Laparoscopy-assisted versus open distal gastrectomy for early gastric cancer: A meta-analysis based on seven randomized controlled trials

A meta-analysis of the effect of laparoscopic gastric resection on the surgical site wound infection in patients with advanced gastric cancer

By conducting a meta-analysis of relevant clinical studies on the treatment of advanced gastric cancer (GC) using laparoscopic and open surgeries, we aimed to evaluate the impact of these two surgical approaches on postoperative surgical site infections (SSIs) in patients with advanced GC. We aimed to provide evidence-based support for preventing SSIs in postoperative patients with advanced GC. From database establishment until May 2023, we systematically searched PubMed, Cochrane Library, MEDLINE, Embase, China National Knowledge Infrastructure, and Wanfang Data databases for relevant studies comparing laparoscopic and open surgeries for the treatment of advanced GC. Two researchers independently performed the literature screening and data extraction based on predefined inclusion and exclusion criteria. The meta-analysis was conducted using STATA 17.0. Twenty articles involving 3084 patients met the inclusion criteria, including 1462 patients in the laparoscopic group and 1622 cases in the open surgery group. The meta-analysis results revealed that the incidence of postoperative SSIs was significantly lower in the laparoscopic group than in the open surgery group (odds ratio = 0.341, 95% confidence interval: 0.219-0.532, p < 0.001). The current evidence indicates that laparoscopic radical gastrectomy can significantly reduce the incidence of postoperative site infections in patients with advanced GC.

Comparison of complications between laparoscopic and open gastrectomies for early gastric cancer by a nationwide propensity score-matched cohort study

The safety of laparoscopic gastrectomy compared with that of open surgery for the treatment of early gastric cancer (EGC) is unidentified on a national scale. We aimed to compare the morbidity between laparoscopic and open gastrectomies for pathological T1 gastric cancer based on nationwide survey data. Data of 14,076 patients who underwent gastric cancer surgery obtained from the 2019 Korean Gastric Cancer Association-led nationwide survey were used. For patients with pathological T1 gastric cancer, the clinical characteristics were compared between the laparoscopic and open gastrectomy groups. Propensity score matching (PSM) was performed to match the baseline characteristics of the groups. Among the 7765 patients with pathological T1 gastric cancer who underwent open or laparoscopic gastrectomy, 612 pairs were matched. After balancing the baseline characteristics, the laparoscopic gastrectomy group had a significantly longer operative time, less blood loss, greater number of harvested lymph nodes, shorter hospital stays, and comparable morbidity, compared with the open gastrectomy group (P < 0.001, P < 0.001, P < 0.001, P = 0.001, and P = 0.709, respectively). The surgical approach was not a risk factor for postoperative complication in logistic regression analysis. The PSM analysis with the 2019 Korean nationwide survey data demonstrated that laparoscopic gastrectomy showed comparable morbidity with open gastrectomy for EGC.

Robotic versus open approach in total gastrectomy for gastric cancer: a comparative single-center study of perioperative outcomes

The robotic approach to gastric cancer has been gaining interest in recent years; however, its benefit over the open procedure in total gastrectomy with D2 lymphadenectomy is still controversial. The aims of the study were to compare postoperative morbidity and mortality, hospital stay, and anatomopathological findings between the robotic and open approaches to oncologic total gastrectomy. We analyzed a prospectively collected database, which included patients who underwent total gastrectomy with D2 lymphadenectomy in our center using a robotic or an open approach between 2014 and 2021. Comparative analysis of clinicopathological, intraoperative, postoperative and anatomopathological variables between the robot-assisted group and the open group was performed. Thirty patients underwent total gastrectomy with D2 lymphadenectomy by a robotic approach and 48 patients by an open procedure. Both groups were comparable. The robot-assisted group presented a lower rate of Clavien-Dindo complications ≥ stage II (20 vs. 48%, p = 0.048), a shorter hospital stay (7 days vs. 9 days, p = 0.003) and had a higher total number of lymph nodes resected (22 nodes vs. 15 nodes, p = 0.001) compared to the open approach. Operative time was longer in the robotic group (325 min vs. 195 min, p < 0.001) compared to the open group. The robotic approach is associated with a longer surgical time, a lower rate of Clavien-Dindo complications ≥ stage II and a shorter hospital stay, and more lymph nodes were resected compared to the open approach.

Laparoscopic and open gastrectomy for locally advanced gastric cancer: a retrospective analysis in Colombia

INTRODUCTION

Radical gastrectomy has traditionally been the pillar treatment with curative intent for malignant tumors of the stomach. The safety of the laparoscopic approach for advanced gastric cancer (AGC) is still under debate. In our institution, laparoscopic gastrectomy is the most performed approach.

OBJECTIVE

Our aim is to describe the experience of a high-volume center in the treatment of AGC in Colombia and to analyze the short-term results and the overall survival rate at 1, 3, and 5 years comparing the open and laparoscopic approaches.

METHODS

A cross-sectional retrospective study of patients who underwent gastrectomy for advanced gastric cancer by open or laparoscopic approaches were performed. A Will-Coxon Mann Whitney test was performed in terms of lymph node status and surgical approach. Survival analysis was performed using the Kaplan-Meier method for overall survival at 1, 3, and 5 years. An initial log-rank test was performed to test the relationships between the operative variables and overall survival, the statistical value was accepted if p < 0.20. Data with an initial statistical relationship in the log-rank test were included in a secondary analysis using multivariate Cox proportional regression, variables with a value of p < 0.05 were considered statistically significant.

RESULTS

310 patients met the inclusion criteria. 89% underwent laparoscopic gastrectomy and 10.9% open gastrectomy. The resection margins were negative at 93.5% and the In terms of lymph node dissection, the median lymph nodes extracted was 20 (12;37), with statistically significant differences between the approaches in favor of the laparoscopic approach (Median 21 vs 12; z = - 2.19, p = 0.02). The survival rate was at 1, 3, and 5 years of 84.04%, 66.9%, and 65.47% respectively. The presence of complications and the ICU requirement have a negative impact on survival at 1 year (p 0.00).

CONCLUSION

A laparoscopic approach is safe with acceptable morbidity and mortality rates for treating gastric cancer. D2 Lymphadenectomy could be performed successfully in a laparoscopic approach in a high-volume center and a properly standardized technique. Major postoperative morbidity with intensive care unit requirement seems to influence overall survival rates.

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.

Laparoscopic versus Open Total Gastrectomy for Locally Advanced Gastric Cancer: Short and Long-Term Results

BACKGROUND

Laparoscopic gastrectomy for early gastric cancer is widely accepted and routinely performed. However, it is still debated whether the laparoscopic approach is a valid alternative to open gastrectomy in advanced gastric cancer (AGC). The aim of this study is to compare short-and long-term outcomes of laparoscopic (LG) and open (OG) total gastrectomy with D2 lymphadenectomy in patients with AGC.

METHODS

A retrospective comparative study was conducted on patients who underwent LG and OG for ACG between January 2015 and December 2021. Primary endpoints were the following: recurrence rate, 3-year disease-free survival, 3-year and 5-year overall survival. Univariate and multivariate analysis was conducted to compare variables influencing outcomes and survival.

RESULTS

Ninety-two patients included: fifty-three OG and thirty-nine LG. No difference in morbidity and mortality. LG was associated with lower recurrence rates (OG 22.6% versus LG 12.8%, p = 0.048). No differences in 3-year and 5-year overall survival; 3-year disease-free survival was improved in the LG group on the univariate analysis but not after the multivariate one. LG was associated with longer operative time, lower blood loss and shorter hospital stay. Lymph node yield was higher in LG.

CONCLUSION

LG for AGC seems to provide satisfactory clinical and oncological outcomes in medium volume centers, improved postoperative results and possibly lower recurrence rates.

A national advanced training program for laparoscopic radical gastrectomy has a positive impact on surgical trainees: A before and after study (ATP-LRG-1)

BACKGROUND

Due to the high technical requirements of laparoscopic radical gastrectomy (LRG), establishing an effective training system to promote clinical technology and operation specifications is necessary. We aimed to evaluate the effect of a national advanced training program for LRG (ATP-LRG).

MATERIALS AND METHODS

The contents of the training include the following: 1) detailed technique descriptions; 2) prevention and solving of intraoperative complications; 3) live surgery performance; 4) theory and practice of clinical research; 5) comments on trainees' videos; and 6) questions, answers, and discussions. This retrospective before and after study surveyed 875 trainees from January 2015 to October 2020. Endpoints were general surgical skills (GSS), laparoscopic gastrectomy acceptance (LGA), and clinical research possibilities (CRP). The analysis took place in December 2021.

RESULTS

The response rate was 70.5% (617/875). ATP-LRG reportedly had a positive impact on the LRG practice of 99.5% (614/617) of trainees. Their GSS (before vs. after: 16.5 ± 3.7 vs. 20.3 ± 3.1, P < 0.001), LGA (4.2 ± 0.9 vs. 4.6 ± 0.7, P < 0.001), and CRP (2.6 ± 1.2 vs. 3.2 ± 1.1, P < 0.001) significantly improved. The improvement in GSS for those with professional titles of associate chief surgeons and below was significantly higher than that for chief surgeons (4.0 ± 3.0 vs 3.3 ± 2.4, P = 0.017), while those of LGA and CRP were not. The annual number of operations before training was negatively correlated with improvement in GSS (P < 0.001, Pearson's correlation coefficient: 0.14). Multivariate logistic regression showed that those with professional titles of associate chief surgeons and below (odds ratio [OR]: 1.719, 95% confidence interval [CI]: 1.038-2.846, P = 0.035), and with annual number of operations before training being <60, (OR: 5.257, 95% CI: 2.573-10.742, P < 0.001) were most prone to high-GSS improvement.

CONCLUSION

The nationwide ATP-LRG facilitates the improvement of trainees' GSS, LGA, and CRP levels. Surgeons with lower professional titles and fewer performed operations are most likely to improve their GSS through training.

Convenience of Adding a Needle Grasper in Single-Incision Laparoscopic Distal Gastrectomy With Billroth I Anastomosis for Clinical Early Gastric Cancer

PURPOSE

To overcome the technical difficulties of single-incision laparoscopic distal gastrectomy (SILDG), needle grasper (Endo Relief^TM)-assisted SILDG (NASILDG) was developed. Here, we compared the operative convenience and postoperative outcomes between SILDG and NASILDG.

MATERIALS AND METHODS

A needle grasper was inserted into the right upper abdomen and used in the NASILDG. We retrospectively reviewed patients who underwent D1 + dissection and delta-shaped Billroth I anastomosis with SILDG or NASILDG performed by a single surgeon between September 2015 and August 2018.

RESULTS

The SILDG (male, 50.0%) and NASILDG (male, 60.0%) groups included 10 and 15 patients, respectively. The operative time without combined operation and anastomosis was significantly shorter in the NASILDG group. Early complications and scar characteristics were not significantly different between the two groups.

CONCLUSIONS

By adding a needle grasper, SILDG became more convenient without decreasing cosmetic results. NASILDG could be a recommended method to reduce the technical difficulty of SILDG.

Laparoscopic versus Open Surgery for Gastric Cancer in Western Countries: A Systematic Review and Meta-Analysis of Short- and Long-Term Outcomes

Background. The advantages of a laparoscopic approach for the treatment of gastric cancer have already been demonstrated in Eastern Countries. This review and meta-analysis aims to merge all the western studies comparing laparoscopic (LG) versus open gastrectomies (OG) to provide pooled results and higher levels of evidence. Methods. A systematic literature search was performed in MEDLINE(PubMed), Embase, WebOfScience and Scopus for studies comparing laparoscopic versus open gastrectomy in western centers from 1980 to 2021. Results. After screening 355 articles, 34 articles with a total of 24,098 patients undergoing LG (5445) or OG (18,653) in western centers were included. Compared to open gastrectomy, laparoscopic gastrectomy has a significantly longer operation time (WMD = 47.46 min; 95% CI = 31.83−63.09; p < 0.001), lower blood loss (WMD = −129.32 mL; 95% CI = −188.11 to −70.53; p < 0.0001), lower analgesic requirement (WMD = −1.824 days; 95% CI = −2.314 to −1.334; p < 0.0001), faster time to first oral intake (WMD = −1.501 days; 95% CI = −2.571 to −0.431; p = 0.0060), shorter hospital stay (WMD = −2.335; 95% CI = −3.061 to −1.609; p < 0.0001), lower mortality (logOR = −0.261; 95% the −0.446 to −0.076; p = 0.0056) and a better 3-year overall survival (logHR 0.245; 95% CI = 0.016−0.474; p = 0.0360). A slight significant difference in favor of laparoscopic gastrectomy was noted for the incidence of postoperative complications (logOR = −0.202; 95% CI = −0.403 to −0.000 the = 0.0499). No statistical difference was noted based on the number of harvested lymph nodes, the rate of major postoperative complication and 5-year overall survival. Conclusions. In Western centers, laparoscopic gastrectomy has better short-term and equivalent long-term outcomes compared with the open approach, but more high-quality studies on long-term outcomes are required.

Laparoscopic vs. Open Gastrectomy for Locally Advanced Gastric Cancer: A Propensity Score-Matched Retrospective Case-Control Study

Introduction: Minimally invasive surgery has been increasingly used in the treatment of gastric cancer. While laparoscopic gastrectomy has become standard therapy for early-stage gastric cancer, especially in Asian countries, the use of minimally invasive techniques has not attained the same widespread acceptance for the treatment of more advanced tumours, principally due to existing concerns about its feasibility and oncological adequacy. We aimed to examine the safety and oncological effectiveness of laparoscopic technique with radical intent for the treatment of patients with locally advanced gastric cancer by comparing short-term surgical and oncologic outcomes of laparoscopic versus open gastrectomy with D2 lymphadenectomy at two Western regional institutions. Methods: The trial was designed as a retrospective comparative matched case-control study for postoperative pathological diagnoses of locally advanced gastric carcinoma. Between January 2015 and September 2021, 120 consecutive patients who underwent curative-intent laparoscopic gastrectomy with D2 lymph node dissection were retrospectively recruited and compared with 120 patients who received open gastrectomy. In order to obtain a comparison that was as homogeneous as possible, the equal control group of pairing (1:1) patients submitted to open gastrectomy who matched those of the laparoscopic group was statistically generated by using a propensity matched score method. The following potential confounder factors were aligned: age, gender, Body Mass Index (BMI), comorbidity, ASA, adjuvant therapy, tumour location, type of gastrectomy, and pT stage. Patient demographics, operative findings, pathologic characteristics, and short-term outcomes were analyzed. Results: In the case-control study, the two groups were clearly comparable with respect to matched variables, as was expected given the intentional primary selective criteria. No statistically significant differences were revealed in overall complications (16.7% vs. 20.8%, p = 0.489), rate of reoperation (3.3% vs. 2.5%, p = 0.714), and mortality (4.2% vs. 3.3%, p = 0.987) within 30 days. Pulmonary infection and wound complications were observed more frequently in the OG group (0.8% vs. 4.2%, p < 0.01, for each of these two categories). Anastomotic and duodenal stump leakage occurred in 5.8% of the patients after laparoscopic gastrectomy and in 3.3% after open procedure (p = 0.072). The laparoscopic approach was associated with a significantly longer operative time (212 vs. 192 min, p < 0.05) but shorter postoperative length of stay (9.1 vs. 11.6 days, p < 0.001). The mean number of resected lymph nodes after D2 dissection (31.4 vs. 33.3, p = 0.134) and clearance of surgical margins (97.5% vs. 95.8%, p = 0.432) were equivalent between the groups. Conclusion: Laparoscopic gastrectomy with D2 nodal dissection appears to be safe and feasible in terms of perioperative morbidity for locally advanced gastric cancer, with comparable oncological equivalency with respect to traditional open surgery.

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.

Impact of laparoscopic gastrectomy on relapse-free survival for locally advanced gastric cancer patients with sarcopenia: a propensity score matching analysis

BACKGROUND

Recent gastric cancer reports have shown that preoperative sarcopenia worsens long-term prognosis after gastrectomy. We investigated the impact of laparoscopic surgery on the long-term prognosis of locally advanced gastric cancer patients with sarcopenia.

METHODS

This retrospective study included consecutive patients who underwent radical gastrectomy for primary c-stage II or III advanced gastric cancer, between April 2008 and April 2017, with computed tomography records of skeletal muscle mass. The skeletal muscle mass index was calculated, and sarcopenia was defined when values were below the cut-off. The patients were divided into a laparoscopy group and open group, in which the background was adjusted using propensity score matching; the relapse-free survival and overall survival were compared between them. The prognostic factors for relapse-free survival and overall survival were investigated by multivariate analyses.

RESULTS

This study included 141 patients with sarcopenia (laparoscopy group, n = 69 [48.9%]; open group, n = 72 [51.1%]). After matching, there were 50 patients in both groups, with no significant differences in patient background. The median follow-up period was 38 months. Relapse-free survival was worse in the open group (hazard ratio: 1.662, 95% confidence interval: 0.910-3.034; P = 0.098), but there was no difference in the overall survival (P = 0.181). Multivariate analysis concluded that open surgery is an independent prognostic factor of relapse-free survival (hazard ratio: 3.219, 95% confidence interval: 1.381-7.502; P = 0.007) but not of OS.

CONCLUSION

Compared with the open surgery group, the laparoscopy group had a better RFS, although the difference was not statistically significant.

Impact of Laparoscopic Converted to Open Gastrectomy on Short- and Long-Term Outcomes of Patients with Locally Advanced Gastric Cancer: A Propensity Score-Matched Analysis

BACKGROUND

It remains unclear whether laparoscopic conversation to open gastrectomy causes higher morbidity and has an adverse effect on the long-term survival outcomes of patients with gastric cancer. This study was designed to evaluate the impact of the conversion on short and long-term outcomes of patients with locally advanced gastric cancer (AGC).

METHODS

We retrospectively investigated 871 patients who initially underwent laparoscopic gastrectomy (LG) for pathologically confirmed diagnosis of AGC between February 2009 and April 2018. The patients were grouped as the conversion (CONV) group and completed laparoscopic (LAP) group. The 1:2 propensity score matching was performed to reduce the effect of bias due to the imbalanced baseline features between the two groups. Multivariate analyses were performed to identify risk factors for conversion and poor survival.

RESULTS

After propensity-score matching, 168 patients (56 in the CONV group and 112 in the LAP group) were studied. The CONV group was associated with significantly longer operation time (252.4 vs. 216.7 min, P < 0.001) and greater estimated blood loss (234.8 vs. 171.2 ml, P < 0.001) as compared with the LAP group. The time to first flatus (3.8 vs. 3.3 days, P = 0.043), time to start a liquid diet (4.1 vs. 3.5 days, P = 0.021), and postoperative hospital stay (8.7 vs. 7.6 days, P = 0.020) were significantly longer in the CONV group than that in the LAP group. The overall complication rate did not differ significantly between the CONV group and the LAP group (16.1% vs. 12.5%, P = 0.692). Both 5-year overall survival (OS) and 5-year disease-free survival (DFS) did not differ significantly between the CONV group and the LAP group (P = 0.805, P = 0.945, respectively). Multivariate analysis showed that lymphovascular invasion and stage III were independent prognostic factors for poor OS and DFS, whereas conversion was not.

CONCLUSIONS

The conversion from laparoscopic to open gastrectomy had no negative impact on morbidity and long-term survival outcomes for patients with locally AGC.

Safety and Efficacy of Laparoscopic Versus Open Gastrectomy in Patients With Advanced Gastric Cancer Following Neoadjuvant Chemotherapy: A Meta-Analysis

Background

Given the expanding clinical applications of laparoscopic surgery and neoadjuvant chemotherapy in advanced gastric cancer treatment, there is an emerging need to summarize the few evidences that evaluated the safety and efficacy of laparoscopic versus open gastrectomy in patients with advanced gastric cancer (AGC) following neoadjuvant chemotherapy (NAC).

Methods

From January 1 to 2, 2021, we searched Ovid Embase, PubMed, Cochrane central register Trials (Ovid), and web of science to find relevant studies published in English, and two authors independently performed literature screening, quality assessment of the included studies, data extraction, and data analysis. This study was registered with PROSPERO (CRD42021228845).

Results

The initial search retrieved 1567 articles, and 6 studies were finally included in the meta-analysis review, which comprised 2 randomized control trials and 4 observational studies involving 288 laparoscopic gastrectomy (LG) and 416 open gastrectomy (OG) AGC patients treated with NAC. For intraoperative conditions, R0 resection rate, blood transfusion, intraoperative blood loss, number of lymph nodes dissected, proximal margin, and distal margin were comparable between LG group and open OG group. For postoperative short-term clinical outcomes, LG has significantly less postoperative complications (OR = 0.65, 95%CI: 0.42-1.00, p = 0.05) and shorter postoperative time to first aerofluxus (WMD = -0.57d, 95%CI: -0.89-0.25, p = 0.0004) than OG, and anastomotic leakage, pulmonary infection, pleural effusion, surgical site infection, thrombosis, intestinal obstruction, peritoneal effusion or abscess formation, postoperative time to first defecation, postoperative time to first liquid diet, and postoperative length of stay were comparable between the two groups. For postoperative survival outcomes, there were no significant differences in disease-free survival (DFS) and overall survival (OS) between the two groups.

Conclusion

The available evidences indicated that LG is an effective and feasible technology for the treatment of AGC patients treated with NAC, and LG patients have much less postoperative complications and faster bowel function recovery than OG patients.

Systematic Review Registration

PROSPERO database (identifier, CRD42021228845).

Totally laparoscopic total gastrectomy using the modified overlap method and conventional open total gastrectomy: A comparative study

BACKGROUND

Although several methods of totally laparoscopic total gastrectomy (TLTG) have been reported. The best anastomosis technique for LTG has not been established.

AIM

To investigate the effectiveness and surgical outcomes of TLTG using the modified overlap method compared with open total gastrectomy (OTG) using the circular stapled method.

METHODS

We performed 151 and 131 surgeries using TLTG with the modified overlap method and OTG for gastric cancer between March 2012 and December 2018. Surgical and oncological outcomes were compared between groups using propensity score matching. In addition, we analyzed the risk factors associated with postoperative complications.

RESULTS

Patients who underwent TLTG were discharged earlier than those who underwent OTG [TLTG (9.62 ± 5.32) vs OTG (13.51 ± 10.67), P < 0.05]. Time to first flatus and soft diet were significantly shorter in TLTG group. The pain scores at all postoperative periods and administration of opioids were significantly lower in the TLTG group than in the OTG group. No significant difference in early, late and esophagojejunostomy (EJ)-related complications or 5-year recurrence free and overall survival between groups. Multivariate analysis demonstrated that body mass index [odds ratio (OR), 1.824; 95% confidence interval (CI): 1.029-3.234, P = 0.040] and American Society of Anaesthesiologists (ASA) score (OR, 3.154; 95%CI: 1.084-9.174, P = 0.035) were independent risk factors of early complications. Additionally, age was associated with ≥ 3 Clavien-Dindo classification and EJ-related complications.

CONCLUSION

Although TLTG with the modified overlap method showed similar complication rate and oncological outcome with OTG, it yields lower pain score, earlier bowel recovery, and discharge. Surgeons should perform total gastrectomy cautiously and delicately in patients with obesity, high ASA scores, and older ages.

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.

Advantageous Short-Term Outcomes of Esophagojejunostomy Using a Linear Stapler Following Open Total Gastrectomy Compared with a Circular Stapler

BACKGROUND

Esophagojejunostomy is one of the most important surgical procedures in total gastrectomy. In the past, esophagojejunostomy was exclusively performed using a circular stapler in open total gastrectomy (OTG). With the increasing frequency of its use in laparoscopic gastrectomy, esophagojejunostomy using a linear stapler has been performed in OTG. However, it is still unclear whether the use of a linear stapler in esophagojejunostomy following OTG has any advantages compared with the conventional use of a circular stapler.

METHODS

A total of 298 patients who underwent OTG for gastric cancer between 2014 and 2019 were enrolled in this study. Patients were categorized into circular and linear groups (group C and group L) according to the stapler type used for the esophagojejunostomy. After propensity score matching, 136 patients (68 each in groups C and L) were selected to compare the surgical outcomes including incidence of esophagojejunostomy-related complications and postoperative nutritional status.

RESULTS

The median operation time was significantly longer in group L than in group C (261.5 min versus 325.5 min; P < 0.001). The incidence of esophagojejunostomy-related complications did not differ between the two groups (5.9% versus 2.9%; P = 0.68); however, no anastomotic stricture and bleeding occurred in group L. Bodyweight loss was significantly lower in group L than in group C at 6 months (15.9% versus 12.6%; P = 0.007) after surgery.

CONCLUSIONS

Esophagojejunostomy using a linear stapler following OTG is equally safe and possibly advantageous in anastomotic stricture, bleeding and nutritional status compared with the use of a circular stapler.

Efficacy of minimally invasive distal gastrectomy for elderly patients with clinical stage I/IIA gastric cancer: a propensity-score matched analysis

BACKGROUND

Phase III trials have shown the non-inferiority of minimally invasive distal gastrectomy (MIDG) comparison with open distal gastrectomy (ODG) in patients with gastric cancer; however, it remains unclear whether MIDG is also effective in the elderly. This study aimed to clarify the efficacy of MIDG in elderly gastric cancer patients.

PATIENTS AND METHODS

This study included 316 patients older than 75 years with clinical stage I/IIA gastric cancer who underwent distal gastrectomy from August 2008 to December 2016 at the Shizuoka Cancer Centre. The long-term outcomes between MIDG and ODG were compared after propensity score matching.

RESULTS

After propensity score matching, there were 97 patients each in the MIDG and ODG groups, with an improved balance of confounding factors between the two groups. MIDG was associated with significantly longer operative time and a lower level of blood loss than ODG. The incidence of complications was comparable between the two groups. Survival outcomes were better in the MIDG group than in the ODG group (overall survival; P = 0.034, relapse-free survival; P = 0.027). In the multivariable analysis, ODG [hazard ratio (HR) 1.971, P = 0.046], being 80 years or older (HR 2.285, P = 0.018), male sex (HR 2.428, 95% P = 0.024), and poor physical status (HR 2.324, P = 0.022) were identified as independent prognostic factors for overall survival.

CONCLUSIONS

We found that MIDG showed better efficacy than ODG in elderly gastric cancer patients. MIDG is an acceptable option for elderly patients.

Robot-assisted laparoscopic subtotal gastrectomy for early-stage gastric cancer: Case series of initial experience

Background

In the last decade's robotic gastrectomy (RG) has increasingly widespread as a valid minimally invasive option for treatment of gastric cancer. In literature, evidence of its routine use is not yet well established. The aims of this study are to report our initial experience and to present possible advantages of our hybrid operative technique for subtotal gastrectomy.

Materials and methods

Retrospectively, we analyzed data from 41 patients (22 male and 19 female) who underwent robot-assisted laparoscopic subtotal gastrectomy (RALG) with D2 lymphadenectomy using the da Vinci XI robotic system. Inclusion criteria were gastric cancer in the middle or lower portion of the stomach amenable of radical subtotal gastrectomy without preoperative suspicion of positive lymph-nodes or other organs involving and distant metastasis. All the procedures were performed by attending surgeons.

Results

The mean operative time was 270 min with one case of conversion to open surgery. The mean age was 71.4 (IQR 68.2-76.8) with 43.9% of patients classified as ASA (American Society of Anesthesiologists) score ≥3. The median of lymph-nodes retrieved was 25 (IQR 19-35). No intra-operative complications occurred. Time to resume a soft diet was 5 days. Patients were hospitalized a median of 7 days. According to pathological AJCC-TNM, 21 patients were classified as advanced gastric cancer. Post-operative morbidity was recorded in 9 patients (21.9%) with major complications requiring surgical operation in 4 patients (9.8%). Elevated ASA score, fewer lymph-nodes retrieved and ICU recovery requirements were significant increased in patients with major complications.

Conclusion

The preliminary results demonstrated that robot-assisted laparoscopic subtotal gastrectomy is safe and feasible. In particular, we found that the da Vinci platform improves surgeon abilities to perform an adequate lymphadenectomy and digestive reconstruction. Further studies are necessary to better clarify the role of this high-cost technology in minimally invasive treatment of gastric cancer.

D2 Lymph Node Dissections during Reduced-port Robotic Distal Subtotal Gastrectomy and Conventional Laparoscopic Surgery Performed by a Single Surgeon in a High-volume Center: a Propensity Score-matched Analysis

Purpose

Various studies have indicated that reduced-port robotic gastrectomies are safe and feasible for treating patients with early gastric cancer. However, there have not been any comparative studies conducted that have evaluated patients with clinically advanced gastric cancer. Therefore, we aimed to compare the perioperative outcomes of D2 lymph node dissections during reduced-port robotic distal subtotal gastrectomies (RRDGs) and conventional 5-port laparoscopic distal subtotal gastrectomies (CLDGs).

Materials and Methods

We retrospectively evaluated 118 patients with clinically advanced gastric cancer who underwent minimally invasive distal subtotal gastrectomies with D2 lymph node dissections between February 2016 and November 2019. To evaluate the patient data, we performed a 1:1 propensity score matching (PSM) according to age, sex, body mass index, American Society of Anesthesiologists physical status classification score, and clinical T status. The short-term surgical outcomes were also compared between the two groups.

Results

The PSM identified 40 pairs of patients who underwent RRDG or CLDG. The RRDG group experienced a significantly longer operation time than the CLDG group (P<0.001), although the RRDG group had significantly less estimated blood loss (P=0.034). The number of retrieved extraperigastric lymph nodes in the RRDG group was significantly higher than that of the CLDG group (P=0.008). The rate of postoperative complications was not significantly different between the two groups (P=0.115).

Conclusions

D2 lymph node dissections can be safely performed during RRDGs and the perioperative outcomes appear to be comparable to those of conventional laparoscopic surgeries. Further studies are needed to compare long-term survival outcomes.

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

BACKGROUND

Controversy persists about the effects of laparoscopic distal gastrectomy (LDG) versus open distal gastrectomy (ODG) on short-term surgical outcomes and long-term survival within the field of advanced gastric cancer (AGC).

METHODS

Studies published from January 1994 to February 2020 that compare LDG and ODG for AGC were identified. All randomized controlled trials (RCTs) were included. The selection of high-quality nonrandomized comparative studies (NRCTs) was based on a validated tool (Methodological Index for Nonrandomized Studies, MINORS). The short- and long-term outcomes of both procedures were compared.

RESULTS

Overall, 30 studies were included in this meta-analysis, which comprised of 8 RCTs and 22 NRCTs involving 16,029 patients (7864 LDGs, 8165 ODGs). The recurrence, 3-year disease-free survival (DFS), 3-year overall survival (OS), and 5-year OS rates for LDG and ODG were comparable. LDG was associated with a lower postoperative complication rate (OR 0.79; P < 0.00001), lower estimated volume of blood loss (WMD -102.21 mL; P < 0.00001), shorter postoperative hospital stay (WMD -1.96 days; P < 0.0001), shorter time to first flatus (WMD -0.54 day; P = 0.0007) and shorter time to first liquid diet (WMD -0.66 day; P = 0.001). The number of lymph nodes retrieved, mortality, intraoperative complications, intraoperative blood transfusion, and time to ambulation were similar. However, LDG was associated with a longer surgical time (WMD 33.57 min; P < 0.00001).

CONCLUSIONS

LDG with D2 lymphadenectomy is a safe and effective technique for patients with AGC when performed by experienced surgeons at high-volume specialized centers.

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 surgery versus open surgery for gastric cancer: big data analysis based on nationwide administrative claims data

Purpose

Accumulated evidence indicates laparoscopic surgery (LS) has the advantages of less wound pain, less blood loss, shorter hospitalization, and faster functional recovery than open surgery (OS). Previous studies have analyzed the advantages of LS based on hospital data. This study is the first to compare surgical outcomes and health economic data using nationwide administrative claims datasets for gastric cancer.

Methods

The claims datasets of the Health Insurance Review and Assessment Service for patients that underwent gastrectomy from May 2012 to April 2017 were analyzed. A total of 76,445 cases (LS, 42,395 and OS, 34,050) were included. Postoperative complications and medical costs were included in the analysis.

Results

We analyzed 76,445 cases of gastrectomy. Analysis showed LS was associated with fewer surgical wound infections (2,114 [6.21%] vs. 1,057 [2.49%], P < 0.001), minor abdominal infections and abscesses (826 [2.43%] vs. 390 [0.92%], P < 0.001), cases of surgery-related peritonitis (50 [0.15%] vs. 31 [0.07%], P = 0.0019), repair surgeries (28 [0.08%] vs. 3 [0.01%], P < 0.001), reoperations (504 [1.48%] vs. 343 [0.81%], P < 0.001), less antibiotic use (1,717 [5.04%] vs. 1,268 [2.99%], P < 0.001), and shorter hospital stays (13.61 days vs. 9.97 days, P < 0.001). However, average medical cost was 510,734 Korean Won (444 US dollar) higher for LS than OS.

Conclusion

The study confirms the clinical benefits of LS over OS for gastrectomy in terms of fewer postoperative complications and shorter hospital stays. However, the average medical cost of LS was higher than that of OS.

Long-Term Outcomes of Laparoscopic Distal Gastrectomy for Locally Advanced Gastric Cancer: The KLASS-02-RCT Randomized Clinical Trial

PURPOSE

It is unclear whether laparoscopic distal gastrectomy for locally advanced gastric cancer is oncologically equivalent to open distal gastrectomy. The noninferiority of laparoscopic subtotal gastrectomy with D2 lymphadenectomy for locally advanced gastric cancer compared with open surgery in terms of 3-year relapse-free survival rate was evaluated.

PATIENTS AND METHODS

A phase III, open-label, randomized controlled trial was conducted for patients with histologically proven locally advanced gastric adenocarcinoma suitable for distal subtotal gastrectomy. The primary end point was the 3-year relapse-free survival rate; the upper limit of the hazard ratio (HR) for noninferiority was 1.43 between the laparoscopic and open distal gastrectomy groups.

RESULTS

From November 2011 to April 2015, 1,050 patients were randomly assigned to laparoscopy (n = 524) or open surgery (n = 526). After exclusions, 492 patients underwent laparoscopic surgery and 482 underwent open surgery and were included in the analysis. The laparoscopy group, compared with the open surgery group, suffered fewer early complications (15.7% v 23.4%, respectively; P = .0027) and late complications (4.7% v 9.5%, respectively; P = .0038), particularly intestinal obstruction (2.0% v 4.4%, respectively; P = .0447). The 3-year relapse-free survival rate was 80.3% (95% CI, 76.0% to 85.0%) for the laparoscopy group and 81.3% (95% CI, 77.0% to 85.0%; log-rank P = .726) for the open group. Cox regression analysis after stratification by the surgeon revealed an HR of 1.035 (95% CI, 0.762 to 1.406; log-rank P = .827; P for noninferiority = .039). When stratified by pathologic stage, the HR was 1.020 (95% CI, 0.751 to 1.385; log-rank P = .900; P for noninferiority = .030).

CONCLUSION

Laparoscopic distal gastrectomy with D2 lymphadenectomy was comparable to open surgery in terms of relapse-free survival for patients with locally advanced gastric cancer. Laparoscopic distal gastrectomy with D2 lymphadenectomy could be a potential standard treatment option for locally advanced gastric cancer.

Reconstruction Methods and Complications of Esophagogastrostomy and Jejunal Interposition in Proximal Gastrectomy for Gastric Cancer: A Meta-Analysis

Background

Proximal gastrectomy is used for the treatment of primary gastric cancer by open or laparoscopic surgery in the upper third of the stomach. Esophagogastrostomy (EG) or jejunal interposition (JI) is widely used in various reconstruction methods after proximal gastrectomy. We conducted a meta-analysis of EG and JI for treatment of gastric cancer.

Materials and Methods

A search of PubMed, Embase, MEDLINE, J-STAGE, and Cochrane Library identified retrospective series on EG and JI. Weight mean differences (WMDs), odds ratios (ORs), and 95% confidence intervals (CIs) were used to analyze the operation-related data and postoperative complications. Heterogeneity was evaluated by the I² test, and potential publication bias was assessed with Egger regression tests and sensitivity analysis.

Results

Eight studies were selected, and 496 patients were included. EG group benefits were 44.81 min shorter operating time (P < 0.001), 56.58 mL less blood loss (P = 0.03), and 7.4 days shorter hospital stay time (P < 0.001) than the JI group. Between the two groups, there was no significant difference in anastomotic leakage; otherwise, the EG group had a lower risk of anastomotic stenosis (OR = 0.44, 95%CI = 0.20 to 0.97, P = 0.04), lower risk of intestinal obstruction (OR = 0.07, 95%CI = 0.01 to 0.43, P = 0.004), and higher risk of reflux esophagitis (OR = 2.47, 95%CI = 1.07 to 5.72, P = 0.03).

Conclusion

The results of our study indicated that EG has significant advantages during the perioperative period and in short-term outcomes compared to JI.

Effect of Laparoscopic Distal Gastrectomy vs Open Distal Gastrectomy on Long-term Survival Among Patients With Stage I Gastric Cancer: The KLASS-01 Randomized Clinical Trial

Importance

Laparoscopic distal gastrectomy is gaining popularity over open distal gastrectomy for gastric cancer because of better early postoperative outcomes. However, to our knowledge, no studies have proved whether laparoscopic distal gastrectomy is oncologically equivalent to open distal gastrectomy.

Objective

To examine whether the long-term survival among patients with stage I gastric cancer undergoing laparoscopic distal gastrectomy is noninferior to that among patients undergoing open distal gastrectomy.

Design

The Korean Laparoendoscopic Gastrointestinal Surgery Study (KLASS) group, which includes 15 surgeons from 13 institutes, conducted a phase 3, multicenter, open-label, noninferiority, prospective randomized clinical trial (KLASS-01) of patients with histologically proven, preoperative clinical stage I gastric adenocarcinoma from January 5, 2006, to August 23, 2010. Survival and recurrence status of the patients was determined in December 2016.

Interventions

Patients were randomly assigned (1:1) to laparoscopic distal gastrectomy (n = 705) or open distal gastrectomy (n = 711). Of these patients, 85 received a surgical approach opposite the one to which they were randomized (63 randomized to the open surgery group and 22 to the laparoscopic group).

Main Outcomes and Measures

Difference in 5-year overall survival between the laparoscopic and open distal gastrectomy groups. The noninferiority margin was prespecified as -5% (corresponding hazard ratio of 1.54), with an assumed survival of 90% after 5 years in the open surgery group.

Results

Among the 1416 patients (mean [SD] age, 57.3 [11.1] years; 940 [66.4%] male) included in the study, the 5-year overall survival rates were 94.2% in the laparoscopic group and 93.3% in the open surgery group (log-rank P = .64). Intention-to-treat analysis confirmed the noninferiority of the laparoscopic approach compared with the open approach (difference, 0.9 percentage points; 1-sided 97.5% CI, -1.6 to infinity). The 5-year cancer-specific survival rates were similar between the 2 groups (97.1% in the laparoscopic group and 97.2% in the open surgery group, log-rank P = .91; difference, -0.03 percentage points; 1-sided 97.5% CI, -1.8 to infinity). Per-protocol analysis results were consistent with the intention-to-treat results for overall and cancer-specific survival rates.

Conclusions and Relevance

The KLASS-01 trial revealed similar overall and cancer-specific survival rates between patients receiving laparoscopic and open distal gastrectomy. Laparoscopic distal gastrectomy is an oncologically safe alternative to open surgery for stage I gastric cancer.

Trial Registration

ClinicalTrials.gov identifier: NCT00452751.

Laparoscopic versus open gastrectomy for gastric cancer

Background

Compared with open gastrectomy (OG), laparoscopic gastrectomy (LG) for gastric cancer has achieved rapid development and popularities in the past decades. However, lack of comprehensive analysis in long-term oncological outcomes such as recurrence and mortality hinder its full support as a valid procedure. Therefore, there are still debates on whether one of these options is superior.

Aim

To evaluate the primary and secondary outcomes of laparoscopic versus open gastrectomy for gastric cancer patients

Methods

Two authors independently extracted study data. Risk ratio (RR) with 95% confidence interval (CI) was calculated for binary outcomes, mean difference (MD) or the standardized mean difference (SMD) with 95% CI for continuous outcomes, and the hazard ratio (HR) for time-to-event outcomes. Review Manager 5.3 and STATA software were used for the meta-analysis.

Results

Seventeen randomized controlled trials (RCTs) involving 5204 participants were included in this meta-analysis. There were no differences in the primary outcomes including the number of lymph nodes harvested during operation, severe complications, short-term and long-term recurrence, and mortality. As for secondary outcomes, compared with the OG group, longer operative time was required for patients in the LG group (MD = 58.80 min, 95% CI = [45.80, 71.81], P < 0.001), but there were less intraoperative blood loss (MD = − 54.93 ml, 95% CI = [− 81.60, − 28.26], P < 0.001), less analgesic administration (frequency: MD = − 1.73, 95% CI = [− 2.21, − 1.24], P < 0.001; duration: MD = − 1.26 days, 95% CI = [− 1.40, − 1.12], P < 0.001), shorter hospital stay (MD = − 1.37 days, 95% CI = [− 2.05, − 0.70], P < 0.001), shorter time to first flatus (MD = − 0.58 days, 95% CI = [− 0.79, − 0.37], P < 0.001), ambulation (MD = − 0.50 days, 95% CI = [− 0.90, − 0.09], P = 0.02) and oral intake (MD = − 0.64 days, 95% CI = [− 1.24, − 0.03], P < 0.04), and less total complications (RR = 0.81, 95% CI = [0.71, 0.93], P = 0.003) in the OG group. There was no difference in blood transfusions (number, quantity) between these two groups. Subgroup analysis, sensitivity analysis, and the adjustment of Duval’s trim and fill methods for publication bias did not change the conclusions.

Conclusion

LG was comparable to OG in the primary outcomes and had some advantages in secondary outcomes for gastric cancer patients. LG is superior to OG for gastric cancer patients.

Laparoscopy Assisted Distal Gastrectomy Versus Open Distal Gastrectomy for Patients with Gastric Cancer in A Middle Resources Country

Background:Laparoscopic surgery with a small laparotomy has several advantages over conventional open surgery, including less invasiveness, less pain, earlier recovery, and better cosmoses. The aim of this study was to compare technical feasibility and early clinical outcomes of laparoscopy-assisted distal gastrectomy in comparison with open distal gastrectomy for gastric cancer in a developing country. Patients and methods :In this retrospective study, patients with distal gastric cancer were divided into two groups (a) patients underwent laparoscopy assisted distal gastrectomy (LADG) (21 patients) and (b) open distal gastrectomy (ODG) (21 patients). For the postoperative pathologic results, the tumor-nodal-metastasis (TNM) stage, grade of tumor differentiation, distal and proximal margins, the number of harvested lymph nodes were evaluated. Staging was done according to the 7th edition of the UICC tumor, node, and metastasis (TNM) classification. D1/D2 lymphadenectomy with curative R0 intention was attempted in all cases. Perioperative mortality and morbidity were assessed. Results:The time to initiate oral intake, and postoperative hospital stay were significantly shorter in the LADG group than in the ODG group (P < 0.001). The operative time in the LADG group was significantly less than that of the ODG group (P = 0.05). Blood loss and blood transfusion frequency were significantly lower (P < 0.0001) in the LADG group in comparison to ODG group. Conclusion:Laparoscopic-assisted distal gastrectomy for distal gastric cancer could be safe and feasible technique alternative to open gastrectomy in a middle income country, with at least similar short term surgical and oncological results. However, laparoscopic gastric surgery is in need to adequate training and technical support especially in D2 lymphadenectomy.

[Surgical management for early stage gastric cancer]

BACKGROUND

In the last decade the implementation of the new technique of endoscopic submucosal dissection (ESD) and the rapid progression of laparoscopic gastric cancer (LAG) resection with an adequate lymphadenectomy (LAD) have played an increasing role in the treatment of patients with early stage gastric cancer (EGC).

OBJECTIVE

A systematic review of the currently available data in the literature was carried out to evaluate the contemporary surgical management for treatment of EGC.

RESULTS

Endoscopic resection (ER) of mucosal T1 gastric cancer (T1m) in accordance with the German guidelines on resection criteria is a widely accepted treatment option, if a definitive R0 resection can be achieved. Excellent en bloc and R0 results in more than 90% of these cases have been shown particularly for ESD. In contrast to T1m gastric carcinomas with a low risk of lymph node metastases (approximately 3%), nodal involvement reaches more than 20% for submucosal infiltrated EGC (T1sm). For this reason, a surgical resection with adequate LAD is further recommended in all cases of non-curative ER or any T1sm gastric cancer. In seven randomized controlled trials and a series of meta-analyses including high-quality non-randomized trials, significant benefits in short-term postoperative outcome have been demonstrated for LAG in comparison to open gastrectomy (OG) in the treatment of EGC. The general morbidity was also significantly lower in LAG than in OG. The 30-day mortality and long-term survival outcome were comparable between the two groups.

CONCLUSION

The use of ESD should be the standard treatment for T1m EGC within the guidelines criteria. For non-curative ESD and T1sm gastric cancer, surgical resection with LAD is recommended. The LAG is a technically safe, feasible, and favorable approach in terms of faster recovery compared to OG. The long-term survival outcome is comparable between LAG and OG for EGC.

Laparoscopic versus open gastrectomy for locally advanced gastric cancer: a systematic review and meta-analysis of randomized controlled studies

BACKGROUND

This meta-analysis sought to evaluate the potential benefits and harms of laparoscopic gastrectomy with D2 lymphadenectomy for locally advanced gastric cancer versus open surgery.

METHODS

A comprehensive search for randomized controlled studies that compared laparoscopic versus open gastrectomy with D2 lymphadenectomy for locally advanced gastric cancer published until December 31, 2018, was conducted. Operative outcomes, early postoperative outcomes, and long-term results were analyzed using a random effects model.

RESULTS

Five randomized controlled trials containing a collective total of 2157 patients were included. In comparison with open surgery, laparoscopic gastrectomy for locally advanced gastric cancer showed similar risks of short-term mortality and serious adverse events within 30 days after surgery. Regarding intraoperative outcomes, operative time was increased for the laparoscopic approach, whereas the estimated intraoperative blood loss tended to be less. However, the amount of evidence was low for most outcomes. In addition, the results for the length of hospital stay and time to first flatus did not show statistically significant differences. The number of harvested lymph nodes and compliance with D2 lymphadenectomy did not significantly differ between the two groups, indicating oncological equivalence of both approaches. However, long-term oncological results could not be evaluated due to a lack of relevant data in four of the trials.

CONCLUSION

Laparoscopic gastrectomy with D2 lymphadenectomy can be performed with equivalent overall short-term morbidity and mortality versus the open approach for locally advanced gastric cancer. However, further well-designed randomized controlled trials are necessary to assess the possible advantages and risks of the laparoscopic approach as well as the long-term results.

Laparoscopic D2 Gastrectomy for Gastric Cancer: Mid-Term Results and Current Evidence

INTRODUCTION

Although the first laparoscopic gastrectomy was performed in 1991, there was a long delay until it was incorporated into the regular practice of western surgeons. In Brazil, there are only few case series reported and data on its safety and efficacy along with mid- and long-term results are desired.

OBJECTIVE

Present the mid-term results of laparoscopic gastrectomy with curative intent in the treatment of gastric adenocarcinoma and review the current evidence on the therapy of this neoplasia with the laparoscopic access.

METHODS

Patients who underwent D2 laparoscopic gastrectomy for gastric adenocarcinoma were retrospectively reviewed.

RESULTS

Sixty-nine patients met the inclusion criteria. The mean age was 59.2 years and the mean body mass index was 24.2 kg/m². Subtotal gastrectomy was performed in 73.9%. The mean number of harvested lymph nodes was 36.7, increased lymph node count and shorter operative time were observed in the last 34 cases. Median hospital stay was 8 days. Postoperative complications occurred in 22 (31.9%) cases. Surgical mortality was 4.3%.

CONCLUSION

Laparoscopic gastrectomy can be performed safely with excellent short- and mid-term results. As experience increases, surgical duration is reduced and lymph node count rises.

Laparoscopic versus open gastrectomy for high-risk patients with gastric cancer: A systematic review and meta-analysis

BACKGROUND

It is still remains unclear whether high-risk patients with gastric cancer can benefit from the application of laparoscopic gastrectomy (LG). The aim of this systematic review was to evaluate the surgical and long-term outcomes after LG and open gastrectomy (OG) for high-risk patients with gastric cancer.

METHODS

We performed a systematic literature search in various databases from January 1994 to June 2018. Patients who had≥1 of the following conditions were defined as high-risk patients: (1) age≥70 years; (2) BMI≥30 kg/m²; (3) ASA (American Society of Anesthesiologists) grade≥3; or (4) clinical T4 stage (cT4). The results were analyzed according to predefined criteria.

RESULTS

In the present meta-analysis, the outcomes of 12 non-randomized controlled studies enrolling 1651 patients (873 in the LG group and 778 in the OG group) were pooled. The estimated blood loss was significantly lower in the LG group than those in the OG group (P < 0.01). There was no significant difference between two groups in operative time (P = 0.17) and number of harvested lymph nodes (P = 0.21). In the LG group, the time to flatus (P < 0.01), time to food intake (P < 0.01), and postoperative hospital stay (P < 0.01) were significantly shorter than those in the OG group. A lower overall postoperative complication rate was observed in the LG group (P < 0.01). The incidence of surgical (P < 0.01) and non-surgical (P < 0.01) complication was significantly lower in the LG group than that in the OG group. The pooled analysis showed no significant difference in overall survival (OS) between LG and OG groups (P = 0.98).

CONCLUSIONS

LG can be a safe and feasible procedure for high-risk patients with gastric cancer.

Learning curve and short-term outcomes of modularized LADG for advanced gastric cancer: A retrospective study

Laparoscopy-assisted distal gastrectomy (LADG) is a complicated procedure. To reduce the difficulty of the operation and standardize the surgical procedure, we explored a new operation mode, which we termed modularized LADG (MLADG). To further extend the new operation mode, we conducted this study to evaluate the short-term outcomes of MLADG for advanced gastric cancer, and determine the learning curve.Data from 100 consecutive patients who received LADG between October 2016 and October 2017 were retrospectively analyzed. Short-term outcomes, such as operation time and intraoperative blood loss, were evaluated, and the learning curve was calculated.For MLADG, the mean operation time was 168.2 ± 13.0 minutes, the mean intraoperative blood loss was 93.6 ± 29.1 ml, the mean number of harvested lymph nodes was 28.6 ± 4.2, and conversion to open surgery occurred in only 1 case. In addition, MLADG had an acceptable postoperative complication incidence and fast postoperative recovery. After the first 20 cases, the operation skill reached a mature and stable level.Our results indicate that MLADG is an oncologically feasible and technically safe surgical procedure. For the trainees with rich experience in open distal gastrectomy, the learning curve is considered to be completed after 20 MLADG cases.

Long-term oncological outcomes in laparoscopic versus open gastrectomy for advanced gastric cancer: A meta-analysis of high-quality nonrandomized studies

BACKGROUND

Multicenter randomized controlled trials (RCTs) and several meta-analyses have confirmed that laparoscopic gastrectomy (LG) is a safe and feasible procedure for patients with locally advanced gastric cancer (AGC) in terms of short-term outcomes. However, the long-term oncological outcomes of LG for AGC are still needed for further evaluation. This study aimed to compare the long-term oncological outcomes of LG with open gastrectomy (OG) for patients with AGC.

METHODS

We performed a systematic literature search in various databases from January 1997 to August 2018. Studies comparing the long-term oncological outcomes between LG with OG were evaluated and data were extracted accordingly. We performed the meta-analysis using RevMan 5.3 software.

RESULTS

Fifteen studies with 4494 patients (2273 in LG group and 2221 in OG group) were included. The 5-year overall survival (OS) rate (HR 0.95, 95% CI 0.86 to 1.05, P = 0.28), disease-free survival (DFS) rate (HR 0.93, 95% CI 0.81 to 1.06, P = 0.27), and recurrence rate (OR 0.87, 95% CI 0.72 to 1.04, P = 0.13) were comparable in LG and OG. Subgroup analysis showed the publication year, study region, sample size, extent of resection, extent of lymphadenectomy, retrieved lymph nodes, proportion of stage III, and patients with serosa-positive (pT4a) did not influence the estimates.

CONCLUSIONS

For patients with AGC, LG is a feasible surgical procedure alternative to OG in terms of long-term oncological outcomes.

Current status of laparoscopic total gastrectomy

In this article, the current state of laparoscopic total gastrectomy (LTG) was reviewed, focusing on lymph node dissection and reconstruction. Lymph node dissection in LTG is technically similar to that in laparoscopic distal gastrectomy for early gastric cancer; however, LTG for advanced gastric cancer requires extended lymph node dissections including splenic hilar lymph nodes. Although a recent randomized controlled trial clearly indicated no survival benefit in prophylactic splenectomy for lymph node dissection at the splenic hilum, some patients may receive prognostic benefit from adequate splenic hilar lymph node dissection. Considering reconstruction, there are two major esophagojejunostomy (EJS) techniques, using a circular stapler (CS) or using a linear stapler (LS). A few studies have shown that the LS method has fewer complications; however, almost all studies have reported that morbidity (such as anastomotic leakage and stricture) is not significantly different for the two methods. As for CS, we grouped various studies addressing complications in LTG into categories according to the insertion procedure of the anvil and the insertion site in the abdominal wall for the CS. We compared the rate of complications, particularly for leakage and stricture. The rate of anastomotic leakage and stricture was the lowest when inserting the CS from the upper left abdomen and was significantly the highest when inserting the CS from the midline umbilical. Scrupulous attention to EJS techniques is required by surgeons with a clear understanding of the advantages and disadvantages of each anastomotic device and approach.

Relationship between Clavien-Dindo classification and long-term survival outcomes after curative resection for gastric cancer: A propensity score-matched analysis

BACKGROUND

The impact of postoperative complications (POCs) on the long-term survival outcomes after curative resection for gastric cancer has seldom been reported. The purpose of this study was to evaluate the relationship between the severity of POCs and long-term survival outcomes after curative resection for gastric cancer.

METHODS

The study analyzed 3091 patients who underwent curative resection for gastric cancer in a single center between June 2009 and June 2015. Patients were divided into two groups based on the occurrence or absence of postoperative complications which were recorded using the Clavien-Dindo classification. Long-term survival outcomes were compared between groups after propensity score matching (PSM).

RESULTS

A total of 3091 patients were included in the entire cohort. After PSM, no significant difference in baseline data was observed between the complications (C) group (n = 375) and no complications (NC) group (n = 375). With a median follow-up of 51 months, POCs were associated with decreased 5-year overall survival (OS) (51.7% vs. 67.5%, P < 0.001), disease-free survival (DFS) (49.9% vs. 65.6%, P < 0.001), and disease-specific survival (DSS) (53.9% vs. 68.8%, P < 0.001). Increasing Clavien-Dindo grades from II to IV was significantly associated with a corresponding decrease in OS (60, 48.3, 34%, P = 0.010), DFS (58.3, 46.3, 32.1%, P < 0.001) and DSS (62.9, 50.3, 34%, P < 0.001). Multivariate analysis confirmed POCs was an independent prognostic factor for decreased OS, DFS, and DSS (all P < 0.05).

CONCLUSIONS

POCs had a negative impact on long-term survival outcomes after curative resection for gastric cancer. The negative effects were also increased with higher Clavien-Dindo grades.

Laparoscopic surgery for gastric cancer: where are we now and where are we going?

INTRODUCTION

Minimally-invasive surgery is gaining increasing popularity for the management of gastric cancer (GC). Areas covered: The authors hereby comprehensively and systematically reviewed the randomized and/or prospective evidence on laparoscopic gastrectomy (LG) for GC. For early GC located in the distal stomach, various randomized trials have demonstrated the superiority/non-inferiority of LG especially in reducing surgical trauma and enhancing postoperative recovery without compromising surgical safety and oncologic efficacy. For advanced GC, while multicenter large-scale randomized evidence has demonstrated the safety and feasibility of LG by experienced hands, the long-term survival which is to be clarified by several ongoing trials are crucial to determine whether a more widespread application is acceptable. Randomized evidence regarding the application of laparoscopic total or proximal gastrectomy, which is technically challenging, is scarce. Various attempts in modification of the traditional laparoscopic approach to further reduce the trauma have been evaluated, such as single-incision and totally LG. LG is becoming increasingly individualized and precise. Expert commentary: The current randomized and/or prospective evidence supports the non-inferiority of laparoscopic surgery especially for the management of early GC located in the distal stomach, while the definitive efficacy of the laparoscopic approach for more surgically challenging situations remains largely explorative and investigative.

Comparison of Intracorporeal and Extracorporeal Esophagojejunostomy after Laparoscopic Total Gastrectomy for Gastric Cancer: A Meta-Analysis Based on Short-Term Outcomes

Background:

Laparoscopic total gastrectomy (LTG) is increasingly performed in patients with gastric cancer. However, the usage of intracorporeal esophagojejunostomy (IEJ) following LTG is limited, as the safety and efficacy remain unclear. The present meta-analysis aimed to evaluate the feasibility and safety of IEJ following LTG.

Methods:

Studies published from January 1994 to January 2017 comparing the outcomes of IEJ and extracorporeal esophagojejunostomy (EEJ) following LTG were reviewed and collected from the PubMed, EBSCO, Cochrane Library, Embase, and China National Knowledge Internet (CNKI). Operative results, postoperative recovery, and postoperative complications were compared and analyzed. The weighted mean difference (WMD) and odds ratio (OR) with a 95% confidence interval (CI) were calculated using the Review Manager 5.3.

Results:

Seven nonrandomized studies with 785 patients were included. Compared with EEJ, IEJ has less blood loss (WMD: −13.52 ml; 95% CI: −24.82–−2.22; P = 0.02), earlier time to first oral intake (WMD: −0.49 day; 95% CI: −0.83–−0.14; P < 0.01), and shorter length of hospitalization (WMD: −0.62 day; 95% CI: −1.08–−0.16; P < 0.01). There was no significant difference between IEJ and EEJ regarding the operation time, anastomotic time, number of retrieved lymph nodes, time to first flatus, anastomosis leakage rate, anastomosis stenosis rate, and proximal resections (all P > 0.05).

Conclusions:

Compared with EEJ, IEJ has better cosmesis, milder surgical trauma, and a faster postoperative recovery. IEJ can be performed as safely as EEJ. IEJ should be encouraged to surgeons with sufficient expertise.

Comparative study of laparoscopic radical gastrectomy and open radical gastrectomy

Introduction:

At present, the main treatment of gastric cancer is surgical resection combined with radiotherapy and chemotherapy, the most important part of which is radical gastrectomy. Laparoscopic radical gastrectomy for advanced gastric cancer is difficult to operate, and whether it can achieve the same curative effect with the laparotomy is still controversial.

Materials and Methods:

This study retrospectively analysed the clinical data of 269 gastric cancer patients surgically treated by our medical team from May 2011 to December 2015 for comparative analysis of the clinical efficacy of laparoscopic-assisted radical gastrectomy and traditional open radical gastrectomy.

Results:

The laparoscopic surgery group had longer duration of surgery, less intra-operative blood loss, shorter post-operative exhaust time, shorter post-operative hospital stay and shorter timing of drain removal. The average number of harvested lymph nodes in the laparoscopic surgery group was 22.9 ± 9.5 per case. And in the laparotomy group the average number was 23.3 ± 9.9 per case. The difference had no statistical significance. With the increase of the number of laparoscopic surgical procedures, the amount of intra-operative blood loss gradually decreases, and the duration of surgery is gradually reduced.

Conclusion:

Laparoscopic radical gastrectomy is superior to open surgery in the aspects of intra-operative blood loss, post-operative exhaust time, post-operative hospital stay and timing of drain removal. With the number of laparoscopic radical gastrectomy cases increased, the duration of surgery is shortened and the amount of intra-operative blood loss will decrease.

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.

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.

Comparison of the short-term outcomes between delta-shaped anastomosis and conventional Billroth I anastomosis after laparoscopic distal gastrectomy: A meta-analysis

BACKGROUND

The conventional Billroth I anastomosis (cBIA) after laparoscopic distal gastrectomy (LDG) is performed through circular staple extracorporeally. Now, delta-shaped anastomosis (DA), which is performed using a linear stapler intracorporeally, becomes popular. We conducted a meta-analysis to compare the effectiveness and safety between the 2 techniques.

METHODS

A systematic literature search was performed using PubMed, Ovid, and the Cochrane Library Central. Participants of any age and sex, who underwent DA, or cBIA after LDG, were considered following inclusion criteria.

RESULTS

A total of 11 articles, published between 2010 and 2017, fulfilled the selection criteria. The total sample size of these studies was 2729 cases, including DA group 1008 cases and cBIA group 1721 cases. Compared to cBIA group, patients in DA group had less blood loss (mean deviation [MD] = -0.68, 95% confidence interval [CI] = -0.15 to -0.31, P < .001), fewer administration of analgesics (MD = -0.82, 95% CI = -1.58 to -0.05, P = .04), lower NRS score on POD 1 (MD = -0.84, 95% CI = -1.34 to -0.33, P = .001), lower NRS score on POD 3 (MD = -0.38, 95% CI = -0.50 to -0.26, P < .001). Furthermore, compared to cBIA group, obese patients in DA group had fewer total number of complications (MD = 0.46, 95% CI = 0.22 to 0.95, P = .04), shorter postoperative hospital stays (MD = -0.73, 95% CI = -1.18 to -0.28, P = .001), earlier first flatus (MD = -0.30, 95% CI = -0.50 to -0.10, P = .004), fewer administration of analgesics (MD = -1.08, 95% CI = -1.61 to -0.55, P < .001), lower NRS score on POD 1 (MD = -0.68, 95% CI = -0.99 to -0.37, P < .001) and lower NRS score on POD 3 (MD = -0.63, 95% CI = -0.86 to -0.40, P < .001).

CONCLUSIONS

Compared with cBIA, DA is a safe and feasible procedure, with similar surgical outcomes and postoperative complications. In terms of postoperative recovery, DA is less invasive with quicker resume than cBIA, especially for the obese patients.

Risk factors and management for gastric stenosis after endoscopic submucosal dissection for gastric epithelial neoplasm

BACKGROUND

Only a few studies have reported treatment options for stenosis after endoscopic submucosal dissection (ESD) for gastric neoplasms. This study aimed to identify the risk factors for and evaluate the management of stenosis after ESD for gastric epithelial neoplasms in the cardia and antrum.

METHODS

We retrospectively reviewed 1218 patients (1447 gastric epithelial neoplasms) who underwent ESD at Tonan Hospital from June 2004 to November 2015. Post-ESD stenosis was defined when a standard endoscope could not be passed through the site.

RESULTS

Post-ESD stenosis occurred in 10 (21.3%) of the 47 cardia cases and 14 (3.2%) of the 432 antrum cases. A wide resection of more than three fourths of the circumferential extent was the sole significant risk factor related to post-ESD stenosis in both cardia and antrum. Prophylactic endoscopic balloon dilation (EBD) was performed in 3 of 10 patients with cardiac stenosis and 4 of 14 with antral stenosis. Post-EBD bleeding occurred in one cardia (10%) and one antrum (7.1%) case each and was endoscopically treated. Perforation during EBD occurred in two (14.3%) antrum cases, both of which required emergency open surgery. All complications were observed in patients with conventional EBD, and no complications were associated with prophylactic EBD.

CONCLUSIONS

A wide resection of more than three fourths of the circumferential extent was the significant risk factor for post-ESD stenosis in both cardia and antrum, and prophylactic EBD could be a promising procedure for the management of post-ESD stenosis.

Robot-assisted laparoscopic vs open gastrectomy for gastric cancer: Systematic review and meta-analysis

AIM

To evaluate the potential effectiveness of robot-assisted gastrectomy (RAG) in comparison to open gastrectomy (OG) for gastric cancer patients.

METHODS

A comprehensive systematic literature search using PubMed, EMBASE, and the Cochrane Library was carried out to identify studies comparing RAG and OG in gastric cancer. Participants of any age and sex were considered for inclusion in comparative studies of the two techniques independently from type of gastrectomy. A meta-analysis of short-term perioperative outcomes was performed to evaluate whether RAG is equivalent to OG. The primary outcome measures were set for estimated blood loss, operative time, conversion rate, morbidity, and hospital stay. Secondary among postoperative complications, wound infection, bleeding and anastomotic leakage were also analysed.

RESULTS

A total of 6 articles, 5 retrospective and 1 randomized controlled study, involving 6123 patients overall, with 689 (11.3%) cases submitted to RAG and 5434 (88.7%) to OG, satisfied the eligibility criteria and were included in the meta-analysis. RAG was associated with longer operation time than OG (weighted mean difference 72.20 min; P < 0.001), but with reduction in blood loss and shorter hospital stay (weighted mean difference -166.83 mL and -1.97 d respectively; P < 0.001). No differences were found with respect to overall postoperative complications (P = 0.65), wound infection (P = 0.35), bleeding (P = 0.65), and anastomotic leakage (P = 0.06). The postoperative mortality rates were similar between the two groups. With respect to oncological outcomes, no statistical differences among the number of harvested lymph nodes were found (weighted mean difference -1.12; P = 0.10).

CONCLUSION

RAG seems to be a technically valid alternative to OG for performing radical gastrectomy in gastric cancer resulting in safe complications.

Long-term Outcomes of Laparoscopic Versus Open Surgery for Clinical Stage I Gastric Cancer: The LOC-1 Study

Background:

Clinical trials comparing laparoscopic gastrectomy (LG) versus traditional open gastrectomy (OG) have been planned, their surgical outcomes reported but their oncologic outcomes are still pending. Consequently, we have conducted this large-scale historical cohort study to provide relevant information rapidly to guide our current practice.

Methods:

Through a consensus meeting involving surgeons, biostatisticians, and epidemiologists, 30 variables of preoperative information possibly influencing surgeons’ choice between LG versus OG and potentially associating with outcomes were identified to enable rigorous estimation of propensity scores. A total of 4235 consecutive patients who underwent gastrectomy for gastric adenocarcinoma were identified and their relevant data were gathered from the participating hospitals. After propensity score matching, 1848 patients (924 each for LG and OG) were selected for comparison of long-term outcomes.

Results:

In the propensity-matched population, the 5-year overall survival was 96.3% [95% confidence interval (CI) 95.0–97.6] in the OG as compared with 97.1% (95% CI, 95.9–98.3) in LG. The number of all-cause death was 33/924 in the OG and 24/924 in the LG through the entire period, and the hazard ratio (LG/OG) for overall death was 0.75 (95% CI, 0.44–1.27; P = 0.290). The 3-year recurrence-free survival was 97.4% (95% CI, 96.4–98.5) in the OG and 97.7% (95% CI, 96.5–98.8) in the LG. The number of recurrence was 22/924 in the OG and 21/924 in the LG through the entire period, and the hazard ratio was 1.01 (95% CI, 0.55–1.84; P = 0.981).

Conclusions:

This observational study adjusted for all-known confounding factors seems to provide strong enough evidence to suggest that LG is oncologically comparable to OG for gastric cancer.