Spleen-preserving lymphadenectomy versus splenectomy in laparoscopic total gastrectomy for advanced gastric cancer. Surg Oncol. 2017;26:207-211. [PMID: 28577727 DOI: 10.1016/j.suronc.2017.04.002]

Learning curve of laparoscopic and robotic total gastrectomy: A systematic review and meta-analysis

PURPOSE

Minimally-invasive total gastrectomy (MITG) is associated with lower morbidity in comparison to open total gastrectomy but requires a learning curve (LC). We aimed to perform a pooled analysis of the number of cases required to surmount the LC (NLC) in MITG.

METHODS

A systematic review of PubMed, Embase, Scopus and the Cochrane Library from inception until August 2022 was performed for studies reporting the LC in laparoscopic total gastrectomy (LTG) and/or robotic total gastrectomy (RTG). Poisson mean (95% confidence interval [CI]) was used to determine the NLC. Negative binomial regression was performed as a comparative analysis.

RESULTS

There were 12 articles with 18 data sets: 12 data sets (n = 1202 patients) on LTG and 6 data sets (n = 318 patients) on RTG. The majority of studies were conducted in East Asia (94.4%). The majority of the data sets (n = 12/18, 66.7%) used non-arbitrary analyses. The NLC was significantly smaller in RTG in comparison to LTG [RTG 20.5 (95% CI 17.0-24.5); LTG 43.9 (95% CI 40.2-47.8); incidence rate ratio 0.47, p < 0.001]. The NLC was comparable between totally-laparoscopic total gastrectomy (TLTG) and laparoscopic-assisted total gastrectomy (LATG) [LATG 39.0 (95% CI 30.8-48.7); TLTG 36.0 (95% CI 30.4-42.4)].

CONCLUSIONS

The LC for RTG was significantly shorter for LTG. However existing studies are heterogeneous.

Establishing the Learning Curve of Laparoscopic and Robotic Distal Gastrectomy: a Systematic Review and Meta-Regression Analysis

BACKGROUND

Minimally invasive distal gastrectomy (MIDG) is non-inferior compared with open distal gastrectomy for gastric cancer. However, MIDG bears a learning curve (LC). This study aims to evaluate the number of cases required to surmount the LC (i.e. NLC) in MIDG.

METHODS

PubMed, Embase, Scopus, and the Cochrane Library were systematically searched from inception to August 2022 for studies which reported NLC in MIDG. NLC on reduced-port/single-port MIDG only were separately analysed. Poisson mean (95% confidence interval (CI)) was used to determine NLC. Negative binomial regression was used to compare NLC between laparoscopic distal gastrectomy (LDG) and robotic distal gastrectomy (RDG).

RESULTS

A total of 45 articles with 71 data sets (LDG n=47, RDG n=24) were analysed. There were 7776 patients in total (LDG n=5516, RDG n=2260). Majority of studies were conducted in East Asia (n=68/71). Majority (76.1%) of data sets used non-arbitrary methods of analyses. The overall NLC for RDG was significantly lower compared to LDG (RDG 22.4 (95% CI: 20.4-24.5); LDG 46.7 (95% CI: 44.1-49.4); incidence rate ratio 0.48, p<0.001). The median number of laparoscopic gastrectomy (LG) cases prior was 0 (interquartile range (IQR) 0-105) for LDG and 159 (IQR 101-305.3) for RDG. Meta-regression analysis did not show a significant impact prior experience in LG, extent of lymphadenectomy and intracorporeal vs extracorporeal anastomosis had on overall NLC for LDG and RDG.

CONCLUSION

NLC for RDG is shorter compared to LDG, but this may be due to prior experience in LG and ergonomic advantages of RDG.

Splenic hilar lymph node dissection enhances survival in Bormann type 4 gastric cancer

Splenic hilar (no.10) lymph node dissection during total gastrectomy is no longer recommended for advanced proximal gastric cancer. However, the treatment efficacy of no.10 lymph node dissection in Borrmann type 4 tumors remains unclear. We enrolled 539 patients who underwent total gastrectomy for Borrmann type 4 tumors between 2006 and 2016 in four major institutions in Korea. We compared the long-term survival of the no.10 lymph node dissection (n = 309) and no-dissection groups (n = 230) using the propensity score (inverse probability of treatment weighting). The treatment effects of no.10 lymph node dissection were estimated in the weighted sample using the Cox proportional hazards regression model with a robust sandwich-type variance estimator. After inverse probability of treatment weighting, there were 540.4 patients in the no.10 lymph node dissection group and 532.7 in the no-dissection group. The two groups showed well-balanced baseline characteristics, including tumor node metastasis stage. The 5-year survival rates in the no.10 lymph node dissection and no-dissection groups were 45.7% and 38.6%, respectively (log-rank p = 0.036, hazard ratio 0.786, 95% confidence interval 0.630-0.982). Multivariate analysis revealed that no.10 lymph node dissection was an independent favorable prognostic factor (adjusted hazard ratio 0.747, 95% confidence interval 0.593-0.940) after adjusting for other prognostic factors. Sensitivity analyses in other inverse probability of treatment weighting models and the propensity score matching model showed similar results. Patients undergoing no.10 lymph node dissection showed improved survival compared to those without. No.10 lymph node dissection is recommended during total gastrectomy for patients with Borrmann type 4 gastric cancer.

Effect of the number of negative lymph nodes removed on the survival and recurrence rate after gastrectomy in patients with gastric cancer: a multicenter retrospective cohort study

BACKGROUND

Various factors affect the survival rate of Gastric cancer (GC) patients after gastrectomy. This study aimed to investigate the effect of the number of negative lymph nodes (NLNs) removed on GC patients' survival and recurrence rate after gastrectomy.

METHODS

In this retrospective, multicenter cohort study, we reviewed the medical profile of 639 patients with a definite diagnosis of GC who underwent gastrectomy from 2010 to 2022 in one of the medical centers affiliated with the Iran University of Medical Sciences. Based on the number of NLNs removed, patients were divided into three groups, including (0-9NLNs), (10-15 NLNs), and (≥ 16 NLNs), including 155, 231, and 253 GC patients, respectively. Demographic characteristics, tumor characteristics, and pathological findings of the patients were extracted by referring to the patient's files.

RESULTS

The 5-year survival rate of patients was estimated at 48.2%. The 5-year tumor recurrence rate in patients with the number of NLNs 1-9, NLNs 10-15, and ≥ 16 NLNs were 79.4%, 51.1%, and 30.8%, respectively. (Log-rank = 9.24, P 0.001) The multivariate analysis showed that the 5-year survival rate in patients with fewer NLNs removed ≥ 16 was significantly higher than in the other two groups. In addition, age, BMI, tumor size, tumor stage, metastasis, and tumor differentiation were significantly related to the survival of GC patients after gastrectomy. (p < 0.05) CONCLUSION: Paying attention to the number of NLNs removed during gastrectomy can be a key factor in improving the survival prediction of GC patients.

Prognostic value of preoperative body mass index for diabetic patients with non-metastasis gastric cancer: a single center experience

Aim

This study was designed to investigate the prognostic effect of preoperative body mass index (BMI) for Type 2 diabetes mellitus (T2DM) patients with non-metastasis gastric cancer (GC) who underwent D₂ gastrectomy.

Methods

T2DM patients with pT_1–4bN_0–3bM₀ GC were retrospectively collected in Department of Gastrointestinal Surgical Oncology, Fujian Cancer Hospital & Fujian Medical University Cancer Hospital from January, 2000 to December, 2010. These patients underwent D₂ radical resection of the stomach combined with regional lymphadenectomy. Chi-square test was used to analyze unordered categorical variables and ranked data, followed by Kaplan–Meier analysis as well as Cox regression models to detect risk factors for survival outcomes. In addition, the cut-off point was determined by the X-tile program. All analyses were carried out using survival package of R and SPSS Software.

Results

A total of 302 T2DM patients with pT_1–4bN_0–3bM₀ GC were collected and analyzed. The cut-off points of BMI, identified by the X-tile program, was 19 kg/m². Patients with low BMI (< 19 kg/m²) had a higher percentage of advanced T stage (T_4a and T_4b), more advanced TNM stage (stage IIIA, IIIB and IIIC), and more elevated level of serum carcinoembryonic antigen (CEA), compared to those with high BMI (> 19 kg/m²) (all P < 0.05). In the low BMI subgroup, the 5-year overall survival rate was 39.02%, which was as high as 58.11% in the high BMI subgroup (P < 0.05). In the multivariate Cox regression model revealed that III_C stage (OR = 3.101), N_3b stage (OR = 3.113) were the most important prognostic indicators, followed by pretreatment BMI (OR = 2.136).

Conclusion

Low preoperative BMI (< 19 kg/m²) was a poor prognostic marker for T2DM patients with pT_1–4bN_0–3bM₀ GC.

Feasibility of laparoscopic total gastrectomy with splenectomy for proximal advanced gastric cancer: A comparative study with open surgery

INTRODUCTION

Total gastrectomy with splenectomy (TGS) is sometimes performed for treatment of locally advanced gastric cancer invading the greater curvature because metastasis to splenic hilar nodes is expected. Despite the widespread use of laparoscopic procedures, the feasibility of laparoscopic TGS (LTGS) has been scarcely reported because of its technical difficulties.

METHODS

This retrospective single-institutional study included 93 consecutive patients with proximal advanced gastric cancer who underwent either LTGS or open TGS (OTGS) from 2010 to 2018. The patients who underwent LTGS (n = 12) were compared with a 1:2 ratio propensity score-matched cohort of patients who underwent OTGS (n = 20). Clinical outcomes were retrospectively reviewed and compared between the two groups.

RESULTS

The patients' baseline characteristics were well balanced between the two groups. The operating time was longer (332.5 vs 222.5 minutes, P < .01) but the blood loss volume was smaller (34.5 vs 426 mL, P < .01) in the LTGS than OTGS group. The incidence of postoperative morbidity (≥ Clavien-Dindo grade III) was much lower (0.0% vs 36.8%, P = .02) and the median postoperative hospital stay was shorter (9 vs 11 days, P < .01) in the LTGS than OTGS group. The median number of harvested No. 10 or 11 days lymph nodes was equivalent between the two groups.

CONCLUSIONS

Although TGS is not a common procedure, LTGS may be safely performed in selected patients when carried out by an experienced surgical team. The oncological safety remains unclear and needs to be further examined in future trials.

Is splenic hilar lymph node dissection necessary for proximal gastric cancer surgery?

Advanced proximal gastric cancer sometimes metastasizes to the splenic hilar lymph nodes (No. 10 LN). Total gastrectomy combined with splenectomy is performed for complete removal of the No. 10 LN and was historically a standard procedure in Japan. However, splenectomy is associated with several disadvantages for patients, such as increased postoperative morbidity, risk of thrombogenic disease, fatal infection from encapsulated bacteria, and the development of other types of cancer in the long term because of loss of immune function. Therefore, splenectomy should only be performed when its estimated oncological effect exceeds such disadvantages. A Japanese randomized controlled trial (JCOG0110) clearly demonstrated that prophylactic splenectomy is not necessary unless the tumor has invaded the greater curvature; thus, splenectomy is no longer routinely performed in Japan. However, several retrospective studies have shown a comparatively high incidence of No. 10 LN metastasis and therapeutic value from LN dissection at that station in the tumors invading the greater curvature. Similar tendencies have also been reported in type 4 or remnant gastric cancer involving the greater curvature. In view of these facts, No. 10 LN dissection is presently recommended for such patients; however, robust evidence is lacking. In recent years, laparoscopic/robotic spleen-preserving splenic hilar dissection utilizing augmented visualization without pancreatic mobilization has been developed. This procedure is expected to replace prophylactic splenectomy and provide an equal oncological effect with lower morbidity. In Japan, a prospective phase-II study (JCOG1809) is currently ongoing to investigate the safety and feasibility of this procedure.

The Survival Benefit and Safety of Splenectomy for Gastric Cancer With Total Gastrectomy: Updated Results

Background

Splenectomy was traditionally performed to dissect the splenic hilar lymph nodes. Considering the important functions of spleen, whether splenectomy would bring beneficial to gastric cancer patients is debatable. This meta-analysis aimed to make an updated evaluation on the effectiveness and safety of splenectomy.

Methods

Literature searches were performed to identify eligible RCTs concerning effectiveness or safety of splenectomy with gastrectomy from PubMed, MEDLINE, CBMdisc, EMBASE, and Cochrane Central Register of Controlled Trials. Two reviewers completed the study selection, data extraction, and quality assessment independently. The meta-analyses were performed by RevMan 5.3.

Results

A total of 971 patients from four studies were included (485 in splenectomy group and 486 in spleen preservation group). Splenectomy did not increase 5-year overall survival rate (RR=1.05, 95% CI: 0.96, 1.16) or increase postoperative mortality (RR=1.21, 95% CI: 0.41, 3.54). However, the analysis demonstrated that gastrectomy with splenectomy had significantly higher incidence of postoperative complications (RR=1.80, 95% CI: 1.33, 2.45). No significant differences were found in terms of the number of resected lymph nodes and reoperation rate; however, splenectomy had a tendency to prolong the duration of surgery and hospital stays. Subgroup analyses indicated that splenectomy could not increase overall survival rate for either whole or proximal gastric cancer. Sensitivity analyses also found similar results compared to the primary analyses.

Conclusions

Splenectomy cannot benefit the survival of patients with tumor located at lesser curvature, and it could instead increase postoperative morbidity.

Can laparoscopic spleen-preserving splenic hilar lymph node dissection replace prophylactic splenectomy for proximal advanced gastric cancers that invade the greater curvature?

BACKGROUND AND OBJECTIVES

Proximal advanced gastric cancer that invades the greater curvature is often treated by prophylactic splenectomy because of a risk for metastasis to the splenic hilar lymph node (station No.10). We evaluated whether laparoscopic spleen-preserving splenic hilar dissection (SPSHD) could be a better approach.

METHODS

We reviewed records of patients with proximal gastric cancer who underwent total gastrectomy with No.10 dissection between 2012 and 2018 using our in-house database set. We divided patients by whether they had received SPSHD or splenectomy, first to compare surgical outcomes, and subsequently to analyze survival outcomes among patients with tumors invading the greater curvature.

RESULTS

Of 145 patients enrolled in this study, 82 had SPSHDs and 63 had splenectomies. All SPSHDs were laparoscopic; 80% of splenectomies were laparotomic. Morbidity ≥ grade III was seen in 8.5% of the SPSHD group and 11.1% of the splenectomy group. The median number of retrieved No. 10 nodes was three in each group. In multivariable analysis, SPSHD was not an independent prognostic factor among patients whose tumors invaded the greater curvature (n = 73). Among propensity-matched cohorts (n = 25 each), 5-year relapse-free survival rates were 77.6% in the SPSHD group and 49.9% in the splenectomy group.

CONCLUSION

Laparoscopic SPSHD can potentially replace prophylactic splenectomy.

Systemic Review and Meta-analysis of Impact of Splenectomy for Advanced Gastric Cancer

BACKGROUND/AIM

Prophylactic splenectomy has shown no inferiority for tumors not invading the greater curvature side. Despite this, the clinical impact of prophylactic splenectomy for proximal advanced gastric cancer is not clear. This review aimed to clarify the impact of splenectomy for advanced gastric cancer in the upper third of the stomach.

MATERIALS AND METHODS

A systematic review and meta-analysis were conducted based on PubMed and EMBASE databases. The following search terms were used: "gastric cancer" OR "splenectomy" OR upper third of the stomach" OR preservation of the spleen.

RESULTS

Out of 765 articles, 18 studies (combined n=6,341) were included in the analysis. Four randomized controlled trials (RCT) and eight retrospective studies suggested the benefits of spleen-preserving gastrectomy. Six retrospective studies showed no significant benefit of spleen-preserving gastrectomy. Prophylactic splenectomy showed a close association with a higher incidence of postoperative morbidity (pancreatic fistula and anastomotic leakage) with no concomitant improvement in overall survival. Prophylactic splenectomy should not be routinely performed and RCTs are necessary to confirm the impact of splenectomy for cN(+) at the splenic hilum tumors and tumors invading the greater curvature.

Short-term outcomes of robotic- versus laparoscopic-assisted Total Gastrectomy for advanced gastric Cancer: a propensity score matching study

BACKGROUND

Few studies have been designed to evaluate the short-term outcomes between robotic-assisted total gastrectomy (RATG) and laparoscopy-assisted total gastrectomy (LATG) for advanced gastric cancer (AGC). The purpose of this study was to assess the short-term outcomes of RATG compared with LATG for AGC.

METHODS

We retrospectively evaluated 126 and 257 patients who underwent RATG or LATG, respectively. In addition, we performed propensity score matching (PSM) analysis between RATG and LATG for clinicopathological characteristics to reduce bias and compared short-term surgical outcomes.

RESULTS

After PSM, the RATG group had a longer mean operation time (291.14 ± 59.18 vs. 270.34 ± 52.22 min, p = 0.003), less intraoperative bleeding (154.37 ± 89.68 vs. 183.77 ± 95.39 ml, p = 0.004) and more N2 tier RLNs (9.07 ± 5.34 vs. 7.56 ± 4.50, p = 0.016) than the LATG group. Additionally, the total RLNs of the RATG group were almost significantly different compared to that of the LATG group (34.90 ± 13.05 vs. 31.91 ± 12.46, p = 0.065). Moreover, no significant differences were found between the two groups in terms of the length of incision, proximal resection margin, distal resection margin, residual disease and postoperative hospital stay. There was no significant difference in the overall complication rate between the RATG and LATG groups after PSM (23.8% vs. 28.6%, p = 0.390). Grade II complications accounted for most of the complications in the two cohorts after PSM. The conversion rates were 4.55 and 8.54% in the RATG and LATG groups, respectively, with no significant difference (p = 0.145), and the ratio of splenectomy were 1.59 and 0.39% (p = 0.253). The mortality rates were 0.8 and 0.4% for the RATG and LATG groups, respectively (p = 1.000).

CONCLUSION

This study demonstrates that RATG is comparable to LATG in terms of short-term surgical outcomes.

Normal and Abnormal Postoperative Imaging Findings after Gastric Oncologic and Bariatric Surgery

Surgical resection remains the primary choice of treatment and the only potentially curative option for gastric carcinoma, and is increasingly performed laparoscopically. Gastric resection represents a challenging procedure, with a significant morbidity and non-negligible postoperative mortality. The interpretation of imaging after gastric surgery can be challenging due to significant modifications of the normal anatomy. After the surgery, the familiarity with expected imaging appearances is crucial for diagnosis and appropriate management of potentially life-threatening complications in patients who underwent gastric surgery. We review various surgical techniques used in gastric surgery and describe fluoroscopic and cross-sectional imaging appearances of normal postoperative anatomic changes as well as early and late complications after gastric surgery.

Necessity of prophylactic splenic hilum lymph node clearance for middle and upper third gastric cancer: a network meta-analysis

Background

It remains controversial whether prophylactic No.10 lymph node clearance is necessary for gastric cancer. Thus, the present study aims to investigate the impact of prophylactic No.10 lymph node clearance on the perioperative complications and prognosis of upper and middle third gastric cancer.

Methods

A network meta-analysis to identify both direct and indirect evidence with respect to the comparison of gastrectomy alone (G-A), gastrectomy combination with splenectomy (G + S) and gastrectomy combination with spleen-preserving splenic hilar dissection (G + SPSHD) was conducted. We searched Medline, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) for studies published before September 2018. Perioperative complications and overall survival were analyzed. Hazard ratios (HR) were extracted from the publications on the basis of reported values or were extracted from survival curves by established methods.

Results

Ten retrospective studies involving 2565 patients were included. In the direct comparison analyses, G-A showed comparable 5-year overall survival rate (HR: 1.1, 95%CI: 0.97–1.3) but lower total complication rate (OR: 0.37, 95%CI: 0.17–0.77) compared with G + S. Similarly, the 5-year overall survival rate between G + SPSHD and G + S was comparable (HR: 1.1, 95%CI: 0.92–1.4), while the total complication rate of G + SPSHD was lower than that of G + S (OR: 0.50, 95%CI: 0.28–0.88). In the indirect comparison analyses, both the 5-year overall survival rate (HR: 1.0, 95%CI: 0.78–1.3) and total complication rate (OR: 0.75, 95%CI: 0.29–1.9) were comparable between G-A and G + SPSHD.

Conclusions

Prophylactic No.10 lymph node clearance was not recommended for treatment of upper and middle third gastric cancer.

Disadvantages of Complete No. 10 Lymph Node Dissection in Gastric Cancer and the Possibility of Spleen-Preserving Dissection: Review

Splenic hilar lymph node dissection has been the standard treatment for advanced proximal gastric cancer. Splenectomy is typically performed as part of this procedure. However, splenectomy has some disadvantages, such as increased risk of postoperative complications, especially pancreatic fistula. Moreover, patients who underwent splenectomy are vulnerable to potentially fatal infection caused by encapsulated bacteria. Furthermore, several studies have shown an association of splenectomy with cancer development and increased risk of thromboembolic events. Therefore, splenectomy should be avoided if it does not confer a distinct oncological advantage. Most studies that compared patients who underwent splenectomy and those who did not failed to demonstrate the efficacy of splenectomy. Based on the results of a randomized controlled trial conducted in Japan, prophylactic dissection with splenectomy is no longer recommended in patients with gastric cancer with no invasion of the greater curvature. However, patients with greater curvature invasion or those with remnant gastric cancer still need to undergo splenectomy to facilitate splenic hilar node dissection. Spleen-preserving splenic hilar node dissection is a new procedure that may help delink splenic hilar node dissection and splenectomy. In this review, we examine the evidence pertaining to the efficacy and disadvantages of splenectomy. We discuss the possibility of spleen-preserving surgery for prophylactic splenic hilar node dissection to overcome the disadvantages of splenectomy.

Short-term efficacy of robotic and laparoscopic spleen-preserving splenic hilar lymphadenectomy via Huang's three-step maneuver for advanced upper gastric cancer: Results from a propensity score-matched study

BACKGROUND

Robotic surgery has been considered to be significantly better than laparoscopic surgery for complicated procedures.

AIM

To explore the short-term effect of robotic and laparoscopic spleen-preserving splenic hilar lymphadenectomy (SPSHL) for advanced gastric cancer (GC) by Huang’s three-step maneuver.

METHODS

A total of 643 patients who underwent SPSHL were recruited from April 2012 to July 2017, including 35 patients who underwent robotic SPSHL (RSPSHL) and 608 who underwent laparoscopic SPSHL (LSPSHL). One-to-four propensity score matching was used to analyze the differences in clinical data between patients who underwent robotic SPSHL and those who underwent laparoscopic SPSHL.

RESULTS

In all, 175 patients were matched, including 35 patients who underwent RSPSHL and 140 who underwent LSPSHL. After matching, there were no significant differences detected in the baseline characteristics between the two groups. Significant differences in total operative time, estimated blood loss (EBL), splenic hilar blood loss (SHBL), splenic hilar dissection time (SHDT), and splenic trunk dissection time were evident between these groups (P < 0.05). Furthermore, no significant differences were observed between the two groups in the overall noncompliance rate of lymph node (LN) dissection (62.9% vs 60%, P = 0.757), number of retrieved No. 10 LNs (3.1 ± 1.4 vs 3.3 ± 2.5, P = 0.650), total number of examined LNs (37.8 ± 13.1 vs 40.6 ± 13.6, P = 0.274), and postoperative complications (14.3% vs 17.9%, P = 0.616). A stratified analysis that divided the patients receiving RSPSHL into an early group (EG) and a late group (LG) revealed that the LG experienced obvious improvements in SHDT and length of stay compared with the EG (P < 0.05). Logistic regression showed that robotic surgery was a significantly protective factor against both SHBL and SHDT (P < 0.05).

CONCLUSION

RSPSHL is safe and feasible, especially after overcoming the early learning curve, as this procedure results in a radical curative effect equivalent to that of LSPSHL.

Systematic review and meta-analysis of splenectomy in gastrectomy for gastric carcinoma

BACKGROUND

The role of splenectomy for patients with gastric cancer still remains controversial. We performed this meta-analysis to evaluate the safety and long-term oncological outcomes of splenectomy for patients with gastric cancer.

METHODS

A systematic literature search was performed using PubMed, EMBASE, Cochrane Library, and Web of Science from January 1997 to October 2018. The results were analyzed according to predefined criteria. All statistical analyses were performed using RevMan 5.3 software.

RESULTS

In total, 16 studies with 4457 patients, including 3 randomized controlled trials (RCTs) and 13 non-randomized controlled trials (nRCTs), were analyzed. The meta-analysis showed the splenectomy group was associated with higher rates of overall postoperative complication, anastomosis leakage, abdominal abscess, and pancreatic fistula. Regarding long-term oncological outcomes, the splenectomy group showed lower 5-year overall survival (OS) and higher recurrence rates on subgroup analysis for the nRCTs. No significant difference was observed in the 5-year OS and recurrence rates between the two groups on subgroup analysis for the RCTs.

CONCLUSIONS

Splenectomy increases postoperative complications without clearly improving long-term prognosis.

Laparoscopic perigastric mesogastrium excision technique for radical total gastrectomy

Introduction

Complete mesogastrium excision (CME) of the perigastric mesogastrium and dissection of lymph nodes (LNs) no. 10 and no. 11 remain technically challenging aspects of laparoscopic radical total gastrectomy (LRTG) plus CME. To address some of these difficulties, we introduced the laparoscopic perigastric mesogastrium excision technique (LPMET) and the concept of the “enjoyable space” to partly modify the procedures of conventional radical surgery and characterize the perigastric space and the surgical plane as well as its boundaries.

Aim

To introduce the laparoscopic perigastric mesogastrium excision technique (LPMET) and the “enjoyable space” when undergoing laparoscopic radical total gastrectomy.

Material and methods

From July 2016 to June 2017, 79 cases of upper gastric cancer that were treated by laparoscopic D2 gastrectomy plus CME were investigated. The retrospective database included the patient characteristics, intraoperative and postoperative outcomes, and morbidity and mortality rates depending on the completeness of their medical records.

Results

Laparoscopic D2 gastrectomy plus CME was successfully performed in all 79 cases. The mean surgical time was 232.5 ±46.0 min, and the intraoperative blood loss was 67.6 ±52.3 ml. A total of 2245 LNs were retrieved (mean 28.1 ±10.8 retrieved from each specimen). The mean postoperative hospital stay was 10.3 ±1.6 days. The postoperative morbidity rate was 17.7%. After a median follow-up period of 12 months, one patient experienced liver metastasis; of the other 78 patients, none died or experienced tumor recurrence or metastasis.

Conclusions

Laparoscopic perigastric mesogastrium excision technique and the “enjoyable space” could be a novel, minimally invasive approach and space to achieve CME and provide benefit for the dissection of LNs no. 10 and no. 11.

Analysis of the short- and long-term outcomes of membrane anatomy-guided laparoscopic spleen-preserving circumferential splenic hilar lymph node dissection for treating advanced proximal gastric cancer

Objective

To investigate the short- and long-term efficacy of membrane anatomy-guided laparoscopic spleen-preserving circumferential splenic hilar lymph node dissection for the treatment of advanced proximal gastric cancer.

Methods

A retrospective analysis was conducted in 186 patients with advanced proximal gastric cancer who underwent mesenteric anatomy-guided laparoscopic spleen-preserving splenic hilar lymph node dissection for advanced proximal gastric cancer in our center from March 2013 to March 2018. The patients were divided into two groups: one group was the laparoscopic anterior splenic hilar lymph node dissection group which we named L-ASHD, n = 103), while the other group was the laparoscopic circumferential splenic hilar lymph node dissection group which we named L-CSHD, n = 83).

Results

There was no significant difference in total operative time, intraoperative blood loss, postoperative length of hospital stay, and incidence of postoperative complications, etc. (P > 0.05). The number of harvested splenic hilar lymph nodes and the number of patients with harvested positive splenic hilar lymph nodes were both higher in the L-CSHD than in the L-ASHD (3.90 ± 2.52 vs. 3.02 ± 3.07, P < 0.05; 19 vs. 9 patients, P < 0.05). The positive rate of lymph nodes behind the splenic hilar was 8.4%. Kaplan–Meier survival curves showed that patients in the L-CSHD had similar OS and DFS compared with those of patients in the L-ASHD.

Conclusion

Membrane anatomy-guided laparoscopic spleen-preserving circumferential splenic hilar lymph node dissection for advanced proximal gastric cancer is safe and feasible and can help avoid the incomplete dissection of positive lymph nodes.

Electronic supplementary material

The online version of this article (10.1186/s12957-019-1610-z) contains supplementary material, which is available to authorized users.

Feasibility of laparoscopic total gastrectomy in overweight patients: Implications of less impact of overweight on laparoscopic versus open approach

AIM

To investigate safety and oncological feasibility of laparoscopic total gastrectomy (LTG) in overweight (OW) patients.

METHODS

Patients who underwent total gastrectomy (110 laparoscopic, 211 open) for gastric cancer between January 1999 and July 2016 were included. Propensity score matching selected 152 patients (76 laparoscopic, 76 open), which were subsequently divided into the OW (≥ 25) or non-OW (< 25) group by body mass index. Postoperative outcomes of laparoscopic versus open approaches were compared between OW and non-OW groups.

RESULTS

In the propensity-matched population, baseline characteristics were comparable between the OW and non-OW groups for the laparoscopy and open groups. In the laparoscopy group, operative time was longer (P = 0.01) in the OW group, however, other perioperative results including complication rates were comparable between the non-OW and OW groups. In the open group, number of retrieved lymph nodes were less (P = 0.03) and local complication rate was more frequent (P = 0.03) in the OW group.

CONCLUSION

LTG in OW patients remains technically challenging but can be performed safely. Our findings imply that OW has a lesser effect on the laparoscopic versus open approach to total gastrectomy.

Feasibility and Safety of Totally Laparoscopic Radical Gastrectomy for Advanced Gastric Cancer: Comparison with Early Gastric Cancer

Purpose

Totally laparoscopic gastrectomy (TLG) for advanced gastric cancer (AGC) is a technically and oncologically challenging procedure for surgeons. This study aimed to compare the oncologic feasibility and technical safety of TLG for AGC versus early gastric cancer (EGC).

Materials and Methods

Between 2011 and 2016, 535 patients (EGC, 375; AGC, 160) underwent curative TLG for gastric cancer. Clinicopathologic characteristics and surgical outcomes of both patient groups were analyzed and compared.

Results

Patients with AGC required a longer operation time and experienced more intraoperative blood loss than those with EGC did. However, patients from both the AGC and EGC groups demonstrated similar short-term surgical outcomes such as postoperative morbidity (14.4% vs. 13.3%, P=0.626), mortality (0% vs. 0.5%, P=0.879), time-to-first oral intake (2.7 days for both groups, P=0.830), and postoperative hospital stay (10.2 days vs. 10.1 days, P=0.886). D2 lymph node dissection could be achieved in the AGC group (95%), with an adequate number of lymph nodes being dissected (36.0±14.9). In the AGC group, the 3-year overall and disease-free survival rates were 80.5% and 73.7%, respectively.

Conclusions

TLG is as safe and effective for AGC as it is for EGC.