Laparoscopic gastrectomy for gastric cancer: Current evidences

Extended Lymphadenectomy for Gastric Cancer in the Neoadjuvant Era: Current Status, Clinical Implications and Contentious Issues

Despite its decreasing incidence, gastric cancer remains an important global healthcare problem due to its overall high prevalence and high mortality rate. Since the MAGIC and FNLCC/FFCD trials, the neoadjuvant chemotherapy has been recommended throughout Europe in gastric cancer. Potential benefits of preoperative treatments include a higher rate of R0 resection achieved by downstaging the primary tumor, a likely effect on micrometastases and isolated tumor cells in the lymph nodes, and, as a result, improved cancer-related survival. Nevertheless, distortion of anatomical planes of dissection, interstitial fibrosis, and sclerotic tissue changes may increase surgical difficulty. The collection of at least twenty-five lymph nodes after neoadjuvant therapy would seem to ensure removal of undetectable node metastasis and reduce the likelihood of locoregional recurrence. It is not what you take but what you leave behind that defines survival. Therefore, para-aortic lymph node dissection is safe and effective after neoadjuvant chemotherapy, in both therapeutic and prophylactic settings. In this review, the efficacy of adequate lymph node dissection, also in a neoadjuvant setting, has been investigated in the key studies conducted to date on the topic.

The effect and clinical significance of using nathanson liver retractor on liver function tests in laparoscopic gastric cancer surgery

ABSTRACT Aim: There are very few studies in the literature investigating the changes caused by the Nathanson retractors in liver function tests (LFT) after LG and its clinical significance. The present study investigated the changes made by the Nathanson retractor used during LG on LFT and its clinical significance. Material and Method: The data of 236 patients, who underwent radical gastrectomy for primary gastric cancer at Surgical Oncology Unit in the period between January 2015 and January 2020 were retrospective studied. The patients were divided into two groups: laparoscopic gastrectomy (LG; 136 cases) and open gastrectomy (OG; 106 cases). Patients who have undergone cholecystectomy, with primary or secondary liver tumors, with chronic hepatic disease, who have preoperative high ALT, AST and bilirubin values were excluded from the study. LFT were measured preoperatively and postoperative day 1 (LFT1), LFT3, LFT5 and LFT7. LFT: ALT, AST and Total bilirubin (BIL). Results: ALT1, ALT3, ALT5, ALT7 ALT values and AST1, AST3, AST5 AST values of the patients in the LG group were found to be significantly higher (P <0.001). Mean total bilirubin values of the groups were similar (P >0.05). In order to evaluate how the increase in LFT due to the use of the Nathanson retractors reflected on the patients' clinic, we divided the patients who underwent LG into two groups based on ALT increase in ALT1: Normal and Elevated. The in-hospital mortality rates (P = 0.080) and oral nutrition time (P = 0.913) of the groups were similar. No liver infarction developed in any of the groups. The duration of stay in the ICU was significantly longer in individuals with elevated LFT (P = 0.019). Conclusion: Although the use of the Nathanson retractor during LG causes an increase in liver function tests, this does not cause major clinical problems in patients. Key Words: Gastrectomy; gastric cancer; laparoscopy; liver enzymes; liver dysfunciton

Current evidence on laparoscopic vs. open resection for gastric stromal tumours

Although the use of laparoscopic surgery is increasing, controversy still surrounds its application for malignant conditions. Gastrointestinal stromal tumours (GISTs) are less demanding in terms of lymphadenectomy, meaning that laparoscopic resection might have a more defined benefit when compared with open resection. To the best of our knowledge, no randomized study exists that compares the laparoscopic and open resection of GISTs. The current study aimed to examine the relevant literature by means of a systematic review. A systematic literature search was performed individually by two authors, in which three independent databases were searched using specific search-terms. Titles, abstracts and full texts were screened, as well as references to relevant articles, in order to comprise a comprehensive list of studies. Data were extracted using a detailed pre-agreed spreadsheet. Studies were evaluated according to the modified MINORS criteria. A total of 10 studies were included in the present review, yielding a total of 14 entries. The majority of studies reported significantly improved perioperative outcomes for the laparoscopic approach, including improved duration of operation, blood loss and length of hospital stay. Only four studies reported long-term outcomes and findings that were controversial, with some studies detecting no statistically significant differences, one reporting improved and one reporting worse disease-free and overall survival for the laparoscopic group. Three studies were deemed to be good quality, two of which had not reported significantly different long-term outcomes, while the third had reported significantly improved outcomes in the open resection group. While there is a clear benefit for performing laparoscopic surgery in patients with GIST with regards to perioperative outcomes, when it comes to long-term oncological outcomes, uncertainty over its application remains. The lack of randomized trials, as well as the poor reporting of retrospective studies, limits the amount of evidence that is currently available. Laparoscopic surgery for GIST is certainly safe, feasible and likely cost-effective; however, further studies are required to inform on whether this technique is superior to open resection.

Treatment of Gastric Cancer

Surgery represents the only method for potentially curative intent for gastric cancer (GC) [...].

FLOT Neoadjuvant Chemotherapy Followed by Laparoscopic D2 Gastrectomy in the Treatment of Locally Resectable Advanced Gastric Cancer

BACKGROUND

The prognosis of patients with advanced gastric cancer remains unsatisfactory, highlighting the need for improved therapeutic strategies. We analyzed 23 resectable advanced gastric cancer patients who received FLOT followed by laparoscopic gastrectomy with D2 lymphadenectomy to evaluate the efficacy and safety.

METHODS

Patients aged 18-75 years with gastric adenocarcinoma (stage cT3-4 and/or N + M0) underwent neoadjuvant FLOT therapy (four preoperative and four postoperative 2-week cycles) at Shanghai East Hospital. Laparoscopic gastrectomy was scheduled 3-4 weeks after completion of the last cycle of preoperative chemotherapy. The type of surgical procedure was determined by the location and extent of the primary tumor.

RESULTS

23 patients were reviewed in the study. 20 patients (81.2%) received four courses of FOLT therapy, while 3 patients (18.8%) received three courses of treatment. There were 3 (13.0%) complete responses, 13 (56.5%) partial responses, 4 (26.1%) of stable disease, and 1 (4.3%) of progressive disease. The clinical efficacy response rate was 69.6%. The R0 resection rate was 91.3%. Only one patient exhibited grade III postoperative complications. The pathologic complete remission was 13%. The common grade 3/4 adverse events from chemotherapy were leucopenia (17.4%), neutropenia (30.4%), anemia (13%), anorexia (13%), and nausea (17.4%). Postoperative complications occurred in 5 patients (26.1%). There was no treatment-related mortality or reoperation. The most reason for not completing chemotherapy was the patient's request.

CONCLUSIONS

These findings suggest that FLOT neoadjuvant chemotherapy, followed by laparoscopic D2 gastrectomy, is effective and safe in advanced, resectable advanced gastric cancer.

Surgical treatment outcomes of patients with T1-T2 gastric cancer: does the age matter when excellent treatment results are expected?

BACKGROUND

The proportion of early gastric cancer stages is increasing, as is the incidence of gastric cancer among the elderly population. Therefore, this study was designed to analyze surgical treatment outcomes of T1-T2 gastric cancer in elderly patients.

METHODS

A total of 457 patients with T1-T2 gastric cancer who underwent gastrectomy between 2005 and 2015 were enrolled in this retrospective study. Patients were classified into two groups according to age (< 70 years versus ≥ 70 years). Clinicopathological features, surgical treatment results, and clinical outcomes were compared between the groups.

RESULTS

Higher ASA score (ASA 3/4), differentiated cancer, and intestinal-type tumors were more common in elderly patients. Postoperative complication rates were similar between the two groups; however, postoperative mortality rates were significantly higher in the elderly group. Higher ASA score was independently associated with postoperative complications in the elderly group. Furthermore, severe postoperative complications were found as an independent factor associated with higher 90-day mortality rate. Elderly patients had a significantly poorer 5-year overall survival rate. Two surgery-related factors-total gastrectomy and complicated postoperative course-were revealed as independent prognostic factors for poor overall survival in the elderly group.

CONCLUSIONS

Despite higher postoperative mortality rate and poorer overall survival results, elderly patients with gastric cancer should be considered for radical surgery. ASA score may be useful for predicting surgical treatment outcomes in elderly patients undergoing surgery for GC and hence assists clinicians in planning treatment strategies for each individual patient.

Assessing safety and feasibility of 'pure' laparoscopic total gastrectomy for advanced gastric cancer in the West. Review article

BACKGROUND

Gastric cancer is reported to be the fourth most common cancer and the second leading cause of cancer-related death worldwide. Minimally invasive surgical treatment for gastric cancer is a very challenging approach which offers undoubtedly important advantages.

MATERIALS AND METHODS

There is intense debate concerning the minimally invasive surgical approach for advanced gastric cancer especially in the Western population. A careful literature search was conducted in order to clarify the feasibility and safety of pure laparoscopic total gastrectomy in the West.

RESULTS

Herewith we aim to summarize the current scientific evidence assessing the feasibility and short-term outcomes of laparoscopic gastrectomy for advanced gastric cancer in the West. A lack of data from Western institutions regarding minimally invasive surgical approach for gastric cancer is yet a reality. Nevertheless, the laparoscopic procedure appears to provide satisfactory short-term oncologic outcomes and improved postoperative outcomes.

CONCLUSION

It is obvious that future well-conducted trials on long-term results are necessary for Western patients in order safe conclusions to be reached regarding a potential definitive 'place' for laparoscopy in the curative gastric cancer treatment.

Molecular background of the regional lymph node metastasis of gastric cancer

Gastric cancer (GC) is one of the deadliest types of cancer in the world. Lymph node (LN) metastasis is a complex and malignant behavior of GC, involving a sequence of biological processes, including decreased adherence to adjacent cells, extracellular matrix (ECM) degradation and lymphatic channel permeation. LN metastasis is directly associated with the treatment response, local recurrence and long-term survival of patients with GC. Therefore, the molecular mechanisms of LN metastasis in GC development require further investigation. Recently, a large number of clinical studies have focused on the molecular mechanisms and biological markers of tumor invasion and metastasis. However, few articles have broadly summarized LN metastasis in GC, and the molecular mechanisms of LN metastasis are not yet fully understood. In the present review, the molecular mechanisms of LN metastasis in GC will be discussed, including the following aspects: Cell adhesion and movement, ECM degradation, new vessel formation, and molecular pattern differences between metastatic LNs and the primary tumor. This review may lead to a better understanding of LN metastasis in GC, and the identification of new diagnostic markers.

Minimally Invasive Surgical Approaches for Pancreatic Adenocarcinoma: Recent Trends

BACKGROUND

Pancreatic resection for cancer represents a real challenge for every surgeon. Recent improvements in laparoscopic experience, minimally invasive surgical techniques and instruments make now the minimally invasive approach a real "triumph." There is no doubt that minimally invasive surgery has replaced with great success conventional surgery in many fields, including surgical oncology.

METHODS AND RESULTS

However, its progress in pancreatic resection for adenocarcinoma has been dramatically slow. Recent evidence supports the notion that minimally invasive distal pancreatectomy is safe and feasible and that is becoming the procedure of choice mainly for benign or low-grade malignant lesions in the distal pancreas. On the other side, minimally invasive pancreatoduodenectomy has not yet been widely accepted and there is enormous skepticism when applied for pancreatic head adenocarcinoma. In this review, we summarize the current evidence on the potential applications of minimally invasive surgical approaches for this aggressive, heterogeneous, and enigmatic type of cancer.

CONCLUSIONS

Moreover, the potential future applications of these approaches are discussed with the hope to improve the quality of life as well as the survival rates of pancreatic cancer patients.

Effect of laparoscopic gastrectomy on compliance with adjuvant chemotherapy in patients with gastric cancer

This study was designed to investigate the effect of laparoscopic gastrectomy on adjuvant chemotherapy in patients with gastric cancer.Patients with gastric cancer who underwent radical gastrectomy at our institution from January 2008 to January 2015 with R0 resection, as determined by a pathological examination, were included in this study. According to the surgical approach, patients were divided into the laparoscopic gastrectomy (LG) group and open gastrectomy (OG) group. Short-term and long-term outcomes were compared between the 2 groups.Of the 206 patients enrolled in the study, 114 patients were included in the LG group and 92 patients were included in the OG group. There was no significant difference in patients' general data, including age, sex, medical comorbidities, and pathological staging, between the 2 groups. However, patients in the LG group had less intraoperative blood loss, fewer postoperative complications, and a shorter hospital stay compared with patients in the OG group. There was no significant difference in the start time of adjuvant chemotherapy between the groups. However, compared with OG, LG had the following advantages: patients received more cycles of adjuvant chemotherapy, more patients received a full dose of on-schedule adjuvant chemotherapy, and more patients completed ≥75% of the planned dose. Long-term survival and disease-free survival rates were higher in the LG than in the OG.In summary, LG can improve compliance with adjuvant chemotherapy and long-term outcomes in patients with gastric cancer.

Laparoscopic Radical Gastrectomy for Resectable Advanced Gastric Cancer Within Enhanced Recovery Programs: A Prospective Randomized Controlled Trial

BACKGROUND

Enhanced recovery programs have become an important focus of perioperative management. A few studies have demonstrated the efficacy of an enhanced recovery after surgery (ERAS, which includes optimized pain control, restricted I.V. fluids, early initiation of postoperative oral feeding, and enforced mobilization) protocol in patients undergoing radical gastrectomy. We investigated the feasibility and safety of laparoscopic radical gastrectomy within ERAS programs.

METHODS

In this single-center prospective randomized controlled trial conducted between September 2013 and August 2014, 149 consecutive locally advanced gastric cancer patients (T2-4, any N, M0) diagnosed by the CT scanning were allocated to either ERAS group (N = 73) or conventional pathway group (N = 76). The same surgical technique was used in both groups, that is, laparoscopic gastrectomy with D2 lymphadenectomy and R0 resection. Intergroup differences were evaluated for clinical parameters and C-reactive protein for testing tissue injury.

RESULTS

ERAS combined with laparoscopic gastrectomy was observed in our study. Recovery parameters such as time to return to normal diet (days) 1.90 ± 0.71 versus 3.52 ± 0.81, P = .003 and time to the first defecation (days) 2.97 ± 1.23 versus 5.20 ± 1.81, P = .015 were measured. The post hospital stay (days) in ERAS and the conventional care group were 6.38 ± 2.04 and 8.62 ± 2.87, P < .001, respectively. No statistically significant intergroup differences were observed in terms of postoperative complications and C-reactive protein levels. One patient in the ERAS group was readmitted because of anastomotic leakage. No instances of deaths were reported during the 30-day follow-up period.

CONCLUSION

This study demonstrates the feasibility and safety of ERAS protocol in advanced gastric cancer patients undergoing laparoscopic radical gastrectomy and was associated with shorter duration of hospital stay. ( Clinicaltrials.gov Identifier No NCT02348229).

Training in Laparoscopic Gastric Cancer Surgery in the Western World: Current Educational Practices, Challenges, and Potential Opportunities at a Large University Centre

OBJECTIVE

The purpose of this study was to explore and understand how surgeons distribute tasks during a laparoscopic gastrectomy for gastric cancer in an academic teaching environment.

DESIGN

An anonymous, cross-sectional, census survey was used to poll trainees' and staff members' opinions pertaining to laparoscopic gastrectomy.

SETTING

Academic and community tertiary teaching hospitals, affiliated with the University of Toronto.

PARTICIPANTS

All surgeons, within the Department of General Surgery at the University of Toronto, who practice laparoscopic gastrectomy for gastric cancer, were invited to participate. All general surgery residents, postgraduate year 1-5, minimally invasive surgery and surgical oncology fellows at the University of Toronto were invited to participate. Overall response rate was 74.35% (n = 87/117).

RESULTS

The results suggested that trainees do not routinely perform the major operative steps. Trainees agreed with faculty in this regard; however, there was a statistically significant difference in opinions, related to the degree of the perceived active operating of the trainees. There was also a difference in opinion, between trainees and faculty, regarding the common reasons for takeover.

CONCLUSIONS

The present survey highlights that current level of active exposure of surgical trainees to laparoscopic gastric surgery might be insufficient. A lack of role clarity may further hinder an optimal educational experience during these cases. Adopting a stepwise approach, with task deconstruction, could optimize training. Additional training modalities may be required to ensure technical proficiency is acquired before independent practice.

Alternate current biosusceptometry for the assessment of gastric motility after proximal gastrectomy in rats: a feasibility study

BACKGROUND

This study proposes an experimental model to assess the consequences of gastric surgeries on gastric motility. We investigated the effects of proximal gastrectomy (PG) using a non-invasive technique (alternate current biosusceptometry [ACB]) on gastric contractility (GC), gastric emptying (GE), and orocecal transit (OCT) after the ingestion of liquids and solids in rats.

METHODS

Twenty-four male rats were subjected to gastric motility assessment before and after the PG procedure. The GE and OCT results are expressed as the mean time of gastric emptying (MGET) and cecum arrival (MCAT). The GC recordings are presented as the frequency and amplitude of contractions.

KEY RESULTS

Mean time of gastric emptying after solid meals were significantly different (p < 0.001) between control and PG (113 ± 5 to 99 ± 6 min). Mean time of cecum arrival ranged from 265 ± 9 to 223 ± 11 min (p < 0.001) and 164 ± 9 to 136 ± 17 min (p < 0.050) for solid and liquid meals, respectively. The assessment of GC showed that surgery decreased the phasic frequency (4.4 ± 0.4 to 3.0 ± 1.1 cpm, p < 0.050) and increased the amplitude of contractions (3.6 ± 2.7 to 7.2 ± 3.0 V/s, p < 0.050). No significant difference was found in tonic frequency.

CONCLUSIONS & INFERENCES

The ACB system was able to assess GE, OCT, and GC in gastrectomized rats. Overall, PG accelerated GE and gastrointestinal transit, likely due to the increase in both intragastric pressure and amplitude contraction. Our data presented an efficient model to investigate functional consequences from gastric surgeries that will allow further studies involving different procedures.

CrkL meditates CCL20/CCR6-induced EMT in gastric cancer

BACKGROUND

In recent years, Crk-like adapter protein (CrkL) has been identified as a key regulator in the epithelial-to-mesenchymal transition (EMT). However, the molecular mechanisms underlying the CC chemokine receptor 6 (CCR6) and chemokine (C-C motif) ligand 20 (CCL20)-induced EMT in gastric cancer are still unclear.

METHODS

We conducted the immunohistochemistry and immunoblotting to detect the expression of CCR6 and CrkL in 90 cases of gastric cancer tissues and five kinds of cell lines. And then, gastric cancer cells were subjected to small interfering RNA (siRNA) treatment and in vitro assay.

RESULTS

Both CCR6 and CrkL were aberrantly expressed in gastric cancer specimens and closely correlated with differentiation of cell lines. The expression of CCR6 and CrkL was also significantly associated with metastasis, stage, and poor prognosis of gastric cancer. In addition, we validated CCL20 activated the expression of p-CrkL, p-Erk1/2, p-Akt, vimentin, N-cadherin and MMP2 in MGC803 cells in a dose-dependent manner. However, si-CrkL abrogated the CCL20-induced p-Erk1/2, vimentin, N-cadherin and MMP2 expression. Most importantly, the knockdown of CrkL decreased migration and invasion of MGC803 cells.

CONCLUSIONS

CrkL mediates CCL20/CCR6-induced EMT via Akt pathway, instead of Erk1/2 pathway in development of gastric cancer, which indicated CCL20/CCR6-CrkL-Erk1/2-EMT pathway may be targeted to antagonize the progression of gastric cancer.

C23 protein meditates bone morphogenetic protein-2-mediated EMT via up-regulation of Erk1/2 and Akt in gastric cancer

In our previous study, the epithelial-to-mesenchymal transition (EMT) has been identified to be involved in gastric cancer progression. Notably, nuclear protein C23 and bone morphogenetic protein-2 (BMP2) have been linked into EMT. However, the specific mechanisms underlying BMP2 pathway-mediated EMT are not still unraveled. In this study, we adopted immunohistochemistry and immunoblotting to determine the expression of C23 and BMP2 receptor II (BMPR-II) in 90 gastric cancer samples and cell lines. Subsequently, relevant cell lines were selected to be treated with si-C23 or si-BMPRII and the detection of in vitro assay. Our results revealed that both C23 and BMPRII were aberrantly and constitutively expressed in gastric cancer specimens and cell lines, whose expression was positively associated with metastasis, stage and differentiation, and portended poor survival outcome of gastric cancer patients. In vitro assay validated the increased expression of p-Erk1/2, p-Akt, vimentin, N-cadherin, and MMP2 in BMP2-stimulated MGC803 cells, which was in a dose-dependent manner. By contrast, si-C23 treatment attenuated the BMP2-stimulated expression of p-Erk1/2, p-Akt, vimentin, N-cadherin, and MMP2. Also, the treatment of either si-C23 or si-BMPRII decreased the ability of migration and invasion of MGC803 cells. In conclusion, C23 mediates BMP2-induced EMT progression via the up-regulation of Erk1/2 and Akt signaling pathway in gastric cancer, which indicated both C23 and BMPRII pathway could be recommended as prospective targets or biomarkers to antagonize the progression of gastric cancer.

CCR7 pathway induces epithelial-mesenchymal transition through up-regulation of Snail signaling in gastric cancer

The chemokine receptor 7 (CCR7) and Snail signaling have been linked to various types of cancers. The associations between these signalings and the epithelial-mesenchymal transition (EMT) are not clear in gastric cancer. Here, the expression of CCR7 and Snail was detected in gastric cancer by immunohistochemistry and Western blot. Meanwhile, gastric cancer cells were subjected to CCL19, si-control, and si-Snail treatment. Cell cycle, migration, and invasion were also analyzed. The expression patterns of CCR7 and Snail were similar in either gastric cancer tissues or cells. The increased expression of CCR7 was closely associated with the increased Snail expression, which both were closely correlated with metastasis, stage and differentiation, and poor prognosis. The increased p-ERK, p-AKT, Snail, and MMP9 expression and the decreased E-cadherin were confirmed in MGC803 cells in a dose-dependent manner in response to CCL19 treatment. However, the blockade of Snail abrogated the up-regulation of MMP9 and down-regulation of E-cadherin. CCR7-induced ERK and PI3K pathway regulated Snail signaling. Besides si-Snail treatment led to MGC803 cell cycle arrest and affected the migration and invasion. In conclusion, our study suggested that CCR7 promotes Snail expression to induce the EMT, resulting in cell cycle progression, migration, and invasion in gastric cancer. CCR7-Snail pathway provided more potential regimens for cancer therapy.