Non-Randomized Confirmatory Trial of Laparoscopy-Assisted Total Gastrectomy and Proximal Gastrectomy with Nodal Dissection for Clinical Stage I Gastric Cancer: Japan Clinical Oncology Group Study JCOG1401

Different Methods of Minimally Invasive Esophagojejunostomy After Total Gastrectomy for Gastric Cancer: Outcomes from Two Experienced Centers

BACKGROUND

Esophagojejunostomy after minimally invasive total gastrectomy (MITG) for gastric cancer (GC) is technically challenging. Failure of the esophagojejunal anastomosis can lead to significant morbidity, leading to short- and long-term quality of life (QoL) impairment or mortality. The optimal reconstruction method following MITG remains controversial. We evaluated outcomes of minimally invasive esophagojejunostomy after laparoscopic or robotic total gastrectomies.

METHODS

We retrospectively reviewed MITG patients between 2015 and 2020 at two high-volume centers in China and the United States. Eligible patients were divided into groups by different reconstruction methods. We compared clinicopathologic characteristics, postoperative outcomes, including complication rates, overall survival rate (OS), disease-free survival rate (DFS), and patient-reported QoL.

RESULTS

GC patients (n = 105) were divided into intracorporeal esophagojejunostomy (IEJ, n = 60) and extracorporeal esophagojejunostomy (EEJ, n = 45) groups. EEJ had higher incidence of wound infection (8.3% vs 13.3%, P = 0.044) and pneumonia (21.7% vs 40.0%, P = 0.042) than IEJ. The linear stapler (LS) group was inferior to the circular stapler (CS) group in reflux [50.0 (11.1-77.8) vs 44.4 (0.0-66.7), P = 0.041] and diarrhea [33.3 (0.0-66.7) vs 0.0 (0.0-66.7), P = 0.045] while LS was better than CS for dysphagia [22.2 (0.0-33.3) vs 11.1 (0.0-33.3), P = 0.049] and eating restrictions [33.3 (16.7-58.3) vs 41.7 (16.7-66.7), P = 0.029] at 1 year. OS and DFS did not differ significantly between LS and CS.

CONCLUSIONS

IEJ anastomosis generated better results than EEJ. LS was associated with a better patient eating experience, but more diarrhea and reflux compared with CS. Clinical and patient-reported outcomes show the superiority of IEJ with the LS reconstruction method in MITG for GC.

Five-year long-term comparison of robotic and laparoscopic gastrectomy for gastric cancer: a large single-center cohort study

BACKGROUND

Robotic gastrectomy (RG) has been reported to be technically feasible and safe for patients with gastric cancer. However, 5-year long-term survival and recurrence outcomes for advanced gastric cancer have rarely been reported. This study aimed to compare the long-term oncologic outcomes between RG and laparoscopic gastrectomy (LG) for gastric cancer.

METHODS

The general clinicopathological data of 1905 consecutive patients who underwent RG and LG were retrospectively collected at the Chinese People's Liberation Army General Hospital between November 2011 and October 2017. Propensity score matching (PSM) was used to match groups. The primary endpoints were 5-year disease-free survival (DFS) and overall survival (OS).

RESULTS

After PSM, a well-balanced cohort of 283 patients in the RG group and 701 patients in the LG group were included in the analysis. The 5-year cumulative DFS rates were 67.28% in the robotic group and 70.41% in the laparoscopic group. The 5-year OS rate was 69.01% in the robotic group and 69.58% in the laparoscopic group. No significant differences in Kaplan-Meier survival curves for DFS (HR = 1.08, 95% CI 0.83-1.39, Log-rank P = 0.557) and OS (HR = 1.02, 95% CI 0.78-1.34, Log-rank P = 0.850) were observed between the 2 groups. In the subgroup analyses for potential confounding variables, there were no significant differences in 5-year DFS and 5-year OS survival between the 2 groups (P > 0.05), except for patients with pathological stage III and pathological stage N3 (P < 0.05).

CONCLUSION

For patients with early gastric cancer, robotic and laparoscopic approaches have similar long-term survival. For patients with advanced gastric cancer, further studies need to be conducted to assess the long-term survival outcomes of RG.

Laparoscopic distal gastrectomy demonstrates acceptable outcomes regarding complications compared to open surgery for gastric cancer patients with pylorus outlet obstruction

Background

For gastric cancer (GC) patients with pylorus outlet obstruction (POO), whether laparoscopic surgery has advantages over open surgery remains unclear. This study aims to investigate the differences between patients with and without POO in open and laparoscopic groups and to determine the differences between laparoscopic distal gastrectomy (LDG) and open distal gastrectomy (ODG) in GC patients with POO.

Methods

A total of 241 GC patients with POO who underwent distal gastrectomy at the Department of Gastric Surgery of the First Affiliated Hospital of Nanjing Medical University between 2016 and 2021 were included in this study. A total of 1,121 non-POO patients who underwent laparoscopic surgery and 948 non-POO patients who underwent open surgery from 2016 to 2021 were also enrolled in the study. We compared complication rates and hospital stays between open and laparoscopic groups.

Results

There was no significant difference for LDG between GC patients with and without POO regarding the overall complication rates (P = 0.063), the Grade III-V complication rate (P = 0.673), and the anastomotic complication rate (P = 0.497) from 2016 to 2021. The patients with POO had longer preoperative hospital stay (P = 0.001) and postoperative hospital stay (P=0.007) compared to patients without POO. No significant difference was observed for open patients between POO and non-POO patients regarding the overall complication rate (P = 0.357), grade III-V complication rate (P = 1.000), and anastomosis-related complication rate (P = 0.766). Compared with open surgery in GC patients with POO (n = 111), the total complication rate of the LDG group was 16.2%, which was significantly lower than that of the open group (26.1%, P = 0.041). No significant differences in the Grade III-V complication rate (P = 0.574) and anastomotic complication rate (P = 0.587) were observed between laparoscopic and open groups. Patients receiving laparoscopic surgery had shorter postoperative hospital stay than open surgery (P = 0.001). More resected lymph nodes (LNs) were also observed in the laparoscopic group (P = 0.0145).

Conclusion

The comorbidity of GC with POO does not increase the complication rate after laparoscopic or open distal gastrectomy. In GC patients with POO, laparoscopic surgery shows advantages over open surgery with a lower overall complication rate, shorter postoperative hospital stay, and more harvested lymph nodes. Laparoscopic surgery is a safe, feasible, and effective treatment for GC with POO.

Analysis of Intestinal Flora and Levels of Epidermal Growth Factor Receptor, Interleukin-32, and Gastrin 17 in Patients with Gastric Cancer via Carbon Nanoparticle Laparoscopy

In order to explore the changes of intestinal flora and serum levels of relevant substances in patients with gastric cancer before and after surgery with carbon nanoparticle laparoscopy, a total of 180 patients with early distal gastric cancer who adopted laparoscopic radical gastrectomy for distal gastric cancer in the general surgery department of TCM Hospital of Shi Jia Zhuang City from January 2018 to January 2020 were selected and randomly divided into two groups: traditional laparoscopic operation (control group) and carbon nanoparticle laparoscopic operation (experimental group) were adopted for treatment for the two groups, respectively. Postoperative evaluation included the difference between the two groups in the operative time, the efficiency of intraoperative lymph node dissection, and the number of lymph node detection. The adverse reactions, changes of intestinal flora before and after surgery in the two groups, and the serum levels of epidermal growth factor receptor (EGFR), interleukin-32 (IL-32), and gastrin 17 were evaluated. In the experimental group, the success rate of carbon nanoparticle tracer black staining reached 100%, and the operation time of the experimental group was significantly shorter than that of the control group (P < 0.05). The lymph node detection rate of the experimental group was higher than that of the control group (P < 0.05), but there was no significant difference in the lymph node metastasis rate between the two groups (P > 0.05). The sentinel lymph node sensitivity of the experimental group reached 92.3%, and the specificity, accuracy, and positive and negative prediction rates reached 100%; the experimental group patients were with an obviously higher incidence of level I-II gastrointestinal reaction (P < 0.05). Postoperative increases in Bifidobacteria and Lactobacillus were observed in both groups, while decreases in Enterococcus and Escherichia coli were observed in both groups (P < 0.05). Moreover, the degree of increase and decrease in the experimental group was greater than that in the control group (P < 0.05). The serum levels of EGFR, IL-32, and gastrin 17 in the two groups were significantly lower than those in the control group on 3 d, 7 d, and 15 d after surgery (P < 0.05). In the radical gastrectomy for distal gastric cancer, carbon nanoparticle laparoscopy was not only helpful for the localization of small tumors but also for the thorough dissection of lymph nodes after the surgery, and the postoperative adverse reactions of carbon nanoparticle laparoscopy were also less, which was of great significance for the improvement of intestinal flora and the reduction of serum levels of EGFR, IL-32, and gastrin 17 in gastric cancer patients.

Surgical and oncological efficacy of laparoscopic-assisted total gastrectomy versus open total gastrectomy for gastric cancer by propensity score matching: a retrospective comparative study

Purpose

The application of laparoscopic-assisted total gastrectomy (LATG) for resectable gastric cancer (GC) remains controversial compared with open total gastrectomy (OTG), especially for advanced gastric cancer (AGC) patients according to the inconsistent results demonstrated in the previous studies. The aim of this study was to evaluate the short-term and long-term outcomes between LATG and OTG in a population with more than 80% AGC patients by applying propensity score matching (PSM) method.

Methods

The data of 365 clinical stage I–III GC cases who underwent total gastrectomy with D2 lymphadenectomy were retrospectively collected from January 2011 to April 2018 in the Department of Gastrointestinal Surgery IV of Peking University Cancer Hospital. Propensity scores were generated through taking all covariates into consideration and 131 pairs of patients receiving either LATG or OTG were matched. Intraoperative, postoperative, and survival parameters were compared in the matched groups accordingly. Risk factors for postoperative complications and overall survival were further analyzed.

Results

Patient characteristics in the LATG and OTG groups were well balanced after PSM. LATG showed advantages with respect to shorter time to ambulation, first flatus, and first whole liquid diet intake. No significant differences were found between the two groups with regard to postoperative complications as well as overall survival in terms of different pathological stage. Older age was found as an independent risk factor for postoperative complications, and pathological stage for overall survival as well.

Conclusion

LATG appears to have comparable surgical and oncological safety with OTG by experienced surgeons.

Surgical treatment of gastric cancer: Current status and future directions

Surgery is the most important and effective method for the treatment of gastric cancer. Since the first gastrectomy in the early 19th century, surgical treatment of gastric cancer has undergone more than 100 years of development. With the increasing understanding of gastric cancer and the promotion of a series of clinical trials, the concept of gastric cancer surgery has evolved from the initial "bigger is better" to today's "standardized surgery" and is developing towards individualized surgery focusing on accurate resection and quality of life. This trend has had a tremendous impact on the development of surgical treatments, such as minimally invasive surgeries, function-preserving surgeries, and the optimal extent of lymph node dissection. Understanding the development and current status of gastric cancer surgery and exploring the remaining academic controversies are goals that every gastric surgeon should constantly pursue. However, how should gastric cancer surgery develop in the future? What opportunities and challenges will we encounter? In this review, we elaborate on the development and current status of gastric cancer surgery based on a series of clinical studies and discuss the controversy in the development of gastric cancer surgery.

Non-flap hand-sewn esophagogastrostomy as a simple anti-reflux procedure in laparoscopic proximal gastrectomy for gastric cancer

AIMS

No ideal and generally accepted method of reconstruction for laparoscopic proximal gastrectomy (LPG) has been established because of a high incidence of postoperative reflux and anastomotic stenosis. The aim of this study was to evaluate the short-term outcomes of LPG with a non-flap hand-sewn technique as a simple anti-reflux procedure for the upper part of clinical Stage I gastric cancer.

METHODS

Between November 2016 and June 2019, 23 consecutive gastric cancer patients, who underwent curative LPG with lymphadenectomy, were enrolled in the study. In this study, we devised a simple hand-sewn technique for esophagogastrostomy, which comprises a 5-cm pseudo-fornix as a fundoplication, the posterior pressure mechanism by the remnant stomach and bilateral crus, and a flat-shaped anastomotic hole as a valvuloplasty.

RESULTS

The median operation time and hospital stay was 325 min and 10 days, respectively. There was no patient with anastomotic leakage and delayed gastric empting. No patient had symptoms of gastroesophageal reflux, but two patients (8.6% (2/23): Grade M and Grade A) had endoscopic findings during a follow-up period of more than 6 months. There was no patient with Grade B or more severe reflux esophagitis. One patient (4.3%, 1/23) developed anastomotic stenosis, which was resolved with endoscopic dilatation. The mean body weight loss at 6 months after surgery was 7.5% in comparison with the preoperative body weight.

CONCLUSION

Our non-flap hand-sewn technique for esophagogastrostomy had favorable outcomes and might be one of reliable techniques as an anti-reflux procedure in LPG for gastric cancer.

Visceral Fat Area (VFA) Superior to BMI for Predicting Postoperative Complications After Radical Gastrectomy: a Prospective Cohort Study

BACKGROUND

Obesity may impact surgical outcomes of gastrectomy. Whether visceral fat area (VFA) is a better obesity parameter than body mass index (BMI) is still controversial. The aim of this study is to compare the accuracy and effectiveness of VFA and BMI in predicting the short-term surgical outcomes of gastrectomy.

METHODS

Patients who were diagnosed with gastric cancer were measured for BMI and VFA preoperatively and then divided into a VFA-H (VFA-high) group and VFA-L (VFA-low) group, at the cutoff point of 100 cm², and a BMI-H (BMI-high) group and BMI-L (BMI-low) group, at the cutoff point of 25 kg/m². The short-term surgical outcomes were compared between the different groups.

RESULTS

In total, 276 patients were enrolled in this study; 55 (19.9%) patients were classified into the BMI-H group, and 122 (44.2%) patients were classified into the VFA-H group. There was a significant correlation between BMI and VFA (r = 0.652, p < 0.001). Compared with the VFA-L group, the VFA-H group had a higher incidence of postoperative complications (31.1% vs. 13.0%; p < 0.001), longer operation duration (270.0 (235.0-305.0) vs. 255.0 (223.8-295.0), p = 0.046), and more blood loss (100.0 (100.0-150.0) vs. 80.0 (80.0-100.0), p < 0.001), while the BMI-H group had more blood loss than the BMI-L group (100.0 (100.0-120.0) vs. 100.0(80.0-100.0), p = 0.006). Logistic regression showed that VFA was an independent risk factor for postoperative complications (odds ratio 2.813, 95% CI 1.523-5.194; p = 0.001).

CONCLUSION

For gastric cancer patients, VFA is superior to BMI in accurately and effectively illuminating the impact of obesity on short-term surgical outcomes.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT02800005.

Single-arm confirmatory trial of laparoscopy-assisted total or proximal gastrectomy with nodal dissection for clinical stage I gastric cancer: Japan Clinical Oncology Group study JCOG1401

BACKGROUNDS

Laparoscopy-assisted distal gastrectomy (LADG) for gastric cancer is safe and feasible. In contrast, no prospective study evaluating the safety and efficacy of laparoscopy-assisted total gastrectomy (LATG) or laparoscopy-assisted proximal gastrectomy (LAPG) has been completed. We conducted a single-arm confirmatory trial to evaluate the safety of LATG/LAPG for clinical stage I (T1N0/T1N1/T2N0) proximal gastric cancer.

METHODS

The extent of lymphadenectomy was selected based on the Japanese Gastric Cancer Treatment Guidelines. The mini-laparotomy incision was required to be ≤ 6 cm. The primary endpoint was the proportion of grade 2-4 (CTCAE ver. 4.0) esophagojejunal anastomotic leakage. The planned sample size was 245 considering a threshold of 8% and one-sided alpha of 2.5%.

RESULTS

Between April 2015 and February 2017, 244 eligible patients were enrolled. LATG/LAPG was performed in 195/49. The proportion of conversions was 1.7%. Clinical T1N0/T1N1/T2N0 was 212/9/23. The extents of lymphadenectomy were as follows: D1+: 229; D2: 15. The median operation time was 309 min (IQR 265-353). The median blood loss was 30 ml (IQR 10-86). Grade 2-4 esophagojejunal anastomotic leakage was 2.5% (6/244; 95% CI 0.9-5.3). The overall proportion of in-hospital grade 3-4 adverse events was 29% (71/244). The proportions of intraabdominal abscess and pancreatic fistula were 3.7% and 2.0%, respectively. There were no treatment-related deaths.

CONCLUSIONS

This trial confirmed the safety of LATG/LAPG. After the non-inferiority of LADG is confirmed in our phase III trial (JCOG0912), LATG/LAPG is expected to be established as one of the standard treatments for clinical stage I gastric cancer.

Comparative analysis of robotic gastrectomy and laparoscopic gastrectomy for gastric cancer in terms of their long-term oncological outcomes: a meta-analysis of 3410 gastric cancer patients

BACKGROUND

Data regarding the long-term oncological outcomes of robotic gastrectomy (RG) are limited despite the increased commonality of this method as an alternative for gastric cancer treatment. Here, we conducted a meta-analysis to evaluate the long-term oncological outcomes of RG in comparison to that of laparoscopic gastrectomy (LG).

METHODS

The PubMed, ISI Web of Science, EMBASE, and Cochrane Library databases were comprehensively searched for studies that compared RG and LG in terms of their long-term survival outcomes. The hazard ratios (HRs) of overall survival (OS), disease-free survival (DFS), and relapse-free survival (RFS) were obtained, while the odds ratio (OR) was recorded for the recurrence rate. A sensitivity analysis was performed. Egger's test and Begg's test were applied to evaluate publication bias.

RESULTS

Eight studies were identified and involved 3410 gastric cancer patients (RG, 1009; LG, 2401). The two groups had no significant differences in OS (HR, 0.98; 95% CI, 0.80-1.20; P = 0.81), DFS (HR, 1.36; 95% CI, 0.33-5.59; P = 0.67), RFS (HR, 0.92; 95% CI, 0.72-1.19; P = 0.53), or recurrence rate (OR, 0.92; 95% CI, 0.71-1.19; P = 0.53). Moreover, the two techniques were comparable in length of hospital stay (LOS), postoperative complication rate, 30-day mortality rate, and rate of conversion to open surgery.

CONCLUSIONS

The long-term oncological outcomes, expressed as OS, DFS, RFS, and recurrence rate, were similar between RG and LG. However, more randomized controlled trials with rigorous study designs and patient cohorts are needed to evaluate the oncologic outcomes of RG in patients with gastric cancer.

Obesity is a risk factor for internal hernia after laparoscopic or robot-assisted gastrectomy with mesenteric defect closure for gastric cancer

BACKGROUND

Internal hernia (IH) is a life-threatening complication after gastrectomy. The increase in the frequency of minimally invasive surgery is considered to be related to the increase in the frequency of IH, and mesenteric defect closure has been recommended to reduce this complication. However, IH can occur even when mesenteric defects are closed, so the risk of IH in the patients with mesenteric closure remains uncertain. We attempted to clarify the risk factors for IH in these patients.

METHODS

From 2013 to 2017, we retrospectively reviewed 310 patients with gastric cancer who underwent laparoscopic or robot-assisted gastrectomy with Roux-en-Y (RY) or double-tract (DT) reconstruction with mesenteric defect closure. Univariate and multivariate analyses were performed to identify the risk factors.

RESULTS

The incidence of IH was 1.3% (n = 4). A preoperative body mass index (BMI) ≥ 25 kg/m² (p = 0.044), postoperative chemotherapy (p = 0.034), and body weight loss rate at 6 months ≥ 15% (p = 0.045) were risk factors for IH on a univariate analysis. A multivariate analysis showed that a BMI at the time of surgery of ≥ 25 kg/m² was an independent risk factor for IH (odds ratio = 11.9, p = 0.049).

CONCLUSIONS

Preoperative obesity is an independent risk factor for IH after minimally invasive gastrectomy followed by RY or DT reconstruction with mesenteric defect closure. We need to conduct vigilant follow-up for IH, especially in these patients.

Introducing laparoscopic total gastrectomy for gastric cancer in general practice: a retrospective cohort study based on a nationwide registry database in Japan

BACKGROUND

Although laparoscopic total gastrectomy (LTG) is considered a technically demanding procedure with safety issues, it has been performed in several hospitals in Japan. Data from a nationwide web-based data entry system for surgical procedures (NCD) that started enrollment in 2011 are now available for analysis.

METHODS

A retrospective cohort study was conducted using data from 32,144 patients who underwent total gastrectomy and were registered in the NCD database between January 2012 and December 2013. Mortality and morbidities were compared between patients who received LTG and those who underwent open total gastrectomy (OTG) in the propensity score-matched Stage I cohort and Stage II-IV cohort.

RESULTS

There was no significant difference in mortality rate between LTG and OTG in both cohorts. Operating time was significantly longer in LTG while the blood loss was smaller. In the Stage I cohort, LTG, performed in 33.6% of the patients, was associated with significantly shorter hospital stay but significantly higher incidence of readmission, reoperation, and anastomotic leakage (5.4% vs. 3.6%, p < 0.01). In the Stage II-IV cohort, LTG was performed in only 8.8% of the patients and was associated with significantly higher incidence of leakage (5.7% vs. 3.6%, p < 0.02) although the hospital stay was shorter (15 days vs. 17 days, p < 0.001).

CONCLUSION

LTG was more discreetly introduced than distal gastrectomy, but remained a technically demanding procedure as of 2013. This procedure should be performed only among the well-trained and informed laparoscopic team.

Circular versus linear stapling in esophagojejunostomy after laparoscopic total gastrectomy for gastric cancer: a propensity score-matched study

PURPOSE

We used propensity score matching to compare the complication rates after laparoscopic total gastrectomy (LTG) with esophagojejunostomy (EJS) performed using a circular or a linear stapler.

METHODS

We retrospectively enrolled all patients who underwent curative LTG between November 2004 and March 2016. Patients were categorized into the circular and linear groups according to the stapler type used for the subsequent EJS. Patients in the groups were matched using the following propensity score covariates: age, sex, body mass index, American Society of Anesthesiologists physical status, extent of lymph node dissection, and Japanese Classification of Gastric Carcinoma stage. Clinicopathological characteristics and surgical outcomes were compared.

RESULTS

We identified 66 propensity score-matched pairs among 379 patients who underwent LTG. There was no significant between-group difference in the median operative time, extent of lymph node dissection, number of lymph nodes resected, rate of conversion to open surgery, or number of surgeries performed by a surgeon certified by the Japanese Society of Endoscopic Surgery. In the circular and linear groups, the rate of all complications (Clavien-Dindo [CD] classification ≥ I; 21 vs. 26%, respectively; p = 0.538), complications more severe than CD grade III (14 vs. 14%, respectively; p = 1.000), and occurrence of EJS leakage and stenosis more severe than CD grade III (5 vs. 2%, p = 0.301; 9 vs. 8%, p = 0.753, respectively) were comparable.

CONCLUSIONS

There is no difference in the postoperative complication rate related to the type of stapler used for EJS after LTG.

Comparisons of short-term and survival outcomes of laparoscopy-assisted versus open total gastrectomy for gastric cancer patients

OBJECTIVES

The safety and surgical oncology of laparoscopy-assisted total gastrectomy (LATG) remain inconclusive and challenging. This study aimed to compare the short-term and long-term outcomes between LATG and open total gastrectomy (OTG) procedures.

RESULTS

In the all-included analyses, there were 69 patients in the LATG group and 268 in the OTG group. LATG was as safe as OTG without increasing postoperative morbidity and mortality. Stage imbalance might introduce differences in the numbers of harvested lymph nodes in LATG (34.4 ± 12.0) and OTG (40.9 ± 16.9), whereas 95.7% of patients underwent D2/D2+ dissection during the LATG procedure. After a median 31 months of follow-up, the overall survival outcomes were comparable between the LATG and OTG procedures (HR = 1.16, 95% CI 0.68-1.97). Sensitivity analysis found comparable node retrieval and stage-specific or treatment-specific overall survival.

MATERIALS AND METHODS

A retrospective case-control study was conducted among gastric cancer patients who underwent either LATG or OTG with curative intention between June 2006 and December 2015. Data retrieval was based on the Surgical Gastric Cancer Patient Registry in the West China Hospital. The primary outcome was overall survival. The secondary outcomes were postoperative complication incidence and severity, operation duration, blood loss, number of harvested lymph nodes, and postoperative hospital stay. Matched pairwise case-control comparisons were performed as a sensitivity analysis.

CONCLUSIONS

LATG by experienced surgeons possibly has comparable short-term surgical outcomes and long-term survival outcomes compared with OTG for gastric cancer patients. However, high-quality RCTs are necessary before confirmative judgment and recommendation as an optional treatment in general practice.

Long- and short-term outcomes of laparoscopic gastrectomy versus open gastrectomy in patients with clinically and pathological locally advanced gastric cancer: a propensity-score matching analysis

BACKGROUND

Laparoscopic (laparoscopy-assisted) gastrectomy (LG) has several short-term benefits as compared with open distal gastrectomy (OG) in patients with advanced gastric cancer (AGC). Survival rates did not differ significantly between LG and OG in retrospective studies of AGC, although some studies included unmatched groups of patients or patients with AGC who had a preoperative diagnosis of early gastric cancer. The aim of present study was to compare the short- and long-term outcomes of patients with AGC who underwent LG with those of patients with AGC who underwent OG using a propensity-score matching analysis.

METHODS

The study group comprised patients with a preoperative and pathologically confirmed diagnosis of AGC who underwent LG or OG with lymphadenectomy between January 2001 and December 2012 in our hospital. To minimize bias between the LG and OG groups, propensity scores were calculated using a logistic regression model and the following variables: sex, age, body-mass index, American Society of Anesthesiologists physical status class, type of gastrectomy, and clinical and pathological tumor stage. After propensity-score matching, 104 patients (52 who underwent LG and 52 who underwent OG) were studied.

RESULTS

LG was associated with significantly earlier initiation of food intake (p <0.01) and a significantly shorter period of postoperative hospitalization (p <0.01). The incidence of all-grade overall, surgical, and medical complications did not differ significantly between the LG group and OG group (p = 0.24, p = 0.12, and p >0.99). Overall and relapse-free survival also did not differ between the LG group and OG group (p = 0.96, p = 0.91). In each tumor stage, overall and relapse-free survival did not differ significantly between the LG group and OG group.

CONCLUSION

LG can be a feasible treatment that is beneficial in terms of earlier recovery after operation and can be expected to result in similar survival as OG in patients with AGC.

Feasibility and diagnostic performance of dual-tracer-guided sentinel lymph node biopsy in cT1-2N0M0 gastric cancer: a systematic review and meta-analysis of diagnostic studies

BACKGROUND

Dual-tracer-guided sentinel lymph node (SLN) biopsy may provide a promising diagnostic tool to assess accurately the status of lymph node metastasis in the surgical operation and assure the oncologic safety of the function or stomach preserving surgery. The diagnostic performance of this technology in recent studies varied. Thus, we conducted this meta-analysis.

METHODS

This systematic review and meta-analysis was registered at the PROSPERO. Eligible studies were searched in the PubMed, EMBASE, Web of Knowledge, and Cochrane Library databases. A random-effect model was used to pool the data. Summary receiver operator characteristic curves, analysis for publication bias, meta-regression, and subgroup analysis were also performed.

RESULTS

The pooled SLN identification rate and sensitivity were 0.97 and 0.89. ^99mTc-human serum albumin with indocyanine green (ICG), ^99mTc-antimony sulfur colloid with ICG, performing SLN biopsy ≥15 min after dye injection, an SLN ≥5, the basin dissection, laparoscopic surgery, in studies conducted in Japan and studies published after 2012, were associated with higher sensitivity. CT1 stage, performing SLN biopsy ≥15 min after dye injection, in studies conducted in Japan and studies published after 2012, were related with a higher identification rate.

CONCLUSIONS

Dual tracer is promising in SLN biopsy in gastric cancer, and the clinical application of SLN biopsy should be limited to the patients of cT1N0M0 gastric cancer. The combination of ^99mTc-human serum albumin and ICG as well as the combination of ^99mTc-antimony sulfur colloid and ICG may be the optimal tracer combination. However, it seems not justified to put this technique into routine clinical application recently. Some factors that might enhance diagnostic value are identified.

Can Robotic Gastrectomy Surpass Laparoscopic Gastrectomy by Acquiring Long-Term Experience? A Propensity Score Analysis of a 7-Year Experience at a Single Institution

PURPOSE

It is hypothesized that robotic gastrectomy may surpass laparoscopic gastrectomy after the operators acquire long-term experience and skills in the manipulation of robotic arms. This study aimed to evaluate the long-term learning curve of robotic distal gastrectomy (RDG) for gastric cancer compared with laparoscopic distal gastrectomy (LDG).

MATERIALS AND METHODS

From October 2008 to December 2015, patients who underwent LDG (n=809) were matched to patients who underwent RDG (n=232) at a 1:1 ratio, by using a propensity score matching method after stratification for the operative year. The surgical outcomes, such as trends of operative time, blood loss, and complication rate, were compared between the two groups.

RESULTS

The RDG group showed a longer operative time (171.3 minutes vs. 147.6 minutes, P<0.001) but less estimated blood loss (77.6 ml vs. 116.6 ml, P<0.001). The complication rate and postoperative recovery did not differ between the two groups. The RDG group showed a longer operative time and similar estimated blood loss compared with the LDG group after 5 years of experience (operative time: 159.2 minutes vs. 136.0 minutes in 2015, P=0.003; estimated blood loss: 72.9 ml vs. 78.1 ml in 2015, P=0.793).

CONCLUSIONS

In terms of short-term surgical outcomes, RDG may not surpass LDG after a long-term experience with the technique.

Postoperative Complications of Laparoscopic Total Gastrectomy versus Open Total Gastrectomy for Gastric Cancer in a Meta-Analysis of High-Quality Case-Controlled Studies

Background. Some meta-analyses of case-controlled studies (CCSs) have shown that laparoscopic or laparoscopy-assisted total gastrectomy (LTG) had some short-term advantages over open total gastrectomy (OTG). However, postoperative complications differed somewhat among the meta-analyses, and some CCSs included in the meta-analyses had mismatched factors between LTG and OTG. Methods. CCSs comparing postoperative complications between LTG and OTG were identified in PubMed and Embase. Studies matched for patients' status, tumor stage, and the extents of lymph-node dissection were included. Outcomes of interest, such as anastomotic, other intra-abdominal, wound, and pulmonary complications, were evaluated in a meta-analysis performed using Review Manager version 5.3 software. Result. This meta-analysis included a total of 2,560 patients (LTG, 1,073 patients; OTG, 1,487 patients) from 15 CCSs. Wound complications were significantly less frequent in LTG than in OTG (n = 2,430; odds ratio [OR] 0.30, 95% confidence interval [CI] 0.29-0.85, P = 0.01, I2 = 0%, and OR 0.46, 95% CI 0.17-0.52, P < 0.0001, I2 = 0%). However, the incidence of anastomotic complications was slightly but not significantly higher in LTG than in OTG (n = 2,560; OR 1.44, 95% CI 0.96-2.16, P = 0.08, I2 = 0%). Conclusion. LTG was associated with a lower incidence of wound-related postoperative complications than was OTG in this meta-analysis of CCSs; however, some concern remains about anastomotic problems associated with LTG.