of-four count 1–2) during the surgery. Primary outcomes were time to flatus, serum diamine oxidase (DAO) and D-lactate, and gut microbiota. Other outcomes were surgical condition scores, postoperative visual analog pain scores, and length of hospital stay. Ninety patients in deep NMB group and sixty patients in moderate NMB group completed the study. Main results showed that the time to flatus was decreased in deep NMB group (74 ± 32 h) than that in moderate NMB group (93 ± 52 h, P = 0.006). The level of serum D-lactate was statistically increased in the moderate NMB group than that in the deep NMB group (1,209 ± 224 vs. 1,164 ± 185 ng/ml, p < 0.001). But no significant differences could be detected in the level of DAO between the groups. Additionally, the 16s rRNA analysis indicated that gut microbiota were similar in Alpha diversity but distinct in Beta diversity. Furthermore, the beneficial bacteria, such as genus Lactobacillus and Bifidobacterium, were more abundant in the deep NMB group, while the potentially harmful bacteria were more abundant in the moderate NMB group. Our findings suggested that the intestinal mucosal barrier and gut microbiota were better preserved in deep NMB, which greatly improved the postoperative recovery of intestinal function after laparoscopic gastrectomy.

Postoperative morbidity and quality of life between totally laparoscopic total gastrectomy and laparoscopy-assisted total gastrectomy: a propensity-score matched analysis

BACKGROUND

This study aimed to evaluate the surgical outcome and quality of life (QoL) of totally laparoscopic total gastrectomy (TLTG) compared with laparoscopy-assisted total gastrectomy (LATG) in patients with clinical stage I gastric cancer.

METHODS

From 2012 to 2018, EGC patients who underwent TLTG (n = 223), including the first case with intracorporeal hemi-double stapling, were matched to those who underwent LATG (n = 114) with extracorporeal circular stapling, using 2:1 propensity score matching (PSM). Prospectively collected morbidity was compared between the TLTG and LATG groups in conjunction with the learning curve. The European Organization for Research and Treatment of Cancer (EORTC) QoL questionnaires QLQ-C30, STO22, and OG25 were prospectively surveyed during postoperative 1 year for patient subgroups.

RESULTS

After PSM, grade I pulmonary complication rate was lower in the TLTG group (n = 213) than in the LATG group (n = 111) (0.5% vs. 5.4%, P = 0.007). Other complications were not different between the groups. The learning curve of TLTG was overcome at the 26th case in terms of the comprehensive complication index. The TLTG group after learning curve showed lower grade I pulmonary complication rate than the matched LATG group (0.5% vs. 4.7%, P = 0.024). Regarding postoperative QoL, the TLTG group (n = 63) revealed less dysphagia (P = 0.028), pain (P = 0.028), eating restriction (P = 0.006), eating (P = 0.004), odynophagia (P = 0.023) than the LATG group (n = 21). Multivariate analyses for each QoL item demonstrated that TLTG was the only common independent factor for better QoL.

CONCLUSIONS

TLTG reduced grade I pulmonary complications and provided better QoL in dysphagia, pain, eating, odynophagia than LATG for patients with clinical stage I gastric cancer.

Impact of chronic kidney disease on the short- and long-term outcomes of laparoscopic gastrectomy for gastric cancer patients

BACKGROUNDS

This study was undertaken to investigate the impact of coexisting chronic kidney disease (CKD) on short- and long-term outcomes of laparoscopic gastrectomy in patients with gastric cancer (GC).

METHODS

We reviewed the data of 798 patients treated for GC by laparoscopic gastrectomy. All procedures took place between January 2010 and December 2017. Patients were divided into three groups according to their estimated glomerular filtration rate (eGFR): severe CKD group, 44 patients with eGFR < 45 mL/min/1.73 m2; moderate CKD group, 117 patients with 45 ≤ eGFR < 60; control group, 637 patients with eGFR ≥ 60.

RESULTS

Based on multivariate analysis, severe CKD (eGFR < 45) emerged as an independent predictor of anastomotic leak (Hazard ratio 4.63, 95% confidence interval [CI] 1.62-11.54). The 5-year overall survival (OS) rates by group were 46.3% (severe CKD), 76.6% (moderate CKD), and 81.5% (control). Multivariate analysis likewise identified severe CKD (eGFR < 45) as an independent correlate of poor 5-year OS. The 5-year cancer-specific survival (CSS) rates did not differ significantly by group.

CONCLUSIONS

An eGFR value less than 45 mL/min/1.73 m2 is a useful factor for predicting both anastomotic leak and 5-year OS in GC patients undergoing laparoscopic gastrectomy. Clinical care to improve eGFR should be reinforced before and after gastrectomy for GC patients with severe CKD.

Laparoscopic distal gastrectomy in old-old patients: the first Western experience

BACKGROUND

This is the first Western study presenting short-term results on patients older than 80 years affected by gastric cancer and treated with laparoscopic distal gastrectomy.

METHODS

A multicentre prospective database on patients suffering from distal gastric cancer with age of ≥ 80 undergone to distal gastrectomy was analysed retrospectively. End points were length of hospital stay (LoS) after surgery, and times to stool passage and solid diet initiation, as well as postoperative complications. Univariate analysis of the differences between "laparoscopic" and "open" groups was performed with non-parametric tests.

RESULTS

Forty-six patients (median age: 83 years, median CCI: 5) undergone to distal gastrectomy were analysed. Seventeen out 46 patients (36.9%) underwent laparoscopic distal gastrectomy and extended lymphadenectomy was achieved in 25 cases (25/46, 54.3%). Median number of removed and examined nodes was higher in laparoscopic than in open group. Median LoS was significantly lower in the laparoscopic group (8 vs. 11 days). Complications occurred in 12 patients (26.1%): no significant differences between the two groups. There was a significant difference between the two surgical approaches in term of times for stool passage.

CONCLUSIONS

Laparoscopic approach seems to reduce the effect of the surgical trauma without compromising lymphadenectomy also in octogenarian patients with distal gastric cancer.

Effect of stellate ganglion block on postoperative recovery of gastrointestinal function in patients undergoing surgery with general anaesthesia: a meta-analysis

Background

The return of gastrointestinal function is an important sign of postoperative recovery in patients undergoing surgery with general anaesthesia. We aimed to summarize the effects of stellate ganglion block on the recovery of gastrointestinal function as a means of exploring methods through which anaesthesiologists can contribute to postoperative patient recovery.

Methods

We performed a quantitative systematic review of randomized controlled trials published between January 1, 1988, and November 11, 2019, in PubMed, the Cochrane Library, China National Knowledge Infrastructure, Chinese VIP Information, and the Wanfang and SinoMed databases. Study quality was assessed by using the GRADE criteria and bias of included studies were assessed using the revised Cochrane risk-of-bias tool for randomized trials. The time to peristaltic sound resumption, flatus, postoperative eating and the incidence of abdominal bloating in the stellate ganglion block and control groups were compared. The control group consisted of either a stellate ganglion block with normal saline or no treatment. Meta-analysis was performed using Review Manager software.

Results

After searching for relevant articles, 281 studies were identified, and five articles with data on 274 patients were eligible. Regarding postoperative flatus time, stellate ganglion block resulted in a mean reduction of 15 h (P = 0.02); then a sensitivity analysis was performed, and the standard mean difference decreased to 6 h (P = 0.007). For gastrointestinal surgery, the mean reduction was 23.92 h (P = 0.0002). As for the evaluation of the recovery of peristaltic sounds, stellate ganglion block promoted the recovery of regular peristaltic bowel sounds an average of 14.67 h earlier than in the control (P = 0.0008). When it comes to nutrients, stellate ganglion block shortened the total parenteral nutrition time by more than 50 h in patients who had undergone gastrointestinal surgery (P<0.00001). Finally, stellate ganglion block prevented the occurrence of postoperative abdominal bloating (P = 0.001).) No complications related to stellate ganglion block were reported.

Conclusion

Stellate ganglion block may promote postoperative gastrointestinal recovery in patients undergoing various surgeries under general anaesthesia. However, additional trials investigating the use of stellate ganglion block are necessary to confirm our finding.

Trial registration

This meta-analysis has been registered at the International Prospective Register of Systematic Reviews (registration number CRD42020157602).

Western population-based study of oncologic surgical quality and outcomes of laparoscopic versus open gastrectomy for gastric adenocarcinoma

BACKGROUND

While studies have reported improved morbidity of laparoscopic (LG) compared with open gastrectomy (OG), it remains unclear whether comparable oncologic outcomes can be achieved. This study aims at comparing not only short-term outcomes, including 30- and 90-day mortality, but also survival of LG vs OG.

METHODS

The National Cancer Database was searched for adult patients with histologically proven gastric cancer and complete information regarding M0 disease, tumor size, differentiation grade, T stage, nodal status, comorbidities, type of hospital, hospital stay, type of surgery, oncological treatment and survival data were included. Logistic regression analyses were performed to analyze margin status, 30- and 90-day mortality, and 30-day re-admission rate. Linear regression was performed for length of hospital stay and lymph node yield. Kaplan-Meier survival analyses were performed to evaluate median survival. Cox multivariable regression models were created to correct for confounders and identify factors affecting survival.

RESULTS

A query of the National Cancer Database identified 13,538 patients with complete dataset. A significant regression equation favoring LG for lymph node yield, hospital stay, and unplanned re-admission rate was identified. There was no significant effect of surgical approach on R1 margin rate, 30-day mortality, or 90-day mortality. Median survival was comparable between LG and OG (44.8 vs 40.2 months, p = 0.804).

CONCLUSION

LG offers a safe surgical approach to gastric cancer with shorter hospital stay and lower re-admission rates than OG, and also similar and sometimes improved operative oncologic quality parameters (margin, lymph node yield). More importantly, this Western series demonstrates that equivalent long-term outcomes of LG vs. OG are being achieved.

Laparoscopic Total Gastrectomy for Gastric Cancer in Elderly Patients

BACKGROUND/AIM

The purpose of this study was to evaluate the safety and efficacy of laparoscopic total gastrectomy (LTG) for elderly patients.

PATIENTS AND METHODS

We retrospectively analyzed 136 patients who underwent LTG. We divided the patients into elderly patients (>75 years of age) and non-elderly patients (≤75 years of age).

RESULTS

The American Society of Anesthesiologists score, Charlson comorbidity index, Glasgow Prognostic Score and rate of comorbidities were higher in the elderly group; the rates of other clinicopathological characteristics did not differ between the two groups. Regarding the nutritional status, the body weight loss rate in the elderly group was higher in comparison to the non-elderly group (81% vs. 84%, p=0.004). The disease-specific survival (DSS) did not differ between two groups to a statistically significant extent (3-year DSS rates: 83.7 vs. 94.5%; p=0.152).

CONCLUSIONS

LTG was acceptable for elderly patients as the elderly and non-elderly groups showed comparable short-term and long-term outcomes.

The safety and feasibility of laparoscopic gastrectomy for gastric cancer in very elderly patients: short-and long-term outcomes

PURPOSE

It remains unclear whether laparoscopic gastrectomy (LG) for gastric cancer is a suitable treatment for very elderly (VE) patients. We aimed to assess the safety and feasibility of LG for gastric cancer in VE patients.

METHODS

We reviewed 226 consecutive patients who underwent LG between January 2010 and December 2016. We compared VE patients (age ≥ 80, n = 38) with non-elderly patients (age ≤ 79, n = 188).

RESULTS

An ASA-PS score ≥ 2 was more common in VE group (86.8 vs. 48.9%; P < 0.01). There were no significant differences in the operating time, blood loss, postoperative hospital stay, or postoperative morbidity between the groups. The 3-year survival rate and 3-year disease-specific survival rate were lower in the VE group (53.7 vs. 85.6%; P < 0.0001, 78.5 vs. 92.4%; P = 0.0116). A univariate analysis showed that PS scores ≥ 2, Charlson comorbidity index ≥ 4, and pN stage were independent predictors of decreased overall survival rates in the VE group. A multivariate analysis showed total gastrectomy, a Charlson comorbidity index ≥ 4, and the pN stage to be independent predictors in the VE group.

CONCLUSION

LG for gastric cancer is, thus, considered to be safe for patients aged 80 years or older. Total gastrectomy, a Charlson comorbidity index ≥ 4, and the pN stage were independent risk factors for a poor prognosis in these patients.

Short- and Long-Term Outcomes after Laparoscopic Versus Open Gastrectomy for Elderly Gastric Cancer Patients: A Systematic Review and Meta-Analysis

Background: With the rapid aging of global population, the number of elderly patients with gastric cancer is increasing. This study aimed to evaluate short- and long-term outcomes after laparoscopic gastrectomy (LG) versus open gastrectomy (OG) in elderly gastric cancer patients. Materials and Methods: We searched PubMed, EMBASE, and the Cochrane library databases from January 1994 to May 2019. Surgical safety, postoperative complications, number of harvested lymph nodes, and overall survival rate were included and analyzed. The qualities of the included studies were evaluated by Newcastle-Ottawa Quality Assessment Scale. The evidence of outcomes was evaluated using the GRADE approach. The Review Manager^® 5.3 (Cochrane, London, UK) and Stata^® 14.0 (StataCorp., College Station, Texas) were used to analyze the outcomes. Results: Thirteen studies containing 4768 elderly patients with gastric cancer were included in this meta-analysis. LG was more favorable than OG in terms of overall postoperative morbidity (odds ratio [OR]: 0.56; 95% confidence interval [CI]: 0.44 to 0.70; P < .00001), the postoperative stay (standardized mean difference [SMD]: -0.56; 95% CI: -0.76 to (-0.37); P < .00001), and the number of harvested lymph nodes (SMD: 0.19; 95% CI: 0.09 to 0.29; P = .0003). No significant difference was found in anastomotic leakage rate (OR: 0.82; 95% CI: 0.59 to 1.12; P = .21), mental disease (OR: 0.79; 95% CI: 0.44 to 1.44; P = .44), or overall survival rate (P = .62) between two groups. However, in the subgroup with a cutoff age of 80 years, the anastomotic leakage rate was higher in LG (OR: 10.27; 95% CI: 1.31 to 80.35; P = .03). Conclusions: LG was more favorable than OG in the elderly patients <80 years old with gastric cancer.

Postoperative complication rate and survival of patients with gastric cancer undergoing immunonutrition: A retrospective study

OBJECTIVES

This study aimed to evaluate the effect of preoperative immunonutrition on the rate of postoperative complication and survival of patients with gastric cancer.

METHODS

A retrospective cohort was formed after data collection of patients hospitalized with gastric cancer. Postoperative complications classified according to the Clavien-Dindo classification system, length of hospital stay, readmissions, and rates of survival at 6 mo, 1 y, and 5 y were analyzed. A χ² or Fisher's exact test, Student or Mann-Whitney t test, and Kaplan-Meier and Cox regressions were used in the statistical analysis.

RESULTS

A total of 164 patients were included in the study, with 56 patients assigned to the immunonutrition group and 108 to the conventional group. There were no significant differences in postoperative complications between the immunonutrition and conventional groups (51.8% versus 58.3%; P = 0.423). The most frequent complications were fistula and surgical wound infection. Length of hospital stay did not differ between the groups (median of 7.0 d: P = 0.615) and the presence of readmissions did not differ either (12.5% versus 15.7%; P = 0.648). In the multivariate Cox regression, in a pooled model for group, age, sex, body mass index, Charlson comorbidity index, staging, neoadjuvant chemotherapy, and type of surgery, there was a significant difference in survival rates at 6 mo (P = 0.011), 1 y (P = 0.006), and 5 y (P < 0.001).

CONCLUSIONS

Preoperative immunonutrition in patients with gastric cancer did not reduce postoperative complications or length of hospital stay. More studies are needed to confirm the benefit of immunonutriton supplementation for overall survival when associated with other protective factors.

Robotic Versus Laparoscopic Gastrectomy for Gastric Adenocarcinoma: Propensity-Matched Analysis

Background. We compared the outcomes of laparoscopic-assisted (LA) and robotic-assisted (RA) gastrectomies performed for gastric adenocarcinoma in the National Cancer Database. Methods. The National Cancer Database was queried for patients 18 years old with stages I to III gastric adenocarcinoma who underwent LA or RA gastrectomy. Propensity matching was performed between the 2 groups with regard to clinical staging, adjuvant treatment, demographics, and the extent of surgery. Results. A cohort of 1893 (1262 = LA, 631 = RA) patients was identified in a 2:1 propensity matching. The groups were well matched. The rate of negative margin as well as 30- and 90-day mortality were similar between the 2 cohorts. Long-term survival was similar between the 2 groups (median survival 49.2 months in LA vs 56.2 months for RA, P = .405). However, the average number of lymph nodes (LNs) sampled was significantly higher in the RA group compared with the LA group (19.6 vs 17.4, P < .001). Similarly, the percentage of surgeries in which ≥15 LNs were sampled was also greater in the RA group compared with the LA group (63.9% vs 57.6%, P = .010). On multivariable analysis, having 15 LNs or more examined was associated with better survival (hazard ratio = 0.72, 95% confidence interval = 0.60-0.87, P < .001). Advanced age, nodal positivity, and advanced clinical stages were significantly associated with worse survival. Conclusions. RA gastrectomy may allow a greater harvest of LNs, and thus more accurate staging, without increasing short-term adverse outcomes compared with LA gastrectomy. Short-term and long-term outcomes in this well-matched cohort appear comparable for both approaches.