Defining the role of laparoscopic gastrectomy for gastric cancer

Short-term outcomes and cost-effectiveness of laparoscopic gastrectomy with articulating instruments for gastric cancer compared with the robotic approach

To overcome the limitations of laparoscopic surgery, robotic systems have been commonly used in the era of minimally invasive surgery despite their high cost. However, the articulation of instruments can be achieved without a robotic system at lower cost using articulating laparoscopic instruments (ALIs). Between May 2021 and May 2022, perioperative outcomes following laparoscopic gastrectomy using ALIs versus robotic gastrectomy were compared. A total of 88 patients underwent laparoscopic gastrectomy using ALIs, while 96 underwent robotic gastrectomy. Baseline characteristics were similar between the groups except for a higher proportion of patients with a medical history in the ALI group (p = 0.013). Clinicopathologic and perioperative outcomes were not significantly different between the groups. However, the operation time was significantly shorter in the ALI group (p = 0.026). No deaths occurred in either group. In conclusion, laparoscopic gastrectomy using ALIs was associated with comparable perioperative surgical outcomes and a shorter operation time compared to robotic gastrectomy in this prospective cohort study.

Long-Term Outcomes in Laparoscopic D2 Gastrectomy for Gastric Cancer: a Large Comprehensive Study Proposing Novel Hypotheses

BACKGROUND

The long-term outcomes of laparoscopic gastrectomy (LG) versus open gastrectomy (OG) for gastric cancer (GC) remain obscure, especially for advanced cancer and disease affecting the upper stomach and in older patients. This study aimed to comprehensively assess the long-term efficacy of LG for GC using a large prospective database.

METHODS

Totally, 1877 consecutive patients (1186 receiving LG and 691 OG) operated in 2004-2016 were analyzed, with a median follow-up of 63 months. Association of LG versus OG with disease-specific survival (DSS) and disease-free survival (DFS) overall and in various subgroups were investigated using multivariable Cox regression. Propensity score matching (PSM) was performed for sensitivity analysis.

RESULTS

Before PSM, overall, there was no significant association of LG versus OG with survival after multivariable adjustment; however, in subgroup analyses, LG was associated with superior DSS in patients aged ≥ 70 years and those with upper GC. No significant associations regarding DFS were observed overall or in stratifications. PSM analyses revealed that LG was associated with better DSS also in patients aged ≥ 70 years (hazard ratio (HR) = 0.33, 95% confidence interval (CI) = 0.15-0.72) and in those with upper GC (HR = 0.51, 95% CI = 0.29-0.91), and with better DFS in those with upper GC (HR = 0.60, 95% CI = 0.37-0.99). Multivariable analysis showed that age, hepatitis B, performance status, tumor histology, stage, and vascular invasion were significantly associated with post-LG survival. LG-specific nomograms were then constructed with concordance indexes of 0.814 (DSS) and 0.809 (DFS) and excellent calibration.

CONCLUSIONS

In this large institutional analysis, while LG for GC was associated with DSS and DFS similar to those for OG overall, non-inferior LG-associated survival especially DSS was observed in some subgroups rarely investigated in prospective or randomized settings. There could still be biases even after PSM due to confounders not accounted for in this observational study. However, these findings offer novel hypotheses for further validation.

Robotic oesophago-gastric cancer surgery

A postoperative complications rate of nearly 50% has compelled oesophago-gastric practice to adopt minimally invasive techniques such as robotic surgery

Instrumental Mechanoreceptoric Palpation in Gastrointestinal Surgery

Background and Aims

Small gastric or colorectal tumours can be visually undetectable during laparoscopic surgeries, and available methods still do not provide a 100% localisation rate. Thus, new methods for further improvements in tumour localisation are highly desirable. In this study, we evaluated the usage of the Medical Tactile Endosurgical Complex (MTEC) in gastrointestinal surgery for localisation of tumours. The MTEC provides the possibility of instrumental mechanoreceptoric palpation, which serves as an analogue of conventional manual palpation.

Methods

Ninety-six elective surgeries were performed, including 48 open surgeries, 43 laparoscopies, and 5 robot-assisted surgeries. The 20 mm version of the MTEC tactile mechanoreceptor was used in open surgeries, and the 10 mm version in laparoscopic and robot-assisted surgeries.

Results

The mean time of instrumental mechanoreceptoric palpation was 3 minutes 12 seconds for open surgeries, which constituted the early stage of the learning curve, and 3 minutes 34 seconds for laparoscopic surgeries. No side effects or postoperative complications related to instrumental mechanoreceptoric palpation were observed, and this procedure provided data sufficient for tumour localisation in more than 95% of cases.

Conclusion

Instrumental mechanoreceptoric palpation performed using MTEC is a simple, safe, and reliable method for tumour localisation in gastrointestinal laparoscopic surgery.

Totally laparoscopic versus open total gastrectomy for gastric cancer: A case-matched study about short-term outcomes

Although surgical outcomes of totally laparoscopic total gastrectomy (TLTG) have been reported from several centers, the effectiveness of this technique has not been conclusively established. The aim of this study was to investigate the feasibility, safety, and efficacy of TLTG for gastric cancer.A prospectively collected and retrospectively analyzed data were used by comparing the short-term surgical outcomes of 124 patients who underwent TLTG with those of 124 patients who underwent open total gastrectomy (OTG) between March 2007 and March 2016.The 2 groups were well matched with respect to age, sex, body mass index, ASA score, and tumor stage. There was no significant difference with regard to the operation time but TLTG showed significantly less intraoperative blood loss (115.5 ± 70.2 vs 210.5 ± 146.7 mL, P < .01). Total numbers of retrieved lymph nodes were similar in the 2 groups. Postoperatively, no significant differences were found for morbidity or mortality. The time to first flatus, initiate oral intake, and postoperative hospital stay were significantly shorter in the TLTG group than in the OTG group (3.2 ± 1.0 vs 4.1 ± 1.2 days; 4.4 ± 1.2 vs 5.6 ± 2.0 days; and 8.9 ± 3.1 vs 11.3 ± 4.5 days, respectively; P < .01).TLTG for gastric cancer is technically safe, feasible, and minimally invasive compared with OTG. A prospective randomized trial is needed to establish the value of TLTG.

Status and Prospects of Robotic Gastrectomy for Gastric Cancer: Our Experience and a Review of the Literature

Since the first report of robotic gastrectomy, experienced laparoscopic surgeons have used surgical robots to treat gastric cancer and resolve problems associated with laparoscopic gastrectomy. However, compared with laparoscopic gastrectomy, the superiority of robotic procedures has not been clearly proven. There are several advantages to using robotic surgery for gastric cancer, such as reduced estimated blood loss during the operation, a shorter learning curve, and a larger number of examined lymph nodes than conventional laparoscopic gastrectomy. The increased operation time observed with a robotic system is decreasing because surgeons have accumulated experience using this procedure. While there is limited evidence, long-term oncologic outcomes appear to be similar between robotic and laparoscopic gastrectomy. Robotic procedures have a significantly greater financial cost than laparoscopic gastrectomy, which is a major drawback. Recent clinical studies tried to demonstrate that the benefits of robotic surgery outweighed the cost, but the overall results were disappointing. Ongoing studies are investigating the benefits of robotic gastrectomy in more complicated and challenging cases. Well-designed randomized control trials with large sample sizes are needed to investigate the benefits of robotic gastrectomy compared with laparoscopic surgery.

Minimally invasive surgery for upper gastrointestinal cancer: Our experience and review of the literature

Minimally invasive surgery (MIS) for upper gastrointestinal (GI) cancer, characterized by minimal access, has been increasingly performed worldwide. It not only results in better cosmetic outcomes, but also reduces intraoperative blood loss and postoperative pain, leading to faster recovery; however, endoscopically enhanced anatomy and improved hemostasis via positive intracorporeal pressure generated by CO2 insufflation have not contributed to reduction in early postoperative complications or improvement in long-term outcomes. Since 1995, we have been actively using MIS for operable patients with resectable upper GI cancer and have developed stable and robust methodology in conducting totally laparoscopic gastrectomy for advanced gastric cancer and prone thoracoscopic esophagectomy for esophageal cancer using novel technology including da Vinci Surgical System (DVSS). We have recently demonstrated that use of DVSS might reduce postoperative local complications including pancreatic fistula after gastrectomy and recurrent laryngeal nerve palsy after esophagectomy. In this article, we present the current status and future perspectives on MIS for gastric and esophageal cancer based on our experience and a review of the literature.

Current status of randomized controlled trials for laparoscopic gastric surgery for gastric cancer in China

China alone accounts for nearly 42% of all new gastric cancer cases worldwide, and gastric cancer is the third leading cause of cancer deaths in China nowadays. Without mass screening programs, unfortunately over 80% of all Chinese patients have been diagnosed as advanced diseases. As in other Asian countries, especially Japan and Korea, laparoscopic gastrectomy for the treatment of gastric cancer has gained increasingly popularity in China during the past decade. Whether laparoscopic surgery can be safely and effectively performed in the treatment of gastric cancer remains controversial, particularly with regard to curative intent in advanced diseases. Given the high incidence of these cancers, and their advanced stage at diagnosis, China has a significant interest in determining the safety and effectiveness of laparoscopic gastrectomy. A well-designed randomized controlled trial (RCT) is considered the only feasible way to provide conclusive evidence. To date, China has not played a significant role in terms of conducting RCT concerning laparoscopic surgery for gastric cancer. However, an effort has been made by the Chinese researchers, with the great help from our colleagues in neighboring countries such as Korea and Japan, through the establishment of the Chinese Laparoscopic Gastrointestinal Surgery Study Group. In this review, we present the current status of RCT for laparoscopic gastric surgery for gastric cancer in China, including published and ongoing registered RCT.

Current status of randomized controlled trials for laparoscopic gastric surgery for gastric cancer in Korea

Laparoscopic gastrectomy for gastric cancer has rapidly gained popularity as a result of the increased incidence of early gastric cancer in Korea. Although laparoscopic gastrectomy has been considered as an investigational treatment because of the lack of solid evidence of efficacy and safety, it is increasingly regarded as a standard treatment for early gastric cancer. Moreover, solid evidence is anticipated from two studies in Korea, KLASS 01 and KLASS 02, the latter of which examines the suitability of laparoscopic gastrectomy for advanced gastric cancer. The use of cutting-edge techniques for laparoscopic gastrectomy enables surgeons to deliver various treatment options that offer the best possible quality of life after gastrectomy. In this review, we summarize the current status of clinical trials on laparoscopic gastrectomy in Korea and examine future perspectives regarding laparoscopic gastrectomy for the treatment of gastric cancer.