Safety and Efficacy of Laparoscopic Versus Open Gastrectomy in Patients With Advanced Gastric Cancer Following Neoadjuvant Chemotherapy: A Meta-Analysis

The outcomes of laparoscopic omentum-preserving gastrectomy compared to open surgery with omentectomy in gastric cancer patients: a propensity score matched study of 249 UICC stage 0-IV gastric cancer patients

BACKGROUND

We performed a propensity score matched study comparing patients' short- and long-term results after laparoscopic omentum-preserving gastrectomy and open surgery with omentectomy with UICC stages 0-IV.

METHODS

Between 2015 and 2022, 311 patients with gastric cancer underwent surgery at the University Clinical Centre Maribor. Of these, 249 met the inclusion criteria and 198 were included in the study group after PSM.

RESULTS

Patients in both groups were well-balanced in demographic and pathological characteristics after PSM. There was no significant difference in the 5-year survival between groups (LAP: 62.2% vs. OPN: 54.4%; p = 0.950). The Cox regression model identified UICC stage and age as significant predictors for survival. In both groups, peritoneal dissemination was the most common site of recurrence. The multivariate analysis identified the UICC stage as a significant predictor for peritoneal recurrence, while omental preservation was not associated with a higher risk of peritoneal dissemination. Omentum preservation was not associated with more intestinal obstruction. Patients in the LAP group had significantly shorter hospital stays (LAP: 9(6) vs. OPN: 10(5); p = 0.009), less postoperative morbidity (LAP: 17% vs. OPN: 23.4%; p = 0.009), and significantly more extracted LNs per operation compared to open surgery (LAP: 31 ± 11 LNs vs. OPN: 25 ± 12 LNs; p = 0.002).

CONCLUSION

Based on our results, we recommend the use of laparoscopic omentum-preserving gastrectomy in patients with early and advanced gastric cancer.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Laparoscopic Radical Total Gastrectomy and Pancreatosplenectomy for Synchronous Cancer of the Stomach and Pancreas

The safety of laparoscopic surgery for advanced gastric and pancreatic cancers has been established individually, but there is little evidence for synchronous cancers. In this case, a 59-year-old man with a history of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone) treatment for diffuse large B-cell lymphoma underwent laparoscopic surgery for a suspected pancreatic invasion of advanced gastric cancer. Pathology revealed double cancer of the stomach and pancreas. Laparoscopic total gastrectomy and distal pancreatectomy were successfully performed. The patient had a pancreatic leak on postoperative day seven but was discharged from the hospital on postoperative day 21. This case suggests the possibility of expanding the indications for laparoscopic surgery for similar cancers in the future. Additionally, the anatomical reticulum can be resected as a single mass using laparoscopy alone.

Comparisons of perioperative and long-term outcomes of laparoscopic versus open gastrectomy for advanced gastric cancer after neoadjuvant therapy: an updated pooled analysis of eighteen studies

BACKGROUND

Outcomes of laparoscopic surgery in advanced gastric cancer patients who received neoadjuvant therapy represent a controversial issue. We performed an updated meta-analysis to evaluate the perioperative and long-term survival outcomes of laparoscopic gastrectomy (LG) versus conventional open gastrectomy (OG) in this subset of patients.

METHODS

Electronic databases including PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials and China National Knowledge Infrastructure were comprehensively searched up to May 2023. The short-term and long-term outcomes of LG versus OG in advanced gastric cancer patients undergoing neoadjuvant therapy were evaluated. Effect sizes with 95% confidence intervals were always assessed using random-effects model. The prospective protocol was registered with PROSPERO (CRD42022359126).

RESULTS

Eighteen studies (2 randomized controlled trials and 16 cohort studies) involving 2096 patients were included. In total, 933 patients were treated with LG and 1163 patients were treated with OG. In perioperative outcomes, LG was associated with less estimated blood loss (MD = - 65.15; P < 0.0001), faster time to flatus (MD = - 0.56; P < 0.0001) and liquid intake (MD = - 0.42; P = 0.02), reduced hospital stay (MD = - 2.26; P < 0.0001), lower overall complication rate (OR = 0.70; P = 0.002) and lower minor complication rate (OR = 0.69; P = 0.006), while longer operative time (MD = 25.98; P < 0.0001). There were no significant differences between the two groups in terms of proximal margin, distal margin, R1/R2 resection rate, retrieved lymph nodes, time to remove gastric tube and drainage tube, major complications and other specific complications. In survival outcomes, LG and OG were not significantly different in overall survival, disease-free survival and recurrence-free survival.

CONCLUSION

LG can be a safe and feasible technique for the treatment of advanced gastric cancer patients receiving neoadjuvant therapy. However, more high-quality randomized controlled trials are still needed to further validate the results of our study.

Laparoscopic vs. open distal gastrectomy for locally advanced gastric cancer: A systematic review and meta-analysis of randomized controlled trials

Objective

The aim of this systematic review and meta-analysis is to compare the short- and long-term outcomes of laparoscopic distal gastrectomy (LDG) with those of open distal gastrectomy (ODG) for patients with advanced gastric cancer (AGC) who exclusively underwent distal gastrectomy and D2 lymphadenectomy in randomized controlled trials (RCTs).

Background

Data in published meta-analyses that included different gastrectomy types and mixed tumor stages prevented an accurate comparison between LDG and ODG. Recently, several RCTs that compared LDG with ODG included AGC patients specifically for distal gastrectomy, with D2 lymphadenectomy being reported and updated with the long-term outcomes.

Methods

PubMed, Embase, and Cochrane databases were searched to identify RCTs for comparing LDG with ODG for advanced distal gastric cancer. Short-term surgical outcomes and mortality, morbidity, and long-term survival were compared. The Cochrane tool and GRADE approach were used for evaluating the quality of evidence (Prospero registration ID: CRD42022301155).

Results

Five RCTs consisting of a total of 2,746 patients were included. Meta-analyses showed no significant differences in terms of intraoperative complications, overall morbidity, severe postoperative complications, R0 resection, D2 lymphadenectomy, recurrence, 3-year disease-free survival, intraoperative blood transfusion, time to first liquid diet, time to first ambulation, distal margin, reoperation, mortality, or readmission between LDG and ODG. Operative times were significantly longer for LDG [weighted mean difference (WMD) 49.2 min, p < 0.05], whereas harvested lymph nodes, intraoperative blood loss, postoperative hospital stay, time to first flatus, and proximal margin were lower for LDG (WMD -1.3, p < 0.05; WMD -33.6 mL, p < 0.05; WMD -0.7 day, p < 0.05; WMD -0.2 day, p < 0.05; WMD -0.4 mm, p < 0.05). Intra-abdominal fluid collection and bleeding were found to be less after LDG. Certainty of evidence ranged from moderate to very low.

Conclusions

Data from five RCTs suggest that LDG with D2 lymphadenectomy for AGC has similar short-term surgical outcomes and long-term survival to ODG when performed by experienced surgeons in hospitals contending with high patient volumes. It can be concluded that RCTs should highlight the potential advantages of LDG for AGC.

Systematic Review Registration

PROSPERO, registration number CRD42022301155.

Statins and the Risk of Gastric Cancer: A Systematic Review and Meta-Analysis

Previous epidemiological studies have reported that the use of statins is associated with a decreased risk of gastric cancer, although the beneficial effects of statins on the reduction of gastric cancer remain unclear. Therefore, we conducted a systematic review and meta-analysis to investigate the association between the use of statins and the risk of gastric cancer. Electronic databases such as PubMed, EMBASE, Scopus, and Web of Science were searched between 1 January 2000 and 31 August 2022. Two authors used predefined selection criteria to independently screen all titles, abstracts, and potential full texts. Observational studies (cohort and case-control) or randomized control trials that assessed the association between statins and gastric cancer were included in the primary and secondary analyses. The pooled effect sizes were calculated using the random-effects model. The Meta-analysis of Observational Studies in Epidemiology (MOOSE) reporting guidelines were followed to conduct this study. The total sample size across the 20 included studies was 11,870,553. The use of statins was associated with a reduced risk of gastric cancer (RRadjusted: 0.72; 95%CI: 0.64−0.81, p < 0.001). However, the effect size of statin use on the risk of gastric cancer was lower in Asian studies compared to Western studies (RRAsian: 0.62; 95%CI: 0.53−0.73 vs. RRwestern: 0.88; 95%CI: 0.79−0.99). These findings suggest that the use of statins is associated with a reduced risk of gastric cancer. This reverse association was even stronger among Asian people than Western individuals.

A comparison of neoadjuvant therapies for gastroesophageal and gastric cancer on tumour resection rate: A network meta-analysis

Background

Gastric cancer is one of the most common malignancies around the world, and a variety of neoadjuvant chemotherapies with different drug combinations are available for the treatment. R0 resection refers to a microscopically negative margin on resection, where no gross or microscopic tumour remains in the primary tumour. We aimed to find evidence on the relative effectiveness of neoadjuvant therapies for patients with advanced gastroesophageal and gastric cancer on the R0 resection rate.

Methods

Relevant randomised controlled trials were searched using appropriate keywords in health-related databases. We performed network meta-analysis within a frequentist framework. The endpoint assessed was the R0 resection rate. We assessed consistency and transitivity assumptions that are necessary for network meta-analysis. This study only used data from published studies. The need for consent from participants was waived by the Ethics Review Committee of the International Medical University in Malaysia.

Results

Six randomised controlled trials involving 1700 patients were identified. A network plot was formed with five neoadjuvant regimens [DLX (pyrimidine analogue + platinum compounds + chemoradiotherapy), DELX (pyrimidine analogue + epipodophylllotoxins/etoposide + platinum compounds + chemoradiotherapy), ADL (anthracycline + pyrimidine analogue + platinum compounds), ADM (anthracycline+ pyrimidine analogue + anti-folate compounds) and LTX (platinum compounds + taxane + chemoradiotherapy)] and surgery alone for management of patients with advanced gastroesophageal and gastric cancer. Assumptions required for a network meta-analysis such as consistency ((global test: Chi2 (1): 3.71; p:0.054)), and the transitivity in accord to the characteristics of interventions considered in this review were not violated. In the network comparison, surgery alone has a lower R0 resection rate compared with LTX (OR 0.2, 95%CI:0.01, 0.38) or DLX (OR 0.48, 95%CI: 0.29, 0.79). LTX has higher resection rate compared with DLX (OR 2.47, 95%CI: 1.08 to 5.63), DELX (OR 106.0, 95%CI: 25.29 to 444.21), ADM (OR 5.41, 95%CI: 1.56 to 18.78) or ADL (OR 3.12, 95%CI: 1.27 to 7.67). There were wide or very wide CIs in many of these comparisons. Overall certainty of the evidence was low or very low. Further research in this field is very likely to have an important impact on our confidence in the R0 resection rates between LTX versus other neoadjuvant chemotherapy is likely to change the estimate.

Conclusions

Findings suggest that overall quality of evidence on the relative effectiveness of neoadjuvant chemotherapies was low to very low level. Therefore, we are very uncertain about the true effect of neoadjuvant therapies in the R0 resection rate in patients with gastroesophageal and gastric cancer. Future well-designed large trials are needed. To recruit large samples in this field, multicountry trials are recommended. Future trials also need to assess treatment-related adverse events, and patients-centered outcomes such as health‐related quality of life.

DNA Damage Repair and Current Therapeutic Approaches in Gastric Cancer: A Comprehensive Review

DNA in cells is frequently damaged by endogenous and exogenous agents. However, comprehensive mechanisms to combat and repair DNA damage have evolved to ensure genomic stability and integrity. Improper DNA damage repair may result in various diseases, including some types of tumors and autoimmune diseases. Therefore, DNA damage repair mechanisms have been proposed as novel antitumor drug targets. To date, numerous drugs targeting DNA damage mechanisms have been developed. For example, PARP inhibitors that elicit synthetic lethality are widely used in individualized cancer therapies. In this review, we describe the latent DNA damage repair mechanisms in gastric cancer, the types of DNA damage that can contribute to the development of gastric cancer, and new therapeutic approaches for gastric cancer that target DNA damage repair pathways.

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Systematic Review Registration

PROSPERO (CRD 42021297141).

Assessment of the short-term outcomes of laparoscopic gastrectomy after neoadjuvant chemotherapy for locally advanced gastric cancer: A prospective single-armed clinical trial

BACKGROUND

Laparoscopic surgical approaches for gastric cancer after neoadjuvant chemotherapy are increasing, yet there is limited evidence of their safety and effectiveness.

METHODS

This prospective single-armed clinical trial enrolled 80 neoadjuvant chemotherapy patients who underwent laparoscopic gastrectomy. In addition, to better analyze the outcomes of this study, 1:2 propensity score matching was performed, and a contemporaneous historic control group containing 160 laparoscopic gastrectomy patients without neoadjuvant chemotherapy was established.

RESULTS

Analyses were performed to compare the neoadjuvant chemotherapy group (n = 80) and the control group (n = 160). The general clinical data of both groups were comparable. The neoadjuvant chemotherapy group showed less intraoperative bleeding (P = .029) and recovered more quickly than the control group (all P < .05). The 2 groups did not exhibit major differences in terms of postoperative complications (P = .679) or severe complications (P = .055). The proportion of patients with ypT4 stage and ypN3 stage disease in the neoadjuvant chemotherapy group totaled 20.7% and 23.8%, respectively, which was significantly lower than that observed in the control group (P < .05). The number of metastatic lymph nodes was 4.8 ± 7.0 in the neoadjuvant chemotherapy group, which was lower than that in the control group (P < .001). In the neoadjuvant chemotherapy group, the major pathological regression rate was 27.5%, while the objective radiologic response rate (complete response + partial response) was 64.0%. In contrast to nonresponding patients, the patients who experienced an objective response had a shorter operation time (P < .001), less intraoperative bleeding (P < .001), and fewer metastatic lymph nodes (P = .005). The short-term effects observed in the nonresponding patients were similar to those observed in the control group.

CONCLUSION

Laparoscopic gastrectomy could achieve improved short-term outcomes through NACT tumor downstaging without increasing the incidence of postoperative complications. Further multicenter and prospective clinical trials are warranted.