Laparoscopic gastrectomy plus D2 lymphadenectomy is as effective as open surgery in terms of long-term survival: a single-institution study on gastric cancer

BACKGROUND

Laparoscopic surgery has been widely accepted to treat early-stage gastric cancer. However, it is still controversial to perform laparoscopic gastrectomy plus D2 lymphadenectomy for locally advanced gastric cancer. We performed the present study to compare the long-term outcomes of patients after laparoscopic or open gastrectomy plus D2 lymphadenectomy.

METHODS

The clinicopathological data of 182 gastric cancer patients receiving gastrectomy plus D2 lymphadenectomy between January 2011 and December 2015 at Shenzhen Traditional Chinese Medicine Hospital were retrospectively retrieved. The overall survival (OS) and disease-free survival (DFS) of these 182 patients were compared. Then, the prognostic significance of positive lymph node ratio (LNR) was assessed.

RESULTS

As a whole, OS (P = 0.789) and DFS (P = 0.672) of patients receiving laparoscopic gastrectomy plus D2 lymphadenectomy were not significantly different from those of patients receiving open surgery. For stage I patients, laparoscopic gastrectomy plus D2 lymphadenectomy was not significantly different from open surgery in terms of OS (P = 0.573) and DFS (P = 0.157). Similarly, for stage II patients, laparoscopic gastrectomy plus D2 lymphadenectomy was not significantly different from open surgery in terms of OS (P = 0.567) and DFS (P = 0.830). For stage III patients, laparoscopic gastrectomy plus D2 lymphadenectomy was not significantly different from open surgery in terms of OS (P = 0.773) and DFS (P = 0.404). Laparoscopic or open gastrectomy plus D2 lymphadenectomy was not proven by Cox regression analysis to be an independent prognostic factor for OS and DFS. High LNR was significantly associated with worse OS (P < 0.001) and DFS (P < 0.001). Surgical type did not significantly affect prognosis of patients with low LNR or survival of patients with high LNR.

CONCLUSIONS

For patients with gastric cancer, laparoscopic gastrectomy plus D2 lymphadenectomy was not inferior to open surgery in terms of long-term outcomes. LNR is a useful prognostic marker for GC patients.

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.

Extranodal soft tissue metastasis as an independent prognostic factor in gastric cancer patients aged under 70 years after curative gastrectomy

Background

Accumulating evidence confirms the potential prognostic value of extranodal soft tissue metastasis (ESTM) in patients with solid cancers. The aim of this study was to elucidate the potential relationship between ESTM and lymph node (LN) metastasis, demonstrate clinicopathological predictive prognostic factors for ESTM and LN metastasis, and identify the prognostic value of ESTM for gastric cancer (GC) patients aged under 70 years.

Methods

A total of 580 GC patients who underwent the curative resection between 2003 and 2011 were included to identify if ESTM is essential to improve the accuracy of prognostic evaluation of the GC patients postoperatively. Overall survival rates were tested by Kaplan-Meier analysis. Univariate and multivariate analyses were applied to clarify the independent prognostic factors. Logistic regression analysis was adopted to clarify the risk factors for evaluating the presence of ESTM and LN metastasis. After cut-point survival analysis, the GC patients were divided into three subgroups based on the number of ESTM and then incorporated into the pTNM stage of gastric carcinoma to identify the possibility and necessity of incorporating ESTM into staging.

Results

ESTM was associated with advanced pT, pN and pTNM categories, large tumour size and the presence of signet-ring cell (SRC) variants. Survival analyses revealed that ESTM was associated with the OS and was an independent prognostic predictor in this GC patient cohort. Logistic regression analysis proved that ESTM and pT stage are significantly correlated with LN metastasis. Additionally, the ESTM was incorporated into the eighth edition of the pTNM classification and the prognostic evaluation of pTNME classification were calculated directly, and the results indicated that ESTM can reduce the stage migration.

Conclusions

ESTM is a significant independent predictor of survival in GC patients. To achieve R0 surgery, lymph nodes, soft tissues, fascia and adipose tissue should be resected en bloc at the same time as lymph node dissection. ESTM should be incorporated into pTNM staging according to the number retrieved from postoperative samples.

Right-Side Approach-Duet Totally Laparoscopic Distal Gastrectomy (R-Duet TLDG) Using a Three-Port to Treat Gastric Cancer

BACKGROUND

Gastric cancer is commonly treated via minimally invasive surgery. The present study explored the feasibility of right-side approach-duet (R-duet) totally laparoscopic distal gastrectomy using a three-port compared with a four- or five-port.

METHODS

A total of 251 patients who underwent curative totally laparoscopic distal gastrectomy for gastric cancer (72 R-duet, 74 four-port, and 105 five-port) at the Catholic Medical Center were enrolled. All operations were performed using conventional laparoscopic instruments. The clinicopathological characteristics, operative details, and postoperative short-term outcomes were analyzed retrospectively.

RESULTS

The clinicopathological characteristics did not differ significantly among the groups, except that the N stage was higher in the five-port group. The operating time was significantly longer in the four-port than the R-duet group (R-duet, four-port, and five-port 148.2 ± 30.7, 162.4 ± 30.6, and 159.9 ± 31.5 min, respectively; p = 0.024). The estimated blood loss did not differ significantly. Postoperatively, the times to flatus and to soft diet consumption and the hospital stay were significantly longer in the five-port group. The extent of postoperative complications did not differ among the groups.

CONCLUSIONS

R-duet totally laparoscopic distal gastrectomy is a reliable form of reduced-port surgery when used to treat gastric cancer; no special instruments are required.

Modified vs. standard D2 lymphadenectomy in distal subtotal gastrectomy for locally advanced gastric cancer patients under 70 years of age

The present study was conducted to investigate the prognosis and survival of patients with locally advanced gastric cancer who underwent distal subtotal gastrectomy with modified D2 (D1+) and D2 lymphadenectomy, under 70 years of age. The five-year overall survival rates of 390 patients were compared between those receiving D1+ and D2 lymphadenectomy. Univariate and multivariate analyses were used to identify factors that correlated with prognosis and lymph node metastasis. Tumor size (P=0.039), pT stage (P=0.011), pN stage (P<0.001), and lymphadenectomy (P=0.004) were identified as independent prognostic factors. Furthermore, tumor size (P=0.022), pT stage (P=0.012), and lymphadenectomy (P=0.028) were proven as independent factors predicting lymph node metastasis. In conclusion, cancers of larger size, higher pT stage, and with D1+ lymphadenectomy had a higher risk of lymph node metastasis. Standard D2 lymphadenectomy removes sufficient lymph nodes to improve staging accuracy and survival. Therefore, D2 lymphanectomy is recommended in distal subtotal gastrectomy for locally advanced gastric cancer, especially for cancers of larger size and higher pT stage.

Feasibility of laparoscopic gastrectomy for elderly gastric cancer patients: meta-analysis of non-randomized controlled studies

The aim of this meta-analysis was to determine the feasibility of laparoscopic gastrectomy (LG) for elderly gastric cancer patients by comparing laparoscopic and conventional open gastrectomies (OG). Comprehensive search of the PubMed, EMBASE, and Cochrane Library databases revealed nine non-randomized controlled studies that compared LG and OG in elderly gastric cancer patients We then analyzed dichotomous or continuous parameters using odds ratios (ORs) or weighted mean differences (WMDs). Overall survival was estimated using hazard ratios (HRs) with a fixed effects or random effects model. We observed that the age distribution was similar between the LG and OG patient groups (WMD -0.22 95% CI, -1.26-0.82). LG patients experienced less blood loss (WMD -119.14 95% CI, -204.17--34.11) and had shorter hospital stays (WMD -3.48 95% CI, -5.41--1.56), but endured longer operation times (WMD 10.87 95% CI, 2.50-19.24). Postoperatively, LG patients exhibited lower incidences of postoperative morbidities (OR 0.59 95% CI, 0.43-0.79), surgery related morbidities (OR 0.58 95% CI, 0.41-0.81) and systemic morbidities (OR 0.56 95% CI, 0.38-0.82). We observed no differences between the LG and OG patient groups regarding anastomotic leakage (OR 0.69 95% CI, 0.34-1.41), mental disease (OR 0.72 95% CI, 0.37-1.41) and long term effects (HR 0.98 95% CI, 0.74-1.32). We therefore conclude that laparoscopic gastrectomy might be technically feasible for elderly gastric cancer patients.