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

Application of enhanced recovery after surgery in perioperative patients undergoing laparoscopic surgery for gastric cancer: A meta-analysis

BACKGROUND

To analyze the effect of enhanced recovery after surgery (ERAS) in perioperative patients undergoing laparoscopic surgery for gastric cancer (GC).

METHODS

We searched the literature databases of PubMed (https://pubmed.ncbi.nlm.nih.gov/) and Web of Science (https://www.webofscience.com/) for studies related to ERAS and laparoscopic surgery for GC from their inception till October 2022, and the retrieved articles were further screened for analysis. The literature quality was evaluated based on the Cochrane risk of bias tool. The endpoints included the first postoperative exhaust time, first postoperative bowel movement, length of stay, complications and hospitalization expenses. The meta-analysis was performed using RevMan 5.4 software.

RESULTS

11 studies were included, involving 2039 patients. Meta-analysis showed that the first postoperative exhaust and bowel movement were earlier and the length of stay was shorter in the experimental group (e.g.,) than in the control group (CG) (P < .05). Moreover, a lower incidence of complications and markedly reduced hospitalization expenses were determined in for example (P < .05). Due to the heterogeneity in the comparison of indicators such as the first postoperative exhaust and bowel movement across articles, a funnel plot was drawn for observations. The plot was found to be basically symmetrical, indicating small results bias and reliable reference significance of our findings.

CONCLUSION

ERAS for perioperative patients undergoing laparoscopic surgery for GC can effectively shorten the postoperative rehabilitation cycle of patients, improve surgical safety and reduce treatment costs.

Relaparoscopy in the management of post-operative complications after minimally invasive gastrectomy for gastric cancer

Laparoscopy has already been validated for treatment of early gastric cancer. Despite that, no data have been published about the possibility of a minimally invasive approach to surgical complications after primary laparoscopic surgery. In this multicentre study, we describe our experience in the management of complications following laparoscopic gastrectomy for gastric cancer. A chart review has been performed over data from 781 patients who underwent elective gastrectomy for gastric cancer between January 1996 and July 2020 in two high referral department of gastric surgery. A fully descriptive analysis was performed, considering all the demographic characteristics of patients, the type of primary procedure and the type of complication which required reoperation. Moreover, a logistic regression was designed to investigate if either the patients or the primary surgery characteristics could affect conversion rate during relaparoscopy. Fifty-one patients underwent reintervention after elective laparoscopic gastric surgery. Among patients who received a laparoscopic reintervention, 11 patients (34.3%) required a conversion to open surgery. Recovery outcomes were significantly better in patients who completed the reoperation through laparoscopy. Relaparoscopy is safe and effective for management of complications following laparoscopic gastric surgery and represent a useful tool both for re-exploration and treatment, in expert and skilled hands.

Mapping Lymph Node during Indocyanine Green Fluorescence-Imaging Guided Gastric Oncologic Surgery: Current Applications and Future Directions

Huge strides have been made in the navigation of gastric cancer surgery thanks to the improvement of intraoperative techniques. For now, the use of indocyanine green (ICG) enhanced fluorescence imaging has received promising results in detecting sentinel lymph nodes (SLNs) and tracing lymphatic drainages, which make it applicable for limited and precise lymphadenectomy. Nevertheless, issues of the lack of specificity and unpredictable false-negative lymph nodes were encountered in gastric oncologic surgery practice using ICG-enhanced fluorescence imaging (ICG-FI), which restrict its application. Here, we reviewed the current application of ICG-FI and assessed potential approaches to improving ICG-FI.

Brain metastasis from gastric adenocarcinoma: A large comprehensive population-based cohort study on risk factors and prognosis

Aims

Although brain metastasis from gastric adenocarcinoma (GaC) is rare, it may significantly affect survival and quality of life. The aim of this large, comprehensive, population-based cohort investigation was to investigate factors that were associated with brain metastasis from GaC and to explore the prognostic factors and time-dependent cumulative mortalities among cases with GaC and brain involvement.

Methods

Population-based information on cases with GaC diagnosed from 2010 to 2016 was obtained from a large-scale database. Factors that were associated with brain metastasis were investigated utilizing multivariable logistic regression. Time-dependent tumor-specific mortalities of cases with GaC and brain involvement were then computed utilizing the cumulative incidence functions (CIFs), and mortalities were compared between subgroups utilizing Gray's test. Factors that were associated with death were further evaluated utilizing multivariable Fine-Gray subdistribution hazard regression.

Results

Together, 28,736 eligible cases were included, which comprised 231 (1%) cases with brain metastasis and 10,801 (38%) with metastasis to other sites, encompassing a follow-up of 39,168 person-years. Brain metastasis occurred more often among younger patients (within overall cancers), in cases with stomach cardia tumors, within cases with signet-ring cell carcinoma (within overall cancers), and within cases with positive lymph nodes (within overall tumors); it was less often detected among black people. Brain involvement was associated with more lung and bone metastases. The median survival time of cases having brain metastasis was only 3 months; the 6- and 12-month tumor-specific cumulative mortalities were 57% and 71%, respectively. Among cases with GaC and brain metastasis, those with gastric cardia cancers (when receiving radiotherapy), those undergoing resection, and those receiving chemotherapy had lower mortality risks, while younger patients (when receiving chemotherapy or radiotherapy) and people with positive lymph nodes (when receiving radiotherapy) had higher death hazards.

Conclusion

Among patients with GaC, brain metastasis was correlated with several clinical and pathological variables, including ethnicity, age, cancer histology, location, lymph node involvement, and metastases to other sites. Cases having brain metastasis had poor survival that was correlated with age, cancer location, lymph node metastasis, and management. These findings offer vital clues for individualized patient care and future mechanistic explorations.

Application of multimodal identification technology in the innovative management operation department

Background

The optimization of surgical procedures and the management of surgical quality and safety have become the focus of attention of hospital managers. The application of multimodal identification technology in the innovative management mode of hospital operating department has made remarkable progress.

Methods

To investigate the effect of the upgraded multimodal identification technology on the innovative management of the operating department, 2,280 cases of laparoscopic surgery using traditional surgical management procedures from January to December 2019 before the management upgrade were set as the control group, and 2,350 laparoscopic surgeries with the upgraded multimodal identification management process from January to December 2020 were selected as the experimental group. The operating efficiency, material management efficiency, and patient experience and satisfaction of the two groups were investigated and compared.

Results

Compared with traditional procedures, the upgraded multimodal surgical management system significantly improves the efficiency of laparoscopic surgery and reduces surgical consumption and costs. In addition, the multimodal surgical information identification system significantly improves the surgical experience for patients undergoing laparoscopic surgery.

Conclusion

Application of multimodal identification technology improves the innovative management of operation department compared with traditional surgery management procedure.

Total laparoscopic versus laparoscopic-assisted transabdominal posterior mediastinal digestive tract reconstruction in the treatment of Siewert II adenocarcinoma of the esophagogastric junction: A retrospective study

Background

The method of operation and the range of resection for Siewert II adenocarcinoma of the esophagogastric junction (AEG) remain controversial. This study aims to evaluate the safety, feasibility, and short-term postoperative effect of total laparoscopic versus laparoscopic-assisted transabdominal posterior mediastinal digestive tract reconstruction in the treatment of Siewert II AEG.

Methods

Total laparoscopic or laparoscopic-assisted gastrointestinal reconstruction through abdominal posterior mediastinum was performed in 108 patients with Siewert II AEG from October 2017 to February 2019. This study evaluated the loss of intraoperative blood, the number of lymph nodes, the marginal of the tumor, short-term postoperative complications (within 30 days), the rate of survival at follow-up, and the economic cost, feasibility, and effect of short-term postoperative recovery for patients who received these two operations.

Result

There were no significant differences in general data between the total laparoscopic group and the laparoscopic-assisted group (P > 0.05). However, the total laparoscopic group cost more time on the surgical procedure and digestive tract reconstruction, lost less intraoperative blood, and had more mediastinal lymph nodes compared with the laparoscopic-assisted group (P < 0.05). The total laparoscopic group was significantly better than the laparoscopic-assisted group compared with the short-term postoperative recovery indexes, such as the first exhaust time, the first defecation time, the first fluid time, the first semi-fluid diet time, the postoperative hospital stay, and other postoperative recovery indexes (P < 0.05). In addition, there were no significant differences in postoperative complications, postoperative pathological indexes, the recurrence rate, and mortality between the total laparoscopic group and laparoscopic-assisted group (P > 0.05).

Conclusions

The safety, feasibility, and short-term effect of total laparoscopic transabdominal posterior mediastinal digestive tract reconstruction in the treatment of Siewert II AEG were better than those for the laparoscopic-assisted group.

Application of an Optical Tracking System for Motor Skill Assessment in Laparoscopic Surgery

Objective

Motion analysis of surgical instruments can be used to evaluate laparoscopic surgical skills, and this study assessed the validity of an optical tracking system for the assessment of laparoscopic surgical motor skills.

Methods

Ten experienced surgeons and ten novices were recruited to complete the transferring tasks on a laparoscopic simulator. An optical tracking system, Micron Tracker, was used to capture the marker points on each instrument and to obtain the coordinates of the marker points and the corresponding instrument tip coordinates. The data are processed to create a coordinate system based on the laparoscopic simulator and to calculate the movement parameters of the instruments, such as operating time, path length, speed, acceleration, and smoothness. At the same time, the range of motion of the instrument (insertion depth and pivoting angle) is also calculated.

Results

The position that the tip of the instrument can reach is a small, irregularly shaped spatial area. Significant differences (p < 0.05) were found between the surgeon and novice groups in parameters such as operating time, path length, mean speed, mean acceleration, and mean smoothness. The range of insertion depth of the instruments was approximately 150 mm to 240 mm, and the pivoting angles of the left and right instruments were 30.9° and 46.6° up and down and 28.0° and 35.0° left and right, respectively.

Conclusions

The optical tracking system was effective in subjectively evaluating laparoscopic surgical skills, with significant differences between the surgeon and novice groups in terms of movement parameters, but not in terms of range of motion.

Quantification of Tumor Abnormal Proteins in the Diagnosis and Postoperative Prognostic Evaluation of Gastric Cancer

Background:

Abnormal glycosylation of proteins has been identified in almost all types of cancers and is closely related to the cancer progression, metastasis, and survival of cancer patients. This study was to explore the values of serum tumor abnormal protein (TAP), an abnormal glycochain protein, in the diagnosis and prognosis of gastric cancer (GC).

Methods:

A total of 335 GC patients were included as the study group, and another 335 subjects served as the control group. Tumor abnormal protein expression was compared between the 2 groups. Correlation analysis was used to assess the correlations of TAP with clinicopathological factors. Gastric cancer patients were divided into training set and test set at a ratio of 2:1. Univariate and multivariate Cox regression analyses in training set were used to evaluate the prognostic significance of TAP in GC patients and explore the independent risk factors for overall survival (OS) and disease-free survival (DFS) to establish a prognostic model, followed by testing of the model. According to the median of TAP, 335 GC patients were divided into 2 groups to plot the survival curves of OS and DFS.

Results:

Tumor abnormal protein expression in the study group was significantly higher than in the control group. Taking the best cut-off value of TAP (110.128 μm²) as the diagnostic criteria for GC, the sensitivity and specificity of TAP were 83.58% and 97.61%, respectively, and the area under the receiver operating characteristics (ROC) curve was 0.935, which was not inferior to computed tomography (CT). Tumor abnormal protein expression was an independent risk factor for OS and DFS. The prognostic predictive value of TAP was better than that of pathological stage in GC patients. The model with TAP was effective in predicting prognosis.

Conclusion:

Tumor abnormal protein is an effective indicator for early screening and prognostic evaluation of GC and can also assist the clinical diagnosis and treatment of GC.

Study on the application of preoperative three-dimensional CT angiography of perigastric arteries in laparoscopic radical gastrectomy

To investigate the clinical value and significance of preoperative three-dimensional computerized tomography angiography (CTA) in laparoscopic radical gastrectomy for gastric cancer. The clinical data were analyzed retrospectively from 214 gastric cancer patients. We grouped according to whether to perform CTA, and we compared and analyzed the difference of the data between the two groups. The perigastric arteries were classified according to CTA images of patients in the CTA group. The celiac trunk was classified according to Adachi classification: Type I (118/125, 94.4%), Type II (3/125, 2.4%), Type III (0/125, 0%), Type IV (1/125, 0.8%), Type V (2/125, 1.6%), Type VI (1/125, 0.8%). Hepatic artery classification was performed according to Hiatt classification: Type I (102/125, 81.6%), Type II (9/125, 7.2%), Type III (6/125, 4.8%), Type IV (2/125, 1.6%), Type V (3/125, 2.4%), Type VI (0, 0%), Others (3/125, 2.4%). And this study combined vascular anatomy and surgical risk to establish a new splenic artery classification model. In comparison, the operation time, first exhaust time, and estimated blood loss in the CTA group were significantly lower than those in the non-CTA group. In addition, the blood loss in the CTA group combined with ICG (Indocyanine Green) labeled fluorescence laparoscopy was significantly less than that in the group without ICG labeled. Preoperative CTA could objectively evaluate patients' vascular route and variation and then help us avoid or decrease the risk of vascular injury and bleeding. When combined with ICG labeled fluorescence laparoscopy, it could further reduce the risk of iatrogenic injury during the operation and improve postoperative recovery.

Artificial intelligence-based automated laparoscopic cholecystectomy surgical phase recognition and analysis

BACKGROUND

Artificial intelligence and computer vision have revolutionized laparoscopic surgical video analysis. However, there is no multi-center study focused on deep learning-based laparoscopic cholecystectomy phases recognizing. This work aims to apply artificial intelligence in recognizing and analyzing phases in laparoscopic cholecystectomy videos from multiple centers.

METHODS

This observational cohort-study included 163 laparoscopic cholecystectomy videos collected from four medical centers. Videos were labeled by surgeons and a deep-learning model was developed based on 90 videos. Thereafter, the performance of the model was tested in additional ten videos by comparing it with the annotated ground truth of the surgeon. Deep-learning models were trained to identify laparoscopic cholecystectomy phases. The performance of models was measured using precision, recall, F1 score, and overall accuracy. With a high overall accuracy of the model, additional 63 videos as an analysis set were analyzed by the model to identify different phases.

RESULTS

Mean concordance correlation coefficient for annotations of the surgeons across all operative phases was 92.38%. Also, the overall phase recognition accuracy of laparoscopic cholecystectomy by the model was 91.05%. In the analysis set, there was an average surgery time of 2195 ± 896 s, with a huge individual variance of different surgical phases. Notably, laparoscopic cholecystectomy in acute cholecystitis cases had prolonged overall durations, and the surgeon would spend more time in mobilizing the hepatocystic triangle phase.

CONCLUSION

A deep-learning model based on multiple centers data can identify phases of laparoscopic cholecystectomy with a high degree of accuracy. With continued refinements, artificial intelligence could be utilized in huge data surgery analysis to achieve clinically relevant future applications.

Intraoperative Tumor Localization of Early Gastric Cancers

Recently, endoscopic screening systems have enabled the diagnosis of gastric cancer in the early stages. Early gastric cancer (EGC) is typically characterized by a shallow invasion depth and small size, which can hinder localization of EGC tumors during laparoscopic surgery. Here, we review nine recently reported tumor localization methods for the laparoscopic resection of EGCs. Preoperative dye or blood tattooing has the disadvantage of spreading. Preoperative 3-dimensional computed tomography reconstruction is not performed in real time during laparoscopic gastrectomy. Thus, they are considered to have a low accuracy. Intraoperative portable abdominal radiography and intraoperative laparoscopic ultrasonography methods can provide real-time feedback, but these methods require expertise, and it can be difficult to define the clips in some gastric regions. Despite a few limitations, intraoperative gastrofibroscopy provides real-time feedback with high accuracy. The detection system using an endoscopic magnetic marking clip, fluorescent clip, and radio-frequency identification detection system clip is considered highly accurate and provides real-time feedback; we expect a commercial version of this setup to be available in the near future. However, there is not yet an easy method for accurate real-time detection. We hope that improved devices will soon be developed and used in clinical settings.

The risk factors for cognitive dysfunction in elderly patients after laparoscopic surgery: A retrospective analysis

Postoperative cognitive dysfunction (POCD) is very common in clinical settings, it is necessary to analyze the risk factors for POCD in elderly patients after laparoscopic surgery to provide insights into clinical surgery management.Elderly patients undergone laparoscopy between September 1, 2018 and March 31, 2020 were included. The mini-mental state examination (MMSE) scale was used to evaluate the POCD, and the characteristics and clinical data of patients with and without POCD were collected and compared. Logistic regression was used to analyze the potential influencing factors.A total of 572 patients with laparoscopic surgery were included. The incidence of POCD was 11.89%. There were significant differences in the history of cerebral infarction, preemptive analgesia, preoperative use of dexmedetomidine, general anesthesia combined with continuous epidural block, duration of surgery, low SpO2 during anesthesia induction, PaCO2 after pneumoperitoneum, postoperative PCEA and VAS score at the third day after operation (all P < .05). Logistic regression analysis revealed that history of cerebral infarction (OR3.12, 1.02∼5.13), low SpO2 during anesthesia induction (OR2.03, 1.19∼4.47), Longer duration of surgery (OR1.82, 1.01∼3.16) were risk factors for POCD in elderly patients with laparoscopic surgery, while postoperative PCEA (OR0.43, 0.01∼0.91), General anesthesia combined with continuous epidural block (OR0.59, 0.04∼0.87), preoperative use of dexmedetomidine (OR0.70, 0.08∼0.94) and preemptive analgesia (OR0.75, 0.13-0.90) were the protective factors for POCD in elderly patients with laparoscopic surgery.For the elderly patients undergoing laparoscopic surgery, the health care providers should be fully alert to the POCD based on those relevant factors.

Quantification of fluorescence angiography: Toward a reliable intraoperative assessment of tissue perfusion - A narrative review

BACKGROUND

Accurate intraoperative assessments of tissue perfusion are essential in all forms of surgery. As traditional methods of perfusion assessments are not available during minimally invasive surgery, novel methods are required. Here, fluorescence angiography with indocyanine green has shown promising results. However, to secure objective and reproducible assessments, quantification of the fluorescent signal is essential (Q-ICG). This narrative review aims to provide an overview of the current status and applicability of Q-ICG for intraoperative perfusion assessment.

RESULTS

Both commercial and custom Q-ICG software solutions are available for intraoperative use; however, most studies on Q-ICG have performed post-operative analyses. Q-ICG can be divided into inflow parameters (ttp, t0, slope, and T_1/2max) and intensity parameters (Fmax, PI, and DR). The intensity parameters appear unreliable in clinical settings. In comparison, inflow parameters, mainly slope, and T_1/2max have had superior clinical performance.

CONCLUSION

Intraoperative Q-ICG is clinically available; however, only feasibility studies have been performed, rendering an excellent usability score. Q-ICG in a post-operative setting could detect changes in perfusion following a range of interventions and reflect clinical endpoints, but only if based on inflow parameters. Thus, future studies should include the methodology outlined in this review, emphasizing the use of inflow parameters (slope or T_1/2max), a mass-adjusted ICG dosing, and a fixed camera position.

CuS-NiS2 nanomaterials for MRI guided phototherapy of gastric carcinoma via triggering mitochondria-mediated apoptosis and MLKL/CAPG-mediated necroptosis

Gastric carcinoma is one of the most lethal malignant tumors. As part of our long-term efforts on seeking effective diagnosis and therapeutic strategies of gastric cancer, we present herein novel ternary copper-based chalcogenide nanoplatform CuS-NiS₂ nanomaterials with outstanding photothermal (PT)/photodynamic (PD) property that could effectively suppress human gastric cancer in vitro and in vivo without obvious side effects. We revealed that CuS-NiS₂ induced reactive oxygen species (ROS) generation, leading to apoptosis through Bcl-2/Bax pathway of human gastric cancer cells under 808 nm near-infrared (NIR) irradiation. In addition, we also confirmed that the combination of CuS-NiS₂ and 808 nm NIR laser treatment triggered necroptosis by regulating the novel pathway MLKL/CAPG of human gastric cancer cells. Moreover, the CuS-NiS₂ exhibited excellent contrast enhancement according to magnetic resonance imaging (MRI). Taken together, we reported new ternary copper-based chalcogenide nanomaterials CuS-NiS₂, which could be successfully applied for MRI-guided PT/PD therapy of gastric carcinoma through mitochondria-mediated apoptosis and MLKL/CAPG-mediated necroptosis.

Management of duodenal stump fistula after gastrectomy for malignant disease: a systematic review of the literature

Background

Duodenal stump fistula (DSF) remains one of the most serious complications following subtotal or total gastrectomy, as it endangers patient’s life. DSF is related to high mortality (16–20%) and morbidity (75%) rates. DSF-related morbidity always leads to longer hospitalization times due to medical and surgical complications such as wound infections, intra-abdominal abscesses, intra-abdominal bleeding, acute pancreatitis, acute cholecystitis, severe malnutrition, fluids and electrolytes disorders, diffuse peritonitis, and pneumonia. Our systematic review aimed at improving our understanding of such surgical complication, focusing on nonsurgical and surgical DSF management in patients undergoing gastric resection for gastric cancer.

Methods

We performed a systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) guidelines. PubMed/MEDLINE, EMBASE, Scopus, Cochrane Library and Web of Science databases were used to search all related literature.

Results

The 20 included articles covered an approximately 40 years-study period (1979–2017), with a total 294 patient population. DSF diagnosis occurred between the fifth and tenth postoperative day. Main DSF-related complications were sepsis, abdominal abscess, wound infection, pneumonia, and intra-abdominal bleeding. DSF treatment was divided into four categories: conservative (101 cases), endoscopic (4 cases), percutaneous (82 cases), and surgical (157 cases). Length of hospitalization was 21–39 days, ranging from 1 to 1035 days. Healing time was 19–63 days, ranging from 1 to 1035 days. DSF-related mortality rate recorded 18.7%.

Conclusions

DSF is a rare but potentially lethal complication after gastrectomy for gastric cancer. Early DSF diagnosis is crucial in reducing DSF-related morbidity and mortality. Conservative and/or endoscopic/percutaneous treatments is/are the first choice. However, if the patient clinical condition worsens, surgery becomes mandatory and duodenostomy appears to be the most effective surgical procedure.