Laparoscopic-assisted versus open total gastrectomy for Siewert type II and III esophagogastric junction carcinoma: a propensity score-matched case-control study

Case Report: Intraoperative endoscopic treatment for the "pseudo" lumen formation of jejuno-esophageal anastomosis in laparoscopic total gastrectomy

Recently, the incidence of adenocarcinoma of esophagogastric junction (AEG) is increasing in China. Laparoscopic total gastrectomy plus D2 lymph node dissection is an important treatment method for AEG of Siewert type II. In order to achieve the esophagojejunostomy, surgical techniques, no matter in open surgery or in laparoscopic one, are highly demanding. This report describes a case of surgical complication during laparoscopic total gastrectomy, in which a pseudoaneurysm developed at the gastroesophageal junction during anastomosis. The condition was successfully managed with endoscopic mucosal incision and placement of a self-expanding covered metal stent (SEMs) as a salvage intervention. The purpose of this report is to share an clinical treatment experience of similar cases, and at the same time to warn surgeon to perform esophagojejunostomy carefully.

Comparing the Effectiveness of Open, Laparoscopic, and Robotic Gastrectomy in the United States: A Retrospective Analysis of Perioperative, Oncologic, and Survival Outcomes

INTRODUCTION

Minimally invasive surgery (MIS) is increasingly used in the surgical management of gastric cancer; however, its adoption lags that of other cancers. Most randomized controlled trials comparing MIS to open gastrectomy have been conducted in Asia, with limited data from the United States. This study aimed to compare perioperative, oncologic, and survival outcomes between open, laparoscopic, and robotic gastrectomy in a large US cohort.

METHODS

Using the National Cancer Database, we identified patients with gastric adenocarcinoma who underwent open, laparoscopic, or robotic gastrectomy between 2010 and 2020. Multivariate regression models were used to examine the association between surgical approach and various outcomes, including 30-d readmission, length of stay (LOS), surgical margin status, lymph node yield, 30- and 90-d mortality, and overall survival (OS). The interaction between surgical approach and tumor location (distal versus proximal or gastroesophageal junction [GEJ]) was also assessed.

RESULTS

Of the 34,937 included patients, 64.8% underwent open gastrectomy, 25.7% underwent laparoscopic surgery, and 9.5% underwent robotic surgery. MIS was associated with lower odds of 30-d readmission (laparoscopic: odds ratio [OR] 0.78, 95% confidence interval [CI] 0.67-0.89; robotic: OR 0.75, 95% CI 0.60-0.92), positive margins (laparoscopic: OR 0.83, 95% CI 0.74-0.93; robotic: OR 0.75, 95% CI 0.62-0.90), 30-d mortality (laparoscopic: OR 0.69, 95% CI 0.55-0.85; robotic: OR 0.66, 95% CI 0.44-0.95), and 90-d mortality (laparoscopic: OR 0.74, 95% CI 0.63-0.87; robotic: OR 0.63, 95% CI 0.47-0.84), as well as improved OS (laparoscopic: hazard ratio 0.83, 95% CI 0.79-0.87; robotic: hazard ratio 0.76, 95% CI 0.69-0.83) compared to open surgery. Considering the interaction of approach with tumor location, for proximal/GEJ tumors, the associated outcome improvements with MIS were attenuated. We observe that the odds for 30-d readmission, 90-d mortality, and OS are similar to those for open operations. However, regardless of tumor location, robotic gastrectomy was associated with decreased LOS and yielded a higher lymph node count than laparoscopic or open approaches.

CONCLUSIONS

In this large US cohort, MIS gastrectomy was associated with improved perioperative, oncologic, and survival outcomes compared to open surgery for distal gastric cancers. However, the associated benefits of MIS were attenuated for proximal/GEJ tumors, with higher odds of readmission, mortality, and worse OS. Notably, robotic gastrectomy was associated with superior lymph node yield and LOS compared to laparoscopic and open approaches, even for proximal/GEJ tumors. These findings underscore the need for further research, especially randomized controlled trials conducted in Western populations, to definitively determine the efficacy of MIS for distal and proximal/GEJ tumors and guide surgical decision-making for gastric adenocarcinoma.

Short-Term Outcomes Analysis Comparing Open, Lap-Assisted, Totally Laparoscopic, and Robotic Total Gastrectomy for Gastric Cancer: A Network Meta-Analysis

BACKGROUND/OBJECTIVES

Total gastrectomy (TG) is the cornerstone treatment for gastric cancer (GC). While open TG (OTG) with D2 lymphadenectomy remains the gold standard, alternative techniques such as lap-assisted TG (LATG), totally laparoscopic TG (TLTG), and robotic TG (RTG) have been reported with promising outcomes. The present analysis aimed to compare the short-term outcomes of different techniques for TG comprehensively in the setting of GC.

METHODS

A systematic review and network meta-analysis were performed. The primary outcomes were overall complications (OC), severe postoperative complications (SPCs), and anastomotic leak (AL). Pooled effect-size measures included risk ratio (RR), weighted mean difference (WMD), and 95% credible intervals (CrIs).

RESULTS

Sixty-eight studies (44,689 patients) were included. Overall, 52.4% underwent OTG, 6.5% LATG, 39.2% TLTG, and 1.9% RTG. Both TLTG (RR 0.82; 95% CrI 0.73-0.92) and RTG (RR 0.75; 95% CrI 0.59-0.95) showed a reduced rate of postoperative OC compared to OTG. SPCs and AL RR were comparable across all techniques. Despite the longer operative time, LATG, TLTG, and RTG showed reduced intraoperative blood loss, time to first flatus, ambulation, liquid diet resumption, and hospital stay compared to OTG.

CONCLUSIONS

Minimally invasive approaches seem to be associated with improved OC and functional outcomes compared to OTG.

Transthoracic single-port-assisted laparoscopic gastrectomy versus laparoscopic transhiatal approach for Siewert type II adenocarcinoma of the esophagogastric junction: a single-center retrospective study

BACKGROUND

The surgical approach for patients with Siewert type II AEG remains controversial. Several studies have described a new laparoscopic radical resection approach of Siewert type II AEG through the left diaphragm. However, the technical safety and feasibility of the new surgical approach compared with the transhiatal approach have not yet been tested.

STUDY DESIGN

We retrospectively reviewed patients with AEG who underwent TSLG and LTH operations in the Guangdong Provincial Hospital of Chinese Medicine between January 2017 and April 2021. Histologically confirmed AEG and D2 lymphadenectomy with curative R0 patients were included, and patients with Siewert I/III AEG or distant metastasis were excluded. Blood loss, the amount of harvested lymph node, and complications related to surgery were evaluated.

RESULTS

A total of 99 patients with Siewert type II AEG were analyzed, 44 in the TSLG group and 55 in the LTH group. There was no difference in clinicopathological features between the two groups. The more harvested lymph node (23.33 ± 11.41 vs. 32.18 ± 12.85, p < 0.01), lower mediastinal lymph node (1.07 ± 2.08 vs. 3.25 ± 3.31, p < 0.01), and longer proximal margin length (3.08 ± 1.19 vs. 4.47 ± 0.95 cm, p < 0.01) were observed in the TSLG group. The rate of cure (R0 gastrectomy) in the TSLG group was higher than that in the LTH group (100% vs. 89.09%, p = 0.03).

CONCLUSION

The TSLG approach is associated with improved surgical views, simplified lymphatic dissection in the inferior mediastinum, and more reliable margins. TSLG surgery may be an effective addition to LTH surgery, particularly when lower mediastinal lymph node metastases are suspected.

Surgical and Perioperative Treatments for Esophagogastric Junction Cancer

Esophagogastric junction cancer (EGJC) is a rare malignant disease that occurs in the gastroesophageal transition zone. In recent years, its incidence has been rapidly increasing not only in Western countries but also in East Asia, and it has been attracting the attention of both clinicians and researchers. EGJC has a worse prognosis than gastric cancer (GC) and is characterized by complex lymphatic drainage pathways in the mediastinal and abdominal regions. EGJC was previously treated in the same way as GC or esophageal cancer, but, in recent years, it has been treated as an independent malignant disease, and treatment focusing only on EGJC has been developed. A recent multicenter prospective study revealed the frequency of lymph node metastasis by station and established the optimal extent of lymph node dissection. In perioperative treatment, the combination of multi-drug chemotherapy, radiation therapy, molecular targeted therapy, and immunotherapy is expected to improve the prognosis. In this review, we summarize previous clinical trials and their important evidence on surgical and perioperative treatments for EGJC.

Minimally invasive surgery for gastro-oesophageal junction adenocarcinoma: Current evidence and future perspectives

Minimally invasive surgery is increasingly indicated in the management of malignant disease. Although oesophagectomy is a difficult operation, with a long learning curve, there is actually a shift towards the laparoscopic/thoracoscopic/ robotic approach, due to the advantages of visualization, surgeon comfort (robotic surgery) and the possibility of the whole team to see the operation as well as and the operating surgeon. Although currently there are still many controversial topics, about the surgical treatment of patients with gastro-oesophageal junction (GOJ) adenocarcinoma, such as the type of open or minimally invasive surgical approach, the type of oesophago-gastric resection, the type of lymph node dissection and others, the minimally invasive approach has proven to be a way to reduce postoperative complications of resection, especially by decreasing pulmonary complications. The implementation of new technologies allowed the widening of the range of indications for this type of surgical approach. The short-term and long-term results, as well as the benefits for the patient - reduced surgical trauma, quick and easy recovery - offer this type of surgical treatment the premises for future development. This article reviews the updates and perspectives on the minimally invasive approach for GOJ adenocarcinoma.

Long-term oncologic and surgical outcomes of robotic and laparoscopic gastrectomy for Siewert II/III esophagogastric junction carcinoma: A propensity score-matched retrospective cohort study

BACKGROUND

This study aimed to investigate the short-term surgical and long-term survival outcomes after robotic gastrectomy (RG) or laparoscopic gastrectomy (LG) for patients with Siewert type II and III adenocarcinoma of the esophagogastric junction (AEG).

METHODS

We retrospectively analyzed 84 and 312 patients with Siewert type II/III AEG who underwent RG or LG between January 2005 and September 2016 in our center. We performed a 1:2 matched propensity score matching (PSM) analysis between the RG and LG group for clinical features to reduce confounding bias. Additionally, the long- and short-term outcomes between the RG and LG group were compared.

RESULTS

The clinicopathological characteristics of 246 patients (RG group: n = 82; LG group: n = 164) were well balanced after PSM. Patients in the RG group showed less estimated blood loss, less time to first flatus, less time to first ambulation, less drainage tube removed time, and retrieved more lymph nodes than the LG group. The overall complication rate was comparable between the RG and LG groups. The 5-year overall survival (OS) was 44.4% in the RG group and 43.7% in the LG group (p = 0.898). The 5-year disease-free survival (DFS) was 43.2% in the RG group and 43.2% in the LG group (p = 0.990). The RG and LG groups exhibited a similar recurrence rate and pattern within 5 years after surgery.

CONCLUSION

Robotic gastrectomy could be a feasible and safe option for patients with Siewert II/III AEG in terms of surgical and oncologic outcomes.

Essential updates 2021/2022: Perioperative and surgical treatments for gastric and esophagogastric junction cancer

In recent years, important clinical trials for gastric cancer (GC) and esophagogastric junction cancer (EGJC) have been reported, changing the strategies of surgical and perioperative treatment. Although laparoscopic gastrectomy has already been shown to be effective for early-stage cancer, recent evidence from both Asia (JLSSG0901, CLASS-01 and KLASS-02) and Europe (LOGICA and STOMACH trials) has demonstrated that it is useful for advanced GC. Robotic surgery has been rapidly gaining popularity in recent years, and randomized controlled trials are ongoing to evaluate its efficacy. A prospective nationwide multicenter study mapped sites with frequent metastasis and revealed lymphatic flow specific to EGJC, thus establishing the optimal lymph node dissection area and surgical approach based on esophageal involvement. Perioperative chemotherapy, the mainstay of treatment in Europe, also has been established in Asia by the PRODIGY and RESOLVE studies. New clinical trials have been conducted to evaluate the efficacy of combining immunotherapy or molecular-targeted therapy with perioperative chemotherapy or chemoradiotherapy. In this review, we present important recent clinical trials regarding the treatment of GC and EGJC published in 2021 or 2022.

Robotic versus open approach in total gastrectomy for gastric cancer: a comparative single-center study of perioperative outcomes

The robotic approach to gastric cancer has been gaining interest in recent years; however, its benefit over the open procedure in total gastrectomy with D2 lymphadenectomy is still controversial. The aims of the study were to compare postoperative morbidity and mortality, hospital stay, and anatomopathological findings between the robotic and open approaches to oncologic total gastrectomy. We analyzed a prospectively collected database, which included patients who underwent total gastrectomy with D2 lymphadenectomy in our center using a robotic or an open approach between 2014 and 2021. Comparative analysis of clinicopathological, intraoperative, postoperative and anatomopathological variables between the robot-assisted group and the open group was performed. Thirty patients underwent total gastrectomy with D2 lymphadenectomy by a robotic approach and 48 patients by an open procedure. Both groups were comparable. The robot-assisted group presented a lower rate of Clavien-Dindo complications ≥ stage II (20 vs. 48%, p = 0.048), a shorter hospital stay (7 days vs. 9 days, p = 0.003) and had a higher total number of lymph nodes resected (22 nodes vs. 15 nodes, p = 0.001) compared to the open approach. Operative time was longer in the robotic group (325 min vs. 195 min, p < 0.001) compared to the open group. The robotic approach is associated with a longer surgical time, a lower rate of Clavien-Dindo complications ≥ stage II and a shorter hospital stay, and more lymph nodes were resected compared to the open approach.

Thoracolaparoscopic radical resection of esophagogastric junction cancers with a NOSE-like approach to extract large specimens

To investigate the efficacy and safety of combined thoracoscopic and laparoscopic radical resection of esophagogastric junction cancers using a natural orifice specimen extraction-like approach for extraction of large surgical specimens. Patients who had esophagogastric junction cancers treated with thoracolaparoscopic resection using the natural orifice specimen extraction-like approach for specimen extraction were retrospectively enrolled. A 5-cm transverse incision on the abdominal wall at the middle of the superior pubic symphysis was made for surgical specimen extraction. The clinical, surgical, complications, and follow-up data were analyzed. A total of 162 patients were enrolled, and the surgery was successful in all patients (100%). The total surgical duration ranged 165 to 270 minutes, with blood loss 20 to 150 mL, hospital stay 8 to 22 days, first flatus time 2 to 7 days, extubation time of drainage tubes 1 to 26 days, first oral feeding time 5 to 10 days, number of lymph nodes resected 15 to 39, postoperative ambulation time 1 to 2 days, and postoperative residual rate of cancerous cells at the surgical margins 0. Postoperative complications occurred in 14 (8.6%), including anastomotic leakage in 4 (2.5%), anastomotic stenosis in 3 (1.9%), hydrothorax in 4 (2.5%), and incision infection in 3 (1.9%). At follow-up (mean 12 months), all patients were alive, and the transverse incision was a linear scar concealed in the suprapubic pubic hair area. The combined laparoscopic and thoracoscopic surgery for radical resection of carcinomas at the esophagogastric junction is safe and effective, and a transverse incision at the suprapubic symphysis for specimen extraction results in improved minimal invasiveness and cosmesis.

Total laparoscopic versus laparoscopic-assisted transabdominal posterior mediastinal digestive tract reconstruction in the treatment of Siewert II adenocarcinoma of the esophagogastric junction: A retrospective study

BACKGROUND

The method of operation and the range of resection for Siewert II adenocarcinoma of the esophagogastric junction (AEG) remain controversial. This study aims to evaluate the safety, feasibility, and short-term postoperative effect of total laparoscopic versus laparoscopic-assisted transabdominal posterior mediastinal digestive tract reconstruction in the treatment of Siewert II AEG.

METHODS

Total laparoscopic or laparoscopic-assisted gastrointestinal reconstruction through abdominal posterior mediastinum was performed in 108 patients with Siewert II AEG from October 2017 to February 2019. This study evaluated the loss of intraoperative blood, the number of lymph nodes, the marginal of the tumor, short-term postoperative complications (within 30 days), the rate of survival at follow-up, and the economic cost, feasibility, and effect of short-term postoperative recovery for patients who received these two operations.

RESULT

There were no significant differences in general data between the total laparoscopic group and the laparoscopic-assisted group (P > 0.05). However, the total laparoscopic group cost more time on the surgical procedure and digestive tract reconstruction, lost less intraoperative blood, and had more mediastinal lymph nodes compared with the laparoscopic-assisted group (P < 0.05). The total laparoscopic group was significantly better than the laparoscopic-assisted group compared with the short-term postoperative recovery indexes, such as the first exhaust time, the first defecation time, the first fluid time, the first semi-fluid diet time, the postoperative hospital stay, and other postoperative recovery indexes (P < 0.05). In addition, there were no significant differences in postoperative complications, postoperative pathological indexes, the recurrence rate, and mortality between the total laparoscopic group and laparoscopic-assisted group (P > 0.05).

CONCLUSIONS

The safety, feasibility, and short-term effect of total laparoscopic transabdominal posterior mediastinal digestive tract reconstruction in the treatment of Siewert II AEG were better than those for the laparoscopic-assisted group.

Laparoscopic-assisted vs open transhiatal gastrectomy for Siewert type II adenocarcinoma of the esophagogastric junction: A retrospective cohort study

BACKGROUND

The studies of laparoscopic-assisted transhiatal gastrectomy (LTG) in patients with Siewert type II adenocarcinoma of the esophagogastric junction (AEG) are scarce.

AIM

To compare the surgical efficiency of LTG with the open transhiatal gastrectomy (OTG) for patients with Siewert type II AEG.

METHODS

We retrospectively evaluated a total of 578 patients with Siewert type II AEG who have undergone LTG or OTG at the First Medical Center of the Chinese People’s Liberation Army General Hospital from January 2014 to December 2019. The short-term and long-term outcomes were compared between the LTG (n = 382) and OTG (n = 196) groups.

RESULTS

Compared with the OTG group, the LTG group had a longer operative time but less blood loss, shorter length of abdominal incision and an increased number of harvested lymph nodes (P < 0.05). Patients in the LTG group were able to eat liquid food, ambulate, expel flatus and discharge sooner than the OTG group (P < 0.05). No significant differences were found in postoperative complications and R0 resection. The 3-year overall survival and disease-free survival performed better in the LTG group compared with that in the OTG group (88.2% vs 79.2%, P = 0.011; 79.7% vs 73.0%, P = 0.002, respectively). In the stratified analysis, both overall survival and disease-free survival were better in the LTG group than those in the OTG group for stage II/III patients (P < 0.05) but not for stage I patients.

CONCLUSION

For patients with Siewert type II AEG, LTG is associated with better short-term outcomes and similar oncology safety. In addition, patients with advanced stage AEG may benefit more from LTG in the long-term outcomes.

Feasibility and efficacy of transthoracic single-port assisted laparoscopic esophagogastrectomy for Siewert type II adenocarcinoma of the esophagogastric junction

Background

The surgical treatment of Siewert type II adenocarcinoma of the esophagogastric junction (AEG) is controversial, and no systematic technology has been established. The aim of this retrospective study is to introduce the technology of transthoracic single-port assisted laparoscopic esophagogastrectomy.

Methods

Data from patients with Siewert type II AEG who underwent transthoracic single-port assisted laparoscopic esophagogastrectomy in Guangdong Provincial Hospital of Chinese Medicine from May 2017 to December 2020 were analyzed.

Results

A total of 35 patients, including 30 males and 5 females, were enrolled in this study. Eight patients underwent proximal gastrectomy while the other 27 patients underwent total gastrectomy. The median operative times were 247.5 (195.0–275.0) min and 290.0 (173.0–530.0) min for proximal and total gastrectomy, respectively. The median lower mediastinal lymph node dissection (LMLD) time was 41.5 (20.0–57.0) min and the median estimated blood loss was 100.0 (20.0–200.0) mL. The median number of harvested mediastinal lymph nodes was 5 [2–13]. Lower mediastinal lymph node metastasis occurred in 9 patients (25.7%). The lower mediastinal lymph node metastasis rate was significantly higher in patients with esophageal involvement exceeding 2 cm [>2 vs. ≤2 cm: 55.6% (5/9) vs. 15.4% (4/26), P=0.03]. The median postoperative hospital stay was 10 [6–73] days. Overall morbidity was 11.8% (4 patients), including 2 cases of pleural effusion, 1 case of pancreatic fistula, and 1 case of anastomotic leakage.

Conclusions

Transthoracic single-port assisted laparoscopic esophagogastrectomy is safe and feasible. It has the advantages of reducing the difficulty of LMLD and digestive tract reconstruction.

Surgical and survival outcomes after laparoscopic and open gastrectomy for serosa-invasive Siewert type II/III esophagogastric junction carcinoma: a propensity score matching analysis

BACKGROUND

The potential advantage of laparoscopic gastrectomy (LG) compared with open gastrectomy (OG) for serosa-invasive (pT4a) Siewert type II and III adenocarcinoma of the esophagogastric junction (AEG) remains uncertain. Thus, the purpose of this study was to investigate the short- and long-term outcomes of LG compared to OG for pT4a Siewert type II/III AEG cancers.

METHODS

We retrospectively evaluated 283 patients with pathological confirmed T4a Siewert type II and type III AEG who underwent LG or OG in our center between January 2004 and September 2015. The short- and long-term outcomes were compared between the groups using a 1:1 matched propensity score matching method (PSM).

RESULTS

The LG group had a longer operation time, less estimated blood loss, less time to first flatus, less time to start liquid diet, less time to first ambulation, and shorter length of incision than the OG group. The conversion rates were 5.4% in the LG groups. There was no significant difference in the overall complication rate between the LG and OG groups. The 5-year overall survival (OS) and the 5-year disease-free survival (DFS) were comparable between the LG and OG groups (35.4% vs 32.1%, p = 0.541; 34.1% vs 31.0%, p = 0.523, respectively). There was no significant difference in the recurrence rate and pattern between the LG and OG groups.

CONCLUSIONS

Laparoscopic gastrectomy is associated with better short-term outcomes and similar long-term outcomes for pT4a Siewert type II/III AEG. This study reveals that LG could be a safe and feasible option for pT4a Siewert type II/III AEG compared to OG.

Short-Term Clinical Efficacy of Neoadjuvant Chemotherapy Combined With Laparoscopic Gastrectomy for Locally Advanced Siewert Type II and III Adenocarcinoma of the Esophagogastric Junction: A Retrospective, Propensity Score-Matched Study

Background

Laparoscopic gastrectomy (LG) has been increasingly used for the treatment of locally advanced Siewert type II and III adenocarcinoma of the esophagogastric junction (AEG). However, whether LG can achieve the same short-term efficacy in the treatment of patients who receive neoadjuvant chemotherapy (NACT) remains controversial. Thus, the aim of this study was to investigate the clinical outcomes of NACT combined with LG for Siewert type II and III AEG.

Methods

This retrospective study identified patients with locally advanced Siewert type II and III AEG diagnosed between May 2011 and October 2020 using the clinical tumor-node-metastasis (cTNM) staging system. The short-term outcomes were compared between the matched groups using a 1:3 propensity score matching (PSM) method, which was performed to reduce bias in patient selection.

Results

After PSM, 164 patients were selected, including 41 in the NACT group and 123 in the LG group. The baseline characteristics were similar between the two groups. Compared with the LG group, the NACT group exhibit a smaller tumor size and significantly less advanced pathological tumor classification and nodal classification stages. The time to first flatus of the NACT group was significantly shorter, but the hospital stay was significantly longer than that of the LG group. The NACT group showed similar overall (29.3% vs 25.2%, P=0.683), systemic (24.4% vs 21.1%, P=0.663), local (12.2% vs 9.8%, P=0.767), minor (19.5% vs 19.5%, P=1.000) and major (9.8% vs 5.7%, P=0.470) complications as the LG group. Subgroup analyses showed no significant differences in most stratified parameters. Operation time≥ 300 minutes was identified as an independent risk factor for overall complications. Age≥ 60 years was identified as an independent risk factor for major complications.

Conclusion

NACT combined with LG for AEG does not increase the risk of postoperative morbidity and mortality compared with LG.

Laparoscopic versus open transhiatal approach for adenocarcinoma of the esophagogastric junction: A systematic review and meta-analysis

BACKGROUND

The incidence of adenocarcinoma of the esophagogastric junction (AEG) is increasing worldwide. Laparoscopic transhiatal approach (LTH) has gained growing popularity in the treatment of AEG. However, its safety and efficacy need to be evaluated.

METHODS

Original studies comparing LTH with open transhiatal approach (OTH) were searched. Meta-analysis was performed using RevMan 5.3.

RESULTS

Nine studies involving 2149 patients were eligible. Compared with OTH, LTH was associated with longer operation time (mean difference [MD] = 31min, 95%CI [20,41], P < 0.001) while less blood loss (MD = -103ml [-135, -72], P < 0.001), and harvested similar number of lymph nodes (MD = 0.1 [-1.2, 1.4], P = 0.89). There were no differences in time to ambulation (MD = -0.79 days [-1.77, 0.20], P = 0.12) or time to first flatus (MD = -0.82 days [-1.76, 0.11], P = 0.08); however, LTH was associated with shorter postoperative hospital stay (MD = -1.70 days [-2.34, -1.05], P < 0.001). The mortality after surgery was comparable for LTH and OTH (risk difference [RD] = -0.00 [-0.01, 0.01], P = 0.55). The incidence of total major complications was similar in LTH (6.1%) and OTH (8.4%) (RD = -0.02 [-0.05, 0.01], P = 0.12); there were no significant differences in the incidence of each complication. Furthermore, LTH achieved similar 2-year overall survival (OS) rate (risk ratio [RR] = 1.17 [0.86, 1.60], P = 0.31) while higher 5-year OS rate (RR = 1.43 [1.18, 1.73], P = 0.0003) and significant improvement of OS (univariable hazard ratio = 0.65 [0.50, 0.84], P = 0.0009; multivariable hazard ratio = 0.59 [0.44, 0.80], P = 0.0006).

CONCLUSIONS

LTH is feasible and safe for AEG, and may provide more favorable short-term outcomes and potential long-term survival benefit, which needs to be confirmed by randomized trials.

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.

Laparoscopic versus open gastrectomy for Siewert type II/III adenocarcinoma of the esophagogastric junction: a meta-analysis

BACKGROUND

The potential advantages of laparoscopic gastrectomy (LG) compared with open gastrectomy (OG) for Siewert type II/III adenocarcinoma of the esophagogastric junction (AEG) have not been fully clarified. The aim of this meta-analysis was to evaluate the safety and efficacy of LG for Siewert type II/III AEG, compared with OG.

METHODS

A comprehensive search was performed in various medical databases up to December 30, 2018. Seven non-randomized controlled trials comparing LG and OG for Siewert type II/III AEG were included. Outcomes evaluated including operation time, estimated blood loss, number of retrieved lymph nodes (LNs), post-operation complications, postoperative hospital stay, time to first flatus, time to ambulation, and overall survival (OS).

RESULTS

Seven studies of 1915 patients were included for meta-analysis. The estimated blood loss [weighted mean difference (WMD) = - 77.49, 95%CI - 111.84 to - 43.15; P < 0.00001] was significantly less and the postoperative hospital stay (WMD = - 1.98, 95%CI - 2.14 to - 1.83; P < 0.00001) was significantly shorter in the LG group than in the OG group, while the operation time, number of retrieved LNs, time to first flatus, and time to ambulation showed no significant difference between LG and OG groups. The overall postoperative complications [odds ratio (OR) 0.78, 95%CI 0.60-1.02; P = 0.07] in LG group were less than those in OG group, although the difference was not significant between the two groups.

CONCLUSION

LG can achieve short-term surgical outcomes comparable to OG, with respect to safety and efficiency in treatment of Siewert type II/III AEG.

Long-term oncological outcomes of laparoscopic versus open transhiatal resection for patients with Siewert type II adenocarcinoma of the esophagogastric junction

BACKGROUND

Insufficient information is available about the long-term outcomes of patients with Siewert type II adenocarcinoma of the esophagogastric junction (AEG) who undergo laparoscopic transhiatal approach (LTH). Here we evaluated the oncological safety of LTH for patients with Siewert type II AEG compared with the open transhiatal approach (OTH).

METHODS

Subjects included 79 patients with Siewert type II AEG who underwent gastrectomy combined with lower esophagectomy from 2008 to 2018 at our institution. Overall survival (OS), recurrence-free survival (RFS), status of adjuvant chemotherapy, late-phase complications, and recurrence patterns were compared between the OTH (n = 29) and LTH groups (n = 43).

RESULTS

The median observation periods were 60 months (6-120 months) and 36 months (1-88) for the OTH and LTH groups, respectively. The 5-year OS rates were significantly different: 74% (95% CI 71-77%) and 98% (95% CI 97-99) in the OTH and LTH groups (HR 0.10, 95% CI 0.01-0.83), respectively, though the OTH group included more patients with advanced disease. After stratification, according to pathological stage to adjust for selection bias, the 5-year OS and RFS rates were longer, but not significantly different among patients in the LTH group with pStage III (HR 0.42, 95% CI 0.05-3.47; HR 0.47, 95% CI 0.10-2.12, respectively). Recurrence patterns were similar in the both groups.

CONCLUSIONS

Long-term outcomes of the LTH group were not inferior to those of the OTH group, suggesting the possibility of LTH as a treatment option for selected patients with Siewert type II AEG.

The safety of esophagojejunostomy via a transorally inserted-anvil method vs extracorporeal anastomosis using a circular stapler during total gastrectomy for Siewert type 2 adenocarcinoma of the esophagogastric junction

Background

Intracorporeal esophagojejunostomy via a transorally inserted-anvil method during laparoscopic total gastrectomy (LTG) for upper gastric cancer has been demonstrated to be feasible, but the use of this assessment exclusively for Siewert type 2 adenocarcinoma of the esophagogastric junction (AEG) has not been reported.

Methods

A total of 428 consecutive gastric-cancer patients who underwent LTG in Nanfang Hospital from January 2008 to December 2016 were reviewed. Among these patients, 98 were classified as Siewert type 2 AEG. The patients underwent intracorporeal esophagojejunostomy through either a transorally inserted-anvil method (n = 27) or extracorporeal anastomosis usinga circular stapler (n = 71). After generating propensity scores with covariates that were associated with developing anastomotic leakage, 26 patients who underwent esophagojejunostomy via the transorally inserted-anvil method (transoral group) were 1:1 matched with 26 patients who underwent the procedure via extracorporeal anastomosis using a circular stapler (extracorporeal group). The safety after 30 days post-operatively was compared between the two groups.

Results

The transoral group and extracorporeal group were balanced regarding the baseline variables. The operative time, reconstruction duration, number of dissected lymph nodes, length of the proximal resection margins, estimated blood loss, intra-operative complication rate, and post-operative recovery course were not significantly different between the two groups. The mean anvil-insertion completion time (9.7 ± 3.0 vs 13.4 ± 2.0 minutes, P < 0.001) and the median incision length (5.5 vs 7.0 cm, P < 0.001) in the transoral group were shorter than those in the extracorporeal group. The incidence of post-operative complications (26.9% vs 23.1%, P = 0.749) and the classification of complication severity (P = 0.939) were similar between the two groups.

Conclusions

Intracorporeal esophagojejunostomy through a transorally inserted-anvil method may be a potentially safe approach to simplify and optimize the procedure during LTG for Siewert type 2 AEG.

Minimally invasive and robotic surgery in the surgical treatment of esophagogastric junction cancer

Minimally invasive surgery provides for the treatment of esophagogastric junction tumors under safe conditions, reducing respiratory and abdominal wall complications. Recovery is improved, while maintaining the oncological principles of surgery to obtain an optimal long-term outcome. It is important to have a sufficient volume of activity to progress along the learning curve with close expert supervision in order to guarantee R0 resection and adequate lymphadenectomy. Minimal invasiveness ought not become an objective in itself. Should total gastrectomy be performed, the risk of a positive proximal margin makes intraoperative biopsy compulsory, without ruling out a primary open approach. Meanwhile, minimally invasive esophagectomy has been gaining ground. Its main difficulty, the intrathoracic anastomosis, can be safely carried out either with a mechanical side-to-side suture or a robot-assisted manual suture, thanks to the 3-D vision and versatility of the instruments.

Long-term Outcomes of Laparoscopic Versus Open Transhiatal Approach for the Treatment of Esophagogastric Junction Cancer

Purpose

The laparoscopic transhiatal approach (LA) for adenocarcinoma of the esophagogastric junction (AEJ) is advantageous since it allows better visualization of the surgical field than the open approach (OA). We compared the surgical outcomes of the 2 approaches.

Materials and Methods

We analyzed 108 patients with AEJ who underwent transhiatal distal esophagectomy and gastrectomy with curative intent between 2003 and 2015. Surgical outcomes were reviewed using electronic medical records.

Results

The LA and OA were performed in 37 and 71 patients, respectively. Compared to the OA, the LA was associated with significantly shorter duration of postoperative hospital stay (9 vs. 11 days, P=0.001), shorter proximal resection margins (3 vs. 7 mm, P=0.004), and extended operative times (240 vs. 191 min, P=0.001). No significant difference was observed between the LA and OA for intraoperative blood loss (100 vs. 100 mL, P=0.392) or surgical morbidity rate (grade≥II) for complications (8.1% vs. 23.9%, P=0.080). Two cases of anastomotic leakage occurred in the OA group. The number of harvested lymph nodes was not significantly different between the LA and OA groups (54 vs. 51, P=0.889). The 5-year overall and 3-year relapse-free survival rates were 81.8% and 50.7% (P=0.024) and 77.3% and 46.4% (P=0.009) for the LA and OA groups, respectively. Multivariable analyses revealed no independent factors associated with overall survival.

Conclusions

The LA is feasible and safe with short- and long-term oncologic outcomes similar to those of the OA.

Novel abdominal approach for dissection of advanced type II/III adenocarcinoma of the esophagogastric junction: a new surgical option

OBJECTIVE

The optimal surgical approach for Siewert type II adenocarcinoma of the esophagogastric junction (AEG) is controversial. In this study, we evaluated the outcomes of total gastrectomy for Siewert type II/III AEG via the left thoracic surgical approach that is used at our center.

METHODS

We identified 41 patients with advanced AEG in our retrospective database and analyzed their 3-year survival rate, upper surgical margin, postoperative complications, and index of estimated benefit from lymph node dissection.

RESULTS

The 3-year overall survival rate of the whole group was 63%, but no difference was observed between Siewert type II and III AEGs. Esophageal exposure and lymphadenectomy were sufficient. Eight patients developed postoperative complications, but none of the patients developed anastomotic leakage. Dissection of lymph node station Nos. 19 and 110 may be necessary for patients with Siewert type II AEG. Multivariate analysis revealed that the cT category was the only independent risk factor.

CONCLUSIONS

Total gastrectomy via an approach from the abdominal cavity into the thoracic cavity may be an optimal surgical technique for advanced Siewert type II AEG.

Long-term results of hand-assisted laparoscopic gastrectomy for advanced Siewert type II and type III esophagogastric junction adenocarcinoma

BACKGROUND

Hand-assisted laparoscopic surgery (HALS) combines laparoscopic surgery with the tactile feedback of a hand-assist device for complex laparoscopic operations. This study aimed to comparatively evaluate the long-term outcomes of patients who underwent HALS versus open surgery for the treatment of advanced Siewert type II and type III adenocarcinoma of the esophagogastric junction (AEG).

METHODS

A retrospective analysis of 77 patients with advanced Siewert type II and IIIAEG between March 2010 and March 2011. Data concerning the basic characteristics of patients, pathological staging, early postoperative course, and long-term follow-up were collected and analyzed.

RESULTS

HALS resulted in significantly lower mean blood loss and mean postoperative hospital stay in comparison to open surgery (P = 0.007 and 0.01, respectively). The mean number of resected lymph nodes was 23.22 ± 9.36 in the HALS group, which was more than in the open surgery group (18.61 ± 6.91, P = 0.015). The cumulative 5-year overall survival (OS) rate was 52.8% (95% CI 43.07-60.09) for all patients in the HALS group (78.6% for stage II patients and 36.4% for stage III patients). The 5-year OS rate was not significantly different between both groups.

CONCLUSIONS

While achieving similar oncological outcomes to open surgery, the HALS approach resulted in reduced blood loss, shortened postoperative hospital stay, and the resection of more lymph nodes. This analysis suggests that HALS may serve as a less invasive and as successful alternative to open surgery for the treatment of advanced Siewert type II and type IIIAEG.

Current status and future perspectives of laparoscopic radical surgery for advanced gastric cancer

Laparoscopic radical gastrectomy with lymph node dissection has widely penetrated to East Asian countries, where incidence of gastric cancer occurrence is higher than the rest of the world. Laparoscopic distal gastrectomy for cStageI disease is regarded as one of the option in daily practice in the latest Japanese guidelines; however its applicability to more advanced disease (Stage II/III) is still under debate. Actually, operative techniques of laparoscopic D2 dissection is being matured, but still, necessity of total omentectomy, splenic hilar dissection, management of bulky nodes or large primary tumor, high-level anastomosis in esophageal invasion cases, and extensive peritoneal lavage can be raised as technical limitations. In the future perspective, further technological innovation, including next generation surgical robot, may help surgeons overcome these difficulties. Currently, three large-scaled randomized phase-III clinical trials are ongoing in East Asia, in which patients' accruals have been already completed. With coming long-term outcomes of these well-designed studies, oncological validity of laparoscopic approach will be adequately elucidated.