Comparative analysis of station-specific lymph node yield in laparoscopic and open distal gastrectomy for early gastric cancer

Examined lymph node count for gastric cancer patients after curative surgery

Lymph node (LN) metastasis is the most common form of metastasis in gastric cancer (GC). The status and stage of LN metastasis are important indicators that reflect the progress of GC. The number of LN metastases is still the most effective index to evaluate the prognosis of patients in all stages of LN metastasis. Examined LN (ELN) count refers to the number of LNs harvested from specimens by curative gastrectomy for pathological examination. This review summarizes the factors that influence ELN count, including individual and tumor factors, intraoperative dissection factors, postoperative sorting factors, and pathological examination factors. Different ELN counts will lead to prognosis-related stage migration. Fine LN sorting and regional LN sorting are the two most important LN sorting technologies. The most direct and effective way to harvest a large number of LNs is for surgeons to perform in vitro fine LN sorting.

Laparoscopic Gastrectomy with D2 Lymphadenectomy for pT1a Adenocarcinoma: Case Report and Literature Review

Gastric cancer is one of the most common malignancies, associated with a high mortality and morbidity rate, especially in the elderly, the fourth leading cause of cancer mortality in Europe. Although the rate of diagnosis has declined in recent years, the prognosis of the disease and the mortality rate is still quite high. Laparoscopic surgery, accompanied by lymphadenectomy, is a curative method of treatment, used more and more frequently, especially in Eastern countries, both in the incipient disease and in advanced stages of the disease, which has many advantages over classical surgery.

We report the case of an 86-year-old man, who presented for marked physical asthenia, weight loss and severe anemia, in whom we performed laparoscopic distal radical gastrectomy with D2 lymphadenectomy and Roux-en-Y reconstruction. Histopathological examination established the diagnosis of low-grade / well-differentiated tubular adenocarcinoma G1 (WHO) / intestinal carcinoma (Lauren), with invasion in the lamina propria, developed on an intestinal-type adenoma. 21 lymph nodes were taken without tumor invasion.

This case highlights the complexity of laparoscopic intervention, with the proven advantages for the patient, like reduced surgical trauma and pain, with the decrease of postoperative complications, but also the difficulty of the surgical technique which requires advanced laparoscopic skills. Thus, in addition to its proven efficacy in cases of early gastric cancer, the technique can be extended to advanced malignancies, without affecting the oncological safety limit.

Surgeon Quality Control and Standardization of D2 Lymphadenectomy for Gastric Cancer: A Prospective Multicenter Observational Study (KLASS-02-QC)

OBJECTIVE

To qualify surgeons to participate in a randomized trial comparing laparoscopic and open distal D2 gastrectomy for advanced gastric cancer.

SUMMARY OF BACKGROUND DATA

No studies have sought to qualify surgeons for a randomized trial comparing laparoscopic and open D2 gastrectomy for advanced gastric cancer.

METHODS

We conducted a multicenter prospective observational study evaluating unedited videos of laparoscopic and open D2 gastrectomy performed by 27 surgeons. Surgeons performed 3 of each laparoscopic and open distal gastrectomies with D2 lymphadenectomy for gastric cancer. Five peers reviewed each unedited video using a video assessment form. Based on experts' review of videos, a separate review committee decided surgeons as "Qualified" or "Not-qualified."

RESULTS

Twelve surgeons (44.4%) were qualified on initial evaluation whereas the other 15 surgeons were not. Another 9 surgeons were finally qualified after re-evaluation. The median score for Qualified was significantly higher than Not-qualified (P < 0.001).Significant differences between Qualified and Not-qualified were noted both in operation type and in all evaluation area of surgical skill, perigastric, and extra-perigastric lymphadenectomy, although the inter-rater variability of the assessment score was low (kappa = 0.285). However, Not-qualified surgeons' scores improved upon re-evaluation of resubmitted videos.When compared laparoscopy with open surgery, median scores were similar between the 2 groups (P = 0.680). However, open gastrectomy scores for surgical skills were significantly higher than for laparoscopic surgery (P = 0.016).

CONCLUSIONS

Our surgeon quality control study for gastrectomy represents a milestone in surgical standardization for surgical clinical trials. Our methods could also serve as a system for educating surgeons and assessing surgical proficiency.

Application of da Vinci robot with the"3 + 2" mode in radical gastrectomy for gastric cancer

The aim of this study is to investigate the feasibility and advantages of the da Vinci robotic system with the "3 + 2" mode (3 robotic arms and 2 assistants) in radical gastrectomy for gastric cancer.The clinical data of 65 patients who underwent da Vinci robotic gastrectomy with the "3 + 2" mode from July 2016 to October 2019 were grouped into an observation group. An additional 65 patients who underwent robotic gastrectomy under the classic mode during the same period were grouped into a control group. The short-term surgical outcomes were compared between 2 different groups.Compared with the control group, the observation group had a significantly shorter operative time (176.18 ± 15.49 vs 203.85 ± 12.77 minutes, P < .001) and lower operation costs ($2761.19 ± $191.91 vs $3690.91 ± $162.82; P < .001). No statistical differences in other outcomes were observed (P > .05).We show that robotic gastrectomy with "3 + 2" mode is a safe and beneficial surgical procedure in new robotic surgery institutions.

Laparoscopic versus open subtotal gastrectomy for gastric adenocarcinoma: cost-effectiveness analysis

Background

Laparoscopic subtotal gastrectomy (LSG) for cancer is associated with good perioperative outcomes and superior quality of life compared with the open approach, albeit at higher cost. An economic evaluation was conducted to compare the two approaches.

Methods

A cost–effectiveness analysis between LSG and open subtotal gastrectomy (OSG) for gastric cancer was performed using a decision‐tree cohort model with a healthcare system perspective and a 12‐month time horizon. Model inputs were informed by a meta‐analysis of relevant literature, with costs represented in 2016 Canadian dollars (CAD) and outcomes measured in quality‐adjusted life‐years (QALYs). A secondary analysis was conducted using inputs extracted solely from European and North American studies. Deterministic (DSA) and probabilistic (PSA) sensitivity analyses were performed.

Results

In the base‐case model, costs of LSG were $935 (€565) greater than those of OSG, with an incremental gain of 0·050 QALYs, resulting in an incremental cost–effectiveness ratio of $18 846 (€11 398) per additional QALY gained from LSG. In the DSA, results were most sensitive to changes in postoperative utility, operating theatre and equipment costs, as well as duration of surgery and hospital stay. PSA showed that the likelihood of LSG being cost‐effective at willingness‐to‐pay thresholds of $50 000 (€30 240) per QALY and $100 000 (€60 480) per QALY was 64 and 68 per cent respectively. Secondary analysis using European and North American clinical inputs resulted in LSG being dominant (cheaper and more effective) over OSG, largely due to reduced length of stay after LSG.

Conclusion

In this decision analysis model, LSG was cost‐effective compared with OSG for gastric cancer.

Laparoscopic Surgery for Gastric Cancer: The European Point of View

Objective

Multiple Asian studies have proved the feasibility of laparoscopic approach for surgical treatment of gastric cancer. The difference between Asian and European patients could limit their application in Europe. We reviewed the literature for European studies comparing open gastrectomy with laparoscopic approach in the treatment of gastric cancer.

Method

We searched the keywords gastric cancer and laparoscopy in MEDLINE and EMBASE. We included all studies published between 1990 and 2016 and conducted in Europe.

Result

We found 1 randomized and 13 cohort studies which compared laparoscopic with open gastrectomy. We found no mean difference in the number of lymph nodes harvested between laparoscopic and open group (mean difference: -0.49; 95% CI: -2.42; 1.44, p=0.62) and no difference of short-term or long-term mortality (short-term odds ratio: 0.74, p=0.47; long-term odds ratio: 0.65, p=0.11). We found a longer operative time in the laparoscopic group (mean difference: 35.75 minutes, p<0.01) but lesser reoperation rate than the open group (odds ratio: 1.55 p=0.01).

Conclusion

European based population studies found results comparable with their Asian counterpart. In the current state of evidence, minimally invasive surgery for gastric cancer is safe and can achieve the same oncological results.

Robot-assisted laparoscopic gastrectomy for gastric cancer

Phase III evidence in the shape of a series of randomized controlled trials and meta-analyses has shown that laparoscopic gastrectomy is safe and gives better short-term results with respect to the traditional open technique for early-stage gastric cancer. In fact, in the East laparoscopic gastrectomy has become routine for early-stage gastric cancer. In contrast, the treatment of advanced gastric cancer through a minimally invasive way is still a debated issue, mostly due to worries about its oncological efficacy and the difficulty of carrying out an extended lymphadenectomy and intestinal reconstruction after total gastrectomy laparoscopically. Over the last ten years the introduction of robotic surgery has implied overcoming some intrinsic drawbacks found to be present in the conventional laparoscopic procedure. Robot-assisted gastrectomy with D2 lymphadenectomy has been shown to be safe and feasible for the treatment of gastric cancer patients. But unfortunately, most available studies investigating the robotic gastrectomy for gastric cancer compared to laparoscopic and open technique are so far retrospective and there have not been phase III trials. In the present review we looked at scientific evidence available today regarding the new high-tech surgical robotic approach, and we attempted to bring to light the real advantages of robot-assisted gastrectomy compared to the traditional laparoscopic and open technique for the treatment of gastric 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.

Comparison Between Minimally Invasive and Open Gastrectomy for Gastric Cancer in Europe: A Systematic Review and Meta-analysis

AIMS

We compared laparoscopic and robotic gastrectomies with open gastrectomies and with each other that were held for gastric cancer in Europe.

METHODS

We searched for studies conducted in Europe and published up to 20 February 2015 in the PubMed database that compared laparoscopic or robotic with open gastrectomies for gastric cancer and with each other.

RESULTS

We found 18 original studies (laparoscopic vs open: 13; robotic vs open: 3; laparoscopic vs robotic: 2). Of these, 17 were non-randomized trials and only 1 was a randomized controlled trial. Only four studies had more than 50 patients in each arm. No significant differences were detected between minimally invasive and open approaches regarding the number of retrieved lymph nodes, anastomotic leakage, duodenal stump leakage, anastomotic stenosis, postoperative bleeding, reoperation rates, and intraoperative/postoperative mortality. Nevertheless, laparoscopic procedures provided higher overall morbidity rates when compared with open ones, but robotic approaches did not differ from open ones. On the contrary, blood loss was less and hospital stay was shorter in minimally invasive than in open approaches. However, the results were controversial concerning the duration of operations when comparing minimally invasive with open gastrectomies. Additionally, laparoscopic and robotic procedures provided equivalent results regarding resection margins, duodenal stump leakage, postoperative bleeding, intraoperative/postoperative mortality, and length of hospital stay. On the contrary, robotic operations had less blood loss, but lasted longer than laparoscopic ones. Finally, there were relatively low conversion rates in laparoscopic (0%-6.7%) and robotic gastrectomies (0%-5.6%) in most studies.

CONCLUSION

Laparoscopic and robotic gastrectomies may be considered alternative approaches to open gastrectomies for treating gastric cancer. Minimally invasive operations are characterized by less blood loss and shorter hospital stay than open ones. In addition, robotic procedures have less blood loss, but last longer than laparoscopic ones.

Comparison of laparoscopy-assisted surgery and laparotomy for treating locally advanced distal gastric antral cancer

The aim of this study was to investigate the safety, feasibility and mid-term results of laparoscopy-assisted surgery in the treatment of locally advanced gastric antral cancer. The clinical data of 50 patients who received laparoscopy-assisted surgery (Group A) and 62 patients who were treated by conventional laparotomy (Group B) from August 2009 to January 2011 were retrospectively analyzed. The surgical incision length, the volume of blood loss, the intestinal function recovery time, the postoperative complications, the postoperative 1- and 3-year cumulative survival rates and the average survival time in the two groups were observed. The results of the two groups were compared using the χ² test for the enumeration data, a t-test for the numerical data and a Wilcoxon rank sum test for the skewed data. In addition, the Kaplan-Meier method of single factor analysis was utilized to comwpare the 1- and 3-year cumulative survival rates, as well as the average survival time of the two groups. The results indicated that the duration of surgery for Group A was significantly longer compared with that of Group B (P<0.05); however, the incision length and the volume of intraoperative blood loss in Group A were significantly smaller compared with those of Group B (P<0.01). Furthermore, in Group A, the recovery of intestinal function was more rapid and the time spent in hospital was shorter. However, between Groups A and B, the respective number of dissected lymph nodes (16.3 and 17.2), 1-year survival rates (86.0 and 88.6%) and 3-year survival rates (52.6 and 53.7%) were not significantly different (P<0.05). The results indicate that laparoscopy-assisted surgery is a safe approach for the treatment of locally advanced gastric antral cancer and has beneficial treatment effects. Laparoscopy-assisted surgery is advantageous compared with laparotomy, due to the smaller incision length and reductions in intraoperative blood loss, invasiveness, postoperative recovery time and the number of complications.