Learning curve and short-term outcomes of modularized LADG for advanced gastric cancer: A retrospective study

Establishing the Learning Curve of Laparoscopic and Robotic Distal Gastrectomy: a Systematic Review and Meta-Regression Analysis

BACKGROUND

Minimally invasive distal gastrectomy (MIDG) is non-inferior compared with open distal gastrectomy for gastric cancer. However, MIDG bears a learning curve (LC). This study aims to evaluate the number of cases required to surmount the LC (i.e. NLC) in MIDG.

METHODS

PubMed, Embase, Scopus, and the Cochrane Library were systematically searched from inception to August 2022 for studies which reported NLC in MIDG. NLC on reduced-port/single-port MIDG only were separately analysed. Poisson mean (95% confidence interval (CI)) was used to determine NLC. Negative binomial regression was used to compare NLC between laparoscopic distal gastrectomy (LDG) and robotic distal gastrectomy (RDG).

RESULTS

A total of 45 articles with 71 data sets (LDG n=47, RDG n=24) were analysed. There were 7776 patients in total (LDG n=5516, RDG n=2260). Majority of studies were conducted in East Asia (n=68/71). Majority (76.1%) of data sets used non-arbitrary methods of analyses. The overall NLC for RDG was significantly lower compared to LDG (RDG 22.4 (95% CI: 20.4-24.5); LDG 46.7 (95% CI: 44.1-49.4); incidence rate ratio 0.48, p<0.001). The median number of laparoscopic gastrectomy (LG) cases prior was 0 (interquartile range (IQR) 0-105) for LDG and 159 (IQR 101-305.3) for RDG. Meta-regression analysis did not show a significant impact prior experience in LG, extent of lymphadenectomy and intracorporeal vs extracorporeal anastomosis had on overall NLC for LDG and RDG.

CONCLUSION

NLC for RDG is shorter compared to LDG, but this may be due to prior experience in LG and ergonomic advantages of RDG.

Laparoscopic versus open gastrectomy for gastric cancer: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Laparoscopic gastrectomy (LG) has been widely used for advanced gastric cancer (GC), and its resection extent is not limited to distal gastrectomy. However, the superiority of this minimally invasive approach remains controversial. This study aimed to evaluate the benefits and risks of LG on the short- and long-term outcomes compared with open gastrectomy (OG) for GC.

MATERIALS AND METHODS

A systematic literature search was performed to identify randomized controlled trials (RCTs) comparing LG and OG for treatment of GC. The primary outcomes were adverse events, recurrence, mortality, and the quality of life. The secondary outcomes included operation-relevant outcomes and postoperative recovery outcomes. We employed random-effects meta-analyses to pool results with Hartung-Knapp adjustment. The prediction interval (PI) was used to quantify the between-study heterogeneity. Meta-regression and subgroup analyses were performed to examine the potential sources of heterogeneity.

RESULTS

Twenty-eight studies involving 7643 patients were included. Most studies (22 out of 28) reported results from experienced surgeons. Compared to OG, LG was found to have the advantages of less blood loss, fewer postoperative complications, and faster recovery, but at the expense of lesser proximal resection margin length, longer operation time, and fewer retrieved lymph nodes. There were no significant differences for anastomosis-related complications, recurrence and survival and other outcomes between LG and OG. Significant between-study heterogeneity was observed. Body mass index (BMI) and age were two major sources of heterogeneity.

CONCLUSIONS

For experienced surgeons, LG is an alternative approach to OG for patients with GC. Patients with lower BMI and older age may benefit most from LG. Future studies are needed to confirm our findings in low-volume hospitals and for less-experienced surgeons. Future trials focusing on patient-important outcomes are warranted for clinical decision-making.

Palliative care physicians' recognition of patients after immune checkpoint inhibitors and immune-related adverse events

PURPOSE

This study investigated the experience of palliative care physicians (PCPs) and their knowledge and recognition of immune checkpoint inhibitors (ICIs) and immune-related adverse events (irAEs) in clinical practice as well as the need to provide palliative care services for patients after ICI treatments.

METHODS

A cross-sectional survey with self-administered questionnaires was conducted between February and April 2020. A total of 759 questionnaires were sent to PCPs in Japan. The changes in the PCPs' knowledge and recognition of ICIs and irAEs due to the increased experiences of treating patients after ICI treatments were analyzed.

RESULTS

Four hundred ninety-two responses (64.8%) were analyzed. Only 15.0% of respondents had no experience of patients after ICI treatments, while 53.9% had experience of more than six patients. On the other hand, 40% of respondents had no experience of patients with suspected irAEs, while only 13.4% had experience of more than six patients. Respondents with more experience of patients after ICI treatments or those with suspected irAEs had extensive knowledge of ICIs and irAEs, were more confident in treating these patients, and tended to consider irAEs as therapeutic indications. The majority of respondents required guidelines and efficient consultation systems with oncologists.

CONCLUSION

This study demonstrated that PCPs with experience had extensive knowledge and confidence of ICIs and irAEs and tended to recognize irAEs as therapeutic indications. The establishment of a more intimate relationship between PCPs and oncologists is important for providing better treatment for these patients.

[Laparoscopic subtotal distal gastrectomy for distal gastric cancer]

OBJECTIVE

To analyze the primary results of laparoscopic distal gastrectomy in patients with distal gastric cancer.

MATERIAL AND METHODS

There were 21 laparoscopic distal gastrectomies in patients with distal gastric cancer. Mean age of patients was 63.7±6.3 years. According to TNM staging system, cancer stage 1 was detected in 90% of patients (n=19), stage 2a - in 10% (n=2) of patients.

RESULTS

Time of distal gastrectomy was 190.4±51.6 min, blood loss - 90.3±51.2 ml. The number of excised lymph nodes was 21.2±5.1. We were able to achieve R0 resection edge in all patients. Length of hospital-stay was 7.6±2.3 days, incidence of postoperative complications - 23.8%. Complications Clavien-Dindo grade IIIb-V were observed in 9.5% of patients (n=2). Overall postoperative mortality was 4.7% (n=1). No progression of the underlying disease has been revealed in any patient throughout the follow-up period (since May 2018). To date, the maximum median follow-up is 25 months of overall and disease-free survival.

CONCLUSION

Laparoscopic subtotal distal resection is an appropriate intervention ensuring R0 resection edge in most cases.

[Laparoscopic subtotal distal resection for distal gastric cancer]

OBJECTIVE

To analyze the primary experience of laparoscopic distal gastrectomy in patients with distal gastric cancer.

MATERIAL AND METHODS

There were 21 laparoscopic distal gastrectomies in patients with antrum malignancies. Mean age of patients was 63.7±6.3 years. According to TNM staging system, cancer stage I was detected in 90% of patients (n=19), stage IIa - in 10% (n=2) of patients.

RESULTS

Duration of distal gastrectomy was 190.4±51.6 minutes, blood loss - 90.3±51.2 ml. The number of harvested lymph nodes was 21.2±5.1. We were able to reach R0 resection edge in all patients. Length of hospital-stay was 7.6±2.3 days, incidence of postoperative complications - 23.8%. Complications Clavien-Dindo grade IIIb-V were observed in 9.5% of patients (n=2). Overall postoperative mortality was 4.7% (n=1). No progression of the underlying disease has been revealed in any patient throughout the follow-up period (since May 2018). To date, the maximum median follow-up is 25 months of overall and disease-free survival.

CONCLUSION

Laparoscopic subtotal distal resection is appropriate intervention ensuring R0 resection edge in most cases.