Laparoscopic versus open approach in gastrectomy for advanced gastric cancer: a systematic review

The efficacy and safety of enhanced recovery after surgery (ERAS) Program in laparoscopic distal gastrectomy: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Although ERAS Program had some advantages in laparoscopic distal gastrectomy (LDG), its efficacy and safety remained unclear. We conducted a systematic review and meta-analysis to assess the efficacy and safety of the ERAS group and the traditional care (TC) group in LDG.

METHODS

Multiple databases were retrieved from 1 January 2000 to 30 April 2023. The risk ratio (RR), standardized mean difference (SMD) and their 95% confidence interval (CI) were used to estimate the results.

RESULTS

Our meta-analysis contained 17 randomized controlled trials (RCTs) studies, which comprised 1468 patients. Regarding efficacy, the ERAS group had significantly shorter postoperative time to first flatus (SMD = -1.29 [95% CI: -1.68, -0.90]), shorter time to first defecation (SMD = -1.26 [95% CI: -1.90, -0.61]), shorter hospital stays (SMD = -0.99 [95% CI: -1.34, -0.63]), and lower hospitalization costs (SMD = -1.17 [95% CI: -1.86, -0.48]) compared to the TC group. Furthermore, in the ERAS group, C-reactive protein levels were lower on postoperative days 1, 3 or 4, and 7; albumin levels were higher on postoperative days 3 or 4 and 7; and interleukin-6 levels were lower on postoperative days 1 and 3. Regarding safety, the overall postoperative complication rate was lower in the ERAS group (RR: 0.76 [95% CI: 0.60, 0.97]), but there was no significant difference in the individual postoperative complication rate. Other indicators were also not statistically significant.

CONCLUSION

The combination of ERAS Program with laparoscopy surgery was safe and effective for the perioperative management of patients with distal gastric cancer.

Laparoscopic Versus Open Gastrectomy for Advanced Gastric Cancer: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Laparoscopy-assisted gastrectomy (LAG) is a well-established surgical technique in treating patients with early gastric cancer. However, the efficacy and safety of LAG versus open gastrectomy (OG) in patients with advanced gastric cancer (AGC) remains unclear.

METHODS

We systematically searched PubMed, Embase, and Cochrane Library in June 2023 for RCTs comparing LAG versus OG in patients with AGC. We pooled risk ratios (RR) and mean differences (MD) with 95% confidence intervals (CI) for binary and continuous endpoints, respectively. We performed all statistical analyses using R software version 4.3.1 and a random-effects model.

RESULTS

Nine RCTs comprising 3827 patients were included. There were no differences in terms of intraoperative complications (RR 1.14; 95% CI 0.72 to 1.82), number of retrieved lymph nodes (MD -0.54 lymph nodes; 95% CI -1.18 to 0.09), or mortality (RR 0.91; 95% CI 0.30 to 2.83). LAG was associated with a longer operative time (MD 49.28 minutes; 95% CI 30.88 to 67.69), lower intraoperative blood loss (MD -51.24 milliliters; 95% CI -81.41 to -21.06), shorter length of stay (MD -0.83 days; 95% CI -1.60 to -0.06), and higher incidence of pancreatic fistula (RR 2.44; 95% CI 1.08 to 5.50). Postoperatively, LAG was also superior to OG in reducing bleeding rates (RR 0.44; 95% CI 0.22 to 0.86) and time to first flatus (MD -0.27 days; 95% CI -0.47 to -0.07), with comparable results in anastomotic leakage, wound healing issues, major complications, time to ambulation, or time to first liquid intake. In the long-term analyses at 3 and 5 years, there were no significant differences between LAG and OG in terms of overall survival (RR 0.99; 95% CI 0.96 to 1.03) or relapse-free survival (RR 0.99; 95% CI 0.94 to 1.04).

CONCLUSION

This meta-analysis of RCTs suggests that LAG may be an effective and safe alternative to OG for treating AGC; albeit, it may be associated with an increased risk for pancreatic fistula.

Myosteatosis predicts postoperative complications and long-term survival in robotic gastrectomy for gastric cancer: A propensity score analysis

BACKGROUND

Robotic gastrectomy is increasingly utilized for gastric cancer, but high morbidity remains a concern. Myosteatosis or low skeletal muscle density reflecting fatty infiltration, associates with complications after other cancer surgeries but has not been evaluated for robotic gastrectomy.

METHODS

This retrospective study analysed 381 patients undergoing robotic gastrectomy for gastric cancer from September 2019 to October 2022. Myosteatosis was quantified on preoperative computed tomography (CT) images at lumbar 3 (L3). Propensity score matching addressed potential confounding between myosteatosis and non-myosteatosis groups. Outcomes were postoperative complications, 30 days mortality, 30 days readmissions and survival.

RESULTS

Myosteatosis was present in 33.6% of patients. Myosteatosis associated with increased overall (47.7% vs. 26.5%, p < 0.001) and severe complications (12.4% vs. 4.9%, p < 0.001). After matching, myosteatosis remained associated with increased overall complications, major complications, intensive care unit (ICU) transfer and readmission (all p < 0.05). Myosteatosis independently predicted overall [odds ratio (OR) = 2.86, 95% confidence interval (CI): 1.57-5.20, p = 0.001] and severe complications (OR = 4.81, 95% CI: 1.51-15.27, p = 0.008). Myosteatosis also associated with reduced overall (85.0% vs. 93.2%, p = 0.015) and disease-free survival (80.3% vs. 88.4%, p=0.029). On multivariate analysis, myosteatosis independently predicted poorer survival [hazard ratio (HR) = 2.83, 95% CI: 1.32-6.08, p=0.012] and disease-free survival (HR = 1.83, 95% CI: 1.01-3.30, p=0.032).

CONCLUSION

Preoperative CT-defined myosteatosis independently predicts increased postoperative complications and reduced long-term survival after robotic gastrectomy for gastric cancer. Assessing myosteatosis on staging CT could optimize preoperative risk stratification.

Five-Year Survival Outcomes of Laparoscopy-Assisted vs Open Distal Gastrectomy for Advanced Gastric Cancer: The JLSSG0901 Randomized Clinical Trial

Importance

Evidence of implementation of laparoscopic gastrectomy for locally advanced gastric cancer is currently insufficient, as the primary end point in previous prospective studies was evaluated at a median follow-up time of 3 years. More robust evidence is necessary to verify noninferiority of laparoscopic gastrectomy.

Objective

To compare 5-year survival outcomes between laparoscopy-assisted distal gastrectomy (LADG) and open distal gastrectomy (ODG) with D2 lymph node dissection for locally advanced gastric cancer.

Design, Setting, and Participants

This was a multicenter, open-label, noninferiority, prospective randomized clinical trial. Between November 26, 2009, and July 29, 2016, eligible patients with histologically proven gastric carcinoma from 37 institutes in Japan were enrolled. Two interim analyses and final analysis were performed in October 2014, May 2018, and November 2021, respectively.

Interventions

Patients were randomly assigned (1:1) to either the ODG or LADG group. The procedures were performed exclusively by qualified surgeons.

Main Outcomes and Measures

The primary end point was 5-year relapse-free survival, and the noninferiority margin for the hazard ratio (HR) was set at 1.31. The secondary end points were 5-year overall survival and safety.

Results

A total of 502 patients were included in the full-analysis set: 254 (50.6%) in the ODG group and 248 (49.4%) in the LADG group. Patients in the ODG group had a median (IQR) age of 67 (33-80) years and included 168 males (66.1%). Patients in the LADG group had a median (IQR) age of 64 (34-80) years and included 169 males (68.1%). No significant differences were observed in severe postoperative complications between the 2 groups in the safety analysis (ODG, 4.7% [11 of 233] vs LADG, 3.5% [8 of 227]; P = .64). The median (IQR) follow-up for all patients after randomization was 67.9 (60.3-92.0) months. The 5-year relapse-free survival was 73.9% (95% CI, 68.7%-79.5%) and 75.7% (95% CI, 70.5%-81.2%) for the ODG and LADG groups, respectively, and the HR was 0.96 (90% CI, 0.72-1.26; noninferiority 1-sided P = .03). Further, no significant difference was observed in overall survival time between the 2 groups, and the HR was 0.83 (95% CI, 0.57-1.21; P = .34). The pattern of recurrence was similar between the 2 groups.

Conclusions and Relevance

Results of this study show that on the basis of 5-year follow-up data, LADG with D2 lymph node dissection for locally advanced gastric cancer, when performed by qualified surgeons, was proved noninferior to ODG. This laparoscopic approach could become a standard treatment for locally advanced gastric cancer.

Trial Registration

UMIN Clinical Trial Registry: UMIN000003420.

Short-and long-term outcomes of laparoscopic versus open gastrectomy in patients with gastric cancer: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Laparoscopic gastrectomy (LG) for gastric cancer has rapidly developed and become more popular in recent decades. Additional high-quality randomized controlled trial (RCT) studies comparing LG versus open gastrectomy (OG) for gastric cancer (GC) have been published in recent years. An updated systematic review is warranted. The aim of our meta-analysis was to comprehensively evaluate the short- and long-term outcomes of LG versus OG for GC.

MATERIALS AND METHODS

The PubMed, Embase, Web of Science, and Cochrane Center Register of Controlled Trials databases were comprehensively searched to identify RCTs comparing LG versus OG for GC published between January 1994 and December 7, 2021. This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Cochrane Collaboration and the Quality of Reporting of Meta-analyses (QUORUM) guidelines. All RCTs comparing the short- and long-term outcomes of LG with those of OG were included. A random effects model was adopted with significant heterogeneity (I² > 50%), while a fixed effects model was employed in all other cases (I² ≤ 50%).

RESULTS

A total of 26 RCTs with 8301 patients were included in this meta-analysis. The results indicated that the intraoperative complication rate was comparable between the LG group and the OG group (OR=1.14, 95% CI [0.76, 1.70], I²=0%, p=0.53). The LG group had fewer postoperative complications than the OG group (OR=0.65, 95% CI [0.57, 0.74], I²=26%, p<0.00001). However, the severe postoperative complication rate and perioperative mortality were comparable between the two groups (OR=0.83, 95% CI [0.67, 1.04], I²=10%, p=0.10; OR=1.11, 95% CI [0.59, 2.09], I²=0%, p=0.74, respectively). The number of lymph nodes retrieved by the LG group was less than that of the OG group (MD=-1.51, 95% CI [-2.29, -0.74], I²=0%, p<0.0001). The proximal resection margin distance in the LG group was shorter than that in the OG group (MD=-0.34, 95% CI [-0.57, -0.12], I²=23%, p=0.003), but the distal resection margin distance in the two groups was comparable (MD=-0.21, 95% CI [-0.47, 0.04], I²=0%, p=0.10). The time to first ambulation was shorter in the LG group than in the OG group (MD=-0.14, 95% CI [-.26, -0.01], I²=40%, p=0.03). The time to first flatus was also shorter in the LG group than in the OG group (MD=-0.15, 95% CI [-0.23, -0.07], I²=4%, p=0.0001). However, the first time on a liquid diet was comparable between the two groups (MD=-0.30, 95% CI [-0.64, 0.04], I²=88%, p=0.09). Furthermore, the postoperative length of stay was shorter in the LG group than in the OG group (MD=-1.26, 95% CI [-1.99, -0.53], I²=90%, p=0.0007). The 5-year overall survival (OS) was comparable between the two groups (HR=0.97, 95% CI [0.80, 1.17], I²=0%, p=0.73), and the 5-year disease-free survival (DFS) was also similar between the LG group and OG group (HR=1.08, 95% CI [0.77, 1.52], I²=0%, p=0.64).

CONCLUSION

LG is a technically safe and feasible alternative to OG with the advantages of a fewer postoperative complication rate, faster recovery of gastrointestinal function, and greater cosmetic benefit for patients with GC. Meanwhile, LG has comparable long-term outcomes to OG for GC.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The application of enhanced recovery after surgery in minimally invasive gastrectomy for gastric cancer: a meta-analysis of randomized controlled trials

OBJECTIVE

We aimed to investigate the efficacy and safety of enhanced recovery after surgery (ERAS) for patients with gastric cancer undergoing minimally invasive surgery (MIS).

METHODS

We searched the PubMed, Cochrane Library, Web of Science, Embase, CNKI, VIP, WanFang, and CBM for relevant RCTs from the database inception until December 2021, for studies that compared the ERAS and traditional care (TC) in MIS for gastric cancer.

RESULTS

A total of 25 RCTs comprising 2809 patients were included in this study. When compared with the traditional care TC group, the ERAS group had a shorter postoperative hospital stay [MD = -1.88,95%CI (-2.22, -1.55), P < 0.00001] and an earlier time at first postoperative flatus [MD = -18.12,95%CI (-21.45,-14.80), P < 0.00001] along with lower medical costs [SMD = -0.64, 95% CI (-0.85, -0.43), P < 0.00001] and an overall reduction in postoperative complication rates [RR = 0.55, 95% CI (0.44, 0.69), P < 0.00001]. However, the difference in the readmission rates    was not significant.

CONCLUSIONS

ERAS can shorten the postoperative hospital stay, hasten the first postoperative flatus and reduce medical costs and overall postoperative complication rate without increasing readmission rates. Therefore, the ERAS protocol is preferable for gastric cancer patients undergoing MIS.

The Comparison of Short- and Long-Term Outcomes for Laparoscopic Versus Open Gastrectomy for Patients With Advanced Gastric Cancer: A Meta-Analysis of Randomized Controlled Trials

Objectives

The effect of laparoscopic gastrectomy (LG) for the treatment of advanced gastric cancer (AGC) is still controversial. The aim of this meta-analysis was to contrast the short- and long-term outcomes of laparoscopic versus conventional open gastrectomy (OG) for patients with AGC.

Methods

Databases including PubMed, Embase, Scopus, and Cochrane Library were systematically searched until December 2021 for randomized controlled trial-enrolled patients undergoing LG or OG for the treatment of AGC. Short-term outcomes were overall postoperative complications, anastomotic leakage, number of retrieved lymph node, surgical time, blood loss, length of hospital stay, and short-term mortality. Long-term outcomes were survival rates at 1, 3, and 5 years.

Results

A total of 12 trials involving 4,101 patients (2,059 in LG group, 2,042 in OG group) were included. No effect on overall postoperative complications (OR 0.84, 95% CI 0.67 to 1.05, p = 0.12, I² = 34%) and anastomotic leakage (OR 1.26, 95% CI 0.82 to 1.95, p = 0.30, I² = 0%) was found. Compared with the open approach, patients receiving LG had fewer blood loss (MD -54.38, 95% CI -78.09 to -30.67, p < 0.00001, I² = 90%) and shorter length of hospital stay (MD -1.25, 95% CI -2.08 to -0.42, p = 0.003, I² = 86%). However, the LG was associated with a lower number of retrieved lymph nodes (MD -1.02, 95% CI -1.77 to -0.27, p = 0.008, I² = 0%) and longer surgical time (MD 40.87, 95% CI 20.37 to 54.44, p < 0.00001, I² = 94%). Furthermore, there were no differences between LG and OG groups in short-term mortality and survival rate at 1, 3, and 5 years.

Conclusions

LG offers improved short-term outcomes including shorter hospital stays and fewer blood loss, with comparable postoperative complications, short-term mortality, and survival rate at 1, 3, and 5 years when compared to the open approach. Our results support the implementation of LG in patients with AGC.

Systematic Review Registration

PROSPERO (CRD 42021297141).

Low EBI3 Expression Promotes the Malignant Degree of Gastric Cancer

Objective. To explore expression changes and clinical significance of EBI3 in gastric cancer. Methods. Expression of EBI3 in gastric cancer (GC) cell lines, GC tissues, and corresponding adjacent tissues were detected by qRT-PCR, Western blot, or immunohistochemistry. The relationship between the EBI3 expression and clinicopathological features of GC patients was analyzed. Expression of EBI3 in BGC-823 was overexpressed or downregulated, then, the changes of proliferation, migration, invasion, and tumorigenicity of BGC-823 were observed by MTT, scratch test, Transwell test, and tumorigenesis assay model. Results. EBI3 was lowly expressed in GC tissues. EBI3 expression in BGC823 was highest than other cell lines. EBI3 expression was significantly associated with TNM stage. GC patients with low expression of EBI3 had a rather poor prognosis than the GC patients with high expression of EBI3. Low EBI3 expression was an independent risk predictor of the prognosis of GC patients. After EBI3 was overexpressed, the viability, migration, invasion, and tumorigenicity abilities of BGC-823 were significantly reduced. Opposite effect was observed after EBI3 expression was downregulated. Conclusion. EBI3 low expression is closely related to the malignant degree of GC and may be a predictive indicator of the prognosis of GC and potential therapeutic targets.

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

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

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

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

Laparoscopic Compared with Open D2 Gastrectomy on Perioperative and Long-Term, Stage-Stratified Oncological Outcomes for Gastric Cancer: A Propensity Score-Matched Analysis of the IMIGASTRIC Database

Simple Summary

Gastric resection with D2 lymphadenectomy is considered the gold standard for the treatment of both advanced and early gastric cancer with lymph node metastasis. The performance of D2 lymphadenectomy is technically challenging and represents a key factor in improving patients’ survival. For these reasons, the execution of gastrectomy with D2 lymphadenectomy using the traditional open surgical technique still represents the most widespread approach and, based on current international guidelines, the indication for laparoscopic surgery is limited to early gastric cancer that does not require a D2 lymphadenectomy. The present study aimed to investigate the use of laparoscopic versus open surgical approaches in performing gastrectomy with D2 lymphadenectomy for cancer in terms of intraoperative and postoperative outcomes and long-term survival. The study was conducted using the data collected in the International study group on Minimally Invasive surgery for Gastric Cancer (IMIGASTRIC) international database.

Abstract

Background: The laparoscopic approach in gastric cancer surgery is being increasingly adopted worldwide. However, studies focusing specifically on laparoscopic gastrectomy with D2 lymphadenectomy are still lacking in the literature. This retrospective study aimed to compare the short-term and long-term outcomes of laparoscopic versus open gastrectomy with D2 lymphadenectomy for gastric cancer. Methods: The protocol-based, international IMIGASTRIC (International study group on Minimally Invasive surgery for Gastric Cancer) registry was queried to retrieve data on patients undergoing laparoscopic or open gastrectomy with D2 lymphadenectomy for gastric cancer with curative intent from January 2000 to December 2014. Eleven predefined, demographical, clinical, and pathological variables were used to conduct a 1:1 propensity score matching (PSM) analysis to investigate intraoperative and recovery outcomes, complications, pathological findings, and survival data between the two groups. Predictive factors of long-term survival were also assessed. Results: A total of 3033 patients from 14 participating institutions were selected from the IMIGASTRIC database. After 1:1 PSM, a total of 1248 patients, 624 in the laparoscopic group and 624 in the open group, were matched and included in the final analysis. The total operative time (median 180 versus 240 min, p < 0.0001) and the length of the postoperative hospital stay (median 10 versus 14.8 days, p < 0.0001) were longer in the open group than in the laparoscopic group. The conversion to open rate was 1.9%. The proportion of patients with in-hospital complications was higher in the open group (21.3% versus 15.1%, p = 0.004). The median number of harvested lymph nodes was higher in the laparoscopic approach (median 32 versus 28, p < 0.0001), and the proportion of positive resection margins was higher (p = 0.021) in the open group (5.9%) than in the laparoscopic group (3.2%). There was no significant difference between the groups in five-year overall survival rates (77.4% laparoscopic versus 75.2% open, p = 0.229). Conclusion: The adoption of the laparoscopic approach for gastric resection with D2 lymphadenectomy shortened the length of hospital stay and reduced postoperative complications with respect to the open approach. The five-year overall survival rate after laparoscopy was comparable to that for patients who underwent open D2 resection. The types of surgical approaches are not independent predictive factors for five-year overall survival.

Comparative Study of Thoracoscopic and Modified Small Incision Repair for Congenital Diaphragmatic Eventration in Children

Background: Thoracoscopic diaphragmatic plication has gained popularity in the treatment of congenital diaphragmatic eventration (CDE), but the therapeutic effect and prognosis have rarely been compared with nonendoscopic surgery. Materials and Methods: The medical records of 77 children who had received treatment for CDE in our institution from September 2006 to January 2019 were retrospectively analyzed. According to the repair approach, the children were divided into a thoracoscopic plication group and a modified small incision plication group. The perioperative characteristics and follow-up details after diaphragm plication were compared between the two groups. Results: Among 77 children with CDE, 44 cases were in the thoracoscopic plication group and 33 cases were in the modified small incision plication group. All the cases of CDE were unilateral, with 13 cases on the left side and 64 cases on the right side. There were no differences in the preoperative characteristics between the two groups. The modified small incision plication group had a higher bleeding volume (P = .000) and a greater proportion of patients needing chest drainage (P = .000), whereas the differences in the total and postoperative hospital stays (P = .088, P = .247, respectively) did not significantly differ between the two groups. There were no differences in postoperative improvement in the location of the diaphragm between the two groups or between the right and left lesions (P = .438, P = .677, respectively). The total follow-up time was 2-11 years. No recurrence was reported during this period in either of the groups, but the incidence of postoperative thoracic deformities was higher in the modified small incision plication group (P = .013). Conclusions: Compared with the modified small incision plication, thoracoscopic plication has the advantages of smaller blood loss, a low percentage of intrathoracic drainage tube usage, and no occurrence of thoracic deformities.

Oncological outcomes of laparoscopic versus open gastrectomy after neoadjuvant chemotherapy for locally advanced gastric cancer: a retrospective multicenter study

BACKGROUND

The oncological outcomes of laparoscopic gastrectomy (LG) and open gastrectomy (OG) following neoadjuvant chemotherapy have been investigated in a few studies. Our purpose was to evaluate the oncological outcomes of LG and OG after neoadjuvant chemotherapy in patients with locally advanced gastric cancer (GC) and to determine the advantages, preferences, and ease of use of the two techniques after chemotherapy.

METHODS

We conducted a retrospective chart review of all patients who underwent either OG (n = 43) or LG (n = 41). The neoadjuvant treatment regimen consisted of capecitabine plus oxaliplatin for three cycles, which was then repeated 6 to 12 weeks after the operation for four cycles.

RESULTS

The hospital stay time and intraoperative blood loss in the LG group were significantly lower than those in the OG group. The mortality rate and the 3-year survival rate for patients in the LG group were comparable to those of patients in the OG group (4.6% vs. 9.7% and 68.3% vs. 58.1%, respectively). Similar trends were observed regarding the 3-year recurrence rate and metastasis. The mean survival time was 52.9 months (95% confidence interval [CI], 44.2-61.6) in the OG group compared with 43.3 (95% CI, 36.6-49.8) in the LG group. Likewise, the mean disease-free survival was 56.1 months (95% CI, 46.36-65.8) in the LG group compared with 50.9 months (95% CI, 44.6-57.2) in the OG group.

CONCLUSION

LG is a feasible and safe alternative to OG for patients with locally advanced GC receiving neoadjuvant chemotherapy.

Perioperative outcomes and survival in elderly patients aged ≥ 75 years undergoing gastrectomy for gastric cancer: an 18-year retrospective analysis in a single Western centre

PURPOSE

Surgical resection for elderly patients with gastric cancer is controversial. This study aims to evaluate the preoperative features and postoperative short- and long-term outcomes of elderly patients following surgical resection for gastric adenocarcinoma.

METHODS

Between January 2000 and May 2018, a total of 177 consecutive patients underwent curative gastrectomy for gastric adenocarcinoma was retrospectively reviewed. Propensity score matching (PSM) analysis was used to balance confounding covariates between the elderly and non-elderly groups. Clinicopathological characteristics, intraoperative characteristics, postoperative complications and long-term survival outcomes including overall survival (OS) and Disease Specific Survival (DSS) were compared and analysed using the Kaplan-Meier log-rank test. Multivariate cox proportional hazards regression analysis of clinicopathological factors influencing survival were evaluated.

RESULTS

There were 50 patients in the elderly group (age ≥ 75 years) and 127 patients in the non-elderly group (age < 75 years). Elderly patients had more comorbid conditions (p < 0.001), lower albumin concentration (p = 0.034), lower haemoglobin levels (p = 0.001), and poorer renal function (p = 0.043). TNM stage was similar between both groups (p = 0.174); however, lymphatic invasion (p = 0.006) and lymph node metastasis (p = 0.029) were higher in the elderly group. Elderly patients were much less likely to receive any chemo- (p < 0.001) or radiotherapy treatment (p = 0.007) with surgical treatment. After PSM, there were 50 patients in each group. Elderly patients were more likely to develop complications (Clavien Dindo ≥ 2: 50% vs. 26%, p = 0.003). The most common postoperative complications were pneumonia (12% vs. 6%, p = 0.498) and delirium (10% vs. 0%, p = 0.066). Elderly patients had a longer median length of hospital stay (median (IQR): 15.6(9.5) vs. 11.3 (9.9), p = 0.030). There were no differences in 30-day mortality (elderly vs. non-elderly: 1% vs. 1%, p = 0.988). Before and after PSM, age remains an independent predictor of postoperative complications. Before PSM, the estimated mean OS for the elderly and non-elderly patients were 108 months (95%CI, 72.5-143.5) and 143 months (95%CI, 123.0-163.8), respectively (p = 0.264). After PSM, the estimated mean OS for the elderly and non-elderly patients were 108 months (95%CI, 72.5-143.5) and 140 months (95%CI, 112.1-168.2), respectively, (p = 0.360). Before PSM, the estimated mean DSS for the elderly and non-elderly patients were 94 months (95%CI, 61.9-127.5) and 121 months (95%CI, 100.9-141.0), respectively (p = 0.405). After PSM, the estimated mean DSS for the elderly and non-elderly patients were 94 months (95%CI, 61.9-127.5) and 115 months (95%CI, 87.3-143.3), respectively (p = 0.721). Age was not an independent predictor of mortality following gastrectomy for gastric cancer in both PSM matched and unmatched cohort.

CONCLUSION

Chronological age alone is not a contraindication to curative resection of gastric adenocarcinoma in elderly patients with acceptable risk. Whilst age affects perioperative complications, the incidence of postoperative mortality and overall survival were not significantly different between elderly and non-elderly gastric cancer patients treated with curative surgery. Gastrectomy with D2 lymphadenectomy can also be performed in carefully selected elderly patients by surgeons with expertise in gastric resection along with appropriate perioperative management.