Meta-analysis of laparoscopy assisted distal gastrectomy and conventional open distal gastrectomy for EGC

Laparoscopic gastrectomy for gastric cancer: has the time come for considered it a standard procedure?

Radical gastrectomy with an adequate lymphadenectomy is the main procedure which makes it possible to cure patients with resectable gastric cancer. A number of randomized controlled trials and meta-analysis provide phase III evidence that laparoscopic gastrectomy is technically safe and that it yields better short-term outcomes than conventional open gastrectomy for early-stage gastric cancer. At present, laparoscopic gastrectomy is considered a standard procedure for early-stage gastric cancer, especially in Asian countries. On the other hand, the use of minimally invasive techniques is still controversial for the treatment of more advanced tumours, principally due to existing concerns about its oncological adequacy and capacity to carry out an adequately extended lymphadenectomy. Additional high-quality studies comparing laparoscopic gastrectomy versus open gastrectomy for gastric cancer have been recently published, in particular concerning the latest results obtained by laparoscopic approach to advanced gastric cancer. It seems very useful to update the review of literature in light of these new evidences for this subject and draw some considerations.

Laparoscopic gastrectomy for early gastric cancer and the risk factors of lymph node metastasis

Objective:

Lymph node metastasis (LNM) is one of the important prognostic factors of early gastric cancer (EGC). Moreover, LNM is also important when choosing therapeutic intervention for EGC patients. The purpose of this study is to explore the risk factors of LNM in EGC and to discuss the corresponding treatment.

Design:

We retrospectively reviewed the medical records of 253 patients with EGC who underwent surgical therapy in our department between 2012 and 2015. Univariate analysis and Multivariate Cox regression were used to evaluate the independent risk factors of LNM.

Results:

LNM was present in 38 cases among 253 patients (15%). Univariate analysis showed an obvious correlation between LNM and tumour location, tumour size, depth of invasion, morphological classification, gross type of the lesion and venous invasion. Multivariate analysis indicated that poorly differentiated carcinoma, submucosal cancer, tumour size ≥2 cm and venous invasion were the independent risk factors for LNM.

Conclusion:

Tumour size, depth of invasion, morphological classification and blood vessel invasion were predictive risk factors for LNM in EGC. We propose that EGC patients with those risk factors should be accepted gastrectomy with LN dissection.

Hot issues in minimally invasive surgery for gastric cancer

Minimally invasive surgery has become an indispensable part of gastric cancer treatment after more than 20 years of rapid development. The change of operation indications, the innovation of minimally invasive devices and surgical technique, and the idea of innovation are hot issues in minimally invasive surgery for gastric cancer. In this paper, we will discuss these hot issues in detail.

Reevaluation of laparoscopic versus open distal gastrectomy for early gastric cancer in Asia: A meta-analysis of randomized controlled trials

BACKGROUND

The benefits and risks of laparoscopic distal gastrectomy (LADG) are not yet sufficiently clear for acceptance as a standard treatment of early gastric cancer. Previous meta-analyses were not powered to reach definitive conclusions.

MATERIALS AND METHODS

Randomized controlled trials comparing LADG with open distal gastrectomy (ODG) for early gastric cancer in Asia and published between January 1994 and January 2018 were retrieved from PubMed, Embase, the Cochrane Library, and Google Scholar. Patient characteristics, oncological safety and efficacy, and surgical safety were evaluated following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Grading of Recommendations Assessment, Development and Evaluation guidelines (GRADE) guidelines. Trial Sequential Analysis (TSA) reduced random error and reinforced the reliability and strength of evidence.

RESULTS

Eight trials including 2666 participants were selected. LADG benefits were an 11.6 cm shorter incision (95% CI: -13.31 to -9.88 cm; P < 0.0001), 103.81 ml less blood loss (95% CI: -133.68 to -73.94; P < 0.0001), 1.73 times less analgesic use (95% CI: -2.21 to -1.24; P < 0.0001), 0.51 days shorter time to first flatus (95% CI: -0.88 to -0.15 days; P = 0.006), lower risk of wound dehiscence (RR = 0.24, 95% CI: 0.08-0.78; P = 0.02), lower risk of surgical adverse events (RR = 0.69, 95% CI: 0.53-0.91; P = 0.008), and lower risk of respiratory complications (RR = 0.40; 95% CI: 0.20-0.79; P = 0.009) than ODG. LADG had 2.22 fewer resected lymph nodes (95% CI: -4.33 to -0.12; P = 0.04) and 76.61 min longer procedures (76.61 min, 95% CI: 57.74-95.47 min; P < 0.0001).

CONCLUSIONS

In Asian patients, LADG had similar mortality and oncological safety, better surgical safety, less operative morbidity, less trauma, and faster recovery than ODG. It has a high role to play in node-negative cases due to better short-term outcomes but less nodal harvest. It is a recommended alternative treatment for experienced surgeons in high-volume centers.

Evolution trends of indications for laparoscopic surgery in patients with gastric cancer

Laparoscopic surgery for gastric cancer has the advantages open surgery of less blood loss, shorter postoperative hospital stay, faster postoperative recovery and smaller scar and has been widely carried out worldwide. Since laparoscopic surgery for gastric cancer was carried out 20 years ago, the indications for laparoscopic gastric surgery has been expanding with the continuous progress of science and technology, the innovation of equipment, the improvement of the level of laparoscopic surgeons' awareness, and the obtainment of high quality clinical evidence. Here we review the evolution trends of indications for laparoscopic surgery in patients with gastric cancer.

Laparoscopic and robot-assisted gastrectomy for gastric cancer: Current considerations

Radical gastrectomy with an adequate lymphadenectomy is the main procedure which makes it possible to cure patients with resectable gastric cancer (GC). A number of randomized controlled trials and meta-analysis provide phase III evidence that laparoscopic gastrectomy is technically safe and that it yields better short-term outcomes than conventional open gastrectomy for early-stage GC. While laparoscopic gastrectomy has become standard therapy for early-stage GC, especially in Asian countries such as Japan and South Korea, the use of minimally invasive techniques is still controversial for the treatment of more advanced tumours, principally due to existing concerns about its oncological adequacy and capacity to carry out an adequately extended lymphadenectomy. Some intrinsic drawbacks of the conventional laparoscopic technique have prevented the worldwide spread of laparoscopic gastrectomy for cancer and, despite technological advances in recent year, it remains a technically challenging procedure. The introduction of robotic surgery over the last ten years has implied a notable mutation of certain minimally invasive procedures, making it possible to overcome some limitations of the traditional laparoscopic technique. Robot-assisted gastric resection with D2 lymph node dissection has been shown to be safe and feasible in prospective and retrospective studies. However, to date there are no high quality comparative studies investigating the advantages of a robotic approach to GC over traditional laparoscopic and open gastrectomy. On the basis of the literature review here presented, robot-assisted surgery seems to fulfill oncologic criteria for D2 dissection and has a comparable oncologic outcome to traditional laparoscopic and open procedure. Robot-assisted gastrectomy was associated with the trend toward a shorter hospital stay with a comparable morbidity of conventional laparoscopic and open gastrectomy, but randomized clinical trials and longer follow-ups are needed to evaluate the possible influence of robot gastrectomy on GC patient survival.

Long-term clinical outcomes of laparoscopy-assisted distal gastrectomy versus open distal gastrectomy for early gastric cancer: A comprehensive systematic review and meta-analysis of randomized control trials

The objective of this study was to compare long-term surgical outcomes and complications of laparoscopy-assisted distal gastrectomy (LADG) with open distal gastrectomy (ODG) for the treatment of early gastric cancer (EGC) based on a review of available randomized controlled trials (RCTs) evaluated using the Cochrane methodology.RCTs comparing LADG and ODG were identified by a systematic literature search in PubMed, Cochrane Library, MEDLINE, EMBASE, Scopus, and the China Knowledge Resource Integrated Database, for papers published from January 1, 2003 to July 30, 2015. Meta-analyses were performed to compare the long-term clinical outcomes.Our systematic literature search identified 8 eligible RCTs including 732 patients (374 LADGs and 358 ODGs), with low overall risk of bias. Long-term mortality and relapse rate were comparable for both techniques. The long-term complication rate was 8.47% in LADG groups and 13.62% in the ODG group, indicating that LADG was associated with lower risk for long-term complications (RR = 0.63; 95%CI = 0.39-1.00; P = 0.03).In the treatment of EGC, LADG lowered the rate of long- and short-term complications and promoted earlier recovery, with comparable oncological outcomes to ODG.

Laparoscopic and robot-assisted laparoscopic digestive surgery: Present and future directions

Laparoscopic surgery is applied today worldwide to most digestive procedures. In some of them, such as cholecystectomy, Nissen's fundoplication or obesity surgery, laparoscopy has become the standard in practice. In others, such as colon or gastric resection, the laparoscopic approach is frequently used and its usefulness is unquestionable. More complex procedures, such as esophageal, liver or pancreatic resections are, however, more infrequently performed, due to the high grade of skill necessary. As a result, there is less clinical evidence to support its implementation. In the recent years, robot-assisted laparoscopic surgery has been increasingly applied, again with little evidence for comparison with the conventional laparoscopic approach. This review will focus on the complex digestive procedures as well as those whose use in standard practice could be more controversial. Also novel robot-assisted procedures will be updated.

Laparoscopic gastric surgery for cancer: Where do we stand?

Gastric cancer poses a significant public health problem, especially in the Far East, due to its high incidence in these areas. Surgical treatment and guidelines have been markedly different in the West, but nowadays this debate is apparently coming to an end. Laparoscopic surgery has been employed in the surgical treatment of gastric cancer for two decades now, but with controversies about the extent of resection and lymphadenectomy. Despite these difficulties, the apparent advantages of the laparoscopic approach helped its implementation in early stage and distal gastric cancer, with an increase on the uptake for distal gastrectomy for more advanced disease and total gastrectomy. Nevertheless, there is no conclusive evidence about the laparoscopic approach yet. In this review article we present and analyse the current status of laparoscopic surgery in the treatment of gastric cancer.

Upper lesser curvature skeletonization in radical distal gastrectomy

BACKGROUND

To investigate the metastatic status of lymph nodes numbers (no.) 1, 3a, and 3b groups in radical distal gastrectomy with upper lesser curvature skeletonization and the risk factors for lesser curvature regional node (LCRN) metastasis.

METHODS

Data on patients who underwent radical distal gastrectomy were retrospectively collected between May 2010 and September 2013. Clinicopathologic features and surgical outcomes were compared between the LCRN (+) and (-) groups. The correlations among the no. 1, 3a and 3b groups, and other groups were analyzed. Univariate and multivariate analyses were performed to identify the independent risk factors for LCRN metastasis.

RESULTS

A total of 112 patients were analyzed. In all, 45.5% had metastatic LCRNs, and 59.8% were node positive overall. The LCRN (+) and (-) groups had significantly different features, including gender; tumor size; histologic grade; Lauren classification; gross type; and T, N, and TNM stages. The positivity rates of the no. 1, 3a, and 3b groups were 4.5%, 38.4%, and 32.1%, respectively, and the no. 1, 3a, and 3b groups were comprehensively correlated with the D2-tier groups. In the univariate and multivariate analyses, only stage T3-4 and positive no. 4d nodes were documented as independent risk factors, whereas no. 5 and 11p nodes trended toward a positive correlation.

CONCLUSIONS

LCRNs have high frequencies of metastasis in lower gastric cancers, and in the present study, these groups of lymph nodes tended to be associated with each other as an entity in the lesser curvature region. Upper lesser curvature skeletonization can be recommended as a standard procedure in radical distal gastrectomy to thoroughly clear the gastric stump, especially in the case of stage T3-4 or suspicious no. 4d nodes.