Outcomes of Laparoscopic Total Gastrectomy for Elderly Gastric Cancer Patients

The Role of Patient-Controlled Epidural Analgesia in the Short-Term Outcomes of Laparoscopic-Assisted Gastrectomy in Elderly Gastric Cancer Patients

INTRODUCTION

Patient-controlled intravenous analgesia (PCIA) and patient-controlled epidural analgesia (PCEA) constitute two major advances in pain management after major abdominal surgery. However, the role of PCIA or PCEA has not been particularly studied in elderly patients with gastric cancer. The aim of this study is to make a comparison between PCIA and PCEA in terms of their performance on short-term outcomes in elderly patients undergoing laparoscopic-assisted gastrectomy.

METHODS

This single-center, retrospective study included 254 elderly patients (≥70 y) who underwent laparoscopic radical gastrectomy for gastric cancer. Patients received either general anesthesia combined with epidural anesthesia followed by PCEA (PCEA group, n = 123) or general anesthesia alone followed by PCIA (PCIA group, n = 131). The primary endpoint was pain intensity-tested using a 100-mm visual analog scale on postoperative days 1, 2, and 3. Demographics, comorbidities, perioperative data, postoperative short-term outcomes, and analgesia-related side effects were also assessed.

RESULTS

The visual analog scale scores at rest were lower in the PCEA group compared to the PCIA group on postoperative day 1, 2, and 3 (27.8 ± 13.9 versus 33.1 ± 15.0, P = 0.004; 25.2 ± 11.3 versus 30.1 ± 14.3, P = 0.002; 16.9 ± 7.1 versus 20.9 ± 9.5, P < 0.001, respectively). The postoperative hospital stay was shorter in the PCEA group than in the PCIA group (11 versus 12 d, P = 0.018). The times to postoperative first flatus, semifluid diet, independent ambulation, and tracheal extubation after surgery in the PCEA group were significantly shorter than in the PCIA group. Overall morbidity, mortality, hospital readmission rate, and reoperation rate were not significantly different between the two groups. Regarding side-effects related to analgesia, there were no significant differences in terms of the rates of postoperative nausea and vomiting, urinary retention, or oxygen saturation <90% between the two groups. However, PCEA was associated with a higher incidence of postoperative hypotension compared to PCIA (10.6% versus 3.8%, P = 0.036).

CONCLUSIONS

In elderly patients undergoing laparoscopic radical gastrectomy, epidural anesthesia and analgesia may convey superior pain relief, faster restoration of gastrointestinal motility, and shorter hospitalization.

Association of high-risk comorbidity with overall survival among patients with gastric cancer and its sex-specific differences in China: a retrospective observational cohort study

BACKGROUND

Concomitant diseases often occur in cancer patients and are important in decision-making regarding treatments. However, information regarding the prognostic relevance of comorbidities for mortality risk is still limited among Chinese gastric cancer (GC) patients. This study aimed to investigate the association between comorbidities and 3-year mortality risk.

METHODS

This retrospective study enrolled 376 GC patients undergoing radical gastrectomy at the Affiliated Zhongshan Hospital of Dalian University from January 2011 to December 2019. Demographic and clinicopathological information and treatment outcomes were collected. Patients were divided into low-, moderate- and high-risk comorbidity groups based on their Charlson Comorbidity Index (CCI) and age-adjusted CCI (ACCI) scores. Kaplan-Meier survival and Cox regression analyses were used to examine 3-year overall survival (OS) and mortality risk for each group.

RESULTS

The median follow-up time was 43.5 months, and 40.2% (151/376) of GC patients had died at the last follow-up. There were significant differences in OS rates between ACCI-based comorbidity groups (76.56; 64.51; 54.55%, log-rank P = 0.011) but not between CCI-based comorbidity groups (log-rank P = 0.16). The high-risk comorbidity group based on the ACCI remained a significant prognostic factor for 3-year OS in multivariate analysis, with an increased mortality risk (hazard ratio [HR], 1.99; 95% CI, 1.15-3.44). Subgroup analysis revealed that this pattern only held for male GC patients but not for female patients.

CONCLUSION

The present study suggested that high-risk comorbidities were significantly associated with a higher mortality risk, particularly in Chinese male GC patients. Moreover, the ACCI score was an independent prognostic factor of long-term mortality.

Advantages of Function-Preserving Gastrectomy for Older Patients With Upper-Third Early Gastric Cancer: Maintenance of Nutritional Status and Favorable Survival

PURPOSE

The incidence of early gastric cancer is increasing in older patients alongside life expectancy. For early gastric cancer of the upper third of the stomach, laparoscopic function-preserving gastrectomy (LFPG), including laparoscopic proximal gastrectomy (LPG) and laparoscopic subtotal gastrectomy (LSTG), is expected to be an alternative to laparoscopic total gastrectomy (LTG). However, whether LFPG has advantages over LTG in older patients remains unknown.

MATERIALS AND METHODS

We retrospectively analyzed data of consecutive patients aged ≥75 years who underwent LTG, LPG, or LSTG for cT1N0M0 gastric cancer between 2005 and 2019. Surgical and nutritional outcomes, including blood parameters, percentage body weight (%BW) and percentage skeletal muscle index (%SMI) were compared between LTG and LPG or LSTG. Survival outcomes were also compared between LTG and LFPG groups.

RESULTS

A total of 111 patients who underwent LTG (n=39), LPG (n=48), and LSTG (n=24) were enrolled in this study. To match the surgical indications, LTG was further categorized into "LTG for LPG" (LTG-P) and "LTG for LSTG" (LTG-S). No significant differences were identified in the incidence of postoperative complications among the procedures. Postoperative nutritional parameters, %BW and %SMI were better after LPG and LSTG than after LTG-P and LTG-S, respectively. The survival outcomes of LFPG were better than those of LTG.

CONCLUSIONS

LFPG is safe for older patients and has advantages over LTG in terms of postoperative nutritional parameters, body weight, skeletal muscle-sparing, and survival. Therefore, LFPG for upper early gastric cancer should be considered in older patients.

Is surgery the best treatment for elderly gastric cancer patients?

As the elderly population increases, the number of patients with gastric cancer has also been increasing. Elderly people have various preoperative problems such as malnutrition, high frequency of comorbidities, decreased performance status, and dementia. Furthermore, when surgery is performed, high postoperative complication rates and death from other diseases are also concerns. The goal of surgery in the elderly is that short-term outcomes are comparable to those in nonelderly, and long-term outcomes reach life expectancy. Perioperative problems in the elderly include: (1) Poor perioperative nutritional status; (2) Postoperative pneumonia; and (3) Psychological problems (dementia and postoperative delirium). Malnutrition in the elderly has been reported to be associated with increased postoperative complications and dementia, pointing out the importance of nutritional management. In addition, multidisciplinary team efforts, including perioperative respiratory rehabilitation, preoperative oral care, and early postoperative mobilization programs, are effective in preventing postoperative pneumonia. Furthermore, there are many reports on the usefulness of laparoscopic surgery for the elderly, and we considered that minimally invasive surgery would be the optimal treatment after assessing preoperative risk.

Short-term outcomes of laparoscopic versus open total gastrectomy after neoadjuvant chemotherapy: a cohort study using the propensity score matching method

Background

Until now, little is known about the benefit of laparoscopic total gastrectomy (LTG) after neoadjuvant chemotherapy (NACT). This study was designed to compare the safety and efficacy of the LTG versus the open total gastrectomy (OTG) approach after NACT treatment in patients with advanced gastric cancer (AGC).

Methods

This study involved a cohort of 145 patients with AGC who underwent total gastrectomy after NACT at our centre between April 2013 and August 2018 including 24 cases of LTG and 121 OTG. The baseline characteristics were matched based on 1:2 balanced propensity score-matching method.

Results

Sixty-nine marched cases were finally analysed (23 LTG vs. 46 OTG). All patients underwent R0 resection. Compared to the OTG group, the LTG group had a longer surgery duration (P<0.001), but a shorter incision length (P<0.001) and less intravenous patient-controlled analgesia (IV-PCA) time after surgery (P=0.027). No statistical differences were observed in terms of blood loss, retrieved lymph nodes (LNs), resection margin, length of stay, postoperative pain intensity, and complications (P>0.05).

Conclusions

LTG had comparable safety and histological findings to OTG after NACT in the perioperative period; however, LTG is less invasive and patients can benefit from less IV-PCA use. Further research is needed to investigate long-term effects.

Keywords

Gastric cancer (GC); neoadjuvant chemotherapy (NACT); safety; laparoscopic technique.

Evaluation of the Implementation of FDG-PET/CT and Staging Laparoscopy for Gastric Cancer in The Netherlands

BACKGROUND

The role of 18F-fluorodeoxyglucose positron emission tomography with computed tomography (FDG-PET/CT) and staging laparoscopy (SL) has increased in the preoperative staging of gastric cancer. Dutch national guidelines have recommended the use of FDG-PET/CT and SL for patients with locally advanced tumors since July 2016.

OBJECTIVE

The aim of this study was to evaluate the implementation of FDG-PET/CT and SL in The Netherlands.

METHODS

Between 2011 and 2018, all patients who underwent surgery for gastric cancer were included from the Dutch Upper GI Cancer Audit. The use of FDG-PET/CT and SL was evaluated before and after revision of the Dutch guidelines. Outcomes included the number of non-curative procedures (e.g. palliative and futile procedures) and the association of FDG-PET/CT and SL, with waiting times from diagnosis to the start of treatment.

RESULTS

A total of 3310 patients were analyzed. After July 2016, the use of FDG-PET/CT (23% vs. 61%; p < 0.001) and SL (21% vs. 58%; p < 0.001) increased. FDG-PET/CT was associated with additional waiting time to neoadjuvant therapy (4 days), as well as primary surgical treatment (20 days), and SL was associated with 8 additional days of waiting time to neoadjuvant therapy. Performing SL or both modalities consecutively in patients in whom it was indicated was not associated with the number of non-curative procedures.

CONCLUSION

During implementation of FDG-PET/CT and SL after revision of the guidelines, both have increasingly been used in The Netherlands. The addition of these staging methods was associated with increased waiting time to treatment. The number of non-curative procedures did not differ after performing none, solely one, or both staging modalities.

Enhanced Recovery after Surgery in Elderly Gastric Cancer Patients Undergoing Laparoscopic Total Gastrectomy

BACKGROUND

The aim of this study was to evaluate the effects of the enhanced recovery after surgery (ERAS) program versus conventional perioperative care on the short-term postoperative outcomes among elderly patients with gastric cancer who are undergoing laparoscopic total gastrectomy.

METHODS

Elderly patients with gastric cancer (age ≥ 65 y) who are undergoing laparoscopic total gastrectomy were randomized to ERAS or conventional perioperative care groups. Short-term postoperative outcomes, including postoperative hospital stay, mortality, complications, readmission rate, and reoperation rate were compared between the two groups. In addition, blood samples were taken preoperatively (baseline) and on postoperative days 1, 3, and 5. Systemic human leukocyte antigen (HLA)-DR expression on monocytes and C-reactive protein (CRP) were analyzed.

RESULTS

Of the 171 eligible patients, 85 patients were assigned to receive ERAS program treatment (ERAS group) and 86 patients to receive conventional care (conventional group). The patients' characteristics were comparable. Postoperative hospital stay was shorter in the ERAS group than in the conventional group (11 [7-11] versus 13 [8-20] d, P < 0.001). Hospital mortality, overall morbidity, morbidity ≥ Clavien-Dindo (C-D) grade II, readmission rate, and reoperation rate did not show significant differences between the two groups. However, morbidity ≥ C-D grade IIIa was lower in the ERAS group than that in the conventional group (8.2% versus 18.6%, P = 0.047). The ERAS program shortened the number of days to postoperative first flatus, first defecation, semifluid diet, and soft bland diet. Moreover, the ERAS program increased the HLA-DR expression on monocytes and decreased the CRP levels on postoperative days 1, 3, and 5.

CONCLUSIONS

The ERAS program was feasible and effective for elderly patients with gastric cancer who are undergoing laparoscopic total gastrectomy. The benefits of ERAS were associated with improvement of impaired immune function and suppression of inflammatory reaction.

Evaluation of Peroperative and Oncological Results in Laparoscopic Surgery of Gastric Cancer in Elderly Patients: Single-Center Study

Introduction: Laparoscopic treatment of gastric cancer in elderly patients is still controversial. The aim of this retrospective study is to evaluate the safety and feasibility of laparoscopic gastrectomy in elderly gastric cancer patients based on the long- and short-term results of laparoscopic surgery. Materials and Methods: The data of 163 patients who underwent laparoscopic gastrectomy for gastric cancer. Patients were categorized into two groups by age based on World Health Organization (WHO) criteria: elderly (≥65 years, 80 cases) and nonelderly (<65 years, 83 cases). Patient characteristics and clinicopathological findings, surgical findings, short- and long-term results were compared between the two groups. Results: The patients in the study group were in the age range of 22-87 years and 80 (49%) patients were found out to be 65 years old or older. When all complications were categorized according to Clavien-Dindo (C-D) classification, >3 serious complication rates were similar between groups (P = .421). Although the length of hospital stay and the need for intensive care were higher in the elderly group, the difference was not significant (P = .066; P = .072). There was no significant difference between the two in terms of in-hospital mortality (P = .364). No statistically significant differences were found in the rates of overall survival (nonelderly group; 61.17 ± 3.34, 95% confidence interval [CI]: 54.61-67.74 versus elderly group; 56.48 ± 3.80, 95% CI: 49.03-63.93; P = .176) and disease-specific survival (nonelderly group; 64.24 ± 3.15, 95% CI: 58.06-70.40 versus elderly group; 61.93 ± 3.57, 95% CI: 54.93-68.93; P = .363) between the age groups. Conclusion: In conclusion, although laparoscopic gastrectomy is a feasible and safe method in elderly gastric cancer patients, further randomized prospective studies are needed.

Laparoscopic Total Gastrectomy for Gastric Cancer in Elderly Patients

BACKGROUND/AIM

The purpose of this study was to evaluate the safety and efficacy of laparoscopic total gastrectomy (LTG) for elderly patients.

PATIENTS AND METHODS

We retrospectively analyzed 136 patients who underwent LTG. We divided the patients into elderly patients (>75 years of age) and non-elderly patients (≤75 years of age).

RESULTS

The American Society of Anesthesiologists score, Charlson comorbidity index, Glasgow Prognostic Score and rate of comorbidities were higher in the elderly group; the rates of other clinicopathological characteristics did not differ between the two groups. Regarding the nutritional status, the body weight loss rate in the elderly group was higher in comparison to the non-elderly group (81% vs. 84%, p=0.004). The disease-specific survival (DSS) did not differ between two groups to a statistically significant extent (3-year DSS rates: 83.7 vs. 94.5%; p=0.152).

CONCLUSIONS

LTG was acceptable for elderly patients as the elderly and non-elderly groups showed comparable short-term and long-term outcomes.

Upregulation of Cullin 4B Promotes Gastric Cancer and Predicts Poor Prognosis

Aim

Cullin 4B (CUL4B) is a member of the cullin ubiquitin-ligase family, which participates in proteolysis. Aberrant CUL4B expression has been shown in many malignancies. This study aimed to elucidate oncogenic role of CUL4B in gastric cancer (GC).

Methods

CUL4B expression in GC tissues was examined by RT-PCR and immunohistochemistry. The proliferation, invasion and tumorigenicity of GC cells with CUL4B overexpression or knockdown were evaluated.

Results

CUL4B expression significantly increased in GC tissues, and was correlated to UICC stage and differentiation of GC, as well as poor overall survival and disease-free survival. Both univariate and multivariate analysis identified CUL4B as an independent predictor for GC patient prognosis. In addition, CUL4B promoted GC cell proliferation and invasion in vitro and tumor formation in vivo.

Conclusion

CUL4B is overexpressed to promote GC development and progression. CUL4B is a promising prognostic marker and therapeutic target for GC.

Short-term outcomes and prognosis of laparoscopy-assisted total gastrectomy in elderly patients with stomach cancer

BACKGROUND

The aim of this study was to evaluate the short-term outcomes and prognosis of laparoscopy-assisted total gastrectomy (LTG) in elderly patients with gastric cancer.

METHODS

The clinical data of 275 patients aged over 65 years undergoing open total gastrectomy (OTG, n = 184) or laparoscopy-assisted total gastrectomy (LTG, n = 91) were reviewed from January 2015 to August 2017 at the First Affiliated Hospital of the University of Science and Technology of China. Short-term outcomes were compared between the two groups, and risk factors for postoperative complications were explored. In addition, the 2-year overall survival (OS) and disease-free survival (DFS) were investigated for both groups.

RESULTS

Except for the ASA score (P = 0.01), there was no significant difference regarding patient baselines between the two groups. Patients in the LTG group had a longer operative time (P < 0.001), less intraoperative blood loss (P = 0.004), a shorter time of resumption to a semi-liquid diet (P < 0.001) and a shorter postoperative hospital stay (P = 0.001). The incidence of pulmonary complications was significantly lower in the LTG group than in the OTG group (4.4% vs. 13%, P = 0.026). The number of lymph nodes harvested in the LTG group was higher than that in the OTG group (20.7 ± 7.4 vs. 17.5 ± 6.9, P = 0.001), and the proportion of patients with TNM stage III gastric cancer was higher in the LTG group than in the OTG group (P = 0.035). There was no significant difference in the 2-year OS rate or 2-year DFS rate between the two groups (P = 0.057 and P = 0.344). Sex, age, preoperative comorbidity, intraoperative blood loss, and TNM stage were identified as independent prognostic factors for postoperative survival.

CONCLUSION

Comparing with OTG, LTG is feasible and contributes to less surgical trauma and a faster recovery after total gastrectomy. In addition, LTG contributes to a lower risk of postoperative pulmonary complications. Regarding oncological results, LTG is more effective for lymph node dissection and has a comparable long-term prognosis as OTG.