Laparoscopic total gastrectomy versus open total gastrectomy for cancer: a systematic review and meta-analysis

Learning curve of laparoscopic and robotic total gastrectomy: A systematic review and meta-analysis

PURPOSE

Minimally-invasive total gastrectomy (MITG) is associated with lower morbidity in comparison to open total gastrectomy but requires a learning curve (LC). We aimed to perform a pooled analysis of the number of cases required to surmount the LC (NLC) in MITG.

METHODS

A systematic review of PubMed, Embase, Scopus and the Cochrane Library from inception until August 2022 was performed for studies reporting the LC in laparoscopic total gastrectomy (LTG) and/or robotic total gastrectomy (RTG). Poisson mean (95% confidence interval [CI]) was used to determine the NLC. Negative binomial regression was performed as a comparative analysis.

RESULTS

There were 12 articles with 18 data sets: 12 data sets (n = 1202 patients) on LTG and 6 data sets (n = 318 patients) on RTG. The majority of studies were conducted in East Asia (94.4%). The majority of the data sets (n = 12/18, 66.7%) used non-arbitrary analyses. The NLC was significantly smaller in RTG in comparison to LTG [RTG 20.5 (95% CI 17.0-24.5); LTG 43.9 (95% CI 40.2-47.8); incidence rate ratio 0.47, p < 0.001]. The NLC was comparable between totally-laparoscopic total gastrectomy (TLTG) and laparoscopic-assisted total gastrectomy (LATG) [LATG 39.0 (95% CI 30.8-48.7); TLTG 36.0 (95% CI 30.4-42.4)].

CONCLUSIONS

The LC for RTG was significantly shorter for LTG. However existing studies are heterogeneous.

[Prophylactic gastrectomy]

One to 3% of gastric cancers are secondary to genetic predisposition, notably hereditary diffuse gastric cancers (HDGC) caused by CDH1 gene mutations. According to French recommendations, in case of CDH1 gene mutation, a prophylactic total gastrectomy should be performed between 20 and 30 years old. This gastrectomy should remove all the gastric mucosa at both extremities (duodenal and esophageal sides). Histopathological examinations of prophylactic total gastrectomies in asymptomatic CDH1-mutated patients reveal microscopic foci of diffuse-type cancer in 90 to 100% of cases. Lymph node involvement and lympho-vascular invasion are extremely rare, justifying the use of a D1-only lymphadenectomy. In the context of prophylaxis, limited lymphadenectomy and the development of minimally invasive oesogastric surgery, the minimally invasive approach might be the preferred approach, in expert centers. Surgical outcomes seem to be similar to those after gastrectomy for cancer. Prophylactic total gastrectomy is the cornerstone of CGDH management, associated with multidisciplinary follow-up and mammary surveillance in women.

Accuracy of the ACS NSQIP Surgical Risk Calculator for Predicting Postoperative Complications in Gastric Cancer Following Open Gastrectomy

INTRODUCTION

The prediction of complications before gastric surgery is of utmost importance in shared decision making and proper counseling of the patient in order to minimize postoperative complications. Our aim was to evaluate the predictive validity of American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) risk calculator in gastric cancer patients who underwent gastrectomy.

METHODS

Preoperative assessment data of 432 patients were retrospectively reviewed and manually entered into the calculator. The accuracy of the calculator was evaluated using Pearson's chi-squared test, C-statistic, Brier score, and Hosmer-Lemeshow test.

RESULTS

The lowest Brier scores were observed in urinary tract infection, renal failure, venous thromboembolism, pneumonia, and cardiac complications. Best results were obtained for predicting sepsis, discharge to rehabilitation facility, and death (low Brier scores, C-statistic >.7, and Hosmer-Lemeshow P > .05).

CONCLUSION

The calculator had a strong performance in predicting sepsis, discharge to the rehabilitation facility, and death. However, it performed poor in predicting the most commonly observed events (any or serious complication and surgical site infection).

A Modified Purse-String Stapling Technique for Intracorporeal Circular Stapled Esophagojejunostomy During Laparoscopic Total Gastrectomy: Comparison with Extracorporeal Reconstruction Technique

Background: Intracorporeal esophagojejunostomy (EJ) in the context of laparoscopic total gastrectomy remains a complex and technically demanding procedure. We have previously introduced a novel method of intracorporeal circular stapled EJ utilizing a conventional purse-string suture instrument. Since May 2018, we have refined this technique, and the aim of this study was to assess its safety and efficacy. Methods: Between May 2018 and June 2022, we enrolled 92 patients who underwent laparoscopic total gastrectomy with the modified intracorporeal reconstruction method. In addition, between March 2014 and June 2022, we enrolled 121 patients who underwent the procedure with the extracorporeal reconstruction method. We retrospectively collected and compared the clinical data of these 2 patient cohorts. Results: Intracorporeal reconstruction group experienced lower postoperative pain scores (2.7 ± 1.3 versus 4.5 ± 1.4, P = .032), reduced administration of analgesics (3.1 ± 2.2 versus 5.0 ± 3.5, P = .041), and shorter postoperative hospital stays (4.9 ± 2.3 versus 6.3 ± 3.5, P = .045) compared with the extracorporeal reconstruction group. In addition, anastomotic time and postoperative pain score were not increased in the overweight patients in the intracorporeal reconstruction group. Anastomotic leakage occurred in 2 (2.2%) patients in the intracorporeal reconstruction group and 4 (3.3%) patients in the extracorporeal reconstruction group. Anastomotic stricture occurred in 1 (1.1% and 0.8%) patient in each group. There was no significant difference in the overall postoperative complication rate between the 2 groups. Conclusions: The modified intracorporeal purse-string stapling technique for EJ during laparoscopic total gastrectomy is a safe and viable option, exhibiting less invasiveness and comparable outcomes to the extracorporeal reconstruction method, especially suitable for obese patients.

Micronutrient Supplementation and Bone Health After Prophylactic Total Gastrectomy in Patients With CDH1 Variants

INTRODUCTION

Patients with germline variants in CDH1 who undergo prophylactic total gastrectomy (TG) are at risk of altered nutrient and drug absorption due to modified gastrointestinal anatomy. Bone mineral density loss and micronutrient deficiencies have not been described previously in this patient population.

METHODS

In this study we included 94 patients with germline CDH1 variants who underwent prophylactic TG between October 2017 and February 2022. We examined pre- and post-gastrectomy bone mineral density (BMD); serum biomarkers including calcium, phosphorus, alkaline phosphatase, and 25 (OH)-vitamin D; and postoperative adherence to calcium and multivitamin supplementation.

RESULTS

Almost all patients (92/94, 98%) lost a substantial amount of weight post-TG, with an average weight loss of 26.5% at 12 months post-surgery. Serum biomarkers of mineral metabolism, namely calcium and phosphorus, did not change significantly after TG. However, average BMD was decreased in all patients at 12 months post-TG. Nonadherence to calcium supplementation was associated with a decrease in BMD. Nonadherence to multivitamin supplementation was associated with greater percent BMD loss in the femoral neck and total hip.

CONCLUSIONS

Appropriate micronutrient supplementation and nutritional counseling pre- and postoperatively in patients undergoing prophylactic TG are important to mitigate the long-term effects of gastrectomy on bone health.

Pancreatic thickness as a predictor of postoperative pancreatic fistula after laparoscopic or robotic gastrectomy

BACKGROUND

Despite technical advances in minimally invasive gastrectomy for gastric cancer, an increased incidence of postoperative pancreatic fistula (POPF) has been reported. POPF can cause infectious and bleeding complications, which could lead to surgery-related death; therefore, reduction of the post-gastrectomy POPF risk is crucial. This study aimed to investigate the importance of pancreatic anatomy as a predictor of POPF in patients undergoing laparoscopic or robotic gastrectomy.

METHODS

Data were collected from 331 consecutive patients who underwent laparoscopic or robotic gastrectomy for gastric cancer. The thickness of the pancreas anterior to the most ventral level of the splenic artery (TPS) was measured. The correlation between TPS and POPF incidence was investigated using univariate and multivariate analyses.

RESULTS

The cutoff value of TPS was 11.8 mm, which predicted a high drain amylase concentration on postoperative day 1, and patients were categorized into thin (Tn group) and thick TPS groups (Tk group). There was no significant difference in the background characteristics between the two groups, except for sex (P = 0.009) and body mass index (P < 0.001). The incidences of POPF grade B or higher (2% vs. 16%, P < 0.001), all postoperative complications of grade II or higher (12% vs. 28%, P = 0.004), and postoperative intra-abdominal infections of grade II or higher (4% vs. 17%, P = 0.001) were significantly higher in the Tk group. Multivariable analysis identified that high TPS was the only independent risk factor for grade B or higher POPF and grade II or higher postoperative intra-abdominal infectious complications.

CONCLUSIONS

The TPS is a specific predictive factor for POPF and postoperative intra-abdominal infectious complications in patients undergoing laparoscopic or robotic gastrectomy. Careful pancreatic manipulation during suprapancreatic lymphadenectomy is necessary for patients with increased TPS (> 11.8 mm) to avoid postoperative complications.

Hereditary Diffuse Gastric Cancer

Hereditary diffuse gastric cancer (HDGC) is a dominantly inherited cancer syndrome characterized by a high incidence of diffuse gastric cancer (DGC) and lobular breast cancer (LBC). HDGC is caused by germline mutations in 2 genes involved in the epithelial adherens junction complex, CDH1 and CTNNA1. We discuss the genetics of HDGC and the variability of its clinical phenotype, in particular the variable penetrance of advanced DGC and LBC, both within and between families. We review the pathology of the disease, the mechanism of tumor initiation, and its natural history. Finally, we describe current best practice for the clinical management of HDGC, including emerging genetic testing criteria for the identification of new families, methods for endoscopic surveillance, the complications associated with prophylactic surgery, postoperative quality of life, and the emerging field of HDGC chemoprevention.

Cost-effectiveness of Laparoscopic vs Open Gastrectomy for Gastric Cancer: An Economic Evaluation Alongside a Randomized Clinical Trial

Importance

Laparoscopic gastrectomy is rapidly being adopted worldwide as an alternative to open gastrectomy to treat gastric cancer. However, laparoscopic gastrectomy might be more expensive as a result of longer operating times and more expensive surgical materials. To date, the cost-effectiveness of both procedures has not been prospectively evaluated in a randomized clinical trial.

Objective

To evaluate the cost-effectiveness of laparoscopic compared with open gastrectomy.

Design, Setting, and Participants

In this multicenter randomized clinical trial of patients undergoing total or distal gastrectomy in 10 Dutch tertiary referral centers, cost-effectiveness data were collected alongside a multicenter randomized clinical trial on laparoscopic vs open gastrectomy for resectable gastric adenocarcinoma (cT1-4aN0-3bM0). A modified societal perspective and 1-year time horizon were used. Costs were calculated on the individual patient level by using hospital registry data and medical consumption and productivity loss questionnaires. The unit costs of laparoscopic and open gastrectomy were calculated bottom-up. Quality-adjusted life-years (QALYs) were calculated with the EuroQol 5-dimension questionnaire, in which a value of 0 indicates death and 1 indicates perfect health. Missing questionnaire data were imputed with multiple imputation. Bootstrapping was performed to estimate the uncertainty surrounding the cost-effectiveness. The study was conducted from March 17, 2015, to August 20, 2018. Data analyses were performed between September 1, 2020, and November 17, 2021.

Interventions

Laparoscopic vs open gastrectomy.

Main Outcomes and Measures

Evaluations in this cost-effectiveness analysis included total costs and QALYs.

Results

Between 2015 and 2018, 227 patients were included. Mean (SD) age was 67.5 (11.7) years, and 140 were male (61.7%). Unit costs for initial surgery were calculated to be €8124 (US $8087) for laparoscopic total gastrectomy, €7353 (US $7320) for laparoscopic distal gastrectomy, €6584 (US $6554) for open total gastrectomy, and €5893 (US $5866) for open distal gastrectomy. Mean total costs after 1-year follow-up were €26 084 (US $25 965) in the laparoscopic group and €25 332 (US $25 216) in the open group (difference, €752 [US $749; 3.0%]). Mean (SD) QALY contributions during 1 year were 0.665 (0.298) in the laparoscopic group and 0.686 (0.288) in the open group (difference, -0.021). Bootstrapping showed that these differences between treatment groups were relatively small compared with the uncertainty of the analysis.

Conclusions and Relevance

Although the laparoscopic gastrectomy itself was more expensive, after 1-year follow-up, results suggest that differences in both total costs and effectiveness were limited between laparoscopic and open gastrectomy. These results support centers' choosing, based on their own preference, whether to (de)implement laparoscopic gastrectomy as an alternative to open gastrectomy.

An advanced bipolar device helps reduce the rate of postoperative pancreatic fistula in laparoscopic gastrectomy for gastric cancer patients: a propensity score-matched analysis

BACKGROUND

Advanced bipolar devices (ABD; e.g., LigaSure™) have a lower blade temperature than ultrasonically activated devices (USAD; e.g., Harmonic® and Sonicision™) during activation, potentially enabling accurate lymph node dissection with less risk of postoperative pancreatic fistula (POPF) due to pancreatic thermal injury in laparoscopic gastrectomy. Therefore, we compared the efficacy and safety of ABD and USAD in laparoscopic gastrectomy for gastric cancer patients.

METHODS

A retrospective cohort study was conducted on patients who underwent laparoscopic distal gastrectomy (LDG) between August 2008 and September 2020. A total of 371 patients were enrolled, and short-term surgical outcomes, including the incidence of ISGPF grades B and C POPF, were compared between ABD and USAD. The risk factors for POPF in LDG were investigated by univariate and multivariate analyses.

RESULTS

A propensity score-matching algorithm was used to select 120 patients for each group. The POPF rate was significantly lower (0.8 vs. 9.2%, p < 0.001), the morbidity rate was lower (13.3 vs. 28.3%, p < 0.001), the length of postoperative hospitalization was shorter (14 vs. 19 days, p < 0.001), and the lymph node retrieval rate was higher (34 vs. 26, p < 0.001) with an ABD than with a USAD. There were no mortalities in either group. A multivariate analysis showed that a USAD was the only independent risk factor with a considerably high odds ratio for the occurrence of POPF (USAD/ABD, odds ratio 8.38, p = 0.0466).

CONCLUSION

An ABD may improve the safety of laparoscopic gastrectomy for gastric cancer patients.

Robotic Distal Gastrectomy Reduces Drain Amylase Values in Patients With a Small Pancreas-left Gastric Artery Angle

PURPOSE

Pancreatic fistula is a severe complication after laparoscopic distal gastrectomy (LDG). We previously evaluated the pancreas-left gastric artery angle (PLA) as a risk indicator for developing a pancreatic fistula after LDG. This study evaluated the incidence of pancreatic fistula with robotic distal gastrectomy (RDG) in comparison to LDG from the view of the PLA.

MATERIALS AND METHODS

An association between the PLA and the incidence of pancreatic fistula in 165 patients who underwent either RDG (n=45) or LDG (n=120) was investigated retrospectively.

RESULTS

RDG patients had significantly lower drain amylase values (postoperative day 2) than LDG patients. As opposed to LDG patients, drain amylase values were similar for patients with small (PLA <62 degrees) and large (PLA ≥62 degrees) PLA in RDG patients.

CONCLUSION

Robotic surgery may reduce the risk of postoperative pancreatic fistula in patients with a small PLA.

A comparative study of laparoscopic near-total and total gastrectomy for patient nutritional status and quality of life using a propensity score matching analysis

BACKGROUND

Previous studies of LNTG had small sample sizes and short follow-up periods and did not evaluate quality of life after LNTG. We aimed to compare surgical, oncological, nutritional outcomes, and quality of life of patients after laparoscopic near-total and total gastrectomy (LNTG and LTG, respectively).

METHODS

We retrospectively collected and analyzed data of 167 and 294 patients who underwent LNTG and LTG, respectively, for treatment of upper or middle third gastric cancer between January 2008 and December 2018. After propensity score matching, the surgical, oncological, and nutritional outcomes of 324 patients were analyzed. Moreover, we measured quality of life after surgery using a postgastrectomy syndrome scale.

RESULTS

The operation time and the length of hospital stay was significantly shorter in the LNTG group than in the LTG group. In addition, patients with anastomotic complications were fewer in the LNTG group. No significant difference was found in the 5-year overall survival rate between the two groups. However, patients in the LNTG group had a significantly smaller body weight loss after 3 months postoperatively. Furthermore, patients in the LNTG group had significantly healthier albumin and cholesterol than those in the LTG group. The mean scores on the postgastrectomy symptom scale at 3, 6, and 12 months postoperatively were higher in the LNTG group than in the LTG group.

CONCLUSION

LNTG is a surgically safe and oncologically favorable method compared with LTG. Furthermore, patients who underwent LNTG had improved nutritional status and quality of life than those who underwent LTG.

Laparoscopic vs open total gastrectomy for advanced gastric cancer following neoadjuvant therapy: A propensity score matching analysis

BACKGROUND

Laparoscopic total gastrectomy (LTG) has drawn increasing attention over the years. Although LTG has shown surgical benefits compared to open TG (OTG) in early stage gastric cancer (GC), little is known about the surgical and oncological outcomes of LTG for advanced GC following neoadjuvant therapy (NAT).

AIM

To compare the long- and short-term outcomes of advanced GC patients who underwent LTG vs OTG following NAT.

METHODS

Advanced GC patients who underwent TG following NAT between April 2011 and May 2018 at the Cancer Hospital of the Chinese Academy of Medical Sciences were enrolled and stratified into two groups: LTG and OTG. Propensity score matching analysis was performed at a 1:1 ratio to overcome possible bias.

RESULTS

In total, 185 patients were enrolled (LTG: 78; OTG: 109). Of these, 138 were paired after propensity score matching. After adjustment for propensity score matching, baseline parameters were similar between the two groups. Compared to OTG, LTG was associated with a significantly shorter length of hospital stay (P = 0.012). The rates of R0 resection, lymph node harvest, and postoperative morbidity did not significantly differ between the two groups. Overall survival (OS) outcomes were comparable between the two groups. Pathological T and N stages were found to be independent risk factors for OS.

CONCLUSION

LTG can be a feasible method for advanced GC patients following NAT, as it appears to be associated with better short- and comparable long-term outcomes compared to OTG.

Laparoscopic gastrectomy for gastric cancer: has the time come for considered it a standard procedure?

Radical gastrectomy with an adequate lymphadenectomy is the main procedure which makes it possible to cure patients with resectable gastric cancer. A number of randomized controlled trials and meta-analysis provide phase III evidence that laparoscopic gastrectomy is technically safe and that it yields better short-term outcomes than conventional open gastrectomy for early-stage gastric cancer. At present, laparoscopic gastrectomy is considered a standard procedure for early-stage gastric cancer, especially in Asian countries. On the other hand, the use of minimally invasive techniques is still controversial for the treatment of more advanced tumours, principally due to existing concerns about its oncological adequacy and capacity to carry out an adequately extended lymphadenectomy. Additional high-quality studies comparing laparoscopic gastrectomy versus open gastrectomy for gastric cancer have been recently published, in particular concerning the latest results obtained by laparoscopic approach to advanced gastric cancer. It seems very useful to update the review of literature in light of these new evidences for this subject and draw some considerations.

Extent of gastrectomy and lymphadenectomy for gastric adenocarcinoma

Gastric adenocarcinoma is one of the most common and lethal cancers worldwide and is associated with a high frequency of nodal metastasis. The value of multimodality therapy is well-established, but gastric resection and locoregional lymph node dissection are important mainstays in potentially curative therapy. However, there has been considerable regional variation in surgical approach and debate regarding the ideal extent of gastric resection, gastric reconstruction, and extent of lymphadenectomy. This chapter outlines the current evidence in the surgical management of gastric adenocarcinoma. The advent of minimally invasive approaches to gastric operations is also discussed.

A Multicenter Retrospective Study Comparing Surgical Outcomes Between the Overlap Method and Functional Method for Esophagojejunostomy in Laparoscopic Total Gastrectomy: Analysis Using Propensity Score Matching

BACKGROUND

This study aimed to compare the postoperative outcomes after laparoscopic total gastrectomy (LTG) with esophagojejunostomy (EJS) performed using the overlap method or the functional method in a multicenter retrospective study with propensity score matching.

METHODS

We retrospectively enrolled all patients who underwent curative LTG for gastric cancer at 6 institutions between January 2004 and December 2018. Patients were categorized into the overlap group (OG) or functional group (FG) based on the type of anastomosis used in 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. The surgical results and postoperative outcomes were compared.

RESULTS

We identified 69 propensity score-matched pairs among 440 patients who underwent LTG. There was no significant between-group difference in the median operative time, intraoperative blood, or number of lymph nodes resected. In terms of postoperative outcomes, the rates of all complications [Clavien-Dindo (CD) classification ≥II; OG 13.0 vs. FG 24.6%, respectively; P=0.082], complications more severe than CD grade III (OG 8.7 vs. FG 18.8%, respectively; P=0.084), and the occurrence of EJS leakage and stenosis more severe than CD grade III (OG 7.3% vs. FG 2.9%, P=0.245; OG 1.5 vs. FG 8.7%, P=0.115, respectively) were comparable. The median follow-up period was 830 days (range, 18 to 3376 d), and there were no differences in overall survival between the 2 groups.

CONCLUSIONS

There was no difference in surgical outcomes and overall survival based on the type of anastomosis used for EJS after LTG. Therefore, selection of anastomosis in EJS should be based on each surgeon's preference and experience.

Endoscopic diagnosis and treatment of gastric dysplasia and early cancer: Current evidence and what the future may hold

Gastric cancer accounts for a significant proportion of worldwide cancer-related morbidity and mortality. The well documented precancerous cascade provides an opportunity for clinicians to detect and treat gastric cancers at an endoscopically curable stage. In high prevalence regions such as Japan and Korea, this has led to the implementation of population screening programs. However, guidelines remain ambiguous in lower prevalence regions. In recent years, there have been many advances in the endoscopic diagnosis and treatment of early gastric cancer and precancerous lesions. More advanced endoscopic imaging has led to improved detection and characterization of gastric lesions as well as superior accuracy for delineation of margins prior to resection. In addition, promising early data on artificial intelligence in gastroscopy suggests a future role for this technology in maximizing the yield of advanced endoscopic imaging. Data on endoscopic resection (ER) are particularly robust in Japan and Korea, with high rates of curative ER and markedly reduced procedural morbidity. However, there is a shortage of data in other regions to support the applicability of protocols from these high prevalence countries. Future advances in endoscopic therapeutics will likely lead to further expansion of the current indications for ER, as both technology and proceduralist expertise continue to grow.

East meets West: the initial results of laparoscopic gastric cancer resections with Eastern principles in a single Western centre - a propensity score-matched study

BACKGROUND

We compared the initial experience of totally laparoscopic gastric cancer surgery with Eastern principles with the results of propensity score-matched counterparts operated with open surgery.

METHODS

From 1163 patients stored in our database, 62 PSM patients were selected for this study. The quality control was assured with video documentation and standardisation of the procedures.

RESULTS

According to the distribution of age, comorbidities, and general health, patients in the LG and OG were well-balanced. Most of the patients in both groups had advanced gastric cancer (69.3%). In the OG, 67.8% of patients received a total gastrectomy, as well as 54.8% of patients in the LG. There was no significant difference in the postoperative mortality between groups. The recovery of bowel function was significantly faster, and postoperative pain was significantly decreased in the LG. Compared to the OG, the inflammatory response was significantly smaller in the LG. There was no significant difference in the overall survival between LG and OG patients.

CONCLUSION

We have shown that laparoscopic gastrectomy with Eastern principles can be safely introduced in a high-volume Western centre with sufficient laparoscopic training. We have also shown that laparoscopy offers a significant faster bowel function recovery, less postoperative pain, and a smaller inflammatory response.

Textbook outcome and survival of robotic versus laparoscopic total gastrectomy for gastric cancer: a propensity score matched cohort study

Textbook outcome is a composite quality measurement of short-term outcomes for evaluating complex surgical procedures. We compared textbook outcome and survival of robotic total gastrectomy (RTG) with those of laparoscopic total gastrectomy (LTG). We retrospectively reviewed 395 patients (RTG, n = 74; LTG, n = 321) who underwent curative total gastrectomy for gastric cancer via minimally invasive approaches from 2009 to 2018. We performed propensity score matched analysis to adjust for potential selection bias. Textbook outcome included a negative resection margin, no intraoperative complication, retrieved lymph nodes > 15, no severe complication, no reintervention, no unplanned intensive care unit admission, hospitalization ≤ 21 days, no readmission after discharge, and no postoperative mortality. Survival outcomes included 3-year overall and relapse-free survival rates. After matching, 74 patients in each group were selected. Textbook outcome was similar in the RTG and LTG groups (70.3% and 75.7%, respectively), although RTG required a longer operative time. The quality metric least often achieved was the presence of severe complications in both groups (77.0% in both groups). There were no differences in the 3-year overall survival rate (98.6% and 89.7%, respectively; log-rank P = 0.144) and relapse-free survival rate between the RTG and LTG groups (97.3% and 87.0%, respectively; log-rank P = 0.167). Textbook outcome and survival outcome of RTG were similar to those of LTG for gastric cancer.

Totally laparoscopic total gastrectomy using the modified overlap method and conventional open total gastrectomy: A comparative study

BACKGROUND

Although several methods of totally laparoscopic total gastrectomy (TLTG) have been reported. The best anastomosis technique for LTG has not been established.

AIM

To investigate the effectiveness and surgical outcomes of TLTG using the modified overlap method compared with open total gastrectomy (OTG) using the circular stapled method.

METHODS

We performed 151 and 131 surgeries using TLTG with the modified overlap method and OTG for gastric cancer between March 2012 and December 2018. Surgical and oncological outcomes were compared between groups using propensity score matching. In addition, we analyzed the risk factors associated with postoperative complications.

RESULTS

Patients who underwent TLTG were discharged earlier than those who underwent OTG [TLTG (9.62 ± 5.32) vs OTG (13.51 ± 10.67), P < 0.05]. Time to first flatus and soft diet were significantly shorter in TLTG group. The pain scores at all postoperative periods and administration of opioids were significantly lower in the TLTG group than in the OTG group. No significant difference in early, late and esophagojejunostomy (EJ)-related complications or 5-year recurrence free and overall survival between groups. Multivariate analysis demonstrated that body mass index [odds ratio (OR), 1.824; 95% confidence interval (CI): 1.029-3.234, P = 0.040] and American Society of Anaesthesiologists (ASA) score (OR, 3.154; 95%CI: 1.084-9.174, P = 0.035) were independent risk factors of early complications. Additionally, age was associated with ≥ 3 Clavien-Dindo classification and EJ-related complications.

CONCLUSION

Although TLTG with the modified overlap method showed similar complication rate and oncological outcome with OTG, it yields lower pain score, earlier bowel recovery, and discharge. Surgeons should perform total gastrectomy cautiously and delicately in patients with obesity, high ASA scores, and older ages.

Predictive Role of Endoscopic Surveillance after Total Gastrectomy with R0 Resection for Gastric Cancer

BACKGROUND

Endoscopic surveillance after total gastrectomy (TG) for gastric cancer is routinely performed to detect tumor recurrence and postoperative adverse events. However, the reports on the clinical benefits of endoscopic surveillance are ambiguous. We investigated the clinical benefit of endoscopic surveillance after TG for gastric cancer.

METHODS

We analyzed 848 patients who underwent TG with R0 resection for gastric cancer between 2011 and 2012 (380 early gastric cancer and 468 advanced gastric cancer) and underwent regular postoperative surveillance with endoscopy and abdominopelvic computed tomography (CT) with contrast.

RESULTS

Median follow-up periods were 58 months for both endoscopy (range, 3-96) and abdominopelvic CT (range, 1-96). Tumor recurrence occurred in 167 patients (19.7%), of whom seven (4.2%) were locoregional recurrences in the peri-anastomotic area (n = 5) or regional gastric lymph nodes (n = 2). Whereas the peri-anastomotic recurrences were detected by both endoscopy and abdominopelvic CT, regional lymph node recurrences were only detected by abdominopelvic CT. Out of the 23 events of postoperative adverse events, the majority (87%) were detected by radiologic examinations; three events of benign strictures in the anastomotic site were detected only by endoscopy.

CONCLUSION

Endoscopic surveillance did not have a significant role in detecting locoregional tumor recurrence and postoperative adverse events after TG with R0 resection for gastric cancer. Routine endoscopic surveillance after TG may be considered optional and performed according to the capacities of each clinical setting.

Hereditary Diffuse Gastric Cancer Syndrome and the Role of CDH1: A Review

Importance

Inherited variants in the tumor suppressor gene CDH1 are associated with an increased risk of gastric and breast cancers. This review aims to address the most current topics in management of the hereditary diffuse gastric cancer syndrome attributed to CDH1.

Observations

Consensus management guidelines have broadened genetic testing criteria for CDH1. Prophylactic total gastrectomy is recommended for any pathogenic or likely pathogenic CDH1 variant carrier starting at the age of 20 years. Annual surveillance endoscopy is recommended to those who defer prophylactic total gastrectomy. Women with a CDH1 variant should initiate magnetic resonance imaging breast surveillance starting at age 30 years. Further research is needed to understand the pathogenesis of early-stage gastric cancers (T1a), which are pathognomonic of hereditary diffuse gastric cancer syndrome, that lead to advanced gastric cancer to develop both treatment and prevention strategies for this patient population.

Conclusions and Relevance

The heritable CDH1 gene mutation is of importance to today's surgeons because it is associated with a substantial increased risk of developing both gastric and breast cancers. Management of this cancer syndrome currently uses prophylactic surgery and enhanced cancer surveillance strategies.

Laparoscopic Versus Open Gastrectomy for Gastric Cancer (LOGICA): A Multicenter Randomized Clinical Trial

BACKGROUND

The oncological efficacy and safety of laparoscopic gastrectomy are under debate for the Western population with predominantly advanced gastric cancer undergoing multimodality treatment.

METHODS

In 10 experienced upper GI centers in the Netherlands, patients with resectable (cT1-4aN0-3bM0) gastric adenocarcinoma were randomly assigned to either laparoscopic or open gastrectomy. No masking was performed. The primary outcome was hospital stay. Analyses were performed by intention to treat. It was hypothesized that laparoscopic gastrectomy leads to shorter hospital stay, less postoperative complications, and equal oncological outcomes.

RESULTS

Between 2015 and 2018, a total of 227 patients were randomly assigned to laparoscopic (n = 115) or open gastrectomy (n = 112). Preoperative chemotherapy was administered to 77 patients (67%) in the laparoscopic group and 87 patients (78%) in the open group. Median hospital stay was 7 days (interquartile range, 5-9) in both groups (P = .34). Median blood loss was less in the laparoscopic group (150 v 300 mL, P < .001), whereas mean operating time was longer (216 v 182 minutes, P < .001). Both groups did not differ regarding postoperative complications (44% v 42%, P = .91), in-hospital mortality (4% v 7%, P = .40), 30-day readmission rate (9.6% v 9.1%, P = 1.00), R0 resection rate (95% v 95%, P = 1.00), median lymph node yield (29 v 29 nodes, P = .49), 1-year overall survival (76% v 78%, P = .74), and global health-related quality of life up to 1 year postoperatively (mean differences between + 1.5 and + 3.6 on a 1-100 scale; 95% CIs include zero).

CONCLUSION

Laparoscopic gastrectomy did not lead to a shorter hospital stay in this Western multicenter randomized trial of patients with predominantly advanced gastric cancer. Postoperative complications and oncological efficacy did not differ between laparoscopic gastrectomy and open gastrectomy.

Morbidity and Mortality of Laparoscopic vs Open Total Gastrectomy for Clinical Stage I Gastric Cancer: The CLASS02 Multicenter Randomized Clinical Trial

Importance

The safety of laparoscopic total gastrectomy (LTG) for the treatment of gastric cancer remains uncertain given the lack of high-level clinical evidence.

Objective

To compare the safety of LTG for clinical stage I gastric cancer with that of conventional open total gastrectomy (OTG).

Design, Setting, and Participants

The Chinese Laparoscopic Gastrointestinal Surgery Study (CLASS) Group CLASS02 study was a prospective, multicenter, open-label, noninferiority, randomized clinical trial that compared the safety of LTG vs OTG with lymphadenectomy for patients with clinical stage I gastric cancer. From January 2017 to September 2018, a total of 227 patients were enrolled. Final follow-up was in October 2018.

Interventions

Eligible patients were randomized to LTG (n = 113) or OTG (n = 114) by an interactive web response system.

Main Outcomes and Measures

The primary outcome was the morbidity and mortality within 30 days following surgeries between LTG and OTG with a noninferiority margin of 10%. The secondary outcomes were recovery courses and postoperative hospital stays.

Results

A total of 214 patients were analyzed for morbidity and mortality (105 patients in the LTG group and 109 patients in the OTG group). The mean (SD) age was 59.8 (9.4) years in the LTG group and 59.4 (9.2) years in the OTG group, and most were male (LTG group, 75 of 105 [71.4%]; OTG group, 80 of 109 [73.4%]). The overall morbidity and mortality rates were not significantly different between the groups (rate difference, -1.1%; 95% CI, -11.8% to 9.6%). Intraoperative complications occurred in 3 patients (2.9%) in the LTG group and 4 patients (3.7%) in the OTG group (rate difference, -0.8%; 95% CI, -6.5% to 4.9%). In addition, there was no significant difference in the overall postoperative complication rate of 18.1% in the LTG group and 17.4% in the OTG group (rate difference, 0.7%; 95% CI, -9.6% to 11.0%). One patient in the LTG group died from intra-abdominal bleeding secondary to splenic artery hemorrhage. However, there was no significant difference in mortality between the LTG group and the OTG group (rate difference, 1.0%; 95% CI, -2.5% to 5.2%), and the distribution of complication severity was similar between the 2 groups.

Conclusions and Relevance

The results of the CLASS02 trial showed that the safety of LTG with lymphadenectomy by experienced surgeons for clinical stage I gastric cancer was comparable to that of OTG.

Trial Registration

ClinicalTrials.gov Identifier: NCT03007550.

Open versus minimally invasive total gastrectomy after neoadjuvant chemotherapy: results of a European randomized trial

BACKGROUND

Surgical resection with adequate lymphadenectomy is regarded the only curative option for gastric cancer. Regarding minimally invasive techniques, mainly Asian studies showed comparable oncological and short-term postoperative outcomes. The incidence of gastric cancer is lower in the Western population and patients often present with more advanced stages of disease. Therefore, the reproducibility of these Asian results in the Western population remains to be investigated.

METHODS

A randomized trial was performed in thirteen hospitals in Europe. Patients with an indication for total gastrectomy who received neoadjuvant chemotherapy were eligible for inclusion and randomized between open total gastrectomy (OTG) or minimally invasive total gastrectomy (MITG). Primary outcome was oncological safety, measured as the number of resected lymph nodes and radicality. Secondary outcomes were postoperative complications, recovery and 1-year survival.

RESULTS

Between January 2015 and June 2018, 96 patients were included in this trial. Forty-nine patients were randomized to OTG and 47 to MITG. The mean number of resected lymph nodes was 43.4 ± 17.3 in OTG and 41.7 ± 16.1 in MITG (p = 0.612). Forty-eight patients in the OTG group had a R0 resection and 44 patients in the MITG group (p = 0.617). One-year survival was 90.4% in OTG and 85.5% in MITG (p = 0.701). No significant differences were found regarding postoperative complications and recovery.

CONCLUSION

These findings provide evidence that MITG after neoadjuvant therapy is not inferior regarding oncological quality of resection in comparison to OTG in Western patients with resectable gastric cancer. In addition, no differences in postoperative complications and recovery were seen.

Results of laparoscopic intragastric surgery

BACKGROUND

Technological and operative advancements have allowed laparoscopic intragastric surgery (LIGS) to be applied in the treatment of superficial gastric or submucosal lesions. The aim of this study was to evaluate short- and long-term outcomes following LIGS.

METHODS

From 2000 to 2013, 25 LIGSs were performed for superficial gastric lesions. Clinical records were reviewed retrospectively for peri-operative course and long-term outcomes with particular attention to the oncological follow-up for patients with malignant lesions.

RESULTS

Nineteen (76%) lesions were located close to the EGJ, three (12%) in the lesser curvature, two (8%) in the posterior wall and one (4%) in the prepyloric-antral region. A multiport technique was used in 15 (60%) patients and a single-access approach in 10 (40%) patients. The median operative time was 140 (50-210) minutes. No conversion to open or conventional laparoscopic surgery was needed. Mortality was nil, and severe morbidity occurred in one (4%) patient. The median length of stay was 6 (3-10) days. Indications of LIGS were adenocarcinoma in 11 (44%) patients, gastrointestinal stromal tumors (GISTs) in 6 (24%) patients and benign lesions in eight (32%) patients. En bloc resection was obtained in 24 (96%) patients with R0 margins in 23 (92%) patients. After a median follow-up of 76 (26-171) months, recurrence was detected in 4 (36%) patients with advanced malignant adenocarcinoma.

CONCLUSION

LIGS provides an interesting alternative to major gastric and EGJ resection when endoscopic resection is not suitable for highly selected patients with superficial gastric lesions.

Long-Term Results and Current Problems in Laparoscopic Gastrectomy: Single-Center Experience

Introduction: The study aims to evaluate the long-term results of patients who underwent laparoscopic gastrectomy for gastric cancer in Ankara University Medical Faculty, Surgical Oncology Clinic, within 5 years. Materials and Methods: We retrospectively reviewed the data of patients who underwent laparoscopic gastrectomy for gastric cancer at the Surgical Oncology Clinic of Ankara University Medical Faculty between January 2014 and September 2019. One hundred forty-six patients were included in the study. Results: Fifty-one (34.9%) of the patients were female; 95 (65.1%) were male. The mean ± standard deviation and median (minimum-maximum) values of the patients were 60.92 ± 14.13 and 64.00 (22.00-93.00), respectively (Table 1). Eighty-seven (59.6%) cases were located in the antrum, 29 (19.9%) were in the cardia region, and 30 (20.5%) were in the corpus region. Overall, 106 (72.6%) of 146 patients were alive, while 40 (27.4%) were ex. The mean survival was 21.8 months (0-69). Postoperative mortality was seen in 9 patients (6.2%) and our disease-free survival rate was 70.5%. Recurrence occurred in 14 (9.6%) of all patients. [Table: see text] Conclusion: In conclusion, although laparoscopic gastrectomy is a reliable and feasible method for gastric cancer, the standardization of laparoscopic surgery is required in clinics.

Comparison of prognostic impact of anatomic location of the pancreas on postoperative pancreatic fistula in laparoscopic and open gastrectomy

Background

Postoperative pancreatic fistula (POPF) is a serious complication after gastric cancer surgery. The current study aimed to investigate the significance of the anatomic location of the pancreas as a predictor for POPF in both laparoscopic gastrectomy (LG) and open gastrectomy (OG).

Methods

In total, 233 patients with gastric cancer were assessed retrospectively. We measured the maximum vertical (P-L height; PLH) and horizontal length (P-L depth; PLD) between the upper border of pancreas and the root of left gastric artery on a preoperative CT in the sagittal direction. The maximum length of the vertical line between the surface of the pancreas and the aorta (P-A length), previously reported as prognostic factor of POPF, was also measured. We investigated the correlations between these parameters and the incidence of POPF in LG and OG groups.

Results

Among the patients in this study, 118 underwent OG and 115 underwent LG. In LG, the median PLH and P-A length in patients with POPF were significantly longer compared with those without POPF (p = 0.026, 0.034, respectively), but not in OG. There was no significant difference in the median PLD between the patients with or without POPF in both LG and OG. The multivariate analysis demonstrated that PLH (odds ratio [OR] 4.19, 95% confidence interval [CI] 1.57–11.3, P = 0.004) and P-A length (OR 4.06, 95%CI 1.05–15.7, P = 0.042] were independent factors for predicting POPF in LG. However, intraoperative blood loss (OR 2.55, 95%CI 1.05–6.18, P = 0.038) was extracted as an independent factor in OG. The median amylase level in the drained fluid (D-Amy) were significantly higher in patients with high PLH(≥12.4 mm) or high P-A length (≥45 mm) compared with those with low PLH or low P-A length in LG. However, there were no differences in the D-Amy levels by PLH or P-A length in OG patients.

Conclusions

The anatomic location of the pancreas is a specific and independent predictor of POPF in LG but not in OG. PLH is a simple parameter that can evaluate the anatomic position of the pancreas, and it may be useful for preventing POPF after LG.

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.

Implementation of minimally invasive gastrectomy for gastric cancer in a western tertiary referral center

Background

Minimally invasive techniques have gradually come to take a leading position in the surgical treatment of gastrointestinal malignancies. In order to define an effective process for the implementation of similar techniques in the treatment of gastric cancer, patient caseload represents a pivotal factor for education and training, but is a prerequisite not fulfilled in most Western countries. Additionally, as opposed to the East, a variety of additional factors such as the usually advanced stage of the disease and differences in patient characteristics are prevailing and raise further obstacles. Hereby we report a strategy for a safe and effective process for the implementation of laparoscopic gastric cancer surgery in a Western tertiary referral center.

Methods

The present study describes the stepwise implementation of laparoscopic gastrectomy for the treatment of gastric cancer at a tertiary referral center, comprising the time period 2012–2019. This process was facilitated by a close collaboration with two high-volume centers in Japan, as well as exchanging fellowships and observerships between the Karolinska University Hospital and other European centers. From the initially strict selection of cases for laparoscopic surgery, laparoscopic gastrectomy has gradually become the preferred approach also in patients with locally advanced tumors.

Results

From January 1st 2010 until December 31st 2019, 249 patients were operated for gastric cancer, of whom 141 (56.6%) had an open and 108 (43.4%) a laparoscopic procedure. In the latter group, total gastrectomy was performed in 33.3% of the patients. While blood loss, operation time and length of stay decreased during the first years after implementation, these variables increased slightly during the last years of the study period, probably due to the higher proportion of advanced gastric cancer cases, as well as the higher rate of laparoscopic total gastrectomy with more extended lymphadenectomy.

Conclusions

Laparoscopic surgery is currently a valid therapeutic option for gastric cancer, which has expanded to also embrace total gastrectomy and locally advanced tumors. Collaboration between centers in the East and West, centralization to high-volume centers and application of enhanced recovery protocols are essential components in the implementation and further refinement of minimally invasive gastrectomy.

Short- and long-term survival after laparoscopic versus open total gastrectomy for gastric adenocarcinoma: a National database study

BACKGROUND

The use of laparoscopic total gastrectomy for gastric cancer remains controversial. Our objective was to compare outcomes of laparoscopic total gastrectomy (LTG) vs. open total gastrectomy (OTG) for gastric adenocarcinoma using a national cancer database.

METHODS

The National Cancer Database (2010-2014) was analyzed for total gastrectomy cases performed for gastric adenocarcinoma. Patient demographics and surgical outcomes were stratified by stage and compared based on laparoscopic vs. open surgical approach. Primary outcome measures included 30-day and 90-day mortality and Kaplan-Meier curves to estimate long-term survival.

RESULTS

There were 2584 cases analyzed, including 592 (22.9%) stage I, 710 (27.5%) stage II, and 1282 (49.6%) stage III cases. The distribution of LTG vs. OTG cases was 156 (26.4%) vs. 436 (73.6%) for stage I, 163 (23.0%) vs. 547 (77.0%) for stage II, and 241 (18.8%) vs. 1041 (81.2%) for stage III. For all stages analyzed, there was no difference between laparoscopic vs. open approach for adjusted 30-day mortality (stage I: adjusted odds ratio (AOR) 0.52, p = 0.75; stage II: AOR 1.36, p > 0.99; stage III: AOR 0.46, p = 0.29) or 90-day mortality (stage I: AOR 0.46, p = 0.99; stage II: AOR 1.17, p = 0.99; stage III: 0.57, p = 0.29). There was no difference between LTG vs. OTG 5-year Kaplan-Meier estimated survival curves for any stage (stage I: p = 0.20; stage II: p = 0.83; stage III: p = 0.46). When compared to OTG, LTG had a similar hazard ratio (HR) for mortality (HR 0.89 p = 0.20).

CONCLUSIONS

Laparoscopic total gastrectomy and OTG have comparable 30-day mortality, 90-day mortality, and long-term survival.

Effects of Sugammadex on Post-Operative Pulmonary Complications in Laparoscopic Gastrectomy: A Retrospective Cohort Study

The use of sugammadex can reduce post-operative residual neuromuscular blockade, which is known to increase the risk of post-operative respiratory events. However, its effect on post-operative pulmonary complications is not obvious. This study was performed to evaluate the effects of sugammadex on post-operative pulmonary complications in patients undergoing laparoscopic gastrectomy between 2013 and 2017. We performed propensity score matching to correct for selection bias. Post-operative pulmonary complications (i.e., pneumonia, respiratory failure, pleural effusion, atelectasis, pneumothorax, and aspiration pneumonitis) were evaluated from the radiological and laboratory findings. We also evaluated admission to the intensive care unit after surgery, re-admission or an emergency room visit within 30 days after discharge, length of hospital stay, re-operation, and mortality within 90 days post-operatively as secondary outcomes. In the initial cohort of 3802 patients, 541 patients were excluded, and 1232 patients were analyzed after propensity score matching. In the matched cohort, pleural effusion was significantly reduced in the sugammadex group compared to the neostigmine group (neostigmine 23.4% vs. sugammadex 18%, p = 0.02). Other pulmonary complications and secondary outcomes were not significantly different between the groups. In comparison to neostigmine, the use of sugammadex was associated with a lower incidence of post-operative pleural effusion in laparoscopic gastrectomy.

Comparison of the short-term outcomes between totally laparoscopic total gastrectomy and laparoscopic-assisted total gastrectomy for gastric cancer: a meta-analysis

BACKGROUND

Totally laparoscopic total gastrectomy (TLTG) and laparoscopic-assisted total gastrectomy (LATG) are two common surgical approaches for upper and middle gastric cancer. Which surgical approach offers more advantages is still controversial due to a lack of evidence from randomized controlled trials (RCTs). This meta-analysis was conducted to compare the short-term outcomes between the two surgical approaches.

METHODS

A systematic literature search was performed to evaluate short-term outcomes between TLTG and LATG, including overall postoperative complications, anastomosis-related complications, time for anastomosis, operation time, intraoperative blood loss, harvested lymph nodes, proximal margin, distal margin, time to first flatus, time to first diet, and postoperative hospital stay. Short-term outcomes were pooled and compared by meta-analysis using RevMan 5.3. Mean differences (MDs) or risk ratios (RRs) were calculated with 95% confidence intervals (CIs). P < .05 was considered statistically significant.

RESULTS

A total of 9 cohort studies fulfilled the selection criteria. The total sample included 1671 cases. The meta-analysis showed no significant difference between the two surgical approaches in overall postoperative complications (RR = 1.02, 95% CI = 0.82 to 1.26, P = .87),anastomosis-related complications (RR = 0.64, 95%CI = 0.39 to 1.03, P = .06),time for anastomosis (MD = -5.13, 95% CI = -10.54 to 0.27, P = .06),operation time (MD = -10.68, 95% CI = -23.62 to 2.26, P = .11), intraoperative blood loss (MD = -25.58, 95% CI = -61.71 to 10.54, P = .17), harvested lymph nodes (MD = 1.61, 95% CI = -2.09 to 5.31, P = .39), proximal margin (MD = -0.37, 95% CI = -0.78 to 0.05, P = .09), distal margin (MD = 0.79, 95% CI = -0.57 to 2.14, P = .25), time to first flatus (MD = 0.01, 95% CI = -0.13 to 0.15, P = .87), time to first diet (MD = -0.22, 95% CI = -0.45 to 0.02, P = .07), and postoperative hospital stay (MD = -0.51, 95% CI = -1.10 to 0.07, P = .09).

CONCLUSIONS

TLTG is a safe and feasible surgical approach for upper and middle gastric cancer, with short-term outcomes that are similar to LATG. Nevertheless, high-quality, large-sample and multicenter RCTs are still required to further verify our conclusions.

Overlap method versus functional method for esophagojejunal reconstruction using totally laparoscopic total gastrectomy

BACKGROUND

Laparoscopic intracorporeal esophagojejunostomy (EJ) is a useful method in totally laparoscopic total gastrectomy (TLTG) for treating upper-third gastric cancer. The two methods of laparoscopic intracorporeal EJ-functional and overlap-have not been compared side-by-side in terms of safety and feasibility.

METHODS

Retrospective review and analysis of the data of 490 consecutive patients who underwent TLTG by either functional method (n = 365) or overlap (n = 125) method for upper- or middle-third gastric cancer was conducted between January, 2011 and May, 2018 at Asan Medical Center (Seoul, Korea). One-to-one propensity score matching (PSM) was performed to compare age, sex, body mass index, American Society of Anesthesiologist score, the presence of comorbidity, number of comorbidities, clinical T stage, clinical nodal stage, clinical TNM stage, history of previous abdominal surgery, and combined surgery. After PSM, 244 patients were divided into functional method group and overlap method group (n = 122, each). The surgical outcomes and EJ-related complications were compared between the two groups.

RESULTS

No significant difference was found between the two groups in terms of early surgical outcomes such as operative time, time to first flatus, postoperative hospital stay, transfusion during surgery, transfusion after surgery, and administration of analgesics. However, the pain score was significantly lower in overlap method group (6.21 ± 1.83) than functional method group (6.97 ± 2.09, p < 0.05). The overlap method was also associated with significantly fewer late complications (3.28% vs. 12.30%; p < 0.05), lower Clavien-Dindo classification grade (p < 0.05), and fewer EJ-related complications (0.82% vs. 6.56%; p < 0.05), as compared with the functional method.

CONCLUSION

The overlap method was safer and more feasible than the functional method for TLTG in gastric cancer patients, based on the finding of significantly lower incidence of EJ-related complications.

Identification of the clinically most relevant postoperative complications after gastrectomy: a population-based cohort study

BACKGROUND

Postoperative complications frequently occur after gastrectomy for gastric cancer and are associated with poor clinical outcomes, such as mortality and reoperations. The aim of study was to identify the clinically most relevant complications after gastrectomy, using the population-attributable fraction (PAF).

METHODS

Between 2011 and 2017, all patients who underwent potentially curative gastrectomy for gastric adenocarcinoma were included from the Dutch Upper GI Cancer Audit. Postoperative outcomes (morbidity, mortality, recovery and hospitalization) were evaluated. The prevalence of postoperative complications (e.g., anastomotic leakage and pneumonia) and of the study outcomes were calculated. The adjusted relative risk and Confidence Interval (CI) for each complication-outcome pair were calculated. Subsequently, the PAF was calculated, which represents the percentage of a given outcome occurring in the population, caused by individual complications, taking both the relative risk and the frequency in which a complication occurs into account.

RESULTS

In total, 2176 patients were analyzed. Anastomotic leakage and pulmonary complications had the greatest overall impact on postoperative mortality (PAF 29.2% [95% CI 19.3-39.1] and 21.6% [95% CI 10.5-32.7], respectively) and prolonged hospitalization (PAF 12.9% [95% CI 9.7-16.0] and 14.7% [95% CI 11.0-18.8], respectively). Anastomotic leakage had the greatest overall impact on re-interventions (PAF 25.1% [95% CI 20.5-29.7]) and reoperations (PAF 30.3% [95% CI 24.3-36.3]). Intra-abdominal abscesses had the largest impact on readmissions (PAF 7.0% [95% CI 3.2-10.9]). Other complications only had a small effect on these outcomes.

CONCLUSION

Surgical improvement programs should focus on preventing or managing anastomotic leakage and pulmonary complications, since these complications have the greatest overall impact on clinical outcomes after gastrectomy.

Laparoscopic Versus Open Gastrectomy for Cancer: A Western Center Cohort Study

BACKGROUND

Laparoscopic gastrectomy (LG) for cancer has been introduced in institutions worldwide in an effort to minimize surgical trauma, while aiming to provide comparable oncological outcomes to conventional open gastrectomy (OG). The aim of this study was to present our results during the period of implementation of the laparoscopic technique.

MATERIALS AND METHODS

In 2012, LG for the treatment of gastric cancer was introduced at our institution. The results presented are based on a retrospective analysis of data from a cohort of all patients treated with curative intent over the period 2010-2018.

RESULTS

During the study period, 206 patients underwent surgery for gastric cancer: 129 patients (62.6%) had an OG and 77 patients (37.4%) an LG. The conversion rate due to technical reasons was 2.6%. LG was associated with significantly less intraoperative blood loss [mean (mL), OG 544 versus LG 176] and shorter hospital stay than OG [mean (d), OG 12 versus LG 8], fewer severe complications (Clavien-Dindo grade ≥ IIIb) [OG 29 (22.5%) versus LG 9 (11.7%), P = 0.081], significantly lower anastomotic leak rate [OG 18 (14.0%) versus LG 1 (1.3%)] and no 90-day mortality. The percentage of R0 resections was similar between the two groups (OG 82.2% versus LG 85.7%, P = 0.507), while the mean number of resected lymph nodes was significantly higher in the laparoscopic group [OG 34 versus LG 39, P = 0.030].

CONCLUSIONS

Our data suggest that similar and, in some aspects, better short-term outcomes can be achieved with LG with maintained oncological quality.

Precision medicine in gastric cancer

Gastric cancer (GC) is a complex disease linked to a series of environmental factors and unhealthy lifestyle habits, and especially to genetic alterations. GC represents the second leading cause of cancer-related deaths worldwide. Its onset is subtle, and the majority of patients are diagnosed once the cancer is already advanced. In recent years, there have been innovations in the management of advanced GC including the introduction of new classifications based on its molecular characteristics. Thanks to new technologies such as next-generation sequencing and microarray, the Cancer Genome Atlas and Asian Cancer Research Group classifications have also paved the way for precision medicine in GC, making it possible to integrate diagnostic and therapeutic methods. Among the objectives of the subdivision of GC into subtypes is to select patients in whom molecular targeted drugs can achieve the best results; many lines of research have been initiated to this end. After phase III clinical trials, trastuzumab, anti-Erb-B2 receptor tyrosine kinase 2 (commonly known as ERBB2) and ramucirumab, anti-vascular endothelial growth factor receptor 2 (commonly known as VEGFR2) monoclonal antibodies, were approved and introduced into first- and second-line therapies for patients with advanced/metastatic GC. However, the heterogeneity of this neoplasia makes the practical application of such approaches difficult. Unfortunately, scientific progress has not been matched by progress in clinical practice in terms of significant improvements in prognosis. Survival continues to be low in contrast to the reduction in deaths from many common cancers such as colorectal, lung, breast, and prostate cancers. Although several target molecules have been identified on which targeted drugs can act and novel products have been introduced into experimental therapeutic protocols, the overall approach to treating advanced stage GC has not substantially changed. Currently, surgical resection with adjuvant or neoadjuvant radiotherapy and chemotherapy are the most effective treatments for this disease. Future research should not underestimate the heterogeneity of GC when developing diagnostic and therapeutic strategies aimed toward improving patient survival.

Identification of c.1531C>T Pathogenic Variant in the CDH1 Gene as a Novel Germline Mutation of Hereditary Diffuse Gastric Cancer

Germline pathogenic variants in the CDH1 gene are a well-established cause of hereditary diffuse gastric cancer (HDGC) syndrome. The aim of this study was to characterize CDH1 mutations associated with HDGC from Chile, a country with one of the highest incidence and mortality rates in the world for gastric cancer (GC). Here, we prospectively include probands with family history/early onset of diffuse-type of GC. The whole coding sequence of the CDH1 gene was sequenced from genomic DNA in all patients, and a multidisciplinary team managed each family member with a pathogenic sequence variant. Thirty-six cases were included (median age 44 years/male 50%). Twenty-seven (75%) patients had diffuse-type GC at ≤50 years of age and 19 (53%) had first or second-degree family members with a history of HDGC. Two cases (5.5%) carried a non-synonymous germline sequence variant in the CDH1 gene: (a) The c.88C>A missense variant was found in a family with three diffuse-type GC cases; and (b) c.1531C>T a nonsense pathogenic variant was identified in a 22-year-old proband with no previous family history of HDGC. Of note, six family members carry the same nonsense pathogenic variant. Prophylactic gastrectomy in the proband's sister revealed stage I signet-ring cell carcinoma. The finding of 1531C>T pathogenic variant in the CDH1 in proband with no previous family history of HDGC warrants further study to uncover familial clustering of disease in CDH1 negative patients. This finding may be particularly relevant in high incidence countries, such as the case in this report.

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.

Duodenal stump reinforcement might reduce both incidence and severity of duodenal stump leakage after laparoscopic gastrectomy with Roux-en-Y reconstruction for gastric cancer

BACKGROUND

Although duodenal stump leakage (DSL) is a relatively rare complication after gastrectomy with Roux-en-Y (R-Y) reconstruction, it is difficult to treat and can be fatal. We investigated the impact of duodenal stump reinforcement on DSL after laparoscopic gastrectomy with R-Y reconstruction for gastric cancer.

METHODS

This retrospective study of 965 patients with gastric cancer who underwent laparoscopic distal or total gastrectomy (LDG or LTG) with R-Y reconstruction compared surgical outcomes between two groups, the duodenal stump reinforcement group (reinforcement group) (n = 895) and that without duodenal stump reinforcement (non-reinforcement group) (n = 70).

RESULTS

Mean operative duration was significantly longer in the reinforcement than in the non-reinforcement group (LDG; 291 min versus 258 min, p < 0.001, LTG; 325 min versus 285 min, p < 0.001). DSL occurred less frequently in the reinforcement than in the non-reinforcement group (0.67% vs. 5.71%, p < 0.001). Furthermore, non-reinforcement was an independent risk factor for DSL in multiple logistic regression analysis with adjustment for potential confounding factors. Patients with DSL in the non-reinforcement group all required re-operation, while all but one patient with DSL in the reinforcement group recovered with conservative management.

CONCLUSIONS

Duodenal stump reinforcement in laparoscopic gastrectomy with R-Y reconstruction may reduce the risk of DSL development and minimize its severity.

Comparison of totally laparoscopic total gastrectomy and laparoscopic-assisted total gastrectomy: A systematic review and meta-analysis

BACKGROUND

Laparoscopic-assisted total gastrectomy (LATG) has been extensively employed for the removal of gastric tumors, although it has several limitations. Totally laparoscopic total gastrectomy (TLTG) is a new technique that has rapidly been gaining popularity, and may help overcome the limitations of LATG; however, its safety and therapeutic effect remain controversial. In the present study, we aimed to assess the safety and efficacy of TLTG, and compare the short-term outcomes of TLTG and LATG.

METHODS

We searched for studies comparing TLTG and LATG published up to April 2018 from databases such as PubMed and Embase. The study results, including time of surgery, blood loss, anastomosis time, retrieved lymphatic nodes, proximal and distal resection edges, incision length, time to first fluid and soft diet, hospitalization duration, time to first flatus, and postsurgical and anastomotic complications, were compared between the procedures.

RESULTS

A total of 10 studies were included. TLTG led to reduced intraoperative blood loss (P < 0.01), greater number of retrieved lymphatic nodes (P < 0.01), decreased hospitalization duration (P < 0.01), reduced incision length (P = 0.05), and shorter time to first fluid diet (P < 0.05), as compared to LATG. The surgery and anastomosis times, time to first soft diet, resection edge, time to first flatus, overall postsurgical complications, and anastomosis-related complications were similar between TLTG and LATG (P > 0.05).

CONCLUSIONS

TLTG is a safe procedure that yields better cosmesis lower invasiveness, and faster recovery as compared to LATG.

Laparoscopic D2 plus complete mesogastrium excision using the "enjoyable space" approach versus conventional D2 total gastrectomy for local advanced gastric cancer: short-term outcomes

Introduction

Laparoscopy-assisted radical total gastrectomy is technically demanding.

Aim

To introduce the “enjoyable space” approach to achieve D2 plus complete mesogastrium excision (CME) and to investigate its safety and feasibility.

Material and methods

Between January 2015 and December 2017, 165 patients with primary advanced upper gastric cancer underwent laparoscopy-assisted radical total gastrectomy. Among these patients, 81 underwent conventional D2 total gastrectomy (D2 group) and 84 underwent D2 plus CME total gastrectomy (D2 + CME group). Clinicopathological characteristics, surgical outcomes and postoperative complications were compared between the two groups.

Results

There were no significant differences between the two groups (p > 0.05) in clinicopathological characteristics. However, the D2 + CME group had a longer mean operative time, lower mean blood loss and slightly higher mean number of retrieved lymph nodes (LNs) than the D2 group (p < 0.05 each). The mean time to first flatus, liquid diet, and soft diet and the duration of hospital stay were similar between the two groups (p > 0.05 each). No significant difference in postoperative complication rates was found between the groups (16.0% vs. 9.5%, p > 0.05).

Conclusions

The “enjoyable space” approach is an option to achieve D2 + CME, and its safety and feasibility over conventional method are confirmed with lower intraoperative blood loss and more harvested LNs.

Laparoscopic Resection for Adenocarcinoma of the Stomach or Gastroesophageal Junction Improves Postoperative Outcomes: a Propensity Score Matching Analysis

BACKGROUND

Minimally invasive resection for upper gastrointestinal tumors has been associated with favorable results. However, the role of laparoscopic surgery (LS) in the multimodal treatment of patients with advanced adenocarcinoma of the stomach or gastroesophageal junction needs further investigation.

METHODS

Clinicopathological data of patients who underwent gastrectomy between 2005 and 2017 were assessed. Outcomes of patients undergoing LS were compared with those of patients treated with a conventional open resection (OR) using a 1:1 propensity score matching analysis.

RESULTS

Curative resection for adenocarcinoma of the stomach or gastroesophageal junction was performed in 417 patients during the study period. Beginning in June 2014, the majority of patients underwent LS (n = 72) and they were matched with 72 patients who were treated with an OR. The majority of patients treated with LS (89%) had advanced cancer (UICC stages II and III) and 82% of them received neoadjuvant chemotherapy. LS was significantly associated with a higher number of harvested lymph nodes (26 (9-62) vs. 21 (4-46), P = .007), a lower 90-day major complication rate (13 vs. 26%, P = .035), and a lower length of hospital stay (14 vs. 16 days, P = .001). After a median follow-up time of 32 months, 1-year overall survival rate was higher after LS than after OR (93 vs. 74%, P = .126); however, results did not reach statistical significance.

CONCLUSION

LS for adenocarcinoma of the stomach or gastroesophageal junction is feasible and significantly reduces major postoperative morbidity resulting in a reduced length of hospital stay. Therefore, LS should be preferably considered for the curative treatment of patients with these malignancies.

Three-dimensional Stereoscopic Visualization Shortens Operative Time in Laparoscopic Gastrectomy for Gastric Cancer

Laparoscopic gastrectomy for gastric cancer is now widely accepted and has become a standard surgery. This study investigated the advantages of three-dimensional (3D) stereoscopic visualization for laparoscopic gastrectomy over a conventional two-dimensional (2D) planar screen. The primary outcome of this study was operative time. Ninety-four consecutive cases of gastric cancer patients who underwent laparoscopic total gastrectomy (LTG) (25 cases) or laparoscopic distal gastrectomy (LDG) (69 cases) were enrolled in this study before and after the introduction of the 3D system. Operative time was significantly shorter in the 3D groups for both LTG (351 vs. 406 min, P = 0.026) and LDG (269 vs. 344 min, P < 0.01). During intracorporeal procedures, dissection time was significantly shorter in the 3D groups for both LTG (183 vs. 232 min, P = 0.011) and LDG (161 vs. 213 min, P < 0.01), although the time needed for anastomosis was similar between the groups. However, operators preferred intracorporeal knot-tying as a ligature for anastomosis under 3D (LTG, P = 0.012; LDG, P < 0.01). These data suggest that 3D stereoscopic visualization shortens the operative time of laparoscopic gastrectomy by reducing the intracorporeal dissection time.

Current status of laparoscopic total gastrectomy

In this article, the current state of laparoscopic total gastrectomy (LTG) was reviewed, focusing on lymph node dissection and reconstruction. Lymph node dissection in LTG is technically similar to that in laparoscopic distal gastrectomy for early gastric cancer; however, LTG for advanced gastric cancer requires extended lymph node dissections including splenic hilar lymph nodes. Although a recent randomized controlled trial clearly indicated no survival benefit in prophylactic splenectomy for lymph node dissection at the splenic hilum, some patients may receive prognostic benefit from adequate splenic hilar lymph node dissection. Considering reconstruction, there are two major esophagojejunostomy (EJS) techniques, using a circular stapler (CS) or using a linear stapler (LS). A few studies have shown that the LS method has fewer complications; however, almost all studies have reported that morbidity (such as anastomotic leakage and stricture) is not significantly different for the two methods. As for CS, we grouped various studies addressing complications in LTG into categories according to the insertion procedure of the anvil and the insertion site in the abdominal wall for the CS. We compared the rate of complications, particularly for leakage and stricture. The rate of anastomotic leakage and stricture was the lowest when inserting the CS from the upper left abdomen and was significantly the highest when inserting the CS from the midline umbilical. Scrupulous attention to EJS techniques is required by surgeons with a clear understanding of the advantages and disadvantages of each anastomotic device and approach.

A feasibility study of laparoscopic total gastrectomy for clinical stage I gastric cancer: a prospective multi-center phase II clinical trial, KLASS 03

BACKGROUND

With improved short-term surgical outcomes, laparoscopic distal gastrectomy has rapidly gained popularity. However, the safety and feasibility of laparoscopic total gastrectomy (LTG) has not yet been proven due to the difficulty of the technique. This single-arm prospective multi-center study was conducted to evaluate the use of LTG for clinical stage I gastric cancer.

METHODS

Between October 2012 and January 2014, 170 patients with pathologically proven, clinical stage I gastric adenocarcinoma located at the proximal stomach were enrolled. Twenty-two experienced surgeons from 19 institutions participated in this clinical trial. The primary end point was the incidence of postoperative morbidity and mortality at postoperative 30 days. The severity of postoperative complications was categorized according to Clavien-Dindo classification, and the incidence of postoperative morbidity and mortality was compared with that in a historical control.

RESULTS

Of the enrolled patients, 160 met criteria for inclusion in the full analysis set. Postoperative morbidity and mortality rates reached 20.6% (33/160) and 0.6% (1/160), respectively. Fifteen patients (9.4%) had grade III or higher complications, and three reoperations (1.9%) were performed. The incidence of morbidity after LTG in this trial did not significantly differ from that reported in a previous study for open total gastrectomy (18%).

CONCLUSIONS

LTG performed by experienced surgeons showed acceptable postoperative morbidity and mortality for patients with clinical stage I gastric cancer.

Feasibility of laparoscopic gastrectomy for patients with Siewert-type II/III adenocarcinoma of the esophagogastric junction: A propensity score matching analysis

Background/Aim

The feasibility of using laparoscopic gastrectomy for the treatment of Siewert-type II/III adenocarcinoma of the esophagogastric junction (AEG) has not been addressed. This study aimed to comparatively evaluate the short- and long-term effects on laparoscopic versus open surgery using (propensity score matching) PSM for Siewert-type II/III AEG.

Methods

We retrospectively collected data from the patients with Siewert-type II/III AEG who were treated in our cancer center between January 2013 and December 2015. Patients undergoing laparoscopic gastrectomy and open gastrectomy were matched via PSM. The cumulative 2-year Overall survival (OS) rate of patients in the two cohorts was estimated by Kaplan-Meier plots. Multi-variable analysis using a Cox regression model was conducted to identify independent risk factors.

Results

A total of 963 patients with Siewert-type II/III AEG were included, of which 132 cases were in the laparoscopic gastrectomy group, and 831 cases were in the open gastrectomy group. After regrouping with PSM, 132 patients in the laparoscopic gastrectomy group were balanced with 264 similar patients in the open gastrectomy group. As expected, the laparoscopic gastrectomy group had significantly longer operation times, but less blood loss. Furthermore, the two groups showed similar results for post-operative complications, duration of hospital stay and 2-year OS rate. Combined organ resection was an independent risk factor for 2-year OS rate.

Conclusion

This study suggests that laparoscopic gastrectomy may serve as a safe and feasible treatment for Siewert-type II/III AEG and achieve similar oncologic outcomes as open gastrectomy.