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

Enhanced recovery after surgery-based nursing in older patients with postoperative intestinal obstruction after gastric cancer surgery: A retrospective study

BACKGROUND

Gastric cancer-related morbidity and mortality rates are high in China. Patients who have undergone gastric cancer surgery should receive six cycles of chemotherapy according to their condition. During this period, intestinal obstruction is likely to occur. Electrolyte balance disorders, peritonitis, intestinal necrosis, and even hypovolemic shock and septic shock can seriously affect the physical and mental recovery of patients and threaten their health and quality of life (QoL).

AIM

To quantitatively explore the effects of enhanced recovery after surgery (ERAS)–based nursing on anxiety, depression, and QoL of elderly patients with postoperative intestinal obstruction after gastric cancer.

METHODS

The clinical data of 129 older patients with intestinal obstruction after gastric cancer surgery who were treated and cared for in our hospital between January 2019 and December 2021 were examined retrospectively. Nine patients dropped out because of transfer, relocation, or death. According to the order of admissions, the patients were categorized into either a comparison group or an observation group according to the random number table, with 60 cases in each group.

RESULTS

After nursing care, the observation group required significantly less time to eat for the first time, recover bowel sounds, pass gas, and defecate than the comparison group (P < 0.05). No significant difference was noted in nutrition-related indicators between the two groups before care. Before care, the Symptom Check List-90 scores between the two groups were comparable, whereas anxiety, depression, paranoia, fear, hostility, obsession, somatization, interpersonal sensitivity, and psychotic scores were significantly lower in the observation group after care (P < 0.05). The QoL scores between the two groups before care did not differ significantly. After care, the physical, social, physiological, and emotional function scores; mental health score; vitality score; and general health score were significantly higher in the observation group, whereas the somatic pain score was significantly lower in the observation group (P < 0.05).

CONCLUSION

ERAS-based nursing combined with conventional nursing interventions can effectively improve patient’s QoL, negative emotions, and nutritional status; accelerate the time to first ventilation; and promote intestinal function recovery in elderly patients with postoperative intestinal obstruction after gastric cancer surgery.

What defines the "value" of robotic surgery for patients with gastrointestinal cancers? Perspectives from a U.S. Cancer Center

The use of robotic surgery has experienced rapid growth across diverse medical conditions, with a notable emphasis on gastrointestinal cancers. The advanced technologies incorporated into robotic surgery platforms have played a pivotal role in enabling the safe performance of complex procedures, including gastrectomy and pancreatectomy, through a minimally invasive approach. However, there exists a noteworthy gap in high-level evidence demonstrating that robotic surgery for gastric and pancreatic cancers has substantial benefits compared to traditional open or laparoscopic methods. The primary impediment hindering the broader implementation of robotic surgery is its cost. The escalating healthcare expenses in the United States have prompted healthcare providers and payors to explore patient-centered, value-based healthcare models and reimbursement systems that embrace cost-effectiveness. Thus, it is important to determine what defines the value of robotic surgery. It must either maintain or enhance oncological quality and improve complication rates compared to open procedures. Moreover, its true value should be apparent in patients' expedited recovery and improved quality of life. Another essential aspect of robotic surgery's value lies in minimizing or even eliminating opioid use, even after major operations, offering considerable benefits to the broader public health landscape. A quicker return to oncological therapy has the potential to improve overall oncological outcomes, while a speedier return to work not only alleviates individual financial distress but also positively impacts societal productivity. In this article, we comprehensively review and summarize the current landscape of health economics and value-based care, with a focus on robotic surgery for gastrointestinal cancers.

Assessment of diagnostic value of indocyanine green for lymph node metastasis in laparoscopic subtotal gastrectomy with D2 lymphadenectomy for gastric cancer: a prospective single-center study

PURPOSE

Evaluation of diagnostic value for lymph node (LN) metastasis and LN identification using indocyanine green (ICG) fluorescence in laparoscopic subtotal gastrectomy for gastric cancer.

METHODS

A prospective study on 79 patients who underwent radical subtotal gastrectomy with the use of ICG-guided LN dissection. The sensitivity and specificity of the ICG fluorescence lymphography method in detecting metastatic LNs were evaluated.

RESULTS

A total of 79 patients underwent surgery. The number of LNs was retrieved: 2992 LNs, of which 2392 were fluorescent (79.9%) and 600 were nonfluorescent (20.1%). The average number of LNs dissected was 37.7 ± 11.8 LNs, and the average number of fluorescent LNs was 30.3 ± 11.1; the LN metastasis rates in the total LNs and in the ICG group were 6.79% and 7.34%, respectively. The median number of retrieved LNs in patients with LN metastases (37 [IQR, 33-47]) was higher than in patients without LN metastases (36 [IQR, 27-43]), (P = .348). The median number of fluorescent LNs was significantly higher in patients with LN metastases (32 [IQR, 26-44]) than in those without LN metastases (26 [IQR, 21-36]; P < .001). The sensitivity of ICG in metastasis detection was 75.86% (22 of 29 patients), with a false-negative rate of 24.14% (7 of 29 patients). For the identification of metastatic LNs, the sensitivity of ICG was 90.7%, with the specificity of 20.8%. The negative predictive value of nonfluorescent LNs was 97%.

CONCLUSION

ICG fluorescence lymphography-guided lymphadenectomy can clearly visualize the lymphatic system and the LNs alongside the tumor. The high sensitivity in detecting metastatic LNs and the high negative predictive value of a nonfluorescent LNs suggest that this is an effective method for clinically radical gastrectomy for gastric cancer.

Minimally Invasive Techniques for Gastrectomy

Gastric adenocarcinoma is an aggressive disease and a leading cause of cancer-related deaths worldwide. Surgery entails either a total or a subtotal gastrectomy. These complex operations carry elevated morbidity and mortality with an extended recovery time. As such, research has focused on minimizing these risks and enhancing postoperative care. Robotic surgery is a newer platform that helps overcome some of the limitations of laparoscopy through three-dimensional vision, better mobility, and improved surgeon dexterity. As such, many surgeons have embraced robotics and advocated for their implementation in cancer surgery. This review will discuss the technical considerations of performing a robotic gastrectomy.

Robotic gastrectomy is more beneficial for advanced than early-stage gastric cancer: a comparison with laparoscopic gastrectomy using propensity score matching

BACKGROUND

Gastric cancer is the fifth most prevalent malignancy globally and the fourth major contributor to cancer-related mortality. The comparative effectiveness of robotic gastrectomy (RG) versus laparoscopic gastrectomy (LG) at different stages of gastric cancer is unclear regarding surgical and survival outcomes. We compared surgical and survival outcomes between RG and LG in early-stage (cStage I) and advanced (cStage II/III) gastric cancers to elucidate the difference in the efficacy of RG across various stages of gastric cancer.

METHODS

We identified 299 patients (LG, 170; RG, 129) with cStage II/III disease and 569 (LG, 455; RG, 114) with cStage I disease who underwent either LG or RG. Following propensity score matching for RG and LG, 118 pairs were selected for cStage II/II and 113 pairs for cStage I. Surgical and survival outcomes of LG and RG were separately compared for cStage II/III and cStage I.

RESULTS

In cStage II/III, RG showed significantly fewer intra-abdominal complications of Clavien-Dindo (C.D.) Grade ≥ III in the RG group than in the LG group (LG = 8.5 vs. RG = 1.7%, P = 0.033). Multivariate analysis identified LG as an independent risk factor for intra-abdominal complications of C.D. Grade ≥ III (OR 5.69, 95% CI 1.17-27.70, P = 0.031). However, in cStage I, no difference in surgical outcomes between LG and RG was observed. No differences were observed in survival outcomes between LG and RG in both cStage I or cStage II/III.

CONCLUSIONS

The real benefit of RG was demonstrated in surgical outcomes, especially for advanced-stage gastric cancer.

Standardized procedure for preventing late intestinal complications following minimally invasive total gastrectomy for gastric cancer: a single-center retrospective cohort study

BACKGROUND

Although minimally invasive total gastrectomy for gastric cancer is commonly performed, reports regarding late complications are limited. We have made several improvements each time we experienced severe late complications since 2009. This study aimed to evaluate the clinical efficacy of these improved procedures in preventing late complications.

METHODS

Between January 2009 and December 2019, 302 patients who underwent laparoscopic or robotic total gastrectomy for gastric cancer were enrolled. The patients were divided into two groups: Period-I (2009-2013, before established standardization of procedure, 166 patients) and Period-II (2014-2019, after established standardization of procedure, 136 patients). The standardized procedure comprised four major steps, including closure of the mesentery defects and diaphragm crus, circumferential fixation of the anastomotic site into the diaphragm, and linearization around the anastomotic site of esophagojejunostomy. The incidence of late complications was retrospectively compared between the two groups.

RESULTS

Late overall complications that occurred over 30 days after surgery were observed in 19 (6.3%) patients. In all, 14 of 24 (58.3%) patients admitted due to late intestinal complications eventually required reoperation for treatment. The most frequent complication was nonstenotic outlet obstruction of the distal jejunal limb. The incidence of late overall complications was significantly lower in Period-II than in Period-I (2.9 vs 9.0%, p = 0.030). Intestinal complications were reduced considerably in Period-II. The 3-year cumulative incidence rate of late overall complications was significantly lower in Period-II than in Period-I (0.03 vs 0.10, p = 0.035). Period-I as the only independent risk factor for the development of late intestinal complications.

CONCLUSION

Late complications after laparoscopic total gastrectomy sometimes occurred, and more than half of the patients with intestinal complications required reoperation. Our standardized procedure was associated with a lower risk of late intestinal complications after minimally invasive total gastrectomy followed by intracorporeal esophagojejunostomy using linear staplers in a cohort of patients with gastric cancer.

Morbidity and Mortality After Laparoscopy-Assisted Distal Gastrectomy and Totally Laparoscopic Distal Gastrectomy to Treat Gastric Cancer: An Interim Report: A Phase III Multicenter, Prospective, Randomized Trial (The KLASS-07 Trial)

PURPOSE

We conducted a randomized prospective trial (KLASS-07 trial) to compare laparoscopy-assisted distal gastrectomy (LADG) and totally laparoscopic distal gastrectomy (TLDG) for gastric cancer. In this interim report, we describe short-term results in terms of morbidity and mortality.

METHODS AND METHODS

The sample size was 442 participants. At the time of the interim analysis, 314 patients were enrolled and randomized. After excluding patients who did not undergo planned surgeries, we performed a modified per-protocol analysis of 151 and 145 patients in the LADG and TLDG groups, respectively.

RESULTS

The baseline characteristics, including comorbidity status, did not differ between the LADG and TLDG groups. Blood loss was somewhat higher in the LADG group, but statistical significance was not attained (76.76±72.63 vs. 62.91±65.68 mL; P=0.087). Neither the required transfusion level nor the operation or reconstruction time differed between the 2 groups. The mini-laparotomy incision in the LADG group was significantly longer than the extended umbilical incision required for specimen removal in the TLDG group (4.79±0.82 vs. 3.89±0.83 cm; P<0.001). There were no between-group differences in the time to solid food intake, hospital stay, pain score, or complications within 30 days postoperatively. No mortality was observed in either group.

CONCLUSIONS

Short-term morbidity and mortality rates did not differ between the LADG and TLDG groups. The KLASS-07 trial is currently underway.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03393182.

Textbook Outcome of Delta-Shaped Anastomosis in Minimally Invasive Distal Gastrectomy for Gastric Cancer in 4,505 Consecutive Patients

PURPOSE

Textbook outcome is a comprehensive measure used to assess surgical quality and is increasingly being recognized as a valuable evaluation tool. Delta-shaped anastomosis (DA), an intracorporeal gastroduodenostomy, is a viable option for minimally invasive distal gastrectomy in patients with gastric cancer. This study aims to evaluate the surgical outcomes and calculate the textbook outcome of DA.

MATERIALS AND METHODS

In this retrospective study, the records of 4,902 patients who underwent minimally invasive distal gastrectomy for DA between 2009 and 2020 were reviewed. The data were categorized into three phases to analyze the trends over time. Surgical outcomes, including the operation time, length of post-operative hospital stay, and complication rates, were assessed, and the textbook outcome was calculated.

RESULTS

Among 4,505 patients, the textbook outcome is achieved in 3,736 (82.9%). Post-operative complications affect the textbook outcome the most significantly (91.9%). The highest textbook outcome is achieved in phase 2 (85.0%), which surpasses the rates of in phase 1 (81.7%) and phase 3 (82.3%). The post-operative complication rate within 30 d after surgery is 8.7%, and the rate of major complications exceeding the Clavien-Dindo classification grade 3 is 2.4%.

CONCLUSIONS

Based on the outcomes of a large dataset, DA can be considered safe and feasible for gastric cancer.

Comparison of totally robotic and totally laparoscopic gastrectomy for gastric cancer: a propensity score matching analysis

BACKGROUND

With the improvements in laparoscopic or robotic surgical techniques and instruments, a growing number of surgeons have attempted to complete all digestive tract reconstruction intracorporeally; these procedures include totally robotic gastrectomy (TRG) and totally laparoscopic gastrectomy (TLG). This study aimed to evaluate the safety and feasibility of the TRG and compare the short-term outcomes of the TRG and TLG in patients with gastric cancer.

METHODS

Between January 2018 and June 2023, 346 consecutive patients who underwent TRG or TLG at a high-volume academic gastric cancer specialty center were included. 1:1 propensity score matching (PSM) was performed to reduce confounding bias. The surgical outcomes, postoperative morbidity, and surgical burden were compared in PSM cohort.

RESULTS

After PSM, a well-balanced cohort of 194 patients (97 in each group) was included in the analysis. The total operation time of the TRG group was significantly longer than that of the TLG group (244.9 vs. 213.0 min, P < 0.001). There was no significant difference in the effective operation time between the 2 groups (217.8 vs. 207.2 min, P = 0.059). The digestive tract reconstruction time of the TRG group was significantly shorter than that of the TLG group (39.4 vs. 46.7 min, P < 0.001). The mean blood loss in the TRG group was less than that in the TLG group (101.1 vs. 126.8 mL, P = 0.014). The TRG group had more retrieved lymph nodes in the suprapancreatic area than that in the TLG group (16.6 vs 14.2, P = 0.002). The TRG group had a lower surgery task load index (38.9 vs. 43.1, P < 0.001) than the TLG group. No significant difference was found in terms of postoperative morbidity between the 2 groups (14.4% vs. 16.5%, P = 0.691).

CONCLUSION

This study demonstrated that TRG is a safe and feasible procedure, and is preferable to TLG in terms of invasion and ergonomics. The TRG may maximize the superiority of robotic surgical systems and embodies the theory of minimally invasive surgery.

Acute kidney injury after radical gastrectomy: incidence, risk factors, and impact on prognosis

Background

Acute kidney injury (AKI) is a serious adverse event often overlooked following major abdominal surgery. While radical gastrectomy stands as the primary curative method for treating gastric cancer patients, little information exists regarding AKI post-surgery. Hence, this study aimed to ascertain the incidence rate, risk factors, and consequences of AKI among patients undergoing radical gastrectomy.

Methods

This was a population-based, retrospective cohort study. The incidence of AKI was calculated. Multivariate logistic regression was used to identify independent predictors of AKI. Survival curves were plotted by using the Kaplan-Meier method and differences in survival rates between groups were analyzed by using the log-rank test.

Results

Of the 2,875 patients enrolled in this study, 61 (2.1%) developed postoperative AKI, with AKI Network 1, 2, and 3 in 50 (82.0%), 6 (9.8%), and 5 (8.2%), respectively. Of these, 49 patients had fully recovered by discharge. Risk factors for AKI after radical gastrectomy were preoperative hypertension (odds ratio [OR], 1.877; 95% CI, 1.064-3.311; P = 0.030), intraoperative blood loss (OR, 1.001; 95% CI, 1.000-1.002; P = 0.023), operation time (OR, 1.303; 95% CI, 1.030-1.649; P = 0.027), and postoperative intensive care unit (ICU) admission (OR, 4.303; 95% CI, 2.301-8.045; P < 0.001). The probability of postoperative complications, mortality during hospitalization, and length of stay in patients with AKI after surgery were significantly higher than those in patients without AKI. There was no statistical difference in overall survival (OS) rates between patients with AKI and without AKI (1-year, 3-year, 5-year overall survival rates of patients with AKI and without AKI were 93.3% vs 92.0%, 70.9% vs 73.6%, and 57.1% vs 67.1%, respectively, P = 0.137).

Conclusions

AKI following radical gastrectomy is relatively rare and typically self-limited. AKI is linked with preoperative hypertension, intraoperative blood loss, operation time, and postoperative ICU admission. While AKI raises the likelihood of postoperative complications, it does not affect OS.

Increased postoperative complications after laparoscopic gastrectomy in patients with preserved ratio impaired spirometry

BACKGROUND

Preserved ratio impaired spirometry (PRISm), defined as decreased forced expiratory volume in the first second in the setting of normal ratio, is associated with an increased risk of respiratory disease and systemic comorbidities. Unlike severe obstructive pulmonary disease, little is known about the impact of PRISm on short-term outcomes in patients undergoing laparoscopic gastrectomy (LG) and its association with small airway dysfunction (SAD).

METHODS

This study enrolled 830 patients who underwent preoperative spirometry and LG between January 2021 and August 2023. Of these, 228 patients were excluded. Participants were categorized into 3 groups based on their baseline lung function, and postoperative outcomes were subsequently analyzed. Potential associations between postoperative outcomes and various clinical variables were examined using univariate and multivariate analyses.

RESULTS

PRISm was identified in 16.6% of the patients, whereas SAD was present in 20.4%. The incidence of postoperative pulmonary complications (PPCs) was notably higher in the SAD group (20.3% vs 9.8%, P = .002) and the PRISm group (28.0% vs 9.8%, P < .001) than the normal group. Among the 3 groups, pneumonia was the most frequently observed PPC. Multivariate analysis revealed that both SAD (odds ratio [OR], 2.34; 95% CI, 1.30-4.22; P = .005) and PRISm (OR, 3.26; 95% CI, 1.80-5.90; P < .001) independently constituted significant risk factors associated with the occurrence of PPCs. Univariate analysis showed that female was a possible risk factor for PPCs in PRISm group.

CONCLUSION

Our study showed that PRISm and SAD were associated with the increased PPCs in patients undergoing LG for gastric cancer.

Robotic gastrectomy was reliable option for overweight patients with gastric cancer: a propensity score matching study

BACKGROUND

The role of minimally invasive surgery using robotics versus laparoscopy in resectable gastric cancer patients with a high body mass index (BMI) remains controversial.

METHODS

A total of 482 gastric adenocarcinoma patients with BMI ≥ 25 kg/m2 who underwent minimally invasive radical gastrectomy between August 2016 and December 2019 were retrospectively analyzed, including 109 cases in the robotic gastrectomy (RG) group and 321 cases in the laparoscopic gastrectomy (LG) group. Propensity score matching (PSM) with a 1:1 ratio was performed, and the perioperative outcomes, lymph node dissection, and 3-year overall survival (OS) and disease-free survival (DFS) rates were compared.

RESULTS

After PSM, 109 patients were included in each of the RG and LG groups, with balanced baseline characteristics. Compared with the LG group, the RG group had similar intraoperative estimated blood loss [median (IQR) 30 (20-50) vs. 35 (30-59) mL, median difference (95%CI) - 5 (- 10 to 0)], postoperative complications [13.8% vs. 18.3%, OR (95%CI) 0.71 (0.342 to 1.473)], postoperative recovery, total harvested lymph nodes [(34.25 ± 13.43 vs. 35.44 ± 14.12, mean difference (95%CI) - 1.19 (- 4.871 to 2.485)] and textbook outcomes [(81.7% vs. 76.1%, OR (95%CI) 1.39 (0.724 to 2.684)]. Among pathological stage II-III patients receiving chemotherapy, the initiation of adjuvant chemotherapy in the RG group was similar to that in the LG group [median (IQR): 28 (25.5-32.5) vs. 32 (27-38.5) days, median difference (95%CI) - 3 (- 6 to 0)]. The 3-year OS (RG vs. LG: 80.7% vs. 81.7%, HR = 1.048, 95%CI 0.591 to 1.857) and DFS (78% vs. 76.1%, HR = 0.996, 95%CI 0.584 to 1.698) were comparable between the two groups.

CONCLUSION

RG conferred comparable lymph node dissection, postoperative recovery, and oncologic outcomes in a selected cohort of patients with BMI ≥ 25 kg/m2.

Comparison of SOX and CAPOX in patients with advanced gastric cancer after laparoscopic D2 gastrectomy: A randomized controlled trial

BACKGROUND

Optimal adjuvant chemotherapy after laparoscopic surgery in gastric cancer (GC) patients is still undefined. We aimed to evaluate the efficacy of S-1 plus oxaliplatin (SOX) and capecitabine plus oxaliplatin (CAPOX) in patients with GC after laparoscopic gastrectomy.

METHODS

A non-inferiority randomized controlled clinical trial was performed in China. Patients with advanced GC who underwent laparoscopic D2 gastrectomy were randomly assigned to receive SOX and CAPOX regimens.

RESULTS

In total, 191 patients were screened between May 2018 and June 2019, and 140 (73.3%) were included in the modified intent-to-treat analysis (mITT), of whom 69 and 71 were assigned to the SOX and CAPOX groups, respectively. The SOX group had similar 3-year overall survival (OS) and disease-free survival to the CAPOX group. Subgroup analysis revealed significantly better OS in the SOX group for male patients ([HR] = 0.395; 95% [CI], 0.153-1.019; p = 0.045), age >60 (HR = 0.219; 95% [CI], 0.064-0.753; p = 0.016), tumors in the gastric antrum (HR = 0.273; 95% [CI], 0.076-0.981; p = 0.047), and moderately differentiated tumors (HR = 0.338; 95% [CI], 0.110-1.041; p = 0.041). There were no significant differences observed in terms of adverse events and recurrence patterns between the two groups.

CONCLUSION

Adjuvant SOX was non-inferior to CAPOX treatments for patients with GC who underwent curative laparoscopic D2 gastrectomy. For male patients, aged >60 years, tumors in the gastric antrum, and moderately differentiated tumors, adjuvant SOX may achieve an improvement compared with CAPOX.

Feasibility of laparoscopic/robot-assisted surgery for Borrmann type 4 gastric cancer: a comparison study with conventional open surgery

BACKGROUND

Laparoscopic surgery for early gastric cancer is regarded as a standard of care because of robust evidences obtained by several phase-III trials. Furthermore, the efficacy of laparoscopic radical surgery for advanced gastric cancer has been also reported. Meanwhile, the feasibility of laparoscopic surgery for Bormann type 4 gastric cancer, special type with unfavorable prognosis, remains unclear since excluded from eligibility of these trials.

METHODS

This study included 100 patients with type 4 gastric cancer who underwent laparoscopic/robot-assisted (minimally invasive surgery (MIS) group; n = 32) or open (Open group; n = 68) curative surgery between 2008 and 2021. After propensity score matching, 30 patients in each group were extracted for analysis. Clinical data, including surgical and midterm survival outcomes, were retrospectively compared between the two groups.

RESULTS

Incidences of postoperative complication (≥ Clavien-Dindo grade III) were recorded in 23.3% in the MIS group and 13.3% in the Open group, but no statistical significance was demonstrated (P = 0.50). The 3-year overall survival rate in the MIS group was better than that in the Open group (80.2% vs. 53.5%, log-rank, P = 0.03). The trend of recurrence site was similar. Multivariate analysis showed that adjuvant chemotherapy was an independent favorable prognostic factor (hazard ratio, 0.33, 95% confidence interval 0.11-0.93) for overall survival. MIS was indicated as a favorable prognostic factor (hazard ratio, 0.39, 95% confidence interval 0.39-1.07), but without statistical difference.

CONCLUSION

While multidisciplinary treatment is mainstay of treatment because of the poor prognosis of this disease, minimally invasive surgery may play an important role in treatment if appropriate patient selection is done. Further analyses with larger sample size are necessary to reach a final conclusion regarding oncological efficacy.

Advances in Gastric Cancer Surgical Management

The goal of a gastric cancer operation is a microscopically negative resection margin and D2 lymphadenectomy. Minimally invasive techniques (laparoscopic and robotic) have been proven to be equivalent for oncologic care, yet with faster recovery. Endoscopic mucosal resection can be used for T1a N0 tumor resection. Better understanding of hereditary gastric cancer and molecular subtypes has led to specialized recommendations for MSI-high tumors and patients with pathogenic CDH1 mutations. In the future, surgical management will support minimally invasive approaches and personalized cancer care based on subtype.

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.

Robotic versus laparoscopic distal gastrectomy for resectable gastric cancer: a randomized phase 2 trial

Robotic surgery may be an alternative to laparoscopic surgery for gastric cancer (GC). However, randomized controlled trials (RCTs) reporting the differences in survival between these two approaches are currently lacking. From September 2017 to January 2020, 300 patients with cT1-4a and N0/+ were enrolled and randomized to either the robotic (RDG) or laparoscopic distal gastrectomy (LDG) group (NCT03313700). The primary endpoint was 3-year disease-free survival (DFS); secondary endpoints reported here are the 3-year overall survival (OS) and recurrence patterns. The remaining secondary outcomes include intraoperative outcomes, postoperative recovery, quality of lymphadenectomy, and cost differences, which have previously been reported. There were 283 patients in the modified intention-to-treat analysis (RDG group: n = 141; LDG group: n = 142). The trial has met pre-specified endpoints. The 3-year DFS rates were 85.8% and 73.2% in the RDG and LDG groups, respectively (p = 0.011). Multivariable Cox regression model including age, tumor size, sex, ECOG PS, lymphovascular invasion, histology, pT stage, and pN stage showed that RDG was associated with better 3-year DFS (HR: 0.541; 95% CI: 0.314-0.932). The RDG also improved the 3-year cumulative recurrence rate (RDG vs. LDG: 12.1% vs. 21.1%; HR: 0.546, 95% CI: 0.302-0.990). Compared to LDG, RDG demonstrated non-inferiority in 3-year DFS rate.

Long-term oncological outcomes of 3D versus 2D laparoscopic gastrectomy for gastric cancer: a randomized clinical trial

BACKGROUND

Laparoscopy-assisted gastrectomy (LG) is rapidly gaining popularity owing to its minimal invasiveness. Previous studies have found that compared with two-dimensional (2D)-LG, three-dimensional (3D)-LG showed better short-term outcomes. However, the long-term oncological outcomes in patients with locally resectable gastric cancer (GC) remain controversial.

METHODS

In this noninferiority, open-label, randomized clinical trial, a total of 438 eligible GC participants were randomly assigned in a 1:1 ratio to either 3D-LG or 2D-LG from January 2015 to April 2016. The primary endpoint was operating time, while the secondary endpoints included 5-year overall survival (OS), disease-free survival (DFS), and recurrence pattern.

RESULTS

Data from 401 participants were included in the per-protocol analysis, with 204 patients in the 3D group and 197 patients in the 2D group. The 5-year OS and DFS rates were comparable between the 3D and 2D groups (5-year OS: 70.6% vs. 71.1%, Log-rank P = 0.743; 5-year DFS: 68.1% vs. 69.0%, log-rank P = 0.712). No significant differences were observed between the 3D and 2D groups in the 5-year recurrence rate (28.9% vs. 28.9%, P = 0.958) or recurrence time (mean time, 22.6 vs. 20.5 months, P = 0.412). Further stratified analysis based on the type of gastrectomy, postoperative pathological staging, and preoperative BMI showed that the 5-year OS, DFS, and recurrence rates of the 3D group in each subgroup were similar to those of the 2D group (all P > 0.05).

CONCLUSIONS

For patients with locally resectable GC, 3D-LG performed by experienced surgeons in high-volume professional institutions can achieve long-term oncological outcomes comparable to those of 2D-LG.

REGISTRATION NUMBER

NCT02327481 ( http://clinicaltrials.gov ).

Comparison of Short-term and Three-year Oncological Outcomes Between Robotic and Laparoscopic Gastrectomy for Gastric Cancer: A Large Multicenter Cohort Study

OBJECTIVE

To compare the short-term and long-term outcomes between robotic gastrectomy (RG) and laparoscopic gastrectomy (LG) for gastric cancer.

BACKGROUND

The clinical outcomes of RG over LG have not yet been effectively demonstrated.

METHODS

This retrospective cohort study included 3599 patients with gastric cancer who underwent radical gastrectomy at eight high-volume hospitals in China from January 2015 to June 2019. Propensity score matching was performed between patients who received RG and LG. The primary end point was 3-year disease-free survival (DFS).

RESULTS

After 1:1 propensity score matching, 1034 pairs of patients were enrolled in a balanced cohort for further analysis. The 3-year DFS in the RG and LG was 83.7% and 83.1% ( P =0.745), respectively, and the 3-year overall survival was 85.2% and 84.4%, respectively ( P =0.647). During 3 years of follow-up, 154 patients in the RG and LG groups relapsed (cumulative incidence of recurrence: 15.0% vs 15.0%, P =0.988). There was no significant difference in the recurrence sites between the 2 groups (all P >0.05). Sensitivity analysis showed that RG had comparable 3-year DFS (77.4% vs 76.7%, P =0.745) and overall survival (79.7% vs 78.4%, P =0.577) to LG in patients with advanced (pathologic T2-4a) disease, and the recurrence pattern within 3 years was also similar between the 2 groups (all P >0.05). RG had less intraoperative blood loss, lower conversion rate, and shorter hospital stays than LG (all P >0.05).

CONCLUSIONS

For resectable gastric cancer, including advanced cases, RG is a safe approach with comparable 3-year oncological outcomes to LG when performed by experienced surgeons.

Short-Term Outcomes Analysis Comparing Open, Laparoscopic, Laparoscopic-Assisted, and Robotic Distal Gastrectomy for Locally Advanced Gastric Cancer: A Randomized Trials Network Analysis

BACKGROUND

Minimally invasive surgery for the treatment of locally advanced gastric cancer (AGC) is debated. The aim of this study was to execute a comprehensive assessment of principal surgical treatments for resectable distal gastric cancer.

METHODS

Systematic review and randomized controlled trials (RCTs) network meta-analysis. Open (Op-DG), laparoscopic-assisted (LapAs-DG), totally laparoscopic (Lap-DG), and robotic distal gastrectomy (Rob-DG) were compared. Pooled effect-size measures were the risk ratio (RR), the weighted mean difference (WMD), and the 95% credible intervals (CrIs).

RESULTS

Ten RCTs (3823 patients) were included. Overall, 1012 (26.5%) underwent Lap-DG, 902 (23.6%) LapAs-DG, 1768 (46.2%) Op-DG, and 141 (3.7%) Rob-DG. Anastomotic leak, severe complications (Clavien-Dindo > 3), and in-hospital mortality were comparable. No differences were observed for reoperation rate, pulmonary complications, postoperative bleeding requiring transfusion, surgical-site infection, cardiovascular complications, number of harvested lymph nodes, and tumor-free resection margins. Compared to Op-DG, Lap-DG and LapAs-DG showed a significantly reduced intraoperative blood loss with a trend toward shorter time to first flatus and reduced length of stay.

CONCLUSIONS

LapAs-DG, Lap-DG, and Rob-DG performed in referral centers by dedicated surgeons have comparable short-term outcomes to Op-DG for locally AGC.

Surgical options and survival prognosis in geriatric patients beyond average lifespan with locally advanced gastric cancer: a propensity score-matched analysis

BACKGROUND

The appropriateness of laparoscopic gastrectomy (LG) for super-geriatric patients with locally advanced gastric cancer (LAGC) is inconclusive, and the prognostic factors are also yet to be elucidated. Herein, we aimed to investigate the surgical and oncological outcomes of LG versus open gastrectomy (OG) for geriatric patients with LAGC who have outlived the average lifespan of the Chinese population (≥ 78 years).

METHODS

This is a monocentric, retrospective, comparative study. A 1:1 propensity score matching (PSM) was performed to minimize selection bias and ensure well-balanced characteristics. The primary endpoint of interest was 3-year overall survival, while secondary endpoints included procedure-related variables, postoperative recovery indices, and complications. Univariate and multivariate Cox proportional hazards regression analyses were performed to identify unfavorable prognostic factors.

RESULTS

Of 196 eligible individuals, 107 underwent LG and 89 underwent OG, with a median age (interquartile range [IQR]) of 82 [79, 84] years. PSM yielded 61 matched pairs, with comparable demographic and tumor characteristics. The LG group had a significantly lower overall complication rate than the OG group (31.1% vs. 49.2%, P = 0.042), as well as shorter duration of postoperative hospital stay [12 (11, 13) vs. 13 (12, 15.5) d, P < 0. 001], less intraoperative blood loss [95 (75, 150) vs. 230 (195, 290) mL, P < 0.001], but a longer operative time [228 (210, 255.5) vs. 196 (180, 219.5) min, P < 0.001]. The times to first aerofluxus, defecation, liquid diet, and half-liquid diet were comparable. Kaplan-Meier analyses revealed no significant difference in 3-year overall survival between the groups, either in the entire cohort or in subgroups with different TNM staging. Moreover, Age-adjusted Charlson Comorbidity Index scores of > 6 [hazard ratio (HR) 4.003; P = 0.021] and pathologic TNM stage III (HR 3.816, P = 0.023) were independent unfavorable prognostic factors for long-term survival.

CONCLUSIONS

LG performed by experienced surgeons offers the benefits of comparable or better surgical and oncological safety profiles than OG for super-geriatric patients with LAGC.

Minimally invasive versus open gastrectomy for gastric cancer. A pooled analysis of two European randomized controlled trials

INTRODUCTION

Minimally invasive techniques have shown better short term and similar oncological outcomes compared to open techniques in the treatment of gastric cancer in Asian countries. It remains unknown whether these outcomes can be extrapolated to Western countries, where patients often present with advanced gastric cancer.

MATERIALS AND METHODS

A pooled analysis of two Western randomized controlled trials (STOMACH and LOGICA trial) comparing minimally invasive gastrectomy (MIG) and open gastrectomy (OG) in advanced gastric cancer was performed. Postoperative recovery (complications, mortality, hospital stay), oncological outcomes (lymph node yield, radical resection rate, 1-year survival), and quality of life was assessed.

RESULTS

Three hundred and twenty-one patients were included from both trials. Of these, 162 patients (50.5%) were allocated to MIG and 159 patients (49.5%) to OG. A significant difference was seen in blood loss in favor of MIG (150 vs. 260 mL, p < 0.001), whereas duration of surgery was in favor of OG (180 vs. 228.5 min, p = 0.005). Postoperative recovery, oncological outcomes and quality of life were similar between both groups.

CONCLUSION

MIG showed no difference to OG regarding postoperative recovery, oncological outcomes or quality of life, and is therefore a safe alternative to OG in patients with advanced gastric cancer.

[Technique and Study Results of Laparoscopic Gastrectomy for Gastric Cancer]

The aim of this paper was to describe the technique of laparoscopic gastrectomy for gastric carcinoma and to present a review of current international studies on this topic.The first part describes and documents a standard laparoscopic gastrectomy for carcinoma. In the second part, after an EMBASE and PubMed search, a total of 123 quality-relevant randomised (RCT) and non-randomised (non-RCT) studies on laparoscopic gastrectomy are identified from a primary total of 3,042 hits by systematic narrowing. The study results are then summarised conclusively for the target criteria of feasibility, outcome, oncological quality, morbidity and mortality.Both, laparoscopic subtotal resection for distal gastric carcinomas and laparoscopic gastrectomy can now be performed safely and with few complications. In a recent literature review of a total of 15 RCTs with 5,576 patients (laparoscopic 2,793 vs. open 2,756), there were no significant differences in terms of feasibility, intraoperative outcome and oncological quality (R0 and lymph node harvest). Surgical morbidity and mortality were comparable. Patients after laparoscopic surgery showed a significantly faster early postoperative recovery with a lower overall morbidity. In contrast, the operating time was significantly longer - by a mean of 45 min - compared to the open technique. The advantages of the laparoscopic technique were equally evident in studies on early gastric carcinoma and advanced carcinomas (>T2).Laparoscopic gastrectomy for gastric carcinoma is safe to perform and shows better early postoperative recovery. Complication rates, morbidity and mortality as well as long-term oncological results are comparable with open surgery.

Real-world Nationwide Outcomes of Minimally Invasive Surgery for Advanced Gastric Cancer Based on Korean Gastric Cancer Association-Led Survey

PURPOSE

The study aimed to investigate real-world surgical outcomes of minimally invasive surgery (MIS) for advanced gastric cancer using Korean Gastric Cancer Association (KGCA)-led nationwide data.

MATERIALS AND METHODS

A nationwide survey of patients who underwent surgical treatment for gastric cancer in 2019 was conducted by the KGCA. A total of 14,076 patients from 68 institutions underwent surgery, and 4,953 patients diagnosed with pathological stages IB-III gastric cancer were included. Among them, 1,689 patients who underwent MIS (MIS group) and 1,689 who underwent the open approach (open group) were matched using propensity score in a 1:1 ratio. Surgical outcomes were compared, and multivariate analysis was performed to identify the independent factors for overall morbidity.

RESULTS

The MIS group had a lower proportion of D2 lymphadenectomy, total omentectomy, and combined resection. However, the number of harvested lymph nodes was higher in the MIS group. Better surgical outcomes, including less blood loss and shorter hospital stay, were observed in the MIS group, and the overall morbidity rate was significantly lower in the MIS group (17.5% vs. 21.9%, P=0.001). The mortality rates did not differ significantly between the 2 groups. In the multivariate analysis, the minimally invasive approach was a significant protective factor against overall morbidity (odds ratio, 0.799; P=0.006).

CONCLUSIONS

Based on the Korean nationwide data, MIS for stage IB-III gastric cancer had better short-term outcomes than the open approach, including lower rates of wound complications, intra-abdominal abscesses, and cardiac problems.

Comparison of Short-Term Outcomes After Robotic Versus Laparoscopic Radical Gastrectomy for Advanced Gastric Cancer in Elderly Individuals: A Propensity Score-Matching Study

BACKGROUND

Robotic gastrectomy (RG) has been widely used to treat gastric cancer. However, whether the short-term outcomes of robotic gastrectomy are superior to those of laparoscopic gastrectomy (LG) for elderly patients with advanced gastric cancer has not been reported.

METHODS

The study enrolled of 594 elderly patients with advanced gastric cancer who underwent robotic or laparoscopic radical gastrectomy. The RG cohort was matched 1:3 with the LG cohort using propensity score-matching (PSM).

RESULTS

After PSM, 121 patients were included in the robot group and 363 patients in the laparoscopic group. Excluding the docking and undocking times, the operation time of the two groups was similar (P = 0.617). The RG group had less intraoperative blood loss than the LG group (P < 0.001). The time to ambulation and first liquid food intake was significantly shorter in the RG group than in the LG group (P < 0.05). The incidence of postoperative complications did not differ significantly between the two groups (P = 0.14). Significantly more lymph nodes were dissected in the RG group than in the LG group (P = 0.001). Postoperative adjuvant chemotherapy was started earlier in the RG group than in the LG group (P = 0.02).

CONCLUSIONS

For elderly patients with advanced gastric cancer, RG is safe and feasible. Compared with LG, RG is associated with less intraoperative blood loss; a faster postoperative recovery time, allowing a greater number of lymph nodes to be dissected; and earlier adjuvant chemotherapy.

Robot-assisted versus laparoscopic-assisted gastrectomy among malnourished patients with gastric cancer based on textbook outcome

BACKGROUND

Textbook outcome (TO) has been widely employed as a comprehensive indicator to assess the short-term prognosis of patients with cancer. Preoperative malnutrition is a potential risk factor for adverse surgical outcomes in patients with gastric cancer (GC). This study aimed to compare the TO between robotic-assisted gastrectomy (RAG) and laparoscopic-assisted gastrectomy (LAG) in malnourished patients with GC.

METHODS

According to the diagnostic consensus of malnutrition proposed by Global Leadership Initiative on Malnutrition (GLIM) and Nutrition Risk Index (NRI), 895 malnourished patients with GC who underwent RAG (n = 115) or LAG (n = 780) at a tertiary referral hospital between January 2016 and May 2021 were included in the propensity score matching (PSM, 1:2) analysis.

RESULTS

After PSM, no significant differences in clinicopathological characteristics were observed between the RAG (n = 97) and LAG (n = 194) groups. The RAG group had significantly higher operative time and lymph nodes harvested, as well as significantly lower blood loss and hospital stay time compared to the LAG group. More patients in the RAG achieved TO. Logistic regression analysis revealed that RAG was an independent protective factor for achieving TO. There were more adjuvant chemotherapy (AC) cycles in the RAG group than in the LAG group. After one year of surgery, a higher percentage of patients (36.7% vs. 22.8%; P < 0.05) in the RAG group recovered from malnutrition compared to the LAG group.

CONCLUSIONS

For malnourished patients with GC, RAG performed by experienced surgeons can achieved a higher rate of TO than those of LAG, which directly contributed to better AC compliance and a faster restoration of nutritional status.

Evaluation of factors influencing long-term and textbook outcomes in laparoscopic gastrectomy

BACKGROUND

Textbook outcome (TO) in gastric cancer surgery is a multidimensional measure of surgical quality. However, its impact on long-term survival after laparoscopic gastrectomy (LG) is unclear. This study aims to evaluate TO in LG, assess its hospital-level relevance, and examine its association with long-term survival.

METHODS

In this retrospective cohort study, we analyzed 2278 consecutive gastric cancer patients who underwent laparoscopic gastrectomy (LG) from January 2004 to December 2017. We determined TO achievement rates, compared preoperative and intraoperative variables between TO and non-TO groups, identified independent predictors of TO, and assessed long-term oncologic outcomes using Kaplan-Meier analysis and Cox regression.

RESULTS

A total of 1540 LG patients were analyzed, with 994 (64.5%) achieving TO. The least frequently achieved metric was 'hospital stays ≤21 days' (83.4%), followed by 'lymph nodes retrieved ≥15' (84.0%). Factors independently associated with reduced TO likelihood included age ≥65 years, BMI ≥25, ASA III, conversion to open surgery, operation time ≥260 min, and estimated blood loss ≥150 ml. Furthermore, TO was independently linked to improved 5-year overall survival (OS) and disease-free survival (DFS) (HR 0.519 [0.443-0.609] and HR 0.517 [0.443-0.604], respectively).

CONCLUSION

Implementing the TO concept in LG provides a benchmark for achieving improved prognoses and empowers surgeons to devise strategies for enhancing surgical care quality.

Cost Analysis for Robotic and Open Gastrectomy

Objective

To determine the magnitude of the perioperative costs associated with robotic gastrectomy (RG).

Background

A robotic surgery platform has a high implementation cost and requires maintenance costs; however, whether the overall cost of RG, including all perioperative costs, is higher than conventional open gastrectomy (OG) remains unknown.

Methods

Patients who underwent a major gastrectomy during February 2018 through December 2021 were retrospectively identified. We calculated the perioperative costs of RG and OG and compared them overall as well as in different phases, including intraoperative costs and 30-day postsurgery inpatient and outpatient costs. We investigated factors potentially associated with high cost and estimated the likelihood of RG to reduce overall cost under a Bayesian framework. All cost data were converted to ratios to the average cost of all operations performed at our center in year FY2021.

Results

We identified 119 patients who underwent gastrectomy. The incidence of postoperative complications (Clavien-Dindo >IIIa; RG, 10% vs OG, 13%) did not significantly differ between approaches. The median length of stay was 3 days shorter for RG versus OG (4 vs 7 days, P < 0.001). Intraoperative cost ratios were significantly higher for RG (RG, 2.6 vs OG, 1.7; P < 0.001). However, postoperative hospitalization cost ratios were significantly lower for RG (RG, 2.8 vs OG, 3.9; P < 0.001). Total perioperative cost ratios were similar between groups (RG, 6.1 vs OG, 6.4; P = 0.534). The multiple Bayesian generalized linear analysis showed RG had 76.5% posterior probability of overall perioperative cost reduction (adjusted risk ratio of 0.95; 95% credible interval, 0.85-1.07).

Conclusions

Despite increased intraoperative costs, total perioperative costs in the RG group were similar to those in the OG group because of reduced postoperative hospitalization costs.

Efficacy and safety of camrelizumab combined with oxaliplatin and S-1 as neoadjuvant treatment in locally advanced gastric or gastroesophageal junction cancer: A phase II, single-arm study

PURPOSE

In the present study, we aimed to evaluate the efficacy and safety of camrelizumab combined with oxaliplatin plus S-1 in patients with resectable gastric or gastroesophageal junction cancer.

METHODS

In this single-arm, phase II clinical trial, patients with locally advanced gastric or gastroesophageal junction adenocarcinoma were enrolled to receive three cycles of neoadjuvant camrelizumab and oxaliplatin plus S-1 every 3 weeks, followed by surgical resection and adjuvant therapy with the same regimen. The primary endpoint was pathological complete response (pCR) (ypT0) rate and secondary endpoints were R0 resection rate, total pCR (tpCR, ypT0N0) rate, major pathological response (MPR) rate, downstaging, objective response rate (ORR), disease control rate (DCR), event-free survival (EFS), overall survival (OS), and safety.

RESULTS

Between September, 2020 and January, 2022, a total of 29 patients were enrolled in the present study, all of whom completed neoadjuvant therapy and underwent surgery. Three (10.3%) (95% CI: 2.2-27.4) patients achieved pCR as well as tpCR, 20 (69.0%) patients had MPR and 28 (96.6%) patients achieved R0 resection. Treatment-emergent adverse events (AEs) of any grade were observed in 24 (82.8%) patients. Immune-related adverse events of any grade were reported in 13 (44.8%) patients, whereas no grade 3 or higher adverse events occurred.

CONCLUSION

The neoadjuvant therapy with camrelizumab in combination with oxaliplatin and S-1 showed a modest pCR rate, and favorable MPR rate and safety profile in patients with gastric or gastroesophageal junction cancer.

An international Delphi consensus for surgical quality assessment of lymphadenectomy and anastomosis in minimally invasive total gastrectomy for gastric cancer

BACKGROUND

Minimally invasive total gastrectomy (MITG) is a mainstay for curative treatment of patients with gastric cancer. To define and standardize optimal surgical techniques and further improve clinical outcomes through the enhanced MITG surgical quality, there must be consensus on the key technical steps of lymphadenectomy and anastomosis creation, which is currently lacking. This study aimed to determine an expert consensus from an international panel regarding the technical aspects of the performance of MITG for oncological indications using the Delphi method.

METHODS

A 100-point scoping survey was created based on the deconstruction of MITG into its key technical steps through local and international expert opinion and literature evidence. An international expert panel comprising upper gastrointestinal and general surgeons participated in multiple rounds of a Delphi consensus. The panelists voted on the issues concerning importance, difficulty, or agreement using an online questionnaire. A priori consensus standard was set at > 80% for agreement to a statement. Internal consistency and reliability were evaluated using Cronbach's α.

RESULTS

Thirty expert upper gastrointestinal and general surgeons participated in three online Delphi rounds, generating a final consensus of 41 statements regarding MITG for gastric cancer. The consensus was gained from 22, 12, and 7 questions from Delphi rounds 1, 2, and 3, which were rephrased into the 41 statetments respectively. For lymphadenectomy and aspects of anastomosis creation, Cronbach's α for round 1 was 0.896 and 0.886, and for round 2 was 0.848 and 0.779, regarding difficulty or importance.

CONCLUSIONS

The Delphi consensus defined 41 steps as crucial for performing a high-quality MITG for oncological indications based on the standards of an international panel. The results of this consensus provide a platform for creating and validating surgical quality assessment tools designed to improve clinical outcomes and standardize surgical quality in MITG.

Long-term oncological outcomes of robotic versus laparoscopic gastrectomy for gastric cancer: multicentre cohort study

BACKGROUND

The aim of this multicentre cohort study was to compare the long-term oncological outcomes of robotic gastrectomy (RG) and laparoscopic gastrectomy (LG) for patients with gastric cancer.

METHODS

Patients with gastric cancer who underwent radical gastrectomy by robotic or laparoscopic approaches from 1 March 2010 to 31 December 2018 at 10 high-volume centres in China were selected from institutional databases. Patients receiving RG were matched 1 : 1 by propensity score with patients undergoing LG. The primary outcome was 3-year disease-free survival. Secondary outcomes were overall survival and disease recurrence.

RESULTS

Some 2055 patients who underwent RG and 4309 patients who had LG were included. The propensity score-matched cohort comprised 2026 RGs and 2026 LGs. Median follow-up was 41 (i.q.r. 39-58) months for the RG group and 39 (38-56) months for the LG group. The 3-year disease-free survival rates were 80.8% in the RG group and 79.5% in the LG group (log rank P = 0.240; HR 0.92, 95% c.i. 0.80 to 1.06; P = 0.242). Three-year OS rates were 83.9 and 81.8% respectively (log rank P = 0.068; HR 0.87, 0.75 to 1.01; P = 0.068) and the cumulative incidence of recurrence over 3 years was 19.3% versus 20.8% (HR 0.95, 0.88 to 1.03; P = 0.219), with no difference between groups.

CONCLUSION

RG and LG in patients with gastric cancer are associated with comparable disease-free and overall survival.

Laparoscopic radical gastrectomy for gastric cancer: Long-term outcome in a teaching center

BACKGROUND

Laparoscopic gastrectomy for gastric cancer (GC) are increasing, yet the evidence of the relationship between the learning curve and long-term outcomes is limited.

AIMS

To analyze the relationship between the learning curve and survival in GC patients over a 10-year period.

METHODS

This retrospective cohort study studied 3674 patients who underwent laparoscopic radical gastrectomy for gastric cancer. Cusum and Cox regression analysis were used to assess the association between the surgeon's experience and the 3 years overall survival (OS).

RESULTS

The 3-year OS of all patients was 71.8 %. This increase of 3-year OS was associated with laparoscopic cases (r = 0.638, p = 0.047). Analysis of the CUSUM curve showed a significant change in the 3-year OS of 1400 cases. Further propensity score matching (PSM) of patients during and after the learning curve (<1400 and ≥ 1400 cases) showed a significant difference in the 3-year OS between the two groups (68.5 % vs. 72.3 %, p = 0.045). Cox regression analysis verified that in ≥1400 cases, prior laparoscopic surgery (p = 0.045), textbook outcome (TO) and the number of retrieved lymph nodes (LNs) were independent protective factors. The LN non-compliance rate was an independent risk factor. In contrast, the rate of TO and the median number of retrieved LNs were significantly higher after the learning curve (≥1400 cases). Furthermore, the rates of LN non-compliance were significantly lower (p < 0.05).

CONCLUSIONS

Increasing laparoscopic surgical experience is associated with surgical quality and prognostic improvement in patients with gastric cancer. But improvements in outcomes accrued slowly over a long period.

The benefits of R anastomotic technique for Billroth-II reconstruction with Braun anastomosis during totally laparoscopic distal gastrectomy: a propensity score matching analysis

BACKGROUND

Currently, there is no consensus on the most appropriate anastomotic site, anastomotic line, and direction for Billroth-II reconstruction with Braun anastomosis (B-II-B anastomosis) during totally laparoscopic distal gastrectomy (TLDG). Herein, the authors presented a novel anastomotic technique called R anastomosis for B-II-B anastomosis and compared it with the conventional B-II-B anastomosis technique to assess its feasibility, safety, and effectiveness.

METHODS

Between March 2019 and September 2022 in our centre, R anastomosis was performed on 123 patients undergoing TLDG for distal gastric cancer. A retrospective review of a prospectively collected database identified patients who underwent TLDG between January 2010 and September 2022. Patients who underwent R anastomosis were matched in a 1:1 ratio with patients who underwent conventional anastomosis using a propensity score based on age, sex, preoperative BMI, American Society of Anesthesiologists (ASA) score, and the history of abdominal surgery. Surgical and postoperative outcomes and clinicopathological data were analyzed for both groups.

RESULTS

During the study period, 246 patients were included, 123 in each group. No intraoperative complications associated with digestive tract reconstruction and no cases of conversion to open surgery were reported in either group; furthermore, no incidences of perioperative mortality were noted in either group. The R group had a significantly reduced anastomotic time compared to the control group (30 ± 4.1 vs. 36 ± 5.3 min, P < 0.001). Perioperatively, the incidences of Clavien-Dindo grade II or higher complications were 6.5% (8/123) and 12.2% (15/123) in the R and control groups with no significant difference between the two groups. Postoperative gastric emptying dysfunction was found in five and one patient in the control and R groups, respectively.

CONCLUSION

R anastomosis is a safe and effective technique for B-II-B anastomosis following TLDG. This novel technique enhances the convenience of performing anastomosis and can reduce postoperative gastric emptying dysfunction.

[Complicated gastric cancer and modern treatment approaches]

Among all patients with gastric cancer, 40% admit to the hospitals due to cancer-related complications. The most common complications of gastric cancer are bleeding (22-80%), malignant gastric outlet obstruction (26-60%), and perforation (less than 5%). The main treatment methods for gastric cancer complicated by bleeding are various forms of endoscopic hemostasis, transarterial embolization and external beam radiotherapy. Surgical treatment is possible in case of ineffective management. However, surgical algorithm is not standardized. Malignant gastric outlet stenosis requires decompression: endoscopic stenting, palliative gastroenterostomy. Surgical treatment is also possible (gastrectomy, proximal or distal resection of the stomach). The main problem for patients with complicated gastric cancer is the lack of standardized algorithms and abundance of potential surgical techniques. The aim of our review is to systematize available data on the treatment of complicated gastric cancer and to standardize existing methods.

Prince and princesses: The current status of robotic surgery in surgical oncology

Robotic surgery has experienced a dramatic increase in utilization across general surgery over the last two decades, including in surgical oncology. Although urologists and gynecologists were the first to show that this technology could be utilized in cancer surgery, the robot is now a powerful tool in the treatment of gastrointestinal, hepato-pancreatico-biliary, colorectal, endocrine, and soft tissue malignancies. While long-term outcomes are still pending, short-term outcomes have showed promise for this technologic advancement of cancer surgery.

The Chinese Society of Clinical Oncology (CSCO): Clinical guidelines for the diagnosis and treatment of gastric cancer, 2023

The 2023 update of the Chinese Society of Clinical Oncology (CSCO) Clinical Guidelines for Gastric Cancer focuses on standardizing cancer diagnosis and treatment in China, reflecting the latest advancements in evidence-based medicine, healthcare resource availability, and precision medicine. These updates address the differences in epidemiological characteristics, clinicopathological features, tumor biology, treatment patterns, and drug selections between Eastern and Western gastric cancer patients. Key revisions include a structured template for imaging diagnosis reports, updated standards for molecular marker testing in pathological diagnosis, and an elevated recommendation for neoadjuvant chemotherapy in stage III gastric cancer. For advanced metastatic gastric cancer, the guidelines introduce new recommendations for immunotherapy, anti-angiogenic therapy and targeted drugs, along with updated management strategies for human epidermal growth factor receptor 2 (HER2)-positive and deficient DNA mismatch repair (dMMR)/microsatellite instability-high (MSI-H) patients. Additionally, the guidelines offer detailed screening recommendations for hereditary gastric cancer and an appendix listing drug treatment regimens for various stages of gastric cancer. The 2023 CSCO Clinical Guidelines for Gastric Cancer updates are based on both Chinese and international clinical research and expert consensus to enhance their applicability and relevance in clinical practice, particularly in the heterogeneous healthcare landscape of China, while maintaining a commitment to scientific rigor, impartiality, and timely revisions.

Comparison of the effects of open and laparoscopic approach on body composition in gastrectomy for gastric cancer: A propensity score-matched study

Aim

To compare the effects of open (OG) and laparoscopic gastrectomy (LG) on body composition and muscle strength.

Methods

This study performed a propensity score matching analysis using cases from a large-scale, multicenter, phase III randomized controlled trial concerning oral nutritional supplements after gastrectomy and analyzed both the whole and matched cohorts. Measurements of body composition and hand grip strength (HGS) were performed at baseline (preoperatively) and at 1, 2, 3, 6, and 12 months after gastrectomy.

Results

Of 835 patients, 275 and 560 underwent OG and LG, respectively. Skeletal muscle mass (SMM) and HGS loss were significantly lesser in the LG group than in the OG group. The propensity score-matched analysis, including 120 pairs of patients, confirmed that the % SMM loss values at 1, 2, 3, 6, and 12 POM were -4.5%, -4.0%, -4.7%, -4.6%, and -5.8% in the OG group and -3.0%, -1.9%, -2.4%, -2.2%, and -2.7% in the LG group, respectively. The % SMM loss was significantly lesser in the LG group than in the OG group (repeated measures ANOVA p < 0.001). The HGS loss was non-significantly smaller in the LG group than in the OG group.

Conclusion

Skeletal muscle mass loss was significantly lesser in the LG group than in the OG group in both cohorts, indicating that LG may be more effective than OG for maintaining muscle mass.

Application of remimazolam transversus abdominis plane block in gastrointestinal tumor surgery

BACKGROUND

Transversus abdominis plane block (TAPB) is a block of the abdominal afferent nerve fibers between the internal oblique muscle and the transverse abdominal muscle achieved with local anesthetics. It can effectively block the conduction of the anterior nerve of the abdominal wall and exert a good analgesic effect. However, the effect of combining the block with remimazolam on anesthesia in patients undergoing gastrointestinal tumor surgery is still unclear.

AIM

To examine the effects of combining TAPB with remimazolam on the stress response and postoperative recovery of gastrointestinal tumor surgery patients.

METHODS

A retrospective analysis was conducted on the clinical data of 102 individuals diagnosed with gastrointestinal malignancies who underwent laparoscopic surgery under general anesthesia between April 2020 and June 2023. The patients were categorized into a control group (n = 51), receiving remimazolam for general anesthesia, and an observation group (n = 51), receiving TAPB combined with remimazolam for general anesthesia. A comparison was made between both groups in terms of hemodynamic parameters, stress markers, pain levels, recovery quality, analgesic effects, and adverse reactions during the perioperative period.

RESULTS

The observation group had significantly higher heart rates at time points 1 min after induction and upon leaving the operating room than the control group (P < 0.05). The mean arterial pressure at time point T1 in the observation group was significantly higher than that in the control group (P < 0.05). Five minutes after extubation, the levels of the hormones adrenaline and noradrenaline in the observation group were considerably lower than those in the control group (P < 0.05). At 12 h, 24 h, and 48 h following surgery, the visual analog scale scores of the observation group were considerably lower than those of the control group (P < 0.05). The observation group had shorter awakening and extubation times and lower Riker sedation-agitation scale scores than the control group (P < 0.05). The observation group exhibited considerably fewer effective pump presses, lower fentanyl dosages, and lower incidences of rescue analgesia within 24 h following surgery than the control group (P < 0.05).

CONCLUSION

The application effect of TAPB combined with remimazolam general anesthesia in anesthesia of patients undergoing gastrointestinal tumor surgery is good, which is helpful to promote faster recovery after operation.

Impact of robotic and open surgery on patient wound complications in gastric cancer surgery: A meta-analysis

This meta-analysis is intended to evaluate the effect of both robotic and open-cut operations on postoperative complications of stomach carcinoma. From the earliest date until June 2023, a full and systemic search has been carried out on four main databases with keywords extracted from 'Robot', 'Gastr' and 'Opene'. The ROBINS-I instrument has been applied to evaluate the risk of bias in nonrandomized controlled trials. In these 11 trials, a total of 16 095 patients had received surgical treatment for stomach cancer and all 11 trials were nonrandomized, controlled trials. Abdominal abscesses were reported in 5 trials, wound infections in 8 trials, haemorrhage in 7 trials, wound dehiscence in 2 trials and total postoperative complications in 4 trials. Meta-analyses revealed no statistically significantly different rates of postoperative abdominal abscesses among patients who had received robotic operations than in those who had received open surgical procedures (OR, 0.91; 95% CI, 0.25, 3.36; p = 0.89). The incidence of bleeding after surgery was not significantly different from that in both groups (OR, 1.37; 95% CI, 0.69, 2.75; p = 0.37). Similarly, there was no significant difference between the two groups (OR, 0.78; 95% CI, 0.52, 1.18; p = 0.24). No significant difference was found between the two groups (OR, 1. 28; 95% CI, 0.75, 2.21; p = 0.36). No significant difference was found between the two groups of patients who had received the robotic operation and those who had received the surgery after the operation (OR, 1.14; 95% CI, 0.78, 1.66; p = 0.49). Generally speaking, this meta-analysis suggests that the use of robotics does not result in a reduction in certain postsurgical complications, including wound infections and abdominal abscesses. Thus, the use of a microinvasive robot for stomach carcinoma operation might not be better than that performed on the surgical site after the operation. This is a valuable guide for the surgeon to select the operative method.

Laparoscopic gastrectomy for remnant gastric cancer: A single-center retrospective study

BACKGROUND

Laparoscopic gastrectomy (LG) for remnant gastric cancer (RGC) remains controversial because of its rarity and heterogeneity of clinical characteristics. Based on our experience, we posited that our established methodology in LG could be applied to the laparoscopic procedure for RGC surgery and introduced LG for RGC at our institution in 2004.

METHODS

This study enrolled 46 patients who underwent LG for RGC between January 2004 and December 2017. Data were obtained through a review of our prospectively maintained database. Laparoscopic total gastrectomy (LTG) was the standard surgical procedure for RGC. Laparoscopic subtotal gastrectomy (LsTG) was performed as an alternative procedure for patients with RGC located near the anastomotic site after primary gastrectomy. The technical and oncological feasibility and safety of LG for RGC were evaluated.

RESULTS

LTG for RGC was performed on 36 patients. LsTG for RGC was performed on 10 patients. All patients completed LG procedure and succeeded R0 resection. Complications of Clavien-Dindo classification grade ≥ IIIa occurred in 4 (8.7%) patients. The retrospective video reviews showed that the time for adhesiotomy around the suprapancreatic area and the lesser curvature of the remnant stomach was significantly shorter in the primary-benign group than in the primary-malignant group. With the median follow-up period of 40 months, the 3-year recurrence-free survival and 3-year overall survival rates were 72.3% and 80.2%, respectively.

CONCLUSION

LG for RGC represents a safe and feasible surgical option with favorable short-term and long-term outcomes in patients with RGC.

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

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

Robotic versus laparoscopic gastrectomy for adenocarcinoma in the US: a propensity score-matching analysis of 11,173 patients on oncological adequacy

INTRODUCTION

Surgery remains the cornerstone treatment for gastric cancer. Previous studies have reported better lymphadenectomy with minimally invasive approaches. There is a paucity of data comparing robotic and laparoscopic gastrectomy in the US. Herein, we examined whether oncological adequacy differs between laparoscopic and robotic approaches.

METHODS

The National Cancer Database was utilized to identify patients who underwent gastrectomy for adenocarcinoma between 2010 and 2019. A propensity score-matching analysis between robotic gastrectomy (RG) versus laparoscopic gastrectomy (LG) was performed. The primary outcomes were lymphadenectomy ≥ 16 nodes and surgical margins.

RESULTS

A total of 11,173 patients underwent minimally invasive surgery for gastric adenocarcinoma between 2010 and 2019. Of those 8320 underwent LG and 2853 RG. Comparing the unmatched cohorts, RG was associated with a higher rate of adequate lymphadenectomy (63.5% vs 57.1%, p < .0.0001), higher rate of negative margins (93.8% vs 91.9%, p < 0.001), lower rate of prolonged length of stay (26.0% vs 29.6%, p < .0.001), lower 90-day mortality (3.7% vs 5.0%, p < 0.0001), and a better 5-year overall survival (OS) (56% vs 54%, p = 0.03). A propensity score-matching cohort with a 1:1 ratio was created utilizing the variables associated with lymphadenectomy ≥ 16 nodes. The matched analysis revealed that the rate of adequate lymphadenectomy was significantly higher for RG compared to LG, 63.5% vs 60.4% (p = 0.01), respectively. There was no longer a significant difference between RG and LG regarding the rate of negative margins, prolonged length of stay, 90-day mortality, rate of receipt of postoperative chemotherapy, and OS.

CONCLUSIONS

This propensity score-matching analysis with a large US cohort shows that RG was associated with a higher rate of adequate lymphadenectomy compared to LR. RG and LG had a similar rate of negative margins, prolonged length of stay, receipt of postoperative chemotherapy, 90-day mortality, and OS, suggesting that RG is a comparable surgical approach, if not superior to LG.

Oncological Adequacy of Laparoscopic Surgery for Bulky Gastric Cancer: Results of a Western Single-Center Series

BACKGROUND

Gastric cancer is increasing worldwide and one million new cases were estimated globally in 2020. Use of the laparoscopic approach is increasing especially for subtotal gastrectomy. However, to date, solid data on locally advanced bulky tumors are lacking. The aim of this study is to assess the role of laparoscopic surgery in bulky gastric tumors.

METHODS

We performed an observational retrospective single-center analysis. The following data were collected and analyzed for each patient: demographics, tumor-related data, intra-operative data, peri-operative data, and pathological data. Statistical analysis was conducted, including descriptive statistics and chi-squared test, to analyze the differences between categorical variables.

RESULTS

O the 116 patients who underwent gastric surgery, 49 patients were included in the study protocol. All patients had bulky gastric tumors. Eighteen patients underwent laparoscopic gastrectomy and 31 open gastrectomy. The median number of lymph nodes removed was 28.5 (15-46) in the laparoscopic group and 23.05 (6-62) in the open group (p = 0.04). In total, 5.6% of patients of the laparoscopic group had <16 lymph nodes harvested and 35.5% in the open group (p = 0.035). No statistical differences were found between the open and laparoscopic groups in terms of surgical margins (p = 0.69).

CONCLUSIONS

Laparoscopic surgery is still a subject of debate in locally advanced bulky gastric cancer. Limited data are available concerning Western patients. This study showed superiority in terms of the quality of lymphadenectomy and non-inferiority in terms of radical resection margins.

Laparoscopic versus open gastrectomy for locally advanced gastric cancer after neoadjuvant chemotherapy: a comprehensive contrastive analysis with propensity score matching

BACKGROUND

Laparoscopic gastrectomy (LG) is increasingly applied in locally advanced gastric cancer (LAGC) after neoadjuvant chemotherapy (NC). However, there is no study to comprehensively evaluate the clinicopathological, prognostic, and laboratory data such as nutrition, immune, inflammation-associated indexes, and tumor markers between LG and open gastrectomy (OG) for LAGC following NC.

METHODS

The clinicopathological, prognostic, and laboratory data of LAGC patients with clinical stage of cT2-4aN1-3M0 who underwent gastrectomy after NC were retrospectively collected. The effects of LG and OG were compared after propensity score matching (PSM).

RESULTS

This study enrolled 148 cases, of which 110 cases were included after PSM. The LG group had a shorter length of incision (P < 0.001) and was superior to OG group in terms of blood loss (P < 0.001), postoperative first flatus time (P < 0.001), and postoperative first liquid diet time (P = 0.004). No significant difference was found in postoperative complications (P = 0.482). Laboratory results showed that LG group had less reduced red blood cells (P = 0.039), hemoglobin (P = 0.018), prealbumin (P = 0.010) in 3 days after surgery, and less reduced albumin in 1 day (P = 0.029), 3 days (P = 0.015), and 7 days (P = 0.035) after surgery than the OG group. The systemic immune-inflammation index and systemic inflammatory response index were not significantly different between the two groups. As for oncological outcomes, there were no significant differences in postoperative tumor markers of CEA (P = 0.791), CA199 (P = 0.499), and CA724 (P = 0.378). The 5-year relapse-free survival rates (P = 0.446) were 46.9% and 43.3% in the LG and OG groups, with the 5-year overall survival rates (P = 0.742) being 46.7% and 52.1%, respectively; the differences were not statistically significant. Multivariate Cox regression analysis revealed that tumor size ≥ 4 cm (P = 0.021) and the absence of postoperative adjuvant chemotherapy (P = 0.012) were independent risk factors for overall survival.

CONCLUSIONS

LG has faster gastrointestinal recovery, better postoperative nutritional status, and comparable oncological outcomes than OG, which can serve as an alternative surgical method for LAGC patients after NC.

Impact of Hospital Volume on Utilization of Minimally Invasive Surgery for Gastric Cancer

BACKGROUND

Minimally invasive surgery (MIS) for gastric cancer is increasingly performed. The purpose of this study is to evaluate trends in utilization of laparoscopic and robotic techniques compared to open surgery as well as utilization based on hospital volume.

METHODS

We used the National Cancer Database to query patients who underwent gastrectomy from 2010 to 2017 for adenocarcinoma. Regression analyses were used to determine associations between MIS and clinical factors, the trend of MIS over time, and survival.

RESULTS

A total of 18,380 patients met inclusion criteria. The annual rates of MIS increased for all hospital volumes, though lower volume centers were less likely to undergo MIS. MIS was associated with a shorter length of stay compared to open, and robotic gastrectomy had a higher rate of obtaining at least 15 lymph nodes and lower rate of having a positive margin.

CONCLUSIONS

MIS utilization for resection of gastric cancer increased over time, with robotic surgery increasing at a higher rate than laparoscopic surgery. Importantly, this occurred without increased in mortality or sacrificing adequate oncologic outcomes.

Predictive Value of KLASS-02-QC Assessment Score on KLASS-02 Surgical Outcomes: Validation of Surgeon Quality Control and Standardization for D2 Lymphadenectomy

OBJECTIVE

The aim of this study was to audit the 22 items and assessed each item's predictive value on surgical outcomes.

BACKGROUND

The KLASS-02 trial revealed that the oncologic outcomes of laparoscopic distal gastrectomy are not inferior to open distal gastrectomy in patients with advanced gastric cancer. The surgeons participating in this trial were chosen based on the assessment scores from the KLASS-02-QC trial, which used 22 items for standardization of D2 lymphadenectomy and quality control.

METHODS

We reviewed proficiency scores (PSs) for 22 items for 20 surgeons who participated in KLASS-02. The surgeons were divided into 2 groups according to PS, and the perioperative outcomes of 924 patients enrolled in KLASS-02 were compared between groups. Each item's predictive value for perioperative outcome was then assessed using multivariable regression models.

RESULTS

Of the total 924 patients, 529 were operated on by high-score surgeons (high PS) and 395 were operated on by low-score surgeons (low-PS). High-PS group had less intraoperative blood loss, longer operation times, and fewer complications, major complications, reoperations, and shorter first flatus and hospital stay than low-PS group ( P =0.006, P <0.001, P <0.001, P <0.001, P =0.042, P =0.013, and P <0.001, respectively). Some items used in KLASS-02-QC predicted perioperative outcomes, such as intraoperative blood loss, major complications, reoperation, and hospital stay.

CONCLUSIONS

Although this study only analyzed data associated with qualified surgeons, the 22 items effectively assessed the surgeons based on PS. A high score was associated with longer operation times, but better perioperative outcomes.

Safety and feasibility of reduced-port robotic distal gastrectomy for gastric cancer: a phase I/II clinical trial using the da Vinci Single Port(SP) robotic system

Minimally invasive surgery reduces surgical trauma and the size and number of incisions. The da Vinci SP robotic surgical system was designed to overcome the technical demands of single-incision laparoscopic surgery. This study aimed to demonstrate the safety and feasibility of single-port (SP) robotic distal gastrectomy (SPRDG) for patients with gastric cancer using the da Vinci SP system (Intuitive Surgical Inc., Sunnyvale, CA, USA). This study was designed as a single-arm prospective phase I/II clinical trial of SPRDG (first posted date: 21/09/2021, NCT05051670; clinicaltrials.gov). SPRDG using the da Vinci SP system was performed on 19 patients with gastric cancer between December 2021 and October 2022. The primary outcome was the safety of SPRDG as measured by major postoperative complications. The secondary outcomes were operation time, bleeding amount, bowel motility recovery, and length of hospital stay. SPRDG was performed in all 19 patients without unexpected events, such as use of additional trocars or conversion to laparoscopic or open surgery. No major complications occurred postoperatively (0/19, 0.0%). The mean operation time was 218 min (range 164-286 min). The mean hospital stay duration was 3.2 days (range 2-4 days). This phase I/II clinical trial, performed by a single expert surgeon, demonstrated the safety and feasibility of SPRDG with the da Vinci SP system in selected patients with gastric cancer. SPRDG could be a reasonable alternative to conventional or reduced-port minimally invasive gastrectomy, as it has cosmetic advantages, early recovery, and safe discharge.

Safety and Efficacy of Partial Omentectomy in Laparoscopic Distal Gastrectomy for pT3-T4a Stage Gastric Cancer

Purpose

Partial omentectomy (PO) has been gradually applied in laparoscopic gastrectomy for gastric cancer (GC); however, its efficacy remains unclear. The purpose of this study was to assess the safety and efficacy of PO in laparoscopic distal gastrectomy for pT3-T4a stage GC.

Patients and Methods

From June 2019 to May 2021, 108 patients with pT3 or pT4a stage GC who underwent laparoscopic distal gastrectomy were retrospectively included and divided into the PO (n=58) and total omentectomy (TO, n=50) groups. The surgical outcomes, recurrence patterns and postoperative 2-year overall survival (OS) rates were compared between the PO and TO groups.

Results

The PO group showed a shorter operation time than the TO group (183.9±21.6 vs 197.6±22.7 min, p=0.002). Less intraoperative blood loss (155.3±113.0 vs 178.8±154.4 mL, p=0.336) and intraoperative complications (5.1% vs 12.0%, p=0.298) were also observed in the PO group than in the TO group, but the difference was not significant. The numbers of retrieved lymph nodes (LNs) and metastatic LNs, postoperative hospital stays and postoperative complications in the two groups were comparable (p>0.05). Moreover, the postoperative overall recurrence rates (25.9% vs 26.0%, p=0.987) and the 2-year OS rates (63.8% vs 65.4%, p=0.437) in the PO and TO groups were also comparable. TO was not an independent prognostic factor for GC patients (HR=0.806, p=0.443).

Conclusion

In laparoscopic distal gastrectomy, PO could provide better surgical outcomes and comparable oncological outcomes compared to TO for patients with pT3-T4a stage GC, suggesting that PO may be an acceptable surgical procedure for these patients.

Randomized controlled phase III trial to investigate superiority of robot-assisted gastrectomy over laparoscopic gastrectomy for clinical stage T1-4aN0-3 gastric cancer patients (JCOG1907, MONA LISA study): a study protocol

BACKGROUND

Laparoscopic gastrectomy (LG) is considered a standard treatment for clinical stage I gastric cancer. Nevertheless, LG has some drawbacks, such as motion restriction and difficulties in spatial perception. Robot-assisted gastrectomy (RG) overcomes these drawbacks by using articulated forceps, tremor-filtering capability, and high-resolution three-dimensional imaging, and it is expected to enable more precise and safer procedures than LG for gastric cancer. However, robust evidence based on a large-scale randomized study is lacking.

METHODS

We are performing a randomized controlled phase III study to investigate the superiority of RG over LG for clinical T1-2N0-2 gastric cancer in terms of safety. In total, 1,040 patients are planned to be enrolled from 46 Japanese institutions over 5 years. The primary endpoint is the incidence of postoperative intra-abdominal infectious complications, including anastomotic leakage, pancreatic fistula, and intra-abdominal abscess of Clavien-Dindo (CD) grade ≥ II. The secondary endpoints are the incidence of all CD grade ≥ II and ≥ IIIA postoperative complications, the incidence of CD grade ≥ IIIA postoperative intra-abdominal infectious complications, relapse-free survival, overall survival, the proportion of RG completion, the proportion of LG completion, the proportion of conversion to open surgery, the proportion of operation-related death, and short-term surgical outcomes. The Japan Clinical Oncology Group Protocol Review Committee approved this study protocol in January 2020. Approval from the institutional review board was obtained before starting patient enrollment in each institution. Patient enrollment began in March 2020. We revised the protocol to expand the eligibility criteria to T1-4aN0-3 in July 2022 based on the results of randomized trials of LG demonstrating non-inferiority of LG to open surgery for survival outcomes in advanced gastric cancer.

DISCUSSION

This is the first multicenter randomized controlled trial to confirm the superiority of RG over LG in terms of safety. This study will demonstrate whether RG is superior for gastric cancer.

TRIAL REGISTRATION

The protocol of JCOG1907 was registered in the UMIN Clinical Trials Registry as UMIN000039825 ( http://www.umin.ac.jp/ctr/index.htm ). Date of Registration: March 16, 2020. Date of First Participant Enrollment: April 1, 2020.