A case-control study of laparoscopy-assisted and open distal gastrectomy for advanced gastric cancer

Evaluation of factors influencing long-term and textbook outcomes in laparoscopic gastrectomy

BACKGROUND

Textbook outcome (TO) in gastric cancer surgery is a multidimensional measure of surgical quality. However, its impact on long-term survival after laparoscopic gastrectomy (LG) is unclear. This study aims to evaluate TO in LG, assess its hospital-level relevance, and examine its association with long-term survival.

METHODS

In this retrospective cohort study, we analyzed 2278 consecutive gastric cancer patients who underwent laparoscopic gastrectomy (LG) from January 2004 to December 2017. We determined TO achievement rates, compared preoperative and intraoperative variables between TO and non-TO groups, identified independent predictors of TO, and assessed long-term oncologic outcomes using Kaplan-Meier analysis and Cox regression.

RESULTS

A total of 1540 LG patients were analyzed, with 994 (64.5%) achieving TO. The least frequently achieved metric was 'hospital stays ≤21 days' (83.4%), followed by 'lymph nodes retrieved ≥15' (84.0%). Factors independently associated with reduced TO likelihood included age ≥65 years, BMI ≥25, ASA III, conversion to open surgery, operation time ≥260 min, and estimated blood loss ≥150 ml. Furthermore, TO was independently linked to improved 5-year overall survival (OS) and disease-free survival (DFS) (HR 0.519 [0.443-0.609] and HR 0.517 [0.443-0.604], respectively).

CONCLUSION

Implementing the TO concept in LG provides a benchmark for achieving improved prognoses and empowers surgeons to devise strategies for enhancing surgical care quality.

A Systematic Review of Varying Definitions and the Clinical Significance of Fredet's Fascia in the Era of Complete Mesocolic Excision

BACKGROUND

Fredet's fascia represents a crucial landmark for vascular surgical anatomy, especially in minimally invasive complete mesocolic excision (CME) for right-sided colon adenocarcinoma. Fredet's fascia allows access to the gastrocolic trunk of Henle (GCTH), the most critical step in both open and minimally invasive right-sided CME techniques. Despite this, a recent workshop of expert surgeons on the standardization of the laparoscopic right hemicolectomy with CME did not recognize or include the term of Fredet's fascia or area. Hence, we undertook a systematic review of articles that include the terms "Fredet's fascia or area", or synonyms thereof, with special emphasis on the types of articles published, the nationality, and the relevance of this area to surgical treatments.

METHODS

We conducted a systematic review up to 15 July 2022 on PubMed, WOS, SCOPUS, and Google Scholar.

RESULTS

The results of the study revealed that the term "Fredet's fascia" is poorly used in the English language medical literature. In addition, the study found controversial and conflicting data among authors regarding the definition of "Fredet's fascia" and its topographical limits.

CONCLUSIONS

Knowledge of Fredet's fascia's surgical relevance is essential for colorectal surgeons to avoid accidental injuries to the superior mesenteric vascular pedicle during minimally invasive right hemicolectomies with CME. In order to avoid confusion and clarify this fascia for future use, we suggest moving beyond the use of the eponymous term by using a "descriptive term" instead, based on the fascia's anatomic structure. Fredet's fascia could, therefore, be more appropriately renamed "sub-mesocolic pre-duodenopancreatic fascia".

Comparison of estimated treatment effects between randomized controlled trials, case-matched, and cohort studies on laparoscopic versus open distal gastrectomy for advanced gastric cancer: a systematic review and meta-analysis

PURPOSE

In actual surgical research, case-matched studies are frequently conducted as an alternative to randomized controlled trials (RCTs). However, it is still unclear what differences there are between RCTs and case-matched studies in upper gastrointestinal surgery, and clarifying them is a very important clinical issue. Thus, the purpose of this study was to investigate estimated treatment effects between RCTs, case-matched studies, and cohort studies regarding laparoscopic distal gastrectomy (LDG) for advanced gastric cancer (AGC).

METHODS

We searched the PubMed, Cochrane Central Register of Controlled Trials, and Web of Science databases for studies that compared LDG versus open distal gastrectomy for AGC published from the inception of the databases until July 2021. A meta-analysis was performed using the Review Manager version 5.3 software program from the Cochrane Collaboration, and six short-term outcomes and three long-term outcomes were assessed.

RESULTS

Twenty-three studies with 13698 patients were included. There was no difference in estimated treatment effects between RCTs and case-matched studies for all outcomes except for the number of retrieved lymph nodes and postoperative complications. In terms of intraoperative blood loss, postoperative hospital stay, number of retrieved lymph nodes, and recurrence, observational studies tended to overestimate the treatment effects.

CONCLUSION

The estimated treatment effects of LDG for AGC in the case-matched study were almost the same as in the RCTs. However, to assess the true magnitude of the treatment effect, the design and actual implementation of the analysis must be critically evaluated.

Impact of Laparoscopic Converted to Open Gastrectomy on Short- and Long-Term Outcomes of Patients with Locally Advanced Gastric Cancer: A Propensity Score-Matched Analysis

BACKGROUND

It remains unclear whether laparoscopic conversation to open gastrectomy causes higher morbidity and has an adverse effect on the long-term survival outcomes of patients with gastric cancer. This study was designed to evaluate the impact of the conversion on short and long-term outcomes of patients with locally advanced gastric cancer (AGC).

METHODS

We retrospectively investigated 871 patients who initially underwent laparoscopic gastrectomy (LG) for pathologically confirmed diagnosis of AGC between February 2009 and April 2018. The patients were grouped as the conversion (CONV) group and completed laparoscopic (LAP) group. The 1:2 propensity score matching was performed to reduce the effect of bias due to the imbalanced baseline features between the two groups. Multivariate analyses were performed to identify risk factors for conversion and poor survival.

RESULTS

After propensity-score matching, 168 patients (56 in the CONV group and 112 in the LAP group) were studied. The CONV group was associated with significantly longer operation time (252.4 vs. 216.7 min, P < 0.001) and greater estimated blood loss (234.8 vs. 171.2 ml, P < 0.001) as compared with the LAP group. The time to first flatus (3.8 vs. 3.3 days, P = 0.043), time to start a liquid diet (4.1 vs. 3.5 days, P = 0.021), and postoperative hospital stay (8.7 vs. 7.6 days, P = 0.020) were significantly longer in the CONV group than that in the LAP group. The overall complication rate did not differ significantly between the CONV group and the LAP group (16.1% vs. 12.5%, P = 0.692). Both 5-year overall survival (OS) and 5-year disease-free survival (DFS) did not differ significantly between the CONV group and the LAP group (P = 0.805, P = 0.945, respectively). Multivariate analysis showed that lymphovascular invasion and stage III were independent prognostic factors for poor OS and DFS, whereas conversion was not.

CONCLUSIONS

The conversion from laparoscopic to open gastrectomy had no negative impact on morbidity and long-term survival outcomes for patients with locally AGC.

Recanalization in Uncut Roux-en-Y Reconstruction: An Animal Experiment and a Clinical Study

Background: Because of the challenge of jejunal closure recanalization, uncut Roux-en-Y reconstruction remains controversial. This study aimed to investigate the incidence of recanalization after uncut Roux-en-Y reconstruction in pigs and a small number of patients.

Methods: Twenty miniature pigs were subjected to distal gastrectomy and uncut Roux-en-Y reconstruction using various rows of linear staplers to block the intestine. The pigs were sacrificed, and the incidence of recanalization was investigated 1 month after the operation. From December 2018 to June 2019, 10 patients with gastric cancer who had undergone elective laparoscopy-assisted distal gastrectomy and uncut Roux-en-Y reconstruction were included in this study. The primary study outcome was recanalization of the afferent limb, demonstrated by gastrointestinal radiography 1, 3, and 6 months after surgery. Various numbers of staple lines across the afferent jejunal limb were applied for closure: 2 staple lines in 2 pigs, 4 staple lines in 6 pigs, 6 staple lines in 8 pigs, and 8 staple lines in 4 pigs.

Results: Complete recanalization was detected in all 20 pigs 1 month postoperatively. Recanalization was detected in five cases (50%) by gastrointestinal radiography. Among them, 1 case of recanalization was found in the 1st month after the operation, 2 cases were found in the 3rd month, and another 2 cases were found in the 6th month. Bile reflux was detected by endoscopy in 2 patients with recanalization.

Conclusions: The occurrence of afferent limb recanalization after uncut Roux-en-Y reconstruction is high, and using additional staplers alone cannot decrease the incidence of recanalization. Based on our study, uncut Roux-en-Y reconstruction is not recommended.

Risk Factors and Clavien-Dindo Classification of Postoperative Complications After Laparoscopic and Open Gastrectomies for Gastric Cancer: A Single-Center, Large Sample, Retrospective Cohort Study

Background

Laparoscopy has been increasingly used for the surgery of gastric cancer. However, the postoperative complications are still under-investigated and the short-term results of laparoscopic gastrectomy remain controversial. This study aimed to explore the differences of postoperative complications between laparoscopic and open radical gastrectomies in patients with gastric cancer through the large sample size, retrospective cohort study, and evaluate the safety of laparoscopy in patients who underwent radical gastrectomy.

Patients and Methods

A total of 2,966 patients with gastric cancer (TNM I~III) who underwent laparoscopy or open gastrectomy from February 2009 to March 2016 were enrolled in this study. Complications were categorized according to the Clavien–Dindo classification. The incidence and severity of complications between laparoscopic and open gastrectomy were compared using one-to-three propensity score matching (PSM) analysis. Logistic regression analyses were performed to identify risk factors related to postoperative complications.

Results

A total of 2,966 patients were included in the study, including 687 (23.2%) in the LG (Laparoscopy gastrectomies) group and 2,279 (76.8%) in the OG (open gastrectomies) group. After PSM, a well-balanced cohort of 2,373 patients (676 cases in the LG group and 1,697 cases in the OG group) was further analyzed. The results showed that the incidence of overall complications in the LG group was significantly less than the OG group (15.4% vs 20.8%, P=0.003). However, the severe complications of the LG group showed no difference towards the OG group (5.8% vs 5.8%, P=0.952). Multivariate analysis revealed that laparoscopic surgery is a protective factor for the reduction of postoperative complications. Age ≥60 years, ASA classification IIIc and estimated blood loss ≥200 mL were confirmed as independent risk factors of overall complications.

Conclusion

Compared with traditional open gastrectomy, LG is safe and feasible with less trauma and fewer complications for patients with gastric cancer.

Laparoscopic versus open distal gastrectomy for advanced gastric cancer: A meta-analysis of randomized controlled trials and high-quality nonrandomized comparative studies

BACKGROUND

Controversy persists about the effects of laparoscopic distal gastrectomy (LDG) versus open distal gastrectomy (ODG) on short-term surgical outcomes and long-term survival within the field of advanced gastric cancer (AGC).

METHODS

Studies published from January 1994 to February 2020 that compare LDG and ODG for AGC were identified. All randomized controlled trials (RCTs) were included. The selection of high-quality nonrandomized comparative studies (NRCTs) was based on a validated tool (Methodological Index for Nonrandomized Studies, MINORS). The short- and long-term outcomes of both procedures were compared.

RESULTS

Overall, 30 studies were included in this meta-analysis, which comprised of 8 RCTs and 22 NRCTs involving 16,029 patients (7864 LDGs, 8165 ODGs). The recurrence, 3-year disease-free survival (DFS), 3-year overall survival (OS), and 5-year OS rates for LDG and ODG were comparable. LDG was associated with a lower postoperative complication rate (OR 0.79; P < 0.00001), lower estimated volume of blood loss (WMD -102.21 mL; P < 0.00001), shorter postoperative hospital stay (WMD -1.96 days; P < 0.0001), shorter time to first flatus (WMD -0.54 day; P = 0.0007) and shorter time to first liquid diet (WMD -0.66 day; P = 0.001). The number of lymph nodes retrieved, mortality, intraoperative complications, intraoperative blood transfusion, and time to ambulation were similar. However, LDG was associated with a longer surgical time (WMD 33.57 min; P < 0.00001).

CONCLUSIONS

LDG with D2 lymphadenectomy is a safe and effective technique for patients with AGC when performed by experienced surgeons at high-volume specialized centers.

Laparoscopic gastrectomy for elderly gastric-cancer patients: comparisons with laparoscopic gastrectomy in non-elderly patients and open gastrectomy in the elderly

Background

The benefits of laparoscopic gastrectomy (LG) in elderly gastric-cancer patients still remain unclear. The purpose of this study was to evaluate the feasibility and safety of LG in elderly gastric-cancer patients.

Methods

We retrospectively evaluated patients who underwent LG or open gastrectomy (OG) between June 2009 and July 2015 in a single high-volume center. We compared surgical, short-term, and long-term survival outcomes among an elderly (≥70 years old) LG (ELG) group (n = 114), a non-elderly (<70 years old) LG (NLG) group (n = 740), and an elderly OG (EOG) group (n = 383).

Results

Except for extended time to first flatus, the surgical and short-term outcomes of the ELG group were similar to those of the NLG group. The ELG group revealed comparable disease-specific survival (DSS) rates to the NLG group (64.9% vs 66.2%, P = 0.476), although the overall survival (OS) rate was lower (57.0% vs 65.5%, P < 0.001) in the ELG group than in the NLG group. The ELG group showed longer operation time than the EOG group (236.4 ± 77.3 vs 179 ± 52.2 min, P < 0.001). The ELG group had less estimated blood loss (174.0 ± 88.4 vs 209.3 ± 133.8, P = 0.008) and shorter post-operative hospital stay (8.3 ± 2.5 vs 9.2 ± 4.5, P = 0.048) than the EOG group. The severity of complications was similar between the ELG and NLG groups. Multivariate analysis confirmed that LG was not a risk factor for post-operative complications.

Conclusions

LG is a feasible and safe procedure for elderly patients with acceptable short- and long-term survival outcomes.

Laparoscopic versus open approach in gastrectomy for advanced gastric cancer: a systematic review

BACKGROUND

Additional studies comparing laparoscopic gastrectomy (LG) versus open gastrectomy (OG) for advanced gastric cancer (AGC) have been published, and it is necessary to update the systematic review of this subject.

OBJECTIVE

We conducted the meta-analysis to find some proof for the use of LG in AGC and evaluate whether LG is an alternative treatment for AGC.

METHOD

Randomized controlled trials (RCT) and high-quality retrospective studies (NRCT) compared LG and OG for AGC, which were published in English between January 2010 and May 2019, were search in PubMed, Embase, and Web of Knowledge by three authors independently and thoroughly. Some primary endpoints were compared between the two groups, including intraoperative time, intraoperative blood loss, harvested lymph nodes, first flatus, first oral intake, first out of bed, post-operative hospital stay, postoperative morbidity and mortality, rate of disease recurrence, and 5-year over survival (5-y OS). Besides, considering for this 10-year dramatical surgical material development between 2010 and 2019, we furtherly make the same analysis based on recent studies published between 2016 and 2019.

RESULT

Thirty-six studies were enrolled in this systematic review and meta-analysis, including 5714 cases in LAG and 6094 cases in OG. LG showed longer intraoperative time, less intraoperative blood loss, and quicker recovery after operations. The number of harvested lymph nodes, hospital mortality, and tumor recurrence were similar. Postoperative morbidity and 5-y OS favored LG. Furthermore, the systemic analysis of recent studies published between 2016 and 2019 revealed similar result.

CONCLUSION

A positive trend was indicated towards LG. LG can be performed as an alternative to OG for AGC.

Comparison of open gastrectomy and the laparoscopic procedure in advanced gastric cancer

INTRODUCTION AND AIM

Gastric cancer is one of the most frequent neoplasias in Peru and worldwide, with surgery as the only potentially curative or palliative treatment. Laparoscopic gastrectomy is the most frequent alternative surgical technique utilized, but one of its main drawbacks is the technical difficulty involved in perigastric lymphadenectomy. The aim of the present study was to evaluate the clinical and surgical characteristics, postoperative complications, and survival rate in patients with advanced gastric cancer that underwent open gastrectomy or laparoscopic gastrectomy at the Hospital Nacional P.N.P "Luis N. Sáenz" in Lima, Peru, within the time frame of 2005 to 2014.

MATERIALS AND METHODS

An analytic, longitudinal, retrospective cohort study was conducted on 482 patients that underwent surgery for gastric cancer, within the time frame of January 2005 to December 2014. The clinical, epidemiologic, and postoperative characteristics were evaluated, and a survival analysis was carried out.

RESULTS

Of the 475 patients included in the study, 236 underwent open gastrectomy and 239 had laparoscopic gastrectomy. Median follow-up time was 61.9 months in the open surgery group and 46.7 months in the laparoscopy group. There were fewer postoperative complications in the laparoscopy group and no statistically significant difference between the two groups in relation to the survival analysis.

CONCLUSIONS

In our study, laparoscopic gastrectomy resulted in fewer postoperative complications, compared with the open procedure, but did not modify overall survival during the follow-up period.

Laparoscopy Assisted Distal Gastrectomy Versus Open Distal Gastrectomy for Patients with Gastric Cancer in A Middle Resources Country

Background:Laparoscopic surgery with a small laparotomy has several advantages over conventional open surgery, including less invasiveness, less pain, earlier recovery, and better cosmoses. The aim of this study was to compare technical feasibility and early clinical outcomes of laparoscopy-assisted distal gastrectomy in comparison with open distal gastrectomy for gastric cancer in a developing country. Patients and methods :In this retrospective study, patients with distal gastric cancer were divided into two groups (a) patients underwent laparoscopy assisted distal gastrectomy (LADG) (21 patients) and (b) open distal gastrectomy (ODG) (21 patients). For the postoperative pathologic results, the tumor-nodal-metastasis (TNM) stage, grade of tumor differentiation, distal and proximal margins, the number of harvested lymph nodes were evaluated. Staging was done according to the 7th edition of the UICC tumor, node, and metastasis (TNM) classification. D1/D2 lymphadenectomy with curative R0 intention was attempted in all cases. Perioperative mortality and morbidity were assessed. Results:The time to initiate oral intake, and postoperative hospital stay were significantly shorter in the LADG group than in the ODG group (P < 0.001). The operative time in the LADG group was significantly less than that of the ODG group (P = 0.05). Blood loss and blood transfusion frequency were significantly lower (P < 0.0001) in the LADG group in comparison to ODG group. Conclusion:Laparoscopic-assisted distal gastrectomy for distal gastric cancer could be safe and feasible technique alternative to open gastrectomy in a middle income country, with at least similar short term surgical and oncological results. However, laparoscopic gastric surgery is in need to adequate training and technical support especially in D2 lymphadenectomy.

Laparoscopic versus open gastrectomy for advanced gastric cancer: A meta-analysis based on high-quality retrospective studies and clinical randomized trials

BACKGROUND

Additional studies comparing laparoscopic gastrectomy (LG) with open gastrectomy (OG) have been published, and the meta-analysis of this subject should be improved.

METHODS

Randomized controlled trials and high-quality retrospective studies, which compared LG and OG for advanced gastric cancer (AGC) treatment and were published in English and Chinese between January 2000 and February 2017, were selected through PubMed, EMBASE, and the Cochrane Library database by two reviewers independently. The Jadad Composite Scale and the Newcastle-Ottawa scale were used to evaluate the quality and risk of bias for all included studies. Operative outcomes, postoperative outcomes, postoperative morbidity, harvested lymph nodes and 5-year overall survival (OS) were considered as primary endpoints and were compared.

RESULTS

Fifteen studies including a total of 9337 cases (5000 in LG and 4337 in OG) were enrolled. LG showed longer operative time, less intraoperative blood loss, and quicker recovery after operations. Based on the subgroup analysis of the sample size, however, there was no difference in operative time between LG and OG. The number of harvested lymph nodes, 5-year OS, and postoperative morbidity were similar.

CONCLUSION

LG can be performed as an alternative to OG for AGC, with quicker postoperative recovery and comparable safety and efficacy.

Relationship between Clavien-Dindo classification and long-term survival outcomes after curative resection for gastric cancer: A propensity score-matched analysis

BACKGROUND

The impact of postoperative complications (POCs) on the long-term survival outcomes after curative resection for gastric cancer has seldom been reported. The purpose of this study was to evaluate the relationship between the severity of POCs and long-term survival outcomes after curative resection for gastric cancer.

METHODS

The study analyzed 3091 patients who underwent curative resection for gastric cancer in a single center between June 2009 and June 2015. Patients were divided into two groups based on the occurrence or absence of postoperative complications which were recorded using the Clavien-Dindo classification. Long-term survival outcomes were compared between groups after propensity score matching (PSM).

RESULTS

A total of 3091 patients were included in the entire cohort. After PSM, no significant difference in baseline data was observed between the complications (C) group (n = 375) and no complications (NC) group (n = 375). With a median follow-up of 51 months, POCs were associated with decreased 5-year overall survival (OS) (51.7% vs. 67.5%, P < 0.001), disease-free survival (DFS) (49.9% vs. 65.6%, P < 0.001), and disease-specific survival (DSS) (53.9% vs. 68.8%, P < 0.001). Increasing Clavien-Dindo grades from II to IV was significantly associated with a corresponding decrease in OS (60, 48.3, 34%, P = 0.010), DFS (58.3, 46.3, 32.1%, P < 0.001) and DSS (62.9, 50.3, 34%, P < 0.001). Multivariate analysis confirmed POCs was an independent prognostic factor for decreased OS, DFS, and DSS (all P < 0.05).

CONCLUSIONS

POCs had a negative impact on long-term survival outcomes after curative resection for gastric cancer. The negative effects were also increased with higher Clavien-Dindo grades.

Long-term outcomes of laparoscopic versus open D2 gastrectomy for advanced gastric cancer

BACKGROUND

Technical safety and short-term surgical outcomes of laparoscopy-assisted gastrectomy (LAG) for advanced gastric cancer (AGC) have been investigated in many clinical trials. However, studies with large sample size and sufficient follow-up comparing LAG and open gastrectomy (OG) for AGC have seldom been reported. The purpose of this study was to compare the long-term outcomes of LAG versus open OG for AGC using a propensity score matching analysis.

METHODS

We retrospectively evaluated 459 and 856 patients who underwent LG or OG with D2 lymph node dissection, respectively, for AGC between June 2007 and June 2012. One-to-one propensity score matching was performed to compensate for heterogeneity between groups. We compared long-term outcomes between the two groups after propensity score matching.

RESULTS

In the propensity score-matched cohort, no significant differences were observed in 5-year overall survival (OS) (52.0% vs. 53.4%; P = 0.805) and disease-free survival (DFS) (46.8% vs. 47.3%; P = 0.963) between the LAG group and OG group. Stratified analysis showed that the 5-year OS and DFS rates were comparable between the two groups in each tumor stage (P > 0.05). Multivariate analysis revealed that the operation method was not an independent prognostic factor for OS or DFS. Further analysis showed that the recurrence pattern was similar between the LAG group the OG group (P > 0.05).

CONCLUSION

LAG is a feasible surgical procedure for AGC in terms of long-term prognosis, although the results should be confirmed by the ongoing randomized controlled trials.

Severity of complications and long-term survival after laparoscopic total gastrectomy with D2 lymph node dissection for advanced gastric cancer: A propensity score-matched, case-control study

BACKGROUND

Increasing numbers of studies have shown that postoperative complication is a negative predictor of long-term survival outcomes in various malignancies. However, the impact of severity of complications on long-term survival for patients with gastric cancer still remains unclear. This study aimed to explore the relationship between the severity of complications and long-term survival outcomes after laparoscopic total gastrectomy (LTG) for advanced gastric cancer (AGC).

METHODS

The study analyzed 571 patients with AGC who underwent LTG in a single institution between April 2008 and June 2015. Patients were divided into two groups based on the occurrence or absence of postoperative complications which were recorded using the Clavien-Dindo (C-D) classification. Long-term survival outcomes were compared between groups in the propensity score-matched cohort.

RESULTS

The groups were well balanced after the propensity score matched. The complication (C) group was associated with decreased 5-year cancer-specific survival (CSS) (65.1% vs. 76.2%, P=0.049). Subgroup analysis showed that the severe complication (C-D grade > II) group was associated with decreased 5-year overall survival (OS) (46.3% vs. 65.9%, P = 0.042) and cancer-specific survival (CSS) (53.7% vs. 74.4%, P = 0.030). However, a comparative analysis of 5-year OS and CCS showed no significant differences between the minor complication (C-D grade II) group and matched NC group (68.9% vs. 72.2%, P = 0.578; 75.6% vs. 77.8%, P = 0.649; respectively). Multivariate analysis confirmed severe complication was an independent risk factor for decreased OS. Further analysis showed that older age, lower body mass index (BMI), and combined resection were independent risk factor for the occurrence of severe complications.

CONCLUSIONS

Severe complications adversely affected long-term survival outcomes after LTG with D2 lymph node dissection for AGC. More attention should be paid to patients at high risk for severe complications in preoperative assessment and postoperative management.

Laparoscopy-assisted distal gastrectomy versus laparoscopy-assisted total gastrectomy with D2 lymph node dissection for middle-third advanced gastric cancer

BACKGROUND

There still remains controversy for the choice of resection extent for gastric cancer involving the middle-third of the stomach. The aim of this study was to compare the technical feasibility and long-term outcomes of laparoscopy-assisted distal gastrectomy (LADG) versus laparoscopy-assisted total gastrectomy (LATG) for middle-third advanced gastric cancer (AGC) and to determine which is the optimal surgical procedure.

METHODS

For this study, clinical data for 379 patients who underwent LADG or LATG with D2 lymph node dissection between April 2005 and June 2014 were analyzed retrospectively. The short- and long-term outcomes were compared between the propensity score-matched groups.

RESULTS

The LADG group had a significantly shorter operating time (212.74 vs. 241.79 min, P < 0.001), less estimated blood loss (114.38 vs. 181.51 ml, P = 0.000), shorter first flatus and postoperative hospital stay. Additionally, the total cost of hospitalization was significantly higher in the LATG group than LADG group (71187.58 vs. 65783.25 RMB, P = 0.000). There were no significant differences in postoperative complications rate between the LADG group and the LATG group. The 5-year overall survival (OS) rates were 64.4% in the LADG group and 61.0% in the LATG group (P = 0.548). The resection extent was not an independent prognostic factor for the OS.

CONCLUSIONS

LADG with D2 nodal dissection is a feasible treatment strategy for middle-third AGC with better short-term outcomes and similar long-term survival rates compared with LATG. We recommended that DG should be the optimal surgical procedure for middle one-third AGC under the premise of negative proximal resection margin.

Pancreas-related complications following gastrectomy: systematic review and meta-analysis of open versus minimally invasive surgery

BACKGROUND

Postoperative pancreas-related complications are quite uncommon but potentially life-threatening occurrences that may occasionally complicate the postoperative course of gastrectomy. A number of reports have described such conditions after both standard open and minimally invasive surgery. Our study has the purpose to systematically determine the pooled incidence of pancreatic events following radical gastrectomy. We also aimed to elucidate whether any difference in incidence exists between patients operated via conventional open or minimally invasive surgery.

METHODS

PubMed, EMBASE, and the Cochrane Library were systematically searched for randomized or well-matched studies comparing conventional with minimally invasive oncological gastrectomy and reporting pancreas-related postoperative complications. We evaluated possible differences in outcomes between open and minimally invasive surgery. A meta-analysis of relevant comparisons was performed using RevMan 5.3.

RESULTS

A total of 20 studies, whereby 6 randomized and 14 non-randomized comparative studies including a total of 7336 patients, were considered eligible for data extraction. Globally, more than 1% of patients experienced some pancreatic occurrences during the postoperative course. The use of minimally invasive surgery showed a trend toward increased overall pancreatic morbidity (OR 1.39), pancreatitis (OR 2.69), and pancreatic fistula (OR 1.13).

CONCLUSIONS

Although minimally invasive radical gastrectomy is currently established as a valid alternative to open surgery for the treatment of gastric cancer, a higher risk of pancreas-related morbidity should be taken into account.

Short- and long-term outcomes of laparoscopy-assisted versus open total gastrectomy for gastric cancer: a propensity score-matched analysis

BACKGROUND

Few studies have been designed to evaluate the short- and long-term outcomes of laparoscopy-assisted total gastrectomy (LATG), and a retrospective study of a large patient cohort is valuable before conducting randomized controlled clinical trials.

RESULTS

Among all patients, age, tumor location, histologic type, pT stage, pN stage and pTNM stage significantly differed between the LATG group and OTG group. After the propensity score matching, the clinicopathological characteristics did not significantly differ between groups. The operation time, estimated blood loss, time to first flatus and the number of retrieved lymph nodes (P < 0.05) were better in the LATG group than the OTG group. Morbidity and mortality were lower in the LATG group than the OTG group (P < 0.05) for pre-matched patients. However, significant intergroup differences in morbidity were not identified after propensity matching. Although overall survival did not significantly differ between groups for the pre-matched patients, the 3-year cumulative survival rates were significantly lower in the LATG group (89.9%) than the OTG group (97.7%) for patients with stage I disease (P = 0.028). After propensity score matching, the analysis of the cumulative survival curve did not show a significant difference for any cancer stage.

MATERIALS AND METHODS

We prospectively collected data from 1096 patients who underwent total gastrectomy for gastric cancer. Propensity score matching was applied to compare the covariates between the LATG group and the open total gastrectomy (OTG) group. Operative outcomes and long-term outcomes were compared between the two groups.

CONCLUSIONS

Implementation of LATG for gastric cancer is a safe, reliable and minimally invasive procedure with long-term outcomes similar to those of OTG. Further randomized controlled clinical trials can be conducted to provide valuable evidence of the safety and efficacy of LATG in treating gastric cancer.

Do preoperative enlarged lymph nodes affect the oncologic outcome of laparoscopic radical gastrectomy for gastric cancer?

BACKGROUND

To investigate the long-term outcome of laparoscopic radical gastrectomy (LAG) for gastric cancer (GC) with preoperative enlarged lymph nodes (LNs).

MATERIALS AND METHODS

We retrospectively collected data on 855 patients who underwent LAG for GC. The patients were divided into large (>10 mm) and small (≤10 mm) LN groups (LG and SG) based on the preoperative size of the LNs. The outcomes were compared using a 1:1 propensity score-matching method. The enlarged LNs were divided into five areas according to their location.

RESULTS

Before matching, the LG was associated with more retrieved LNs than the SG, whereas after matching, the numbers of LNs retrieved were similar. These numbers remained similar as the number of areas with enlarged LNs increased. Before matching, patients in the LG demonstrated a significantly lower 3-year overall survival rate than those in the SG (p < 0.001). Additionally, in the LG, 3-year overall survival rates were similar among patients with different total numbers of areas with enlarged LNs. After matching, the 3-year overall survival rate of the LG was close to that of the SG (81.1% vs. 72.4%, p = 0.066). A stratified analysis according to the only independent prognostic factor (pTNM stage) demonstrated that the 3-year overall survival rates at each stage were similar between the LG and SG.

CONCLUSIONS

LAG has similar oncologic outcomes for GC with or without preoperative enlarged LNs in the same tumor stage. Furthermore, the total number of areas with enlarged LNs has no impact on the long-term outcome.

Comparison of short outcomes between laparoscopic and experienced robotic gastrectomy: A meta-analysis and systematic review

OBJECTIVE:

The purpose of this meta-analysis is to compare the short-term outcomes between experienced robotic gastrectomy (RG) and laparoscopic gastrectomy (LG).

MATERIALS AND METHODS:

We searched the PubMed, Springer Link, Elsevier, and Embase databases for articles published in English before June 2015 using an electronic literature search and including cross-referenced articles. Three studies were eligible for the meta-analysis. The outcomes evaluated were operation time, estimated blood loss, harvested lymph nodes, complication, and postoperative hospital stay.

RESULTS:

Of a total of 562 patients, 165 underwent RG and 397 underwent LG. Operation time was significantly longer in the RG group [weighted mean difference (WMD): 21.49, 95% confidence interval (CI): 12.48-30.50, P < 0.00001). Estimated blood loss, harvested lymph nodes, complication, and postoperative hospital stay were similar between the two groups.

CONCLUSION:

Experienced RG has similar short-term outcomes to LG that is performed by sophisticated laparoscopic surgeons, except for operation time.

NOSE laparoscopic gastrectomies for early gastric cancer may reduce morbidity and hospital stay: early results from a prospective nonrandomized study

BACKGROUND

Natural orifice specimen extraction - NOSE laparoscopy is a promising technique that avoids mini-laparotomy, possibly reducing postoperative pain, wound infections and hospital stay. Recent systematic reviews have shown that postoperative morbidity associated with laparoscopically assisted gastrectomies is similar to that after open gastrectomies. More specifically, there is no difference in wound infection rate. The study objective was to evaluate whether postoperative morbidity and hospital stay may be reduced by transoral specimen extraction after laparoscopically assisted gastrectomy for early gastric cancer (EGC).

MATERIAL AND METHODS

A prospective, nonrandomized study was carried out starting in August 2012. Data from all patients operated on during the first year, with minimum 18 months follow-up, were collected to assess feasibility, oncologic results, postoperative morbidity, hospital stay and functional results. Overall, 14 patients were included and followed-up. After gastric resection, a 3 cm opening was created on the gastric stump, and the specimen, divided into three segments stitched one to each other, was sutured to the gastric tube and retrieved through the mouth.

RESULTS

Postoperative morbidity was 7.14% (1/14): one case of pneumonia. No wound infection occurred. The mean postoperative hospital stay was 4.7 ± 1.0 days.

CONCLUSIONS

NOSE laparoscopic subtotal gastrectomy is feasible and safe, with similar oncologic results as LAG, but decreased morbidity and hospital stay.

Extracorporeal Hand-Sewn Anastomosis Through a Minilaparotomy in Laparoscopic Distal Gastrectomy

BACKGROUND

Various methods of reconstruction after laparoscopic distal gastrectomy (LDG) have been developed and reported. In open gastrectomy, gastroduodenostomy or gastroenterostomy is often performed with the hand-sewn technique. Therefore, hand-sewn anastomosis was performed through a small incision in LDG. The aim of this study was to evaluate the feasibility and safety of LDG with hand-sewn anastomosis.

METHODS

Between June 2009 and December 2015, we assessed 263 consecutive patients who underwent LDG in our institution. In all patients, the reconstruction procedures were performed extracorporeally with the hand-sewn technique. The clinical characteristics, surgical outcomes, and operation cost related to anastomosis were evaluated and compared with the other methods.

RESULTS

The average operation time was 157.5 minutes, and average blood loss was 38.8 mL. The types of reconstruction were Billroth I, 95 cases (36.1%); Billroth II, 165 cases (62.7%); and Roux-en-Y, 3 cases (1.1%). The overall incidence of postoperative complications (Clavien-Dindo classification≧Grade II) was 8.0%. Anastomotic leakage was observed in 1 patient (0.4%) and anastomotic bleeding and anastomotic stenosis in 2 patients each (0.8%). There was no postoperative mortality. The cost of the absorbable threads used in anastomosis is less than the cost of a linear or circular stapler, which is often used in intracorporeal anastomosis.

CONCLUSION

This procedure is similar to conventional open surgery, and it is feasible, safe, and cost-effective. In addition, in an institution that plans to introduce LDG, the use of our method during the introductory phase of LDG has many advantages.

Comparison of laparoscopic versus open gastrectomy for advanced gastric cancer: an updated meta-analysis

BACKGROUND

Laparoscopic gastrectomy (LG) has been used as an alternative to open gastrectomy (OG) to treat early gastric cancer. However, the use of LG for advanced gastric cancer (AGC) has been in debate.

METHODS

Literature retrieval was performed by searching PubMed, EMBASE, and the Cochrane library up to July 2014. Potential studies comparing the surgical effects between LG with OG were evaluated and data were extracted accordingly. Meta-analysis was carried out using RevMan. The pooled risk ratio and weighted mean difference (WMD) with 95 % confidence interval (95 % CI) were calculated.

RESULTS

Overall, 26 studies were included in this meta-analysis. LG had some advantages over OG, including shorter hospitalization (WMD, -3.63, 95 % CI, -4.66 to -2.60; P < 0.01), less blood loss (WMD, -161.37, 95 % CI, -192.55 to -130.18; P < 0.01), faster bowel recovery (WMD, -0.78, 95 % CI, -1.05 to -0.50; P < 0.01), and earlier ambulation (WMD, -0.95, 95 % CI, -1.47 to -0.44; P < 0.01). In terms of surgical and oncological safety, LG could achieve similar lymph nodes (WMD, -0.49, 95 % CI, -1.78 to 0.81; P = 0.46), a lower complication rate [odds ratio (OR), 0.71, 95 % CI, 0.59 to 0.87; P < 0.01], and overall survival (OS) and disease-free survival (DFS) comparable to OG.

CONCLUSIONS

For AGCs, LG appeared comparable with OG in short- and long-term results. Although more time was needed to perform LG, it had some advantages over OG in achieving faster postoperative recovery. Ongoing trials and future studies could help to clarify this controversial issue.

Oncologic value of laparoscopy-assisted distal gastrectomy for advanced gastric cancer: A systematic review and meta-analysis

BACKGROUND

The oncologic validity of laparoscopic-assisted distal gastrectomy (LADG) in the treatment of advanced gastric cancer (AGC) remains controversial. This study is a systematic review and meta-analysis of the available evidence.

MATERIALS AND METHODS

A comprehensive search was performed between 2008 and 2014 to identify comparative studies evaluating morbidity/mortality, oncologic surgery-related outcomes, recurrence and survival rates. Data synthesis and statistical analysis were carried out using RevMan 5.2 software.

RESULTS

Eight studies with a total of 1456 patients were included in this analysis. The complication rate was lower in LADG [odds ratio (OR) 0.59; 95% confidence interval (CI) = 0.42-0.83; P < 0.002]. The in-hospital mortality rate was comparable (OR 1.22; 95% CI = 0.28-5-29, P = 0.79). There was no significant difference in the number of harvested lymph nodes, resection margins, cancer recurrence rate, cancer-related mortality or overall and disease-free survival (OS and DFS, respectively) rates between the laparoscopic and the open groups (P > 0.05).

CONCLUSION

The current study supports the view that LADG for AGC is a feasible, safe and effective procedure in selected patients. Adequate lymphadenectomy, resection margins, recurrence, cancer-related mortality and long-term outcomes appear equivalent to open distal gastrectomy (ODG).

Evaluation of laparoscopic total gastrectomy for advanced gastric cancer: results of a comparison with laparoscopic distal gastrectomy

OBJECTIVE

To validate the efficacy and safety of laparoscopic total gastrectomy (LTG) for advanced gastric cancer (AGC).

BACKGROUND

Laparoscopic distal gastrectomy (LDG) in the treatment of patients with local AGC is becoming increasingly popular, and there have been several multicenter randomized controlled trials focused on this treatment. However, few reports on the procedure of LTG for AGC exist.

METHODS

The data of 976 patients who underwent LTG for AGC were retrieved from a prospectively constructed database of 2170 patients who underwent laparoscopic gastrectomy between 2007 and 2013. Surgical outcomes of LTG were investigated and compared with those of patients who underwent LDG.

RESULTS

LTG was associated with significantly longer operation time, number of dissected lymph nodes, and time of resume soft diet compared with the LDG group. According to Clavien-Dindo classification, the morbidity and mortality rates of the LTG group were comparable to those of the LDG group. Multivariate analyses revealed that elderly patients, more comorbidities, and longer operation time were the significant independent risk factors for determining postoperative complications. The difference in overall survival rates between the two groups was statistically significant. However, a comparative analysis of overall survival showed no statistical significance for any of the stages of cancer between the LTG and LDG groups.

CONCLUSIONS

The study findings suggest that LTG is an oncologically safe procedure for AGC yields comparable surgical outcomes. A well-designed phase III trial can be carried out to provide valuable evidence for the oncologic safety of LTG for the treatment of AGC.

Comparing the short-term outcomes of laparoscopic distal gastrectomy with D1+ and D2 lymph node dissection for gastric cancer

INTRODUCTION

Laparoscopic distal gastrectomy (LDG) with D1+ lymph node dissection (LND) for early gastric cancer has been widely accepted. However, LDG with D2 LND for advanced gastric cancer remains in limited use. The aim of this retrospective study was to clarify the safety of LDG with D2 LND for gastric cancer.

METHODS

From January 2010 to September 2014, 296 patients underwent LDG; those who received D1+ LND (n = 230) or D2 LND (n = 66) were included in this study. The clinicopathological characteristics and short-term outcomes of both groups were investigated and compared.

RESULTS

There were no significant differences in the incidence of postoperative complications between the two groups. However, the frequency of infectious intra-abdominal complications was higher in the D2 LND group than in the D1+ LND group. Additionally, a lower risk of infectious intra-abdominal complications was seen with certified than with uncertified operators.

CONCLUSION

The evaluation of short-term outcomes demonstrated that LDG with D2 LND is generally feasible. However, the risk of infectious intra-abdominal complications is higher with D2 LND than with D1+ LND. Also, D2 LND should be performed by trained operators.

Is All Advanced Gastric Cancer Suitable for Laparoscopy-Assisted Gastrectomy With Extended Lymphadenectomy? A Case-Control Study Using a Propensity Score Method

BACKGROUND

The oncologic outcomes of laparoscopy-assisted gastrectomy (LAG) for the treatment of patients with local advanced gastric cancer (AGC) have not been evaluated. This study aimed to validate the oncologic efficacy of LAG for AGC.

METHODS

The data from 539 patients who underwent LAG and 539 patients treated with open gastrectomy (OG) were selected using the propensity score-matching method from a database prospectively constructed between 2005 and 2011. The therapeutic value of lymph node (LN) dissection and the long-term surgical outcomes of these matched groups were compared.

RESULTS

The groups were well balanced after the propensity score matched. The LAG and OG groups did not differ significantly in terms of clinicopathologic characteristics. The number of dissected LNs at stations 11 and 12a were significantly higher in the LAG group. However, the therapeutic index at each LN station did not differ significantly between the two groups. Although the overall survival curve at each stage did not differ significantly (P > 0.05), the survival rate increased overall for patients with pT4aN3bM0 in the OG group (P < 0.05). The stratified analysis showed that overall survival was inferior for LAG surgeons with fewer than 40 completed cases. The survival results for surgeons who had performed more than 40 cases were similar to the results from open surgery.

CONCLUSIONS

Although LAG yields comparable oncologic outcomes for local AGC, patients with pT4aN3bM0 gastric cancer may not be suitable for laparoscopic surgery, especially for surgeons with limited experience.

Gastric cancer: Current status of lymph node dissection

D2 procedure has been accepted in Far East as the standard treatment for both early (EGC) and advanced gastric cancer (AGC) for many decades. Recently EGC has been successfully treated with endoscopy by endoscopic mucosal resection or endoscopic submucosal dissection, when restricted or extended Gotoda's criteria can be applied and D1+ surgery is offered only to patients not fitted for less invasive treatment. Furthermore, two randomised controlled trials (RCTs) have been demonstrating the non inferiority of minimally invasive technique as compared to standard open surgery for the treatment of early cases and recently the feasibility of adequate D1+ dissection has been demonstrated also for the robot assisted technique. In case of AGC the debate on the extent of nodal dissection has been open for many decades. While D2 gastrectomy was performed as the standard procedure in eastern countries, mostly based on observational and retrospective studies, in the west the Medical Research Council (MRC), Dutch and Italian RCTs have been conducted to show a survival benefit of D2 over D1 with evidence based medicine. Unfortunately both the MRC and the Dutch trials failed to show a survival benefit after the D2 procedure, mostly due to the significant increase of postoperative morbidity and mortality, which was referred to splenopancreatectomy. Only 15 years after the conclusion of its accrual, the Dutch trial could report a significant decrease of recurrence after D2 procedure. Recently the long term survival analysis of the Italian RCT could demonstrate a benefit for patients with positive nodes treated with D2 gastrectomy without splenopancreatectomy. As nowadays also in western countries D2 procedure can be done safely with pancreas preserving technique and without preventive splenectomy, it has been suggested in several national guidelines as the recommended procedure for patients with AGC.

Simultaneous laparoscopy-assisted resection for rectal and gastric cancer

Laparoscopy-assisted surgery for either rectal or gastric cancer has been increasingly performed. However, simultaneous laparoscopy-assisted resection for synchronous rectal and gastric cancer is rarely reported in the literature. In our study, 3 cases of patients who received simultaneous laparoscopy-assisted resection for synchronous rectal and gastric cancer were recorded. The results showed that all 3 patients recovered well, with only 253 minutes of mean operation time, 57 mL of intraoperative blood loss, 5 cm of assisted operation incision, 4 days to resume oral intake, 12 days' postoperative hospital stay, and no complication or mortality. No recurrence or metastasis was found within the follow-up period of 22 months. When performed by surgeons with plentiful experience in laparoscopic technology, simultaneous laparoscopy-assisted resection for synchronous rectal and gastric cancer is safe and feasible, with the benefits of minimal trauma, fast recovery, and better cosmetic results, compared with open surgery.

Minimally invasive gastrectomy for gastric adenocarcinoma in the United States: Utilization and short-term oncologic outcomes

BACKGROUND AND OBJECTIVES

When performed at select centers, minimally invasive gastrectomy (MIG) for gastric adenocarcinoma is associated with reduced perioperative morbidity, and similar oncologic outcomes as compared to open gastrectomy (OG). Utilization of, and outcomes associated with, MIG in the United States have not been characterized.

METHODS

The National Cancer Database (2010-2011) was queried for AJCC pStage IB-IIIC patients who underwent curative-intent OG (n = 2,303) or MIG (n = 331). Multivariable models identified factors associated with MIG utilization, R0 resection rates, and adequate lymph node staging (LNS).

RESULTS

MIG was more frequently utilized for T1/T2 (P < 0.001), N0 (P = 0.022), and stage IB (P = 0.001) tumors. MIG was associated with shorter hospital stay (P < 0.001), equivalent lymph node examination (P = 0.337) and superior rates of R0 resection (P = 0.011) compared with OG. In patients undergoing MIG, R0 resection was associated with performance of near-total/total gastrectomy (OR 3.90, 95%CI 1.10-13.9) and tumors < 5 cm (OR 2.78, 95%CI 1.07-7.26). Adequate LNS was associated with surgery at academic (OR 1.99, 95%CI 1.19-3.32) or high-volume facilities (OR 2.97, 95%CI 1.59-5.54), tumor size ≥ 5 cm (OR 1.85, 95%CI 1.10-3.11), and node positivity (OR 1.75, 95%CI 1.04-2.93).

CONCLUSIONS

MIG is selectively utilized in cases with favorable tumor characteristics. In such cases, short-term oncologic outcomes are equivalent to those achieved with OG. Worse oncologic outcomes in specific subgroups underscore opportunities for quality improvement.

Robotic versus laparoscopic gastrectomy for gastric cancer: comparison of short-term surgical outcomes

BACKGROUND

Robot-assisted gastrectomy (RAG) is a new minimally invasive surgical technique for gastric cancer. This study was designed to compare RAG with laparoscopy-assisted gastrectomy (LAG) in short-term surgical outcomes.

METHODS

Between October 2011 and August 2014, 423 patients underwent robotic or laparoscopic gastrectomy for gastric cancer: 93 RAG and 330 LAG. We performed a comparative analysis between RAG group and LAG group for clinicopathological characteristics and short-term surgical outcomes.

RESULTS

RAG was associated with a longer operative time (P < 0.001), lower blood loss (P = 0.001), and more harvested lymph nodes (P = 0.047). Only three patients in LAG group had positive margins, and R0 resection rate for RAG and LAG was similar (P = 0.823). The RAG group had postoperative complications of 9.8 %, comparable with those of the LAG group (P = 0.927). Proximal margin, distal margin, hospital stay, days of first flatus, and days of eating liquid diet for RAG and LAG were similar. In the subgroup of serosa-negative patients, RAG had a longer operation time (P = 0.003), less intraoperative blood loss (P = 0.005), and more harvested lymph nodes (P = 0.04). However, in the subgroup of serosa-positive patients, RAG had a longer operation time (P = 0.001), but no less intraoperative blood loss (P = 0.139) and no more harvested lymph nodes (P = 0.139). Similarly, in the subgroup of total gastrectomy patients, RAG had a longer operation time (P = 0.018), but no less intraoperative blood loss (P = 0.173).

CONCLUSIONS

The comparative study demonstrates that RAG is as acceptable as LAG in terms of surgical and oncologic outcomes. With lower estimated blood loss, acceptable complications, and radical resection, RAG is a promising approach for the treatment of gastric cancer. However, the indication of patients for RAG is critical.

Laparoscopic-assisted versus open distal gastrectomy with D2 lymph node resection for advanced gastric cancer: effect of learning curve on short-term outcomes. a meta-analysis

Laparoscopic-assisted distal gastrectomy (LADG) with D2 resection is gradually being performed for treating advanced gastric cancer. This meta-analysis aims to compare the clinical outcomes between LADG and open distal gastrectomy (ODG) when considering the impact of the learning curve. The PubMed, Embase, and ISI databases and the Cochrane Library were electronically searched. Randomized controlled trails and retrospective comparative studies published between 1994 and 2013 were collected. We divided the included studies into two subgroups according to whether the authors had experience of at least or fewer than 40 cases of LADG with D2 resection and then compared the operative time, intraoperative bleeding, the amount of resected lymph nodes, short-term recovery parameters, and complications between LADG and ODG groups. Ten comparative studies including 1100 patients were selected. Meta-analysis showed that when LADG was compared with ODG, surgeons with experience of at least 40 cases could achieve more resected lymph nodes (P=.002), reduced time to flatus (P<.0001), shortened time to liquid diet (P<.00001), and lower complication rates (P=.02). However, the above advantages of LADG faded in the subgroup of surgeons with experience of fewer than 40 cases. Our meta-analysis suggested that the learning curve has significant effects on most of the important surgical and short-term recovery outcome parameters. Accomplishment of 40 cases of LADG with D2 lymphadenectomy is required to achieve optimum proficiency.

Surgical outcomes of 2041 consecutive laparoscopic gastrectomy procedures for gastric cancer: a large-scale case control study

BACKGROUND

Laparoscopic gastrectomy (LG) for gastric cancer has increased in popularity due to advances in surgical techniques. The aim of this study is to validate the efficacy and safety of laparoscopic gastrectomy for gastric cancer compared with open gastrectomy (OG).

METHODS

The study comprised 3,580 patients who were treated with curative intent either by laparoscopic gastrectomy (2,041 patients) or open gastrectomy (1,539 patents) between January 2005 and October 2013. The surgical outcomes were compared between the two groups.

RESULTS

Laparoscopic gastrectomy was associated with significantly less blood loss, transfused patient number, time to ground activities, and post-operative hospital stay, but with similar operation time, time to first flatus, and time to resumption of diet, compared with the open gastrectomy. No significant difference in the number of lymph nodes dissected was observed between these two groups. The morbidity and mortality rates of the LG group were comparable to those of the OG group (13.6% vs. 14.4%, P = 0.526, and 0.3% vs. 0.2%, P = 0.740). The 3-year disease-free and overall survival rates between the two groups were statistically significant (P<0.05). According to the UICC TNM classification of gastric cancer, the 3-year disease-free and overall survival rates were not statistically different at each stage.

CONCLUSIONS

Our single-center study of a large patient series revealed that LG for gastric cancer yields comparable surgical outcomes. This result was also true of local advanced gastric cancer (AGC). A well-designed randomized controlled trial comparing surgical outcomes between LG and OG in a larger number of patients for AGC can be carried out.

Laparoscopic distal gastrectomy reduced surgical site infection as compared with open distal gastrectomy for gastric cancer in a meta-analysis of both randomized controlled and case-controlled studies

BACKGROUND

In some meta-analyses of randomized controlled trials (RCTs), laparoscopic or laparoscopy-assisted distal gastrectomy (LDG) had several short-term advantages. However, several specific postoperative complications (PCs) were not analyzed sufficiently.

METHODS

RCTs and case-controlled studies (CCSs) comparing postoperative complications between LDG and open distal gastrectomy (ODG) were identified in PubMed and Embase. Studies in which patients' status, extent of lymph-node dissection, or reconstruction procedures were matched between the groups were included in a meta-analysis. Postoperative complications such as surgical-site infection (SSI; which included wound infection and intra-abdominal abscess), leakage, anastomotic stenosis, bleeding, ileus, delayed gastric emptying, pneumonia were evaluated in a meta-analysis performed using Review Manager version 5.2 software.

RESULT

This meta-analysis included a total of 2144 patients (1065 underwent LDG and 1079 underwent ODG) from 5 RCTs and 13 CCSs. SSI and wound infections were reported in 14 studies, and the incidences were significantly lower in LDG than in ODG (n = 1737; odds ratio [OR] 0.50, 95% confidence interval [CI] 0.29-0.85, P = 0.01, I(2) = 0%, and OR 0.46, 95% CI 0.24-0.88, P = 0.02; I(2) = 0%). There were no significant differences in intra-abdominal abscess or other specific complications between the procedures.

CONCLUSION

LDG was associated with a lower incidence of SSI, especially wound infection, as compared with ODG in a meta-analysis of both RCTs and CCSs.

Long-term survival outcomes of laparoscopic versus open gastrectomy for gastric cancer: a systematic review and meta-analysis

Many meta-analyses have confirmed the technical feasibility and favorable short-term surgical outcomes of laparoscopic gastrectomy (LG) for gastric cancer patients, but the long-term survival outcome of LG remains controversial compared with open gastrectomy (OG). This study aimed to compare the 5-year overall survival (OS), recurrence, and gastric cancer-related death of LG with OG among gastric cancer patients. PubMed was searched to February 2014. The resectable gastric cancer patients who underwent curative LG or OG were eligible. The studies that compared 5-year OS, recurrence, or gastric cancer-related death in the LG and OG groups were included. A meta-analysis, meta-regression, sensitivity analysis, subgroup analysis, and stage-specific analysis were performed to estimate the survival outcome between the two groups and identify the potential confounders. Quality assessment was based on a tailored comparability scoring system. Twenty-three studies with 7336 patients were included. The score of comparability between two groups and the extent of lymphadenectomy were two independent confounders. Based on the well-balanced studies, the 5-year OS (OR = 1.07, 95% CI 0.90-1.28, P = 0.45), recurrence (OR = 0.83, 95% CI 0.68-1.02, P = 0.08), and gastric cancer-related death (OR = 0.86, 95% CI 0.65-1.13, P = 0.28) rates were comparable in LG and OG. Several subsets such as the publication year, study region, sample size, gastrectomy pattern, extent of lymphadenectomy, number of nodes harvested, and proportion of T1-2 or N0-1 did not influence the estimates, if they were well balanced. Particularly, the stage-specific estimates obtained comparable results between the two groups. Randomized controlled trials comparing LG with OG remain sparse to assess their long-term survival outcomes. The major contributions of this systematic review compared with other meta-analyses are a comprehensive collection of available long-term survival outcomes within a much larger number of observations and a more precise consideration of confounders. Current knowledge indicates that the long-term survival outcome of laparoscopic gastric cancer surgery is comparable to that of open surgery among early or advanced stage gastric cancer patients, and LG is acceptable with regard to oncologic safety.

Laparoscopic vs open D2 gastrectomy for locally advanced gastric cancer: a meta-analysis

AIM

To conduct a meta-analysis comparing laparoscopic (LGD2) and open D2 gastrectomies (OGD2) for the treatment of advanced gastric cancer (AGC).

METHODS

Randomized controlled trials (RCTs) and non-RCTs comparing LGD2 with OGD2 for AGC treatment, published between 1 January 2000 and 12 January 2013, were identified in the PubMed, Embase, and Cochrane Library databases. Primary endpoints included operative outcomes (operative time, intraoperative blood loss, and conversion rate), postoperative outcomes (postoperative analgesic consumption, time to first ambulation, time to first flatus, time to first oral intake, postoperative hospital stay length, postoperative morbidity, incidence of reoperation, and postoperative mortality), and oncologic outcomes (the number of lymph nodes harvested, tumor recurrence and metastasis, disease-free rates, and overall survival rates). The Cochrane Collaboration tools and the modified Newcastle-Ottawa scale were used to assess the quality and risk of bias of RCTs and non-RCTs in the study. Subgroup analyses were conducted to explore the incidence rate of various postoperative morbidities as well as recurrence and metastasis patterns. A Begg's test was used to evaluate the publication bias.

RESULTS

One RCT and 13 non-RCTs totaling 2596 patients were included in the meta-analysis. LGD2 in comparison to OGD2 showed lower intraoperative blood loss [weighted mean difference (WMD) = -137.87 mL, 95%CI: -164.41--111.33; P < 0.01], lower analgesic consumption (WMD = -1.94, 95%CI: -2.50--1.38; P < 0.01), shorter times to first ambulation (WMD = -1.03 d, 95%CI: -1.90--0.16; P < 0.05), flatus (WMD = -0.98 d, 95%CI: -1.30--0.66; P < 0.01), and oral intake (WMD = -0.85 d, 95%CI: -1.67--0.03; P < 0.05), shorter hospitalization (WMD = -3.08 d, 95%CI: -4.38--1.78; P < 0.01), and lower postoperative morbidity (odds ratio = 0.78, 95%CI: 0.61-0.99; P < 0.05). No significant differences were observed between LGD2 and OGD2 for the following criteria: reoperation incidence, postoperative mortality, number of harvested lymph nodes, tumor recurrence/metastasis, or three- or five-year disease-free and overall survival rates. However, LGD2 had longer operative times (WMD = 57.06 min, 95%CI: 41.87-72.25; P < 0.01).

CONCLUSION

Although a technically demanding and time-consuming procedure, LGD2 may be safe and effective, and offer some advantages over OGD2 for treatment of locally AGC.

Quality of D2 lymphadenectomy for advanced gastric cancer: is laparoscopic-assisted distal gastrectomy as effective as open distal gastrectomy?

OBJECTIVE

To determine by meta-analysis, whether D2 lymphadenectomy at laparoscopic-assisted distal gastrectomy (LADG) is as effective as that during open distal gastrectomy (ODG) for patients with advanced gastric cancer (AGC).

DATA SOURCES AND REVIEW METHODS

All clinical trials that compared laparoscopic with open D2 lymphadenectomy for AGC published in English from January 1995 to June 2013 were identified in PubMed, Embase, Web of Science, and Cochrane library searches. A modified scale was used to assess the quality of the literature. We analyzed the number of harvested lymph nodes (HLNs), body mass index (BMI), tumor size, serosa invasion status, and positive lymph node rate. Meta-analyses were performed using weighted mean differences (WMD) for continuous variables, and risk differences (RD) or odds ratios (OR) for dichotomous variables.

RESULTS

No eligible randomized trials were identified, but eight non-randomized trials were analyzed. In the pooled data of 677 patients who underwent LADG and 687 ODG, there were no significant differences the number of HLN (WMD: -0.98, 95 % confidence interval, CI -3.21 to 1.26), BMI (WMD: -1.20, 95 % CI -2.64 to 0.24), tumor size (WMD: -0.30, 95 % CI -0.65 to 0.05), serosa invasion status (RD: 0.04, 95 % CI -0.03 to 0.11), and positive lymph node rate (OR: 0.66, 95 % CI -0.44 to 1.01) between the groups.

CONCLUSION

Our findings suggest that for patients with comparable BMI and tumor status, surgical technique did not significantly influence the number of HLNs, suggesting that D2 lymphadenectomy performed laparoscopically is as effective as an open procedure in AGC.

A multi-institutional analysis of open versus minimally-invasive surgery for gastric adenocarcinoma: results of the US gastric cancer collaborative

BACKGROUND

Surgical experience with minimally invasive surgery (MIS) has increased; however, published reports on MIS resection of gastric adenocarcinoma are limited.

METHODS

Between 2000 and 2012, 880 patients who underwent surgical resection of gastric adenocarcinoma were identified from a multi-institutional database. Clinicopathological characteristics, operative details, and outcomes were stratified by operative approach (open vs. MIS) and analyzed.

RESULTS

Overall, 70 (8 %) patients had a MIS approach. Patients who underwent a MIS resection were more likely to have a smaller tumor (open 4.5 cm vs. MIS 3.0 cm, p < 0.001). MIS resections were associated with lower estimated blood loss (open 250 cc vs. MIS 150 cc) and longer operative time (open 232 min vs. MIS 271 min) compared with open surgery (both p < 0.05). An R0 resection was achieved in most patients (open 90.9 % vs. MIS 98.6 %, p = 0.03) and median lymph node yield was good in both groups (open 17 vs. MIS 14, p = 0.10). MIS had a similar incidence of complications (open 33.1 % vs. MIS 20 %, p = 0.07) and a similar length of stay (open 9 days vs. MIS 7 days, p = 0.13) compared with open surgery. In the propensity-matched analysis, median recurrence-free and overall were not impacted by operative approach.

CONCLUSION

An MIS approach to gastric cancer was associated with adequate lymph node retrieval, a high incidence of R0 resection, and comparable long-term oncological outcomes versus open gastrectomy.

Meta-analysis of outcomes compared between robotic and laparoscopic gastrectomy for gastric cancer

This meta-analysis was performed to evaluate and compare the outcomes of robotic gastrectomy (RG) and laparoscopic gastrectomy (LG) for treating gastric cancer. A systematic literature search was carried out using the PubMed database, Web of Knowledge, and the Cochrane Library database to obtain comparative studies assessing the safety and efficiency between RG and LG in May, 2013. Data of interest were analyzed by using of Review Manager version 5.2 software (Cochrane Collaboration). A fixed effects model or random effects model was applied according to heterogeneity. Seven papers reporting results that compared robotic gastrectomy with laparoscopic gastrectomy for gastric cancer were selected for this meta-analysis. Our meta- analysis included 2,235 patients with gastric cancer, of which 1,473 had undergone laparoscopic gastrectomy, and 762 had received robotic gastrectomy. Compared with laparoscopic gastrectomy, robotic gastrectomy was associated with longer operative time but less blood loss. There were no significant difference in terms of hospital stay, total postoperative complication rate, proximal margin, distal margin, numbers of harvested lymph nodes and mortality rate between robotic gastrectomy and laparoscopic gastrectomy. Our meta-analysis showed that robotic gastrectomy is a safe technique for treating gastric cancer that compares favorably with laparoscopic gastrectomy in short term outcomes. However, the long term outcomes between the two techniques need to be further examined.

A meta-analysis of robotic versus laparoscopic gastrectomy for gastric cancer

BACKGROUND

Robot-assisted gastrectomy (RAG) for gastric cancer is still a controversial surgical technique for adequate tumor resection, lymphadenectomy, and postoperative outcome.

METHODS

A meta-analysis analyzed updated clinical trials that have compared RAG with laparoscopy-assisted gastrectomy (LAG) to evaluate whether RAG is equivalent to LAG.

RESULTS

Eight studies were included in the analysis, comprising 1,875 patients. RAG was associated with a longer operative time (p < 0.05), lower estimated blood loss (p < 0.05), and a longer distal margin (p < 0.05). RAG can be performed safely with lower estimated blood loss and a longer distal margin than with LAG. Complications, hospital stay, proximal margin, and harvested lymph nodes for RAG and LAG were similar.

CONCLUSIONS

RAG is as acceptable as LAG for obtaining safe complications and for performing radical gastrectomy.

Role of 3DCT in laparoscopic total gastrectomy with spleen-preserving splenic lymph node dissection

AIM

To investigate whether computed tomography with 3D imaging (3DCT) can reduce the risks associated with laparoscopic surgery.

METHODS

We performed a retrospective case-control study evaluating the efficacy of preoperative 3DCT of the splenic vascular anatomy on surgical outcomes in patients undergoing laparoscopic spleen-preserving splenic hilar lymph node (LN) dissection for upper- or middle-third gastric cancer. The clinical records of 312 patients with upper- or middle-third gastric cancer who underwent laparoscopic total gastrectomy with spleen-preserving splenic lymph node dissection in our hospital from January 2010 to June 2013 were collected, and the patients were divided into two groups (group 3DCT vs group NO-3DCT) depending on whether they underwent 3DCT or not. Clinicopathologic characteristics, operative and postoperative measures, the number of retrieved LNs, and complications were compared between these two groups. Patients were further compared regarding operative and postoperative measures, the number of retrieved LNs, and complications when subdivided by body mass index ( ≥ 23 and < 23 kg/m(2)) and the number of operations performed by their surgeon (≤ 40 vs > 40).

RESULTS

The mean numbers of retrieved splenic hilar LNs were similar in patients in group 3DCT and group NO-3DCT (2.85 ± 2.33 vs 2.48 ± 2.18, P > 0.05). The operation time and blood loss at the splenic hilum were lower in the patients in group 3DCT (P < 0.05 each). The postoperative recovery time and complication rates were similar between the two groups (P > 0.05 each). Subgroup analysis showed that the operation time at the splenic hilum in patients with a BMI ≥ 23 kg/m(2) was significantly shorter in patients in group 3DCT than in group NO-3DCT (20.27 ± 5.84 min vs 26.17 ± 11.01 min, P = 0.003). In patients with a BMI < 23 kg/m(2), the overall operation time (171.8 ± 26.32 min vs 188.09 ± 52.63 min, P = 0.028), operation time at the splenic hilum (19.39 ± 5.46 min vs 23.74 ± 9.56 min, P = 0.001), and blood loss at the splenic hilum (13.27 ± 4.96 mL vs 17.98 ± 8.12 mL, P = 0.000) were significantly lower in patients in group 3DCT than in group NO-3DCT. After 40 operations, the operation time (18.63 ± 4.40 min vs 23.85 ± 7.92 min, P = 0.000) and blood loss (13.10 ± 4.17 mL vs 15.10 ± 4.42 mL, P = 0.005) at the splenic hilum were significantly lower in patients who underwent 3DCT, but there were no significant between-group differences prior to 40 operations.

CONCLUSION

3DCT is critical for surgical guidance to reduce the risks of splenic LN dissection. This method may be important in safely facilitating laparoscopic spleen-preserving splenic LN dissection.

Systematic review of laparoscopy-assisted versus open gastrectomy for advanced gastric cancer

OBJECTIVE

The study compared laparoscopy-assisted gastrectomy (LAG) with open gastrectomy (OG) in the management of advanced gastric cancer (AGC).

METHODS

Literature search was performed in the Medline, Embase, and Cochrane Library databases to identify control studies that compared LAG and OG for AGC. A meta-analysis was conducted to examine the surgical safety and oncologic adequacy, using the random-effect model.

RESULTS

Seven eligible studies including 815 patients were analyzed. LAG was associated with less blood loss, less use of analgesics, shorter time of flatus and periods of hospital stay, but longer time of operation. The incidence of most complications was similar between the two groups. However, LAG was associated with a lower rate of pulmonary infection (odds ratio (OR) 0.19; 95% confidence interval (CI) 0.05 to 0.68; P<0.05). No significant differences were noted in terms of the number of harvested lymph nodes (weighted mean difference (WMD) 1.165; 95% CI -2.000 to 4.311; P>0.05), overall mortality (OR 0.65; 95% CI 0.39 to 1.10; P>0.05), cancer-related mortality (OR 0.64; 95% CI 0.32 to 1.25; P>0.05), or recurrence (OR 0.62; 95% CI 0.33 to 1.16; P>0.05).

CONCLUSIONS

LAG could be performed safely for AGC with adequate lymphadenectomy and has several short-term advantages compared with conventional OG. No differences were found in long-term outcomes. However, these results should be validated in large randomized controlled studies (RCTs) with sufficient follow-up.