Long-term survival outcomes of laparoscopic versus open gastrectomy for gastric cancer: a systematic review and meta-analysis

Long-term outcomes of laparoscopic versus open total gastrectomy in patients with advanced gastric cancer after neoadjuvant chemotherapy: a retrospective cohort study

BACKGROUND

This study was conducted to investigate the long-term outcomes of laparoscopic total gastrectomy (LTG) versus open total gastrectomy (OTG) in patients with advanced gastric cancer (AGC) after neoadjuvant chemotherapy (NACT).

METHODS

Patients with AGC who received NACT before surgery were enrolled in either the LTG or OTG group. Propensity score matching (PSM) (1:2) was performed between the two groups based on the propensity score using a 0.15 calliper width. Three-year overall survival (OS) and disease-free survival (DFS) were compared between these two groups before and after PSM. OS and DFS rates were calculated by the Kaplan‒Meier method, and any differences in survival were evaluated with a log-rank test. Univariate and multivariate Cox proportional hazards analyses were used to estimate the simultaneous effects of prognostic factors on survival and the hazard ratio (HR) between LTG and OTG patients.

RESULTS

A total of 144 patients completed the follow-up, with 24 patients in the LTG group and 120 patients in the OTG group. After a mean follow-up of 64.40 months, there were no significant differences in the 3-year OS or DFS rates between the two groups before (P = 0.453 and P = 0.362, respectively) or after PSM (P = 0.972 and P = 0.884, respectively). Multivariate Cox proportional hazards analysis indicated that ypN stage was an independent risk factor for worse OS (P = 0.013).

CONCLUSIONS

This study showed that LTG with D2 lymphadenectomy performed by an experienced surgical team resulted in comparable 3-year OS and DFS compared with OTG in patients with AGC after NACT.

TRIAL REGISTRATION

This study is not registered.

Laryngeal Anaplastic Lymphoma Kinase-Positive B-cell Lymphoma: Case Report and Review

Larynx is an uncommon extranodal site for non-Hodgkin lymphoma (NHL). Anaplastic lymphoma kinase (ALK)-positive B-cell lymphoma is a rare and aggressive form of NHL. A 19-year-old male presented to the ENT department with globus sensation, hoarseness, cervical lymphadenopathy and weight loss. A 70-degree rigid endoscopic examination of the larynx showed a vascular, irregular, submucosal mass arising from the right aryepiglottic fold causing near complete obstruction of the laryngeal airway. PET-CT showed hypermetabolic lesions in the supraglottis, cervical lymph nodes, cervical spine, ribs and abdominal lymph nodes. Biopsy was taken from the supraglottic mass as well as the enlarged cervical lymph nodes, which revealed ALK-positive large B-cell NHL. In this report, we present a rare case of ALK-positive large B-cell NHL of the larynx, discussing its clinical, radiological and pathological features. A limited review of literature is also presented. There is a need to develop a database for the description of lymphomas affecting the larynx and this case report adds to the existing knowledge of this rare entity.

Current standards of surgical management of gastric cancer: an appraisal

PURPOSE

Gastric cancer (GC) is the fifth most common malignancy worldwide and portends a grim prognosis due to a lack of appreciable improvement in 5-year survival. We aimed to analyze the available literature and summarize the current standards of surgical care for curative and palliative intent treatment of GC.

METHODS

We conducted a systematic search on the PubMed database for studies on the management of GC.

RESULTS

Endoscopic resection is an acceptable treatment option for T1a tumors. The role of optimal resection margin for GC remains unclear. D2 lymph node dissection remains the standard of care with splenectomy needed selectively for splenic hilum involvement. A distal pancreatic resection should be avoided. The advantage of bursectomy and omentectomy in GC surgery is not clear. Multi-visceral resection may be considered for locally advanced GC in carefully selected patients. Minimally invasive approaches are non-inferior to open surgery. Surgery should be abandoned prior even in metastatic GC within the frame of multimodal therapy approach.

CONCLUSION

Various trials have conclusively shown improved patient outcomes when well-established surgical standards are followed.

Relationship between laparoscopic total gastrectomy-associated postoperative complications and gastric cancer prognosis

This study aimed to investigate the incidence and prognosis of postoperative complications after laparoscopic total gastrectomy (LTG) for gastric cancer (GC). We retrospectively enrolled 411 patients who underwent curative LTG for GC at seven institutions between January 2004 and December 2018. The patients were divided into two groups, complication group (CG) and non-complication group (non-CG), depending on the presence of serious postoperative complications (Clavien-Dindo grade III [≥ CD IIIa] or higher complications). Short-term outcomes and prognoses were compared between two groups. Serious postoperative complications occurred in 65 (15.8%) patients. No significant difference was observed between the two groups in the median operative time, intraoperative blood loss, number of lymph nodes harvested, or pathological stage; however, the 5-year overall survival (OS; CG 66.4% vs. non-CG 76.8%; p = 0.001), disease-specific survival (DSS; CG 70.1% vs. non-CG 76.2%; p = 0.011), and disease-free survival (CG 70.9% vs. non-CG 80.9%; p = 0.001) were significantly different. The Cox multivariate analysis identified the serious postoperative complications as independent risk factors for 5-year OS (HR 2.143, 95% CI 1.165-3.944, p = 0.014) and DSS (HR 2.467, 95% CI 1.223-4.975, p = 0.011). A significant difference was detected in the median days until postoperative recurrence (CG 223 days vs. non-CG 469 days; p = 0.017) between the two groups. Serious postoperative complications after LTG negatively affected the GC prognosis. Efforts to decrease incidences of serious complications should be made that may help in better prognosis in patients with GC after LTG.

Perspectives of laparoscopic surgery for gastric cancer

Gastrectomy is the main treatment option for gastric cancer patients. Laparoscopic approach has become popular as an alternative to open method during the last decades, and clinical trials have revealed safety and feasibility in the short- and long-term outcomes of laparoscopic gastrectomy. The aim of this review is to summarize the results of prospective clinical trials and propose future perspectives for laparoscopic gastrectomy.

Enterotomy Closure after Minimally Invasive Distal Gastrectomy with Intracorporeal Anastomosis: A Multicentric Study

INTRODUCTION

Despite progressive improvements in technical skills and instruments that have facilitated surgeons performing intracorporeal gastro-jejunal and jejuno-jejunal anastomoses, one of the big challenging tasks is handsewn knot tying. We analysed the better way to fashion a handsewn intracorporeal enterotomy closure after a stapled anastomosis.

METHODS

All 579 consecutive patients from January 2009 to December 2019 who underwent minimally invasive partial gastrectomy for gastric cancer were retrospectively analysed. Different ways to fashion intracorporeal anastomoses were investigated: robotic versus laparoscopic approach; laparoscopic high definition versus three-dimensional versus 4K technology; single-layer versus double-layer enterotomies. Double-layer enterotomies were analysed layer by layer, comparing running versus interrupted suture; the presence versus absence of deep corner suture; and type of suture thread.

RESULTS

Significantly lower rates of bleeding (p = 0.011) and leakage (p = 0.048) from gastro-jejunal anastomosis were recorded in the double-layer group. Barbed suture thread was significantly associated with reduced intraluminal bleeding and leakage rates both in the first (p = 0.042 and p = 0.010) and second layer (p = 0.002 and p = 0.029).

CONCLUSIONS

Double-layer sutures using barbed suture thread both in first and second layer to fashion enterotomy closure result in lower intraluminal bleeding and anastomotic leak rates.

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 Cancer: Cut Down Complications to Unveil Positive Results of Minimally Invasive Approach

Several randomized controlled trials and meta-analyses have confirmed the advantages of laparoscopic surgery in early gastric cancer, and there are indications that this may also apply in advanced distal gastric cancer. The study objective was to evaluate the safety and effectiveness of laparoscopic gastrectomy (LG), in comparison to open gastrectomy (OG), in the management of locally advanced gastric cancer. The single-center, case–control study included 204 patients, in conveyance sampling, who underwent radical gastrectomy for locally advanced gastric cancer. Out of 204 patients, 102 underwent LG, and 102 patients underwent OG. The primary endpoints were safety endpoints, i.e., complication rates, reoperation rates, and 30-day mortality rates. The secondary endpoints were efficacy endpoints, including perioperative characteristics and oncological outcomes. Even though the overall complication rate was higher in the OG group compared to the LG group (30.4% and 19.6%, respectively), the difference between groups did not reach statistical significance (p = 0.075). No significant difference was identified in reoperation rates and 30-day mortality rates. Time spent in the intensive care unit (ICU) and overall hospital stay were shorter in the LG group compared to the OG group (p < 0.001). Although the number of retrieved lymph nodes is oncologically adequate in both groups, the median number is higher in the OG group (35 vs. 29; p = 0.024). Resection margins came out to be negative in 92% of patients in the LG group and 73.1% in the OG group (p < 0.001). The study demonstrated statistically longer survival rates for the patients in the laparoscopic group, which particularly applies to patients in the most prevalent, third stage of the disease. When patients with the Clavien–Dindo grade ≥II were excluded from the survival analysis, further divergence of survival curves was observed. In conclusion, LG can be safely performed in patients with locally advanced gastric cancer and accomplish the oncological standard with short ICU and overall hospital stay. Since postoperative complications could affect overall treatment results and diminish and blur the positive effect of the minimally invasive approach, further clinical investigations should be focused on the patients with no surgical complications and on clinical practice to cut down the prevalence of complications.

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.

Increasing rates of laparoscopic gastrointestinal surgery and decreasing rates of surgical site infections: an observational study in Japan from 2012-2017

BACKGROUND

Surgical site infections (SSI) are the most common healthcare-associated infection, and gastrointestinal surgery is frequently followed by a high incidence of SSI. Epidemiological analysis of the temporal trends in SSI following gastrointestinal surgery has yet to be performed in Japan. Our purpose was to descriptively investigate these trends.

METHODS

Extracting national surveillance data from the Japan Nosocomial Infections Surveillance (JANIS) system, we analyzed the frequency of SSI events following gastrointestinal surgery, which consisted of seven surgical procedures, from 2012-2017. We calculated the standardized infection ratio to compute risk-adjusted SSI frequency, and used the trend test to detect time-dependent changes.

RESULTS

The frequency of SSI events, except for those associated with surgery of the upper gastrointestinal tract, revealed a decreasing time-dependent trend. The use of laparoscopic surgery increased dramatically over time (p < 0.01 for the six applicable surgical sites), while the frequency of SSI events during laparoscopic surgery remained unchanged.

CONCLUSIONS

The increasing use of laparoscopic surgery was identified, and the observation coincided with the decreasing trend in SSI, especially in lower gastrointestinal tract surgery. If the relationship is causal, the overall SSI incidence among previously healthy individuals is expected to decrease, because the use of laparoscopic surgery has large growth potential in Japan.

Ninety-day mortality after total gastrectomy for gastric cancer

BACKGROUND

Total gastrectomy for gastric cancer is associated with significant 30-day mortality, but this endpoint may underestimate the short-term mortality of the procedure.

METHODS

Retrospective analysis was performed using the National Cancer Database (2004-2015). Patients who underwent total gastrectomy for stage I to III gastric adenocarcinoma were identified and divided into cohorts based on 90-day mortality. Predictors of mortality were analyzed using multivariable logistic regression, and annual trends in mortality rates were calculated by Joinpoint Regression.

RESULTS

Of the 5,484 patients who underwent total gastrectomy, 90-day and 30-day mortality rates were 9.1% and 4.7%, respectively. Factors associated with 90-day mortality included increasing age (odds ratio 1.0, P < .001), income below the median (odds ratio 1.2, P = .039), Charlson-Deyo score ≥2 (odds ratio 1.4, P = .039), treatment at low-volume facilities (odds ratio 1.5, P < .001), N1 (odds ratio 2.0, P < .001), N2 (odds ratio 2.0, P < .001), or N3 (odds ratio 2.7, P < .001) stage disease, having <16 lymph nodes harvested (odds ratio 1.5, P < .001), and lack of treatment with chemotherapy (3.7, P < .001). Lack of health insurance (odds ratio 4.1, P = .080), and positive microscopic margins (odds ratio 1.3, P = .080) were correlated, but not significantly associated, with 90-day mortality. The 90-day mortality rate significantly declined from 14.3% in 2004 to 7.9% in 2015 (P = .006), and the 30-day mortality rate significantly declined from 7.7% in 2004 to 4.8% in 2015 (P = .009).

CONCLUSION

Nearly half of the deaths within 90 days after total gastrectomy for cancer occur beyond 30 days postoperative. Ninety-day mortality has improved over time, but rates remain high, suggesting the need for improved out-of-hospital postoperative care beyond 30 days.

Short-term outcomes and prognosis of laparoscopy-assisted total gastrectomy in elderly patients with stomach cancer

BACKGROUND

The aim of this study was to evaluate the short-term outcomes and prognosis of laparoscopy-assisted total gastrectomy (LTG) in elderly patients with gastric cancer.

METHODS

The clinical data of 275 patients aged over 65 years undergoing open total gastrectomy (OTG, n = 184) or laparoscopy-assisted total gastrectomy (LTG, n = 91) were reviewed from January 2015 to August 2017 at the First Affiliated Hospital of the University of Science and Technology of China. Short-term outcomes were compared between the two groups, and risk factors for postoperative complications were explored. In addition, the 2-year overall survival (OS) and disease-free survival (DFS) were investigated for both groups.

RESULTS

Except for the ASA score (P = 0.01), there was no significant difference regarding patient baselines between the two groups. Patients in the LTG group had a longer operative time (P < 0.001), less intraoperative blood loss (P = 0.004), a shorter time of resumption to a semi-liquid diet (P < 0.001) and a shorter postoperative hospital stay (P = 0.001). The incidence of pulmonary complications was significantly lower in the LTG group than in the OTG group (4.4% vs. 13%, P = 0.026). The number of lymph nodes harvested in the LTG group was higher than that in the OTG group (20.7 ± 7.4 vs. 17.5 ± 6.9, P = 0.001), and the proportion of patients with TNM stage III gastric cancer was higher in the LTG group than in the OTG group (P = 0.035). There was no significant difference in the 2-year OS rate or 2-year DFS rate between the two groups (P = 0.057 and P = 0.344). Sex, age, preoperative comorbidity, intraoperative blood loss, and TNM stage were identified as independent prognostic factors for postoperative survival.

CONCLUSION

Comparing with OTG, LTG is feasible and contributes to less surgical trauma and a faster recovery after total gastrectomy. In addition, LTG contributes to a lower risk of postoperative pulmonary complications. Regarding oncological results, LTG is more effective for lymph node dissection and has a comparable long-term prognosis as OTG.

Surgical and Oncological Outcomes of Laparoscopic Versus Open Pancreaticoduodenectomy in Patients With Pancreatic Duct Adenocarcinoma

It is not clear which of the 2 principal treatments for patients with pancreatic duct adenocarcinoma (PDAC), laparoscopic pancreaticoduodenectomy (LPD) and open pancreaticoduodenectomy (OPD), has greater safety and efficacy. We performed the present meta-analysis to assess the efficacy of both treatments for PDAC patients undergoing LPD. Multiple electronic databases were systematically searched to identify studies (up to October 2018) comparing LPD with OPD for PDAC. Short- and long-term oncological outcomes were evaluated. Six studies were qualified for inclusion criteria in this meta-analysis with a total of 9144 PDAC participants. Regarding safety, there were fewer overall postoperative complications associated with LPD (P = 0.005), but the results were similar in terms of pancreatic fistula and mortality. Laparoscopic pancreaticoduodenectomy was associated with a better trend of performance both in R0 resection (relative risk, 1.03; 95% confidence interval [CI], 1.00-1.07; P = 0.07) and preserved lymph nodes (median, 2.14; 95% CI, -0.21 to 4.49; P = 0.07). Long-term overall survival was comparable between LPD and OPD (hazard ratio, 1.03; 95% CI, 0.95-1.13; P = 0.49). In conclusion, LPD was found to be a suitable alternative to OPD in selected PDAC patients with respect to both surgical and oncological outcomes.

A comprehensive evaluation of clinical efficacy and safety of celecoxib in combination with chemotherapy in metastatic or postoperative recurrent gastric cancer patients: A preliminary, three-center, clinical trial study

AIM

To evaluate the efficacy and safety of celecoxib combined with chemotherapy in the treatment of metastatic or postoperative recurrent gastric cancer.

METHODS

This preliminary, three-center, clinical trial study was conducted between September 2010 and December 2016. In the experimental group (n = 100), patients were treated with celecoxib combined with chemotherapy, and chemotherapy alone was used in the control group. Progression-free survival (PFS) was considered as the primary efficacy parameter. Overall survival (OS), remission rate (RR), quality of life (QOL) and drug safety were considered as the secondary efficacy parameters.

RESULTS

The PFS of the experimental group was 6 months, which was not significantly longer than that of the control group (5 months, P = .73). The average OS was not significantly different between the experimental group (12 months) and the control group (10 months, P = .59). The average OS of the COX-2 positive patients in the experimental group was 14 months and it was significantly longer than the 10-month OS in the control group (P = .01). The PFS of the COX-2 positive patients in the experimental group was 7.5 months, significantly longer than the 5-month PFS of patients in the control group (P < .001). No statistical significance was identified in the incidence of nausea, neutropenia, anorexia, peripheral neurotoxicity, diarrhea, vomiting, asthenia and thrombocytopenia. The EORTC QLQ-C30 questionnaire revealed that the overall QOL of the experimental group was significantly higher than that of the control group (P < .05). No statistical significance was found in the scores of functioning scale between the 2 groups. However, the scores of the symptom scale, especially for pain and fatigue in the experimental group was remarkably higher than that in the control group (P < .05). The overall score of EORTC QLQ-STO22 for the experimental group was considerably higher compared to that for the control group (P < .05). No statistical significance was identified in term of the domains of restrictions on feeding, dysphagia, anxiety, reflux, sense of taste, dry mouth, hair loss and body shape between the 2 groups (P > .05 for all mentioned outcomes).

CONCLUSION

Celecoxib combined with chemotherapy offers more clinical benefits for COX-2 positive advanced gastric cancer patients.

Comparison of totally laparoscopic total gastrectomy and laparoscopic-assisted total gastrectomy: A systematic review and meta-analysis

BACKGROUND

Laparoscopic-assisted total gastrectomy (LATG) has been extensively employed for the removal of gastric tumors, although it has several limitations. Totally laparoscopic total gastrectomy (TLTG) is a new technique that has rapidly been gaining popularity, and may help overcome the limitations of LATG; however, its safety and therapeutic effect remain controversial. In the present study, we aimed to assess the safety and efficacy of TLTG, and compare the short-term outcomes of TLTG and LATG.

METHODS

We searched for studies comparing TLTG and LATG published up to April 2018 from databases such as PubMed and Embase. The study results, including time of surgery, blood loss, anastomosis time, retrieved lymphatic nodes, proximal and distal resection edges, incision length, time to first fluid and soft diet, hospitalization duration, time to first flatus, and postsurgical and anastomotic complications, were compared between the procedures.

RESULTS

A total of 10 studies were included. TLTG led to reduced intraoperative blood loss (P < 0.01), greater number of retrieved lymphatic nodes (P < 0.01), decreased hospitalization duration (P < 0.01), reduced incision length (P = 0.05), and shorter time to first fluid diet (P < 0.05), as compared to LATG. The surgery and anastomosis times, time to first soft diet, resection edge, time to first flatus, overall postsurgical complications, and anastomosis-related complications were similar between TLTG and LATG (P > 0.05).

CONCLUSIONS

TLTG is a safe procedure that yields better cosmesis lower invasiveness, and faster recovery as compared to LATG.

Current status of the "enhanced recovery after surgery" program in gastric cancer surgery

Since the late 1990s, perioperative care through the enhanced recovery after surgery (ERAS, European Society for Clinical Nutrition and Metabolism [ESPEN]) program has spread. ERAS protocols aim to reduce surgical complications, improving postoperative outcomes and thereby saving resources by addressing various clinical elements through a multidisciplinary approach or based on evidence. In the field of gastric cancer, the philosophy of ERAS has gradually become accepted and, in 2014, consensus guidelines for enhanced recovery after gastrectomy were published. These guidelines consist of "procedure-specific" guidelines and "general (not procedure-specific) enhanced recovery items." In this review, we focused on the procedure-specific guidelines and tried to update the contents of every element of the procedure-specific guidelines. The procedure-specific guidelines consist of the following eight elements: "Preoperative nutrition," "Preoperative oral pharmaconutrition," "Access (of gastrectomy)," "Wound catheters and transversus abdominis plane block," "Nasogastric/Nasojejunal decompression," "Perianastomotic drains," "Early postoperative diet and artificial nutrition," and "Audit." On reviewing papers supporting these elements, it was reconfirmed that the recommendations of the guidelines are pertinent and valid. Four meta-analyses concerning the evaluation of ERAS protocols for gastric cancer were included in this review. Every study showed that the ERAS protocol reduced the cost and duration of hospital stay without increasing surgical complication rates, suggesting that ERAS is effective for gastric cancer surgery. However, it cannot be said that ERAS has achieved full penetration in Japan because most evidence is established in Western countries. Future studies must focus on developing a new ERAS protocols appropriate to Japanese conditions of gastric cancer.

Laparoscopic Resection for Adenocarcinoma of the Stomach or Gastroesophageal Junction Improves Postoperative Outcomes: a Propensity Score Matching Analysis

BACKGROUND

Minimally invasive resection for upper gastrointestinal tumors has been associated with favorable results. However, the role of laparoscopic surgery (LS) in the multimodal treatment of patients with advanced adenocarcinoma of the stomach or gastroesophageal junction needs further investigation.

METHODS

Clinicopathological data of patients who underwent gastrectomy between 2005 and 2017 were assessed. Outcomes of patients undergoing LS were compared with those of patients treated with a conventional open resection (OR) using a 1:1 propensity score matching analysis.

RESULTS

Curative resection for adenocarcinoma of the stomach or gastroesophageal junction was performed in 417 patients during the study period. Beginning in June 2014, the majority of patients underwent LS (n = 72) and they were matched with 72 patients who were treated with an OR. The majority of patients treated with LS (89%) had advanced cancer (UICC stages II and III) and 82% of them received neoadjuvant chemotherapy. LS was significantly associated with a higher number of harvested lymph nodes (26 (9-62) vs. 21 (4-46), P = .007), a lower 90-day major complication rate (13 vs. 26%, P = .035), and a lower length of hospital stay (14 vs. 16 days, P = .001). After a median follow-up time of 32 months, 1-year overall survival rate was higher after LS than after OR (93 vs. 74%, P = .126); however, results did not reach statistical significance.

CONCLUSION

LS for adenocarcinoma of the stomach or gastroesophageal junction is feasible and significantly reduces major postoperative morbidity resulting in a reduced length of hospital stay. Therefore, LS should be preferably considered for the curative treatment of patients with these malignancies.

Laparoscopic distal gastrectomy for gastric cancer patient with intestinal malrotation: report of a case

Background

Intestinal malrotation, which arises from incomplete rotation of the embryonic midgut, is one of the congenital anomalies usually diagnosed in infancy. On the other hand, intestinal malrotation detected in asymptomatic adults is very rare. It is frequently diagnosed incidentally during abdominal surgery. We report a case of asymptomatic intestinal malrotation diagnosed during laparoscopic distal gastrectomy for gastric cancer.

Case presentation

A 59-year-old female was diagnosed with early-stage gastric cancer during health screening and admitted to our hospital for radical surgical treatment. Physical examinations and blood tests revealed nothing of note. The type 0-IIc gastric cancer was located in the posterior wall of the mid-body of the stomach. The histological type was poorly differentiated adenocarcinoma.

Esophagogastroduodenoscopy and computed tomography (CT) suggested that the depth of tumor invasion was the submucosal layer without regional lymph node swelling. The clinical stage according to the TNM 7th edition was cT1b N0 M0, cStage I.

Laparoscopic distal gastrectomy with D1+ lymph node dissection and Billroth-I method reconstruction was planned. During the infrapyloric lymph node dissection, a part of the pancreatic head showed unusual adherence to the first part of the duodenal wall. For safe and accurate lymphadenectomy while avoiding pancreatic injury, we deliberately focused on tracing the dissectible layer between the pancreatic parenchyma and fatty tissues including lymph nodes.

Also, we changed the reconstruction procedure from Billroth-I to Roux-en-Y. After distal gastrostomy, we could not find the ligament of Treitz or jejunum on the left side below the transverse colon. Based on a review of the CT image, this patient was diagnosed with intestinal malrotation.

Although the detection of malrotation during the operation was incidental, we could complete radical surgery and Roux-en-Y reconstruction safely. The type of malrotation was non-rotation (90°). She was discharged from our hospital without any complications.

Conclusion

We encountered a case of adult asymptomatic intestinal malrotation with gastric cancer. Even when encountering such a case during laparoscopic gastrectomy, reviewing CT images carefully to reconsider the anatomical anomalies, and tracing the dissectible layer accurately with adequate countertraction can facilitate safe and successful surgery.

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.

Comparison of totally laparoscopic and open approach in total gastrectomy with D2 lymphadenectomy - systematic review and meta-analysis

Introduction

Gastric cancer is a worldwide health concern, being one of the five most common malignant neoplasms worldwide. Currently, an open approach is the gold standard for surgical treatment. Incorporation of laparoscopy as a method of choice for gastric resections remains controversial because of limited evidence of eligibility. To date, there are no high-quality randomized quality trials on totally laparoscopic D2 total gastrectomies.

Aim

The aim of this study was to assess currently available literature and provide meta-analysis on acquired data regarding short-term outcomes with a subgroup analysis of western and eastern studies.

Materials and methods

We performed a systematic review and meta-analysis according to the PRISMA guidelines. The primary outcomes of interest were morbidity and short-term complications.

Results

An initial reference search yielded 3,073 articles. Finally, we chose eight studies covering 1,582 patients that we included in the quantitative analysis. We did not find statistical differences regarding operative time, anastomotic leakage, surgical site infection, cardiac complications, pulmonary complications, or number of harvested lymph nodes. We found significant differences regarding length of hospital stay and morbidity in the Asian population.

Conclusion

This systematic review indicates that a laparoscopic approach for D2 total gastrectomy does not increase morbidity. Furthermore, it allows for a shorter hospital stay. However, more randomized controlled trials are required to fully assess this approach because available data are of limited quality.

The long-term clinical outcomes of robotic gastrectomy for gastric cancer: a large-scale single institutional retrospective study

BACKGROUNDS AND PURPOSE

Robotic surgery has been applied in gastric carcinoma over a decade. Although a series of studies were performed to investigate the short-term outcomes of robot-assisted gastrectomy, few papers were in view of long-term outcomes. The current study was aimed to explore the oncological outcomes of robotic gastrectomy for gastric cancer patients.

METHODS

A total of 606 gastric cancer patients who underwent robot-assisted gastrectomy during March 2010 through March 2017, were enrolled in this research. The clinicopathologic characteristics, surgical procedures along with follow-up information and prognostic factors were recorded in detail. The disease-free survival and overall survival rates were tested by Kaplan-Meier analysis.

RESULTS

All the patients underwent the robotic surgery including 15 proximal gastrectomies, 403 distal gastrectomies, 169 total gastrectomies and 19 remnant gastrectomies. Fifiy-six (9.24%) patients were lost in the follow-up process (3-87 months, a media of 42 months). There were 119 recurrences observed, including 55 local recurrences, 51 peritoneal metastasis and 13 distant metastasis. The 3-year disease-free survival and overall survival were 73.60% and 74.24%, while the 5-year disease-free survivorship and overall survival rates were 68.73% and 69.33%. The 5-year overall survival rates grouped based on TNM stage were 96.58% for IA, 88.16% for IB, 87.03% for IIA, 80.62% fo IIB, 58.50% for IIIA, 48.62% for IIIB, 45.32% for IIIC and 17.03% for IV.

CONCLUSION

Robot-assisted gastrectomy is a valuable procedure for gastric cancer patients. Beside its feasibility and safety, it reveals an acceptable long-term clinical outcome.

Short-term outcomes in minimally invasive versus open gastrectomy: the differences between East and West. A systematic review of the literature

OBJECTIVE

Minimally invasive surgical techniques for gastric cancer are gaining more interest worldwide. Several Asian studies have proven the benefits of minimally invasive techniques over the open techniques. Nevertheless, implementation of this technique in Western countries is gradual. The aim of this systematic review is to give insight in the differences in outcomes and patient characteristics in Asian countries in comparison to Western countries.

METHODOLOGY

An extensive systematic search was conducted using the Medline, Embase, and Cochrane databases. Analysis of the outcomes was performed regarding operative results, postoperative recovery, complications, mortality, lymph node yield, radicality of the resected specimen, and survival. A total of 12 Asian and 8 Western studies were included.

RESULTS

Minimally invasive gastrectomy shows faster postoperative recovery, fewer complications, and similar outcomes regarding mortality in both the Eastern and Western studies. However, patient characteristics such as age and BMI differ between these populations. Comparison of overall outcomes in minimally invasive and open procedures between East and West showed differences in complications, mortality, and number of resected lymph nodes in favor of the Asian population.

CONCLUSION

Improved outcomes are observed following minimally invasive gastrectomy in comparison to open procedures in both Western and Asian studies. There are differences in patient characteristics between the Western and Asian populations. Overall outcomes seem to be in favor of the Asian population. These differences may fade with centralization of care for gastric cancer patients in the West and increasing surgical experience.

Surgical outcomes of laparoscopic distal gastrectomy compared to open distal gastrectomy: A retrospective cohort study based on a nationwide registry database in Japan

To clarify the safety profile of laparoscopic distal gastrectomy (LDG) for gastric cancer patients, the short‐term outcome of LDG was compared to that of open distal gastrectomy (ODG) by propensity score matching using data from the Japanese National Clinical Database (NCD). We conducted a retrospective cohort study of patients undergoing distal gastrectomy between January 2012 and December 2013. Using the data for 70 346 patients registered in the NCD, incidences of mortality and morbidities were compared between LDG patients and ODG patients in the propensity score matched stage I patients (ODG: n = 14 386, LDG: n = 14 386) and stage II‐IV patients (ODG: n = 3738, LDG: n = 3738), respectively. There was no significant difference in mortality rates between LDG and ODG at all stages. Operating time was significantly longer in LDG compared to ODG, whereas blood loss and incidences of superficial surgical site infection (SSI), deep SSI, and wound dehiscence were significantly higher in ODG at all stages. Interestingly, pancreatic fistula was found significantly more often in LDG (1%) compared to ODG (0.8%) (P = .01) in stage I patients; however, it was not different in stage II‐IV patients. The length of postoperative stay was significantly longer in patients undergoing ODG compared to LDG at all stages. LDG in general practice might be a feasible therapeutic option in patients with both advanced gastric cancer and those with early gastric cancer in Japan.

Laparoscopic versus open resection for sigmoid diverticulitis

BACKGROUND

Diverticular disease is a common condition in Western industrialised countries. Most individuals remain asymptomatic throughout life; however, 25% experience acute diverticulitis. The standard treatment for acute diverticulitis is open surgery. Laparoscopic surgery - a minimal-access procedure - offers an alternative approach to open surgery, as it is characterised by reduced operative stress that may translate into shorter hospitalisation and more rapid recovery, as well as improved quality of life.

OBJECTIVES

To evaluate the effectiveness of laparoscopic surgical resection compared with open surgical resection for individuals with acute sigmoid diverticulitis.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 2) in the Cochrane Library; Ovid MEDLINE (1946 to 23 February 2017); Ovid Embase (1974 to 23 February 2017); clinicaltrials.gov (February 2017); and the World Health Organization (WHO) International Clinical Trials Registry (February 2017). We reviewed the bibliographies of identified trials to search for additional studies.

SELECTION CRITERIA

We included randomised controlled trials comparing elective or emergency laparoscopic sigmoid resection versus open surgical resection for acute sigmoid diverticulitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed the domains of risk of bias from each included trial, and extracted data. For dichotomous outcomes, we calculated risk ratios (RRs) with 95% confidence intervals (CIs). For continuous outcomes, we planned to calculate mean differences (MDs) with 95% CIs for outcomes such as hospital stay, and standardised mean differences (SMDs) with 95% CIs for quality of life and global rating scales, if researchers used different scales.

MAIN RESULTS

Three trials with 392 participants met the inclusion criteria. Studies were conducted in three European countries (Switzerland, Netherlands, and Germany). The median age of participants ranged from 62 to 66 years; 53% to 64% were female. Inclusion criteria differed among studies. One trial included participants with Hinchey I characteristics as well as those who underwent Hartmann's procedure; the second trial included only participants with "a proven stage II/III disease according to the classification of Stock and Hansen"; the third trial considered for inclusion patients with "diverticular disease of sigmoid colon documented by colonoscopy and 2 episodes of uncomplicated diverticulitis, one at least being documented with CT scan, 1 episode of complicated diverticulitis, with a pericolic abscess (Hinchey stage I) or pelvic abscess (Hinchey stage II) requiring percutaneous drainage."We determined that two studies were at low risk of selection bias; two that reported considerable dropouts were at high risk of attrition bias; none reported blinding of outcome assessors (unclear detection bias); and all were exposed to performance bias owing to the nature of the intervention.Available low-quality evidence suggests that laparoscopic surgical resection may lead to little or no difference in mean hospital stay compared with open surgical resection (3 studies, 360 participants; MD -0.62 (days), 95% CI -2.49 to 1.25; I² = 0%).Low-quality evidence suggests that operating time was longer in the laparoscopic surgery group than in the open surgery group (3 studies, 360 participants; MD 49.28 (minutes), 95% CI 40.64 to 57.93; I² = 0%).We are uncertain whether laparoscopic surgery improves postoperative pain between day 1 and day 3 more effectively than open surgery. Low-quality evidence suggests that laparoscopic surgery may improve postoperative pain at the fourth postoperative day more effectively than open surgery (2 studies, 250 participants; MD = -0.65, 95% CI -1.04 to -0.25).Researchers reported quality of life differently across trials, hindering the possibility of meta-analysis. Low-quality evidence from one trial using the Short Form (SF)-36 questionnaire six weeks after surgery suggests that laparoscopic intervention may improve quality of life, whereas evidence from two other trials using the European Organization for Research and Treatment of Cancer core quality of life questionnaire (EORTC QLQ-C30) v3 and the Gastrointestinal Quality of Life Index score, respectively, suggests that laparoscopic surgery may make little or no difference in improving quality of life compared with open surgery.We are uncertain whether laparoscopic surgery improves the following outcomes: 30-day postoperative mortality, early overall morbidity, major and minor complications, surgical complications, postoperative times to liquid and solid diets, and reoperations due to anastomotic leak.

AUTHORS' CONCLUSIONS

Results from the present comprehensive review indicate that evidence to support or refute the safety and effectiveness of laparoscopic surgery versus open surgical resection for treatment of patients with acute diverticular disease is insufficient. Well-designed trials with adequate sample size are needed to investigate the efficacy of laparoscopic surgery towards important patient-oriented (e.g. postoperative pain) and health system-oriented outcomes (e.g. mean hospital stay).

Comparisons of short-term and survival outcomes of laparoscopy-assisted versus open total gastrectomy for gastric cancer patients

OBJECTIVES

The safety and surgical oncology of laparoscopy-assisted total gastrectomy (LATG) remain inconclusive and challenging. This study aimed to compare the short-term and long-term outcomes between LATG and open total gastrectomy (OTG) procedures.

RESULTS

In the all-included analyses, there were 69 patients in the LATG group and 268 in the OTG group. LATG was as safe as OTG without increasing postoperative morbidity and mortality. Stage imbalance might introduce differences in the numbers of harvested lymph nodes in LATG (34.4 ± 12.0) and OTG (40.9 ± 16.9), whereas 95.7% of patients underwent D2/D2+ dissection during the LATG procedure. After a median 31 months of follow-up, the overall survival outcomes were comparable between the LATG and OTG procedures (HR = 1.16, 95% CI 0.68-1.97). Sensitivity analysis found comparable node retrieval and stage-specific or treatment-specific overall survival.

MATERIALS AND METHODS

A retrospective case-control study was conducted among gastric cancer patients who underwent either LATG or OTG with curative intention between June 2006 and December 2015. Data retrieval was based on the Surgical Gastric Cancer Patient Registry in the West China Hospital. The primary outcome was overall survival. The secondary outcomes were postoperative complication incidence and severity, operation duration, blood loss, number of harvested lymph nodes, and postoperative hospital stay. Matched pairwise case-control comparisons were performed as a sensitivity analysis.

CONCLUSIONS

LATG by experienced surgeons possibly has comparable short-term surgical outcomes and long-term survival outcomes compared with OTG for gastric cancer patients. However, high-quality RCTs are necessary before confirmative judgment and recommendation as an optional treatment in general practice.

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.

Laparoscopic Gastrectomy with Enhanced Recovery After Surgery Protocol: Single-Center Experience

Background

Surgery remains the mainstay of gastric cancer treatment. It is, however, associated with a relatively high risk of perioperative complications. The use of laparoscopy and the Enhanced Recovery After Surgery (ERAS) protocol allows clinicians to limit surgically induced trauma, thus improving recovery and reducing the number of complications. The aim of the study is to present clinical outcomes of patients with gastric cancer undergoing laparoscopic gastrectomy combined with the ERAS protocol.

Material/Methods

Fifty-three (21 female/32 male) patients who underwent elective laparoscopic total gastrectomy due to cancer were prospectively analyzed. Demographic and surgical parameters were assessed, as well as the compliance with ERAS protocol elements, length of hospital stay, number of complications, and readmissions.

Results

Mean operative time was 296.4±98.9 min, and mean blood loss was 293.3±213.8 mL. In 3 (5.7%) cases, conversion was required. Median length of hospital stay was 5 days. Compliance with ERAS protocol was 79.6±14.5%. Thirty (56.6%) patients tolerated an early oral diet well within 24 h postoperatively; in 48 (90.6%) patients, mobilization in the first 24 hours was successful. In 17 (32.1%) patients, postoperative complications occurred, with 7 of them (13.2%) being serious (Clavien-Dindo 3-5). The 30-day readmission rate was 9.4%.

Conclusions

The combination of laparoscopy and the ERAS protocol in patients with gastric cancer is feasible and allows achieving good clinical outcomes.

Recent developments and innovations in gastric cancer

Gastric cancer has an important place in the worldwide incidence of cancer and cancer-related deaths. It can metastasize to the lymph nodes in the early stages, and lymph node metastasis is an important prognostic factor. Surgery is a very important part of gastric cancer treatment. A D2 lymphadenectomy is the standard surgical treatment for cT1N+ and T2-T4 cancers, which are potentially curable. Recently, the TNM classification system was reorganized, and the margins for gastrectomy and lymphadenectomy were revised. Endoscopic, laparoscopic and robotic treatments of gastric cancer have progressed rapidly with development of surgical instruments and techniques, especially in Eastern countries. Different endoscopic resection techniques have been identified, and these can be divided into two main categories: endoscopic mucosal resection and endoscopic submucosal dissection. Minimally invasive surgery has been reported to be safe and effective for early gastric cancer, and it can be successfully applied to advanced gastric cancer with increasing experience. Cytoreductive surgery and hyperthermıc intraperıtoneal chemotherapy were developed as a combined treatment modality from the results of experimental and clinical studies. Also, hyperthermia increases the antitumor activity and penetration of chemotherapeutics. Trastuzumab which is a monoclonal antibody interacts with human epidermal growth factor (HER) 2 and is related to gastric carcinoma. The anti-tumor mechanism of trastuzumab is not clearly known, but mechanisms such as interruption of the HER2-mediated cell signaling pathways and cell cycle progression have been reported previously. H. pylori is involved in 90% of all gastric malignancies and Japanese guidelines strongly recommend that all H. pylori infections should be eradicated regardless of the associated disease. In this review, we present innovations discussed in recent studies.

Impact of Type of Surgery on Survival Outcome in Patients With Early Gallbladder Cancer in the Era of Minimally Invasive Surgery: Oncologic Safety of Laparoscopic Surgery

Laparoscopic surgery has been widely accepted as a feasible and safe treatment modality in many cancers of the gastrointestinal tract. However, most guidelines on gallbladder cancer (GBC) regard laparoscopic surgery as a contraindication, even for early GBC. This study aims to evaluate and compare recent surgical outcomes of laparoscopic and open surgery for T1(a,b) GBC and to determine the optimal surgical strategy for T1 GBC.The study enrolled 197 patients with histopathologically proven T1 GBC and no history of other cancers who underwent surgery from 2000 to 2014 at 3 major tertiary referral hospitals with specialized biliary-pancreas pathologists and optimal pathologic handling protocols. Median follow-up was 56 months. The effects of depth of invasion and type of surgery on disease-specific survival and recurrence patterns were investigated.Of the 197 patients, 116 (58.9%) underwent simple cholecystectomy, including 31 (15.7%) who underwent open cholecystectomy and 85 (43.1%) laparoscopic cholecystectomy. The remaining 81 (41.1%) patients underwent extended cholecystectomy. Five-year disease-specific survival rates were similar in patients who underwent simple and extended cholecystectomy (96.7% vs 100%, P = 0.483), as well as being similar in patients in the simple cholecystectomy group who underwent open and laparoscopic cholecystectomy (100% vs 97.6%, P = 0.543). Type of surgery had no effect on recurrence patterns.Laparoscopic cholecystectomy for T1 gallbladder cancer can provide similar survival outcomes compared to open surgery. Considering less blood loss and shorter hospital stay with better cosmetic outcome, laparoscopic cholecystectomy can be justified as a standard treatment for T1b as well as T1a gallbladder cancer when done by well-experienced surgeons based on exact pathologic diagnosis.

Laparoscopic surgery: A qualified systematic review

AIM: To review current applications of the laparoscopic surgery while highlighting the standard procedures across different fields.

METHODS: A comprehensive search was undertaken using the PubMed Advanced Search Builder. A total of 321 articles were found in this search. The following criteria had to be met for the publication to be selected: Review article, randomized controlled trials, or meta-analyses discussing the subject of laparoscopic surgery. In addition, publications were hand-searched in the Cochrane database and the high-impact journals. A total of 82 of the findings were included according to matching the inclusion criteria. Overall, 403 full-text articles were reviewed. Of these, 218 were excluded due to not matching the inclusion criteria.

RESULTS: A total of 185 relevant articles were identified matching the search criteria for an overview of the current literature on the laparoscopic surgery. Articles covered the period from the first laparoscopic application through its tremendous advancement over the last several years. Overall, the biggest advantage of the procedure has been minimizing trauma to the abdominal wall compared with open surgery. In the case of cholecystectomy, fundoplication, and adrenalectomy, the procedure has become the gold standard without being proven as a superior technique over the open surgery in randomized controlled trials. Faster recovery, reduced hospital stay, and a quicker return to normal activities are the most evident advantages of the laparoscopic surgery. Positive outcomes, efficiency, a lower rate of wound infections, and reduction in the perioperative morbidity of minimally invasive procedures have been shown in most indications.

CONCLUSION: Improvements in surgical training and developments in instruments, imaging, and surgical techniques have greatly increased safety and feasibility of the laparoscopic surgical procedures.

High-fat enteral nutrition reduces intestinal mucosal barrier damage after peritoneal air exposure

BACKGROUND

Peritoneal air exposure is needed in open abdominal surgery, but long-time exposure could induce intestinal mucosal barrier dysfunction followed by many postoperative complications. High-fat enteral nutrition can ameliorate intestinal injury and improve intestinal function in many gastrointestinal diseases. In the present study, we investigated the effect of high-fat enteral nutrition on intestinal mucosal barrier after peritoneal air exposure and the underlying mechanism.

METHODS

Male adult rats were administrated saline, low-fat or high-fat enteral nutrition via gavage before and after peritoneal air exposure for 3 h. Rats undergoing anesthesia without laparotomy received saline as control. Twenty four hours after surgery, samples were collected to assess intestinal mucosal barrier changes in serum D-lactate levels, intestinal permeability, intestinal tight junction protein ZO-1 and occludin levels, and intestinal histopathology. The levels of malondialdehyde and the activity of superoxide dismutase in the ileum tissue were also measured to assess the status of intestinal oxidative stress.

RESULTS

High-fat enteral nutrition significantly decreased the serum D-lactate level and increased the intestinal tight junction protein ZO-1 level when compared to the group treated with low-fat enteral nutrition (P < 0.05). Meanwhile, histopathologic findings showed that the intestinal mucosal injury assessed by the Chiu's score and the intestinal epithelial tight junction were also improved much more in the high-fat enteral nutrition-treated group (P < 0.05). In addition, the intestinal malondialdehyde level was lower, and the intestinal superoxide dismutase activity was higher in the high-fat enteral nutrition-treated group than that in the low-fat enteral nutrition-treated group (P < 0.05).

CONCLUSIONS

These results suggest that high-fat enteral nutrition could reduce intestinal mucosal barrier damage after peritoneal air exposure, and the underlying mechanism may be associated with its antioxidative action. Perioperative administration of high-fat enteral nutrition may be a promising intervention to preserve intestinal mucosal barrier function in open abdominal surgery.

Prediction of Prolonged Postoperative Ileus After Radical Gastrectomy for Gastric Cancer: A Scoring System Obtained From a Prospective Study

Currently, there is a paucity of study investigating postoperative ileus in gastric cancer surgery. This prospective study aims to identify the risk factors for prolonged postoperative ileus (PPOI) and to use these risk factors to generate a risk stratification scoring system for the occurrence of PPOI.Patients who underwent radical gastrectomy for gastric cancer were included in this study. A multivariate logistic analysis was applied to identify independent risk factors for PPOI and to generate the scoring system. A receiver operating characteristic curve was generated and the area under the curve was calculated to demonstrate the predictive power of the scoring system.Finally, 296 patients were included and analyzed, of whom 96 (32.4%) developed PPOI. The multivariate analysis showed that age ≥65 years, operative duration ≥4 hours, tumor-node-metastasis (TNM) stage = III, open/converted operative technique, and total postoperative opiates dose (TOD) ≥0.3 mg/kg were independent risk factors for PPOI. Based on these factors, a risk stratification scoring system was generated, classified by low-risk (score 0-2), moderate-risk (score 3-4), and high-risk (score 5-6) groups. The incidence of PPOI increased by 7.5-fold from low-risk to high-risk group. The area under the curve of the scoring system was 0.841 (95% CI, 0.793-0.890), indicating a good predictive capability for the occurrence of PPOI.We have identified independent risk factors for the occurrence of PPOI and used these factors to construct a risk stratification scoring system.

Evaluation of immune responses of gastric cancer patients treated by laparoscopic and open gastrectomy

Laparoscopic surgery has been shown to offer more advantages than open surgery for the treatment of gastric cancer. However, the perioperative immune responses after laparoscopic surgery remain largely unexplored. Here, we analyzed the immunity of gastric cancer patients treated by laparoscopy-assisted gastrectomy (LAG) or open gastrectomy (OG) with D2 dissection. Seventy patients were randomized into LAG and OG groups. The operative details and postoperative outcomes of the two groups were compared. The immune factors were measured preoperatively as well as on the first, third, and seventh postoperative days (POD). Our results indicate that there was no significant difference between two groups in clinical characteristics. The profiles of white blood cells, neutrophils, lymphocytes, as well as the lymphocyte subpopulations, including T lymphocytes, B lymphocytes, CD4(+) T cells, and CD8(+) T cells were similar in the LAG and the OG groups. Only the natural killer cell counts were significantly higher in LAG-treated patients than in OG-treated ones on POD7. Moreover, no statistical differences were found between the two groups with respect to the levels of perioperative cytokines, including IFN-γ, IL-4, IL-6, and TNF-α. However, compared with the OG group, most of the immune factors in the LAG group had trends to return to preoperative levels on POD7. Our study demonstrates that the immune function of LAG-treated patients showed patterns similar to that of OG-treated patients, although larger prospective multicenter trials are needed to further evaluate the immunological status of LAG.