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

A Path to High-Value Gastric Cancer Surgery Care Delivery

Objective

To evaluate the feasibility, safety, and effectiveness of a comprehensive regional program, including the Minimally Invasive Recovery and Empowerment Care (MIREC) pathway, that can significantly reduce hospital stays after laparoscopic gastrectomy without increasing adverse events.

Background

Cost-effectiveness and improving patient outcomes are crucial in providing quality gastric cancer care worldwide.

Methods

To compare the outcomes of gastric cancer surgery using 2 different models of care within an integrated healthcare system from February 2012 to March 2023. The primary endpoint was the length of hospital stay. The secondary endpoints were the need for intensive care unit care, emergency room (ER) visits, readmission, reoperation, and death within 30 days after surgery.

Results

There were 553 patients, 167 in the pre-(February 2012-April 2016) and 386 in the post-MIREC period (May 2016-March 2023). Perioperative chemotherapy utilization increased from 31.7% to 76.4% (P < 0.0001). Laparoscopic gastrectomy increased from 17.4% to 97.7% (P < 0.0001). Length of hospitalization decreased from 7 to 2 days (P < 0.0001), with 32.1% and 88% of patients discharged home on postoperative day 1 and postoperative day 2, respectively. When comparing pre- and post-MIREC, intensive care unit utilization (10.8% vs. 2.9%, P < 0.0001), ER visits (34.7% vs. 19.7%, P = 0.0002), and readmission (18.6% vs. 11.1%, P = 0.019) at 30 days were also considerably lower. In addition, more patients received postoperative adjuvant chemotherapy (31.4% to 63.5%, P < 0.0001), and the time between gastrectomy and starting adjuvant chemotherapy was also less (49-41 days; P = 0.002).

Conclusion

This comprehensive regional program, which encompasses regionalization care, laparoscopic approach, modern oncologic care, surgical subspecialization, and the MIREC pathway, can potentially improve gastric cancer surgery outcomes. These benefits include reduced hospital stays and lower complication rates. As such, this program can revolutionize how gastric cancer surgery is delivered, leading to a higher quality of care and increased value to patients.

Impact of robotic and open surgery on patient wound complications in gastric cancer surgery: A meta-analysis

This meta-analysis is intended to evaluate the effect of both robotic and open-cut operations on postoperative complications of stomach carcinoma. From the earliest date until June 2023, a full and systemic search has been carried out on four main databases with keywords extracted from 'Robot', 'Gastr' and 'Opene'. The ROBINS-I instrument has been applied to evaluate the risk of bias in nonrandomized controlled trials. In these 11 trials, a total of 16 095 patients had received surgical treatment for stomach cancer and all 11 trials were nonrandomized, controlled trials. Abdominal abscesses were reported in 5 trials, wound infections in 8 trials, haemorrhage in 7 trials, wound dehiscence in 2 trials and total postoperative complications in 4 trials. Meta-analyses revealed no statistically significantly different rates of postoperative abdominal abscesses among patients who had received robotic operations than in those who had received open surgical procedures (OR, 0.91; 95% CI, 0.25, 3.36; p = 0.89). The incidence of bleeding after surgery was not significantly different from that in both groups (OR, 1.37; 95% CI, 0.69, 2.75; p = 0.37). Similarly, there was no significant difference between the two groups (OR, 0.78; 95% CI, 0.52, 1.18; p = 0.24). No significant difference was found between the two groups (OR, 1. 28; 95% CI, 0.75, 2.21; p = 0.36). No significant difference was found between the two groups of patients who had received the robotic operation and those who had received the surgery after the operation (OR, 1.14; 95% CI, 0.78, 1.66; p = 0.49). Generally speaking, this meta-analysis suggests that the use of robotics does not result in a reduction in certain postsurgical complications, including wound infections and abdominal abscesses. Thus, the use of a microinvasive robot for stomach carcinoma operation might not be better than that performed on the surgical site after the operation. This is a valuable guide for the surgeon to select the operative method.

A nomogram to predict overall survival and disease-free survival after curative-intent gastrectomy for gastric cancer

An individual prediction of DFS and OS may be useful after surgery for gastric cancer to inform patients and to guide the clinical management. Patients who underwent curative-intent resection for gastric cancer between January 2010 and May 2020 at a single Italian institution were identified. Variables associated with OS and DFS were recorded and analysed according to univariable and multivariable Cox models. Nomograms predicting OS and DFS were built according to variables resulting from multivariable Cox models. Discrimination ability was calculated using the Harrell's Concordance Index. Overall, 168 patients underwent curative-intent resection. Nomograms to predict OS were developed including age, tumor size, tumor location, T stage, N stage, M stage and post-operative complications, while nomogram to predict DFS includes Lauren classification, and lymph node ratio (LNR). On internal validation, both nomograms demonstrated a good discrimination with a Harrell's C-index of 0.77 for OS and 0.71 for DFS. The proposed nomogram to predict DFS and OS after curative-intent surgery for gastric cancer showed a good discrimination on internal validation, and may be useful to guide clinician decision-making, as well help identify patients with high-risk of recurrence or with a poor estimated survival.

Clinical Outcomes Following Regionalization of Gastric Cancer Care in a US Integrated Health Care System

PURPOSE

In 2016, Kaiser Permanente Northern California regionalized gastric cancer care, introducing a regional comprehensive multidisciplinary care team, standardizing staging and chemotherapy, and implementing laparoscopic gastrectomy and D2 lymphadenectomy for patients eligible for curative-intent surgery. This study evaluated the effect of regionalization on outcomes.

METHODS

The retrospective cohort study included gastric cancer cases diagnosed from January 2010 to May 2018. Information was obtained from the electronic medical record, cancer registry, state vital statistics, and chart review. Overall survival was compared in patients with all stages of disease, stage I-III disease, and curative-intent gastrectomy patients using annual inception cohorts. For the latter, the surgical approach and surgical outcomes were also compared.

RESULTS

Among 1,429 eligible patients with gastric cancer with all stages of disease, one third were treated after regionalization, 650 had stage I-III disease, and 394 underwent curative-intent surgery. Among surgical patients, neoadjuvant chemotherapy utilization increased from 35% to 66% (P < .0001), laparoscopic gastrectomy increased from 18% to 92% (P < .0001), and D2 lymphadenectomy increased from 2% to 80% (P < .0001). Dissection of ≥ 15 lymph nodes increased from 61% to 95% (P < .0001). Surgical complication rates did not appear to increase after regionalization. Length of hospitalization decreased from 7 to 3 days (P < .001). Overall survival at 2 years was as follows: all stages, 32.8% pre and 37.3% post (P = .20); stage I-III cases with or without surgery, 55.6% and 61.1%, respectively (P = .25); and among surgery patients, 72.7% and 85.5%, respectively (P < .03).

CONCLUSION

Regionalization of gastric cancer care within an integrated system allowed comprehensive multidisciplinary care, conversion to laparoscopic gastrectomy and D2 lymphadenectomy, increased overall survival among surgery patients, and no increase in surgical complications.

Impact of minimally invasive gastrectomy on use of and time to adjuvant chemotherapy for gastric adenocarcinoma

BACKGROUND

Chemotherapy improves outcomes in patients with resectable gastric cancer. Minimally invasive gastrectomy (MIS) rates are increasing, though the impact of MIS on postoperative chemotherapy remains uncertain. This study examines the impact of MIS vs open gastrectomy (OG) on utilization of adjuvant chemotherapy for high-risk gastric cancer.

METHODS

Patients in the National Cancer Database who underwent resection for high-risk gastric adenocarcinoma between 2010 and 2015 were included. Patients were stratified by surgical approach (MIS vs OG) and analyzed using multivariable regression modeling. Primary endpoints were utilization of and time to initiation of adjuvant chemotherapy.

RESULTS

Overall, 23 071 patients were included; 16 595 (71.9%) underwent OG and 6476 (28.1%) underwent MIS. After adjusting for patient and tumor characteristics, MIS was not associated with increased use of adjuvant chemotherapy (odds ratio [OR]: 1.027, 95% confidence interval [CI]: 0.95 to 1.11, P = .50), and time to initiation of chemotherapy was similar (-2% change, 95% CI: -5% to +1%, P = .27). MIS was associated with shorter hospital stays (-1 day). Thirty-day readmission rates, 90-day mortality, and overall survival were similar between groups.

CONCLUSIONS

In this study, while MIS for gastric adenocarcinoma was associated with shorter hospital stays and comparable survival, it was not associated with improved utilization or time to initiation of adjuvant chemotherapy.

Advancements and challenges in treating advanced gastric cancer in the West

Gastric cancer is a leading cause of cancer incidence and death worldwide. Patients with advanced gastric cancer benefit from a multi-modality treatment regimen. Sound oncologic resection with negative margins and complete lymphadenectomy plays a crucial role in long-term survival for patients with resectable disease. The utilization of minimally invasive techniques for gastric cancer has been slowly increasing and is proving to be both technically and oncologically safe. Perioperative chemotherapy is the current standard of care for advanced gastric cancer. A variety of chemotherapy regimens have been used with the combination of docetaxel, oxaliplatin, 5-fluorouracil, and leucovorin being the current recommendation given its superior ability to induce a complete pathologic response and prolong survival. The use of radiation has been more controversial with its optimal place in the treatment sequence being unclear. There are current ongoing studies assessing the impact of radiation as an adjunct or in place of chemotherapy. Targeted treatments (e.g., trastuzumab for human epidermal growth factor receptor 2 positive tumors and pembrolizumab for programmed death-ligand 1 positive tumors) are showing promise and are part of a continued emphasis on individualized care. Intraperitoneal chemotherapy may also play a role in preventing peritoneal recurrences for patients with high risk lesions. The treatment of patients with advanced gastric cancer in the West continues to advance and improve with a better understanding of optimal treatment sequences and the utilization of personalized treatment regimens.

Small bowel neuroendocrine tumors: A critical analysis of diagnostic work-up and operative approach

BACKGROUND

Small bowel neuroendocrine tumors (SB-NETs) are often small, multifocal, difficult to localize preoperatively, and can be overlooked during operative exploration. The optimal work-up and operative approach is unknown.

METHODS

Patients who underwent resection of SB-NETs at a single-institution from 2000 to 2014 were included. Primary aim was to describe the diagnostic work-up and compare minimally invasive (MIS) to open resection.

RESULTS

Ninety-three patients underwent resection for SB-NETs. About 71% were symptomatic and on average underwent three diagnostic tests: 45% had octreoscans (85% diagnostic yield); 11% had SB-enteroscopy (10% yield); 19% had capsule endoscopy (83% yield, but identified the correct tumor number in only 21%). About 27 pts underwent MIS versus 66 open. MIS pts were younger (56 vs. 61 yrs; P = 0.035), and less likely to have obstruction (4% vs. 24%; P = 0.019) and metastases (19% vs. 44%; P = 0.038). Compared to open, MIS had smaller (1.7 vs. 2.4 cm; P = 0.03) and fewer tumors resected (2 vs. 5; P = 0.049), but similar LN yield (13 vs. 12; P = 0.7). In non-metastatic, curative-intent resections, MIS still resected fewer tumors compared to open (1.5 vs. 4; P = 0.034).

CONCLUSION

Capsule endoscopy may be better than small bowel enteroscopy at identifying occult SB-NETs, but may underestimate tumor burden. While MIS may be appropriate in select patients, recognizing the limitations of preoperative evaluation is critical for these tumors, as heightened operative vigilance is often required. J. Surg. Oncol. 2016;114:671-676. © 2016 Wiley Periodicals, Inc.

Laparoscopic Total Gastrectomy with D2 Lymphadenectomy and Side-to-Side Stapled Esophagojejunostomy

INTRODUCTION

An optimal method has yet to be established for laparoscopic total gastrectomy with intracorporeal anastomosis.

METHODS

We aim to describe a simple technique for intracorporeal anastomoses. Technique of laparoscopic total gastrectomy with side-to-side stapled intracorporeal esophagojejunostomy anastomosis and Roux-en-Y jejunojejunostomy is performed on patients with gastric malignancy in an academic community tertiary care center.

RESULTS

The anastomotic technique of laparoscopic total gastrectomy with side-to-side stapled esophagojejunostomy is described.

CONCLUSION

Laparoscopic total gastrectomy with D2 lymphadenectomy and side-to-side esophagojejunostomy is safe to perform and has the advantage of a wide lumen with low chance for stricture. A laparoscopic total gastrectomy with stapled side-to-side esophagojejunostomy is feasible and safe in advanced gastric cancer.

Ratio of intra-operative fluid to anesthesia time and its impact on short term perioperative outcomes following gastrectomy for cancer: A retrospective cohort study

BACKGROUND

This study evaluates the short-term impact of fluid administration during gastrectomy for cancer.

METHODS

A multi-institutional database of patients undergoing gastrectomy for cancer from three tertiary centers was reviewed. Logistic and linear regression analyses were performed.

RESULTS

205 patients were included. The majority of patients (n = 116, 57%) underwent proximal or total gastrectomy. Median anesthesia time was 280 min (range 95-691 min). Median intraoperative crystalloid administration was 2901 ml (range 500-10,700 ml). Median colloid administration was 0 (range 0-3835 ml), although only 66 patients (32%) received colloid. On multivariate analysis, patients who received <10.0 ml total fluid per minute of anesthesia had a significantly higher risk of complications (OR 4.12, p = 0.010). Crystalloid and total fluid administration ratios did not significantly affect LOS or discharge disposition.

CONCLUSIONS

Restricting intra-operative fluid resuscitation to <10 ml total fluid per minute anesthesia is associated with an increased risk of complications in patients undergoing gastrectomy for cancer.

Laparoscopic and robot-assisted gastrectomy for gastric cancer: Current considerations

Radical gastrectomy with an adequate lymphadenectomy is the main procedure which makes it possible to cure patients with resectable gastric cancer (GC). A number of randomized controlled trials and meta-analysis provide phase III evidence that laparoscopic gastrectomy is technically safe and that it yields better short-term outcomes than conventional open gastrectomy for early-stage GC. While laparoscopic gastrectomy has become standard therapy for early-stage GC, especially in Asian countries such as Japan and South Korea, the use of minimally invasive techniques is still controversial for the treatment of more advanced tumours, principally due to existing concerns about its oncological adequacy and capacity to carry out an adequately extended lymphadenectomy. Some intrinsic drawbacks of the conventional laparoscopic technique have prevented the worldwide spread of laparoscopic gastrectomy for cancer and, despite technological advances in recent year, it remains a technically challenging procedure. The introduction of robotic surgery over the last ten years has implied a notable mutation of certain minimally invasive procedures, making it possible to overcome some limitations of the traditional laparoscopic technique. Robot-assisted gastric resection with D2 lymph node dissection has been shown to be safe and feasible in prospective and retrospective studies. However, to date there are no high quality comparative studies investigating the advantages of a robotic approach to GC over traditional laparoscopic and open gastrectomy. On the basis of the literature review here presented, robot-assisted surgery seems to fulfill oncologic criteria for D2 dissection and has a comparable oncologic outcome to traditional laparoscopic and open procedure. Robot-assisted gastrectomy was associated with the trend toward a shorter hospital stay with a comparable morbidity of conventional laparoscopic and open gastrectomy, but randomized clinical trials and longer follow-ups are needed to evaluate the possible influence of robot gastrectomy on GC patient survival.

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.

Current status of randomized controlled trials for laparoscopic gastric surgery for gastric cancer in China

China alone accounts for nearly 42% of all new gastric cancer cases worldwide, and gastric cancer is the third leading cause of cancer deaths in China nowadays. Without mass screening programs, unfortunately over 80% of all Chinese patients have been diagnosed as advanced diseases. As in other Asian countries, especially Japan and Korea, laparoscopic gastrectomy for the treatment of gastric cancer has gained increasingly popularity in China during the past decade. Whether laparoscopic surgery can be safely and effectively performed in the treatment of gastric cancer remains controversial, particularly with regard to curative intent in advanced diseases. Given the high incidence of these cancers, and their advanced stage at diagnosis, China has a significant interest in determining the safety and effectiveness of laparoscopic gastrectomy. A well-designed randomized controlled trial (RCT) is considered the only feasible way to provide conclusive evidence. To date, China has not played a significant role in terms of conducting RCT concerning laparoscopic surgery for gastric cancer. However, an effort has been made by the Chinese researchers, with the great help from our colleagues in neighboring countries such as Korea and Japan, through the establishment of the Chinese Laparoscopic Gastrointestinal Surgery Study Group. In this review, we present the current status of RCT for laparoscopic gastric surgery for gastric cancer in China, including published and ongoing registered RCT.

Minimally invasive resection of choledochal cyst: a feasible and safe surgical option

BACKGROUND

The use of minimally invasive surgery (MIS) for choledochal cyst (CC) has not been well documented. We sought to define the overall utilization and outcomes associated with the use of the open versus MIS approach for CC. We examined the factors associated with receipt of MIS for CC, as well as characterized perioperative and long-term outcomes following open versus MIS for CC.

METHODS

Between 1972 and 2014, a total of 368 patients who underwent resection for CC were identified from an international, multicenter database. A 2:1 propensity score matching was used to create comparable cohorts of patients to assess the effect of MIS on short-term outcomes.

RESULTS

Three hundred thirty-two patients had an open procedure, whereas 36 patients underwent an MIS approach. Children were more likely to be treated with a MIS approach (children, 24.0 % vs. adults, 2.1 %; P<0.001). Conversely, patients who had any medical comorbidity were less likely to undergo MIS surgery (open, 26.2 % vs. MIS, 2.8 %; P=0.002). In the propensity-matched cohort, MIS resection was associated with decreased length of stay (open, 7 days vs. MIS, 5 days), lower estimated blood loss (open, 50 mL vs. MIS, 17.5 mL), and longer operative time (open, 237 min vs. MIS, 301 min) compared with open surgery (all P<0.05). The overall and degree of complication did not differ between the open (grades I-II, n=13; grades III-IV, n=15) versus MIS (grades I-II, n=5; grades III-IV, n=5) cohorts (P=0.85). Five-year overall survival was 98.6 % (open, 98.0 % vs. MIS, 100.0 %; P=0.45); no patient who underwent MIS developed a subsequent cholangiocarcinoma.

CONCLUSIONS

MIS resection of CC was demonstrated to be a feasible and safe approach with acceptable short-term outcomes in the pediatric population. MIS for benign CC disease was associated with similar perioperative morbidity but a shorter length of stay and a lower blood loss when compared with open resection.

Minimally invasive gastrectomy for cancer: current utilization in US academic medical centers

BACKGROUND

Internationally, the utilization of minimally invasive techniques for gastric cancer resection has been increasing since first introduced in 1994. In the USA, the feasibility and safety of these techniques for cancer have not yet been demonstrated.

METHODS

The University HealthSystem Consortium database was queried for gastrectomies performed between 2008 and 2013. Any adult patient with an abdominal visceral malignancy that necessitated gastric resection was included in the cohort. Clinicopathological and in-hospital outcome metrics were collected for open, laparoscopic, and robotic procedures.

RESULTS

Open gastrectomies comprised 89.5% of the total study group, while 8.2% of procedures were performed laparoscopically, and 2.3% were performed with robotic assistance. When accounting for disparities in patient severity of illness and risk of mortality subclass designations, there were no significant differences in mean length of stay, 30-day readmission, and in-hospital mortality between the three groups; however, mean total cost was highest in the robotic-assisted group (P = 0.017). Overall, complication rates were also similar; however, there was a higher incidence of superficial infection in the laparoscopic group (P = 0.013) and a higher incidence of venous thromboembolism in the robotic group (P = 0.038).

CONCLUSION

Despite widespread adoption for benign indications, minimally invasive gastrectomy for cancer remains underutilized in the USA. In these patients, laparoscopic and robot-assisted gastrectomies appear to be comparable to open resection with respect to overall complications, length of stay, 30-day readmission, and in-hospital mortality. However, when employing minimally invasive techniques, infection and thromboembolism risk reduction strategies should be emphasized in the operative and postoperative periods.

Clinicopathological features and prognosis of gastric cardia adenocarcinoma: a multi-institutional US study

BACKGROUND AND OBJECTIVES

Potential differences in presentation and outcome of patients with gastric cardia adenocarcinoma (GCA) and non-cardia adenocarcinoma may exist. The aim of the present study was to compare the clinicopathological characteristics and the prognosis of GCA versus non-cardia adenocarcinoma.

METHOD

Patients with gastric adenocarcinoma who underwent gastric resection between 2000-2012 were identified. Clinicopathological characteristics and outcomes were analyzed based on tumor site using a 1:2 matched-control, as well as a multivariable Cox model.

RESULTS

Among 743 patients, 80 (10.7%) patients were diagnosed with GCA. Patients with GCA were more likely to have intestinal tumor type (GCA: 80.4% versus non-cardia: 64.2%, P = 0.04) or advanced AJCC T stage tumors (GCA 71.8% versus non-cardia 59.2%, P = 0.03). GCA patients more likely underwent a total gastrectomy (GCA: 85.7% vs. non-cardia: 39.8%) and had a longer length-of-stay (GCA: 10 days vs. non-cardia: 8 days) (both P < 0.05). Outcomes in early stage I patients were worse among GCA (disease-free survival, 44.2%; overall survival, 42.3%) versus non-GCA (disease-free survival, 60.8%; overall survival, 63.0%) patients(both P < 0.05).

CONCLUSION

In general, disease-free survival and overall survival were similar between patients with GCA versus non-cardia adenocarcinoma. However, long-term outcome was worse among patients with GCA and early stage disease.