Strategies of laparoscopic spleen-preserving splenic hilar lymph node dissection for advanced proximal gastric cancer

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.

Assessment of indocyanine green tracer-guided lymphadenectomy in laparoscopic gastrectomy after neoadjuvant chemotherapy for locally advanced gastric cancer: results from a multicenter analysis based on propensity matching

BACKGROUND

This study evaluated the safety, effectiveness, and feasibility of indocyanine green (ICG) tracing in guiding lymph-node (LN) dissection during laparoscopic D2 radical gastrectomy in patients with advanced gastric cancer (AGC) after neoadjuvant chemotherapy (NAC).

METHOD

We retrospectively analyzed data on 313 patients with clinical stage of cT1-4N0-3M0 who underwent laparoscopic radical gastrectomy after NAC between February 2010 and October 2020 from two hospitals in China. Grouped according to whether ICG was injected. For the ICG group (n = 102) and non-ICG group (n = 211), 1:1 propensity matching analysis was used.

RESULTS

After matching, there was no significant difference in the general clinical pathological data between the two groups (ICG vs. non-ICG: 94 vs. 94). The average number of total LN dissections was significantly higher in the ICG group and lower LN non-compliance rate than in the non-ICG group. Subgroup analysis showed that among patients with LN and tumor did not shrink after NAC, the number of LN dissections was significantly more and LN non-compliance rate was lower in the ICG group than in the non-ICG group. Intraoperative blood loss was significantly lesser in the ICG group than in the non-ICG group, while the recovery and complications of the two groups were similar.

CONCLUSION

For patients with poor NAC outcomes, ICG tracing can increase the number of LN dissections during laparoscopic radical gastrectomy, reduce the rate of LN non-compliance, and reduce intraoperative bleeding. Patients with AGC should routinely undergo ICG-guided laparoscopic radical gastrectomy.

Clinical implications of Indocyanine Green Fluorescence Imaging-Guided laparoscopic lymphadenectomy for patients with gastric cancer: A cohort study from two randomized, controlled trials using individual patient data

BACKGROUND

The value of indocyanine green (ICG) fluorescence imaging in tracing metastatic lymph nodes (LNs) has rarely been reported. We aimed to evaluate the clinical implications of fluorescence imaging-guided lymphadenectomy and the sensitivity of fluorescent lymphography to detect metastatic LN stations in gastric cancer (GC).

MATERIALS AND METHODS

This analysis pooled data from two randomized controlled trials (FUGES-012 and FUGES-019 studies) on laparoscopic ICG tracer-guided lymphadenectomy for GC between November 2018 and October 2020. Patients who received ICG injection using either the intraoperative subserosal or preoperative submucosal approaches 1 day before surgery and underwent fluorescence imaging-guided lymphadenectomy were defined as the ICG group. Patients who underwent conventional lymphadenectomy without ICG injection and intraoperative imaging were defined as the non-ICG group.

RESULTS

Among 514 enrolled patients, the ICG and non-ICG groups included 385 and 129, respectively. A significantly higher mean number of LNs was retrieved in the ICG group than in the non-ICG group (49.9 vs. 42.0, P < 0.001). The ICG group showed a lower LN noncompliance rate than that in the non-ICG group (31.9% vs. 57.4%, P < 0.001). The sensitivity of fluorescence imaging for detecting all metastatic LN stations was 86.8%. The negative predictive value was 92.2% for nonfluorescent stations. For detecting all metastatic stations, subgroup analysis revealed 97.7%, 91.7%, 86.2%, and 84.3% sensitivities for pT1, pT2, pT3, and pT4a tumors, respectively. Regardless of gastrectomy type, the diagnostic accuracy for detecting all metastatic stations in the D1+ and D2 stations for cT1-cT2 disease reached 100%.

CONCLUSION

ICG fluorescence imaging, using either the subserosal or submucosal approaches, assisted in the thorough dissection of potentially metastatic LNs, as recommended for individualized laparoscopic lymphadenectomy for GC.

Safety and Efficacy of Indocyanine Green Tracer-Guided Lymph Node Dissection During Laparoscopic Radical Gastrectomy in Patients With Gastric Cancer: A Randomized Clinical Trial

IMPORTANCE

The application of indocyanine green (ICG) imaging in laparoscopic radical gastrectomy is in the preliminary stages of clinical practice, and its safety and efficacy remain controversial.

OBJECTIVE

To investigate the safety and efficacy of ICG near-infrared tracer-guided imaging during laparoscopic D2 lymphadenectomy in patients with gastric cancer.

DESIGN, SETTING, AND PARTICIPANTS

Patients with potentially resectable gastric adenocarcinoma (clinical tumor stage cT1-cT4a, N0/+, M0) were enrolled in a prospective randomized clinical trial at a tertiary referral teaching hospital between November 2018 and July 2019. Patients were randomly assigned to the ICG group or the non-ICG group. The number of retrieved lymph nodes, rate of lymph node noncompliance, and postoperative recovery data were compared between the groups in a modified intention-to-treat analysis. Statistical analysis was performed from August to September 2019.

INTERVENTIONS

The ICG group underwent laparoscopic gastrectomy using near-infrared imaging after receiving an endoscopic peritumoral injection of ICG to the submucosa 1 day before surgery.

MAIN OUTCOMES AND MEASURES

Total number of retrieved lymph nodes.

RESULTS

Of 266 participants randomized, 133 underwent ICG tracer-guided laparoscopic gastrectomy, and 133 underwent conventional laparoscopic gastrectomy. After postsurgical exclusions, 258 patients were included in the modified intention-to-treat analysis, which comprised 129 patients (86 men and 43 women; mean [SD] age, 57.8 [10.7] years) in the ICG group and 129 patients (87 men and 42 women; mean [SD] age, 60.1 [9.1] years) in the non-ICG group. The mean number of lymph nodes retrieved in the ICG group was significantly more than the mean number retrieved in the non-ICG group (mean [SD], 50.5 [15.9] lymph nodes vs 42.0 [10.3] lymph nodes, respectively; P < .001). Significantly more perigastric and extraperigastric lymph nodes were retrieved in the ICG group than in the non-ICG group. In addition, the mean total number of lymph nodes retrieved in the ICG group within the scope of D2 lymphadenectomy was also significantly greater than the mean number retrieved in the non-ICG group (mean [SD], 49.6 [15.0] lymph nodes vs 41.7 [10.2] lymph nodes, respectively; P < .001). The lymph node noncompliance rate of the ICG group (41 of 129 patients [31.8%]) was lower than that of the non-ICG group (74 of 129 patients [57.4%]; P < .001). The postoperative recovery process was comparable, and no significant difference was found between the ICG and non-ICG groups in the incidence (20 of 129 patients [15.5%] vs 21 of 129 [16.3%], respectively; P = .86) or severity of complications within 30 days after surgery.

CONCLUSIONS AND RELEVANCE

Indocyanine green can noticeably improve the number of lymph node dissections and reduce lymph node noncompliance without increased complications in patients undergoing D2 lymphadenectomy. Indocyanine green fluorescence imaging can be performed for routine lymphatic mapping during laparoscopic gastrectomy, especially total gastrectomy.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03050879.

Short-term efficacy of robotic and laparoscopic spleen-preserving splenic hilar lymphadenectomy via Huang's three-step maneuver for advanced upper gastric cancer: Results from a propensity score-matched study

BACKGROUND

Robotic surgery has been considered to be significantly better than laparoscopic surgery for complicated procedures.

AIM

To explore the short-term effect of robotic and laparoscopic spleen-preserving splenic hilar lymphadenectomy (SPSHL) for advanced gastric cancer (GC) by Huang's three-step maneuver.

METHODS

A total of 643 patients who underwent SPSHL were recruited from April 2012 to July 2017, including 35 patients who underwent robotic SPSHL (RSPSHL) and 608 who underwent laparoscopic SPSHL (LSPSHL). One-to-four propensity score matching was used to analyze the differences in clinical data between patients who underwent robotic SPSHL and those who underwent laparoscopic SPSHL.

RESULTS

In all, 175 patients were matched, including 35 patients who underwent RSPSHL and 140 who underwent LSPSHL. After matching, there were no significant differences detected in the baseline characteristics between the two groups. Significant differences in total operative time, estimated blood loss (EBL), splenic hilar blood loss (SHBL), splenic hilar dissection time (SHDT), and splenic trunk dissection time were evident between these groups (P < 0.05). Furthermore, no significant differences were observed between the two groups in the overall noncompliance rate of lymph node (LN) dissection (62.9% vs 60%, P = 0.757), number of retrieved No. 10 LNs (3.1 ± 1.4 vs 3.3 ± 2.5, P = 0.650), total number of examined LNs (37.8 ± 13.1 vs 40.6 ± 13.6, P = 0.274), and postoperative complications (14.3% vs 17.9%, P = 0.616). A stratified analysis that divided the patients receiving RSPSHL into an early group (EG) and a late group (LG) revealed that the LG experienced obvious improvements in SHDT and length of stay compared with the EG (P < 0.05). Logistic regression showed that robotic surgery was a significantly protective factor against both SHBL and SHDT (P < 0.05).

CONCLUSION

RSPSHL is safe and feasible, especially after overcoming the early learning curve, as this procedure results in a radical curative effect equivalent to that of LSPSHL.

Systematic review and meta-analysis of splenectomy in gastrectomy for gastric carcinoma

BACKGROUND

The role of splenectomy for patients with gastric cancer still remains controversial. We performed this meta-analysis to evaluate the safety and long-term oncological outcomes of splenectomy for patients with gastric cancer.

METHODS

A systematic literature search was performed using PubMed, EMBASE, Cochrane Library, and Web of Science from January 1997 to October 2018. The results were analyzed according to predefined criteria. All statistical analyses were performed using RevMan 5.3 software.

RESULTS

In total, 16 studies with 4457 patients, including 3 randomized controlled trials (RCTs) and 13 non-randomized controlled trials (nRCTs), were analyzed. The meta-analysis showed the splenectomy group was associated with higher rates of overall postoperative complication, anastomosis leakage, abdominal abscess, and pancreatic fistula. Regarding long-term oncological outcomes, the splenectomy group showed lower 5-year overall survival (OS) and higher recurrence rates on subgroup analysis for the nRCTs. No significant difference was observed in the 5-year OS and recurrence rates between the two groups on subgroup analysis for the RCTs.

CONCLUSIONS

Splenectomy increases postoperative complications without clearly improving long-term prognosis.

Surgical and Long-Term Survival Outcomes After Laparoscopic and Open Total Gastrectomy for Locally Advanced Gastric Cancer: A Propensity Score-Matched Analysis

BACKGROUND

To compare the surgical and long-term survival outcomes of laparoscopic and open total gastrectomy (OTG) for locally advanced gastric cancer (AGC).

METHODS

We retrospectively evaluated 308 and 900 patients in pathological locally AGC who underwent laparoscopic total gastrectomy (LTG) or OTG between June 2008 and December 2014. We compared surgical and long-term outcomes between the two groups using propensity score matching method.

RESULTS

The LTG group showed a longer operation time (261.42 vs. 171.00 min, P = 0.001), less blood loss (185.47 vs. 217.84 ml, P = 0.000), earlier time to first flatus (3.47 vs. 4.12 days, P = 0.000), earlier time to start liquid diet (3.76 vs. 4.27 days, P = 0.000), and shorter postoperative hospital stay (7.56 vs. 8.22 days, P = 0.007). The overall complication rate was 15.2% in the LTG group and 17.2% in the OTG (P = 0.503). No significant difference was observed in overall survival (OS) and disease-free survival (DFS) between LTG and OTG (60.5% vs. 57.1%, P = 0.337; 57.4% vs. 54.4%, P = 0.341).

CONCLUSIONS

Compared to OTG, LTG provides surgical benefits and comparable survival outcomes for patients with locally AGC.

Is it necessary to dissect the posterior lymph nodes along the splenic vessels during total gastrectomy with D2 lymphadenectomy for advanced gastric cancer?

BACKGROUND

D2 lymphadenectomy including No.10 lymph nodes (LNs) is the standard procedure for treating advanced gastric cancer (AGC) via total gastrectomy. However, there was no research focusing on the posterior LN dissection along the splenic vessels (No.10p LNs). This study is performed to assess the effect of dissecting No.10p LNs.

METHODS

We analyzed 404 consecutive gastric cancer patients who underwent laparoscopic total gastrectomy (LTG) with D2 lymphadenectomy. There were 68 patients with No.10p LN dissection (No.10p group), and 336 patients without No.10p LN dissection (nNo.10p group). The surgical outcomes are compared.

RESULTS

No.10p LN dissection was preferentially performed in patients who were younger and had a lower BMI, concentrated and single-branched type of splenic artery, and pancreatic tail near the lower pole of the spleen. The time for No.10 LN dissection and the number of No.10 LNs were greater in the No.10p group than in the nNo.10p group. There was no No.10p LNs metastasis, and the numbers of positive No.10 LNs were similar between the two groups. The morbidity and mortality rates of the No.10p group were comparable to those of the nNo.10p group. The overall survival (OS) rates of the two groups were not significantly different (P > 0.05).

CONCLUSIONS

Although No.10p LN dissection might retrieve more No.10 LNs, operation times were longer, and the number of positive No.10 LNs and the OS rate were not improved. It might be no necessary to dissect No.10p LNs during total gastrectomy with D2 lymphadenectomy for AGC.

Technical pro & cons of the laparoscopic lymphadenectomy

Laparoscopy has been introduced in treatment of gastric cancer to reduce surgical trauma and to improve post-operative functional recovery. Most of international guidelines allow the use of this minimally invasive approach in general surgical practice only in clinical stage I. One of the most important concerns in fact is the feasibility of D2 lymphadenectomy through laparoscopy. Reduced numbers of harvested lymph nodes have been reported, particularly in stations with a more difficult access. Nevertheless subsequent papers reported adequate numbers of total number of nodes retrieved, even with D2 dissection and even in complex stations but results from randomized controlled trials still lack. Laparoscopic approach has been proven safe and effective also in extremely complex maneuvers as spleen-preserving retropancreatic lymphadenectomy. The minimally invasive approach in D2 lymphadenectomy seems to be associated to comparable incidence of specific complications as compared to open surgery. The use of laparoscopy has extended the operating time but has reduced the blood loss. Because of high complexity of this kind surgery, laparoscopic gastric surgery for cancer should be done only in referral centers.