SURVIVAL AND PERIOPERATIVE MORBIDITY OF TOTALLY LAPAROSCOPIC VERSUS OPEN GASTRECTOMY FOR EARLY GASTRIC CANCER: ANALYSIS FROM A SINGLE LATIN AMERICAN CENTRE

Chinese national clinical practice guidelines on the prevention, diagnosis, and treatment of early gastric cancer

BACKGROUND

Gastric cancer is one of the most common malignant tumors in the digestive system in China. Few comprehensive practice guidelines for early gastric cancer in China are currently available. Therefore, we created the Chinese national clinical practice guideline for the prevention, diagnosis, and treatment of early gastric cancer.

METHODS

This clinical practice guideline (CPG) was developed in accordance with the World Health Organization's recommended process and with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) in assessing evidence quality. We used the Evidence to Decision framework to formulate clinical recommendations to minimize bias and increase transparency in the CPG development process. We used the Reporting Items for practice Guidelines in HealThcare (RIGHT) statement and the Appraisal of Guidelines for Research and Evaluation II (AGREE II) as reporting and conduct guidelines to ensure completeness and transparency of the CPG.

RESULTS

This CPG contains 40 recommendations regarding the prevention, screening, diagnosis, treatment, and follow-up of early gastric cancer based on available clinical studies and guidelines. We provide recommendations for the timing of Helicobacter pylori eradication, screening populations for early gastric cancer, indications for endoscopic resection and surgical gastrectomy, follow-up interval after treatment, and other recommendations.

CONCLUSIONS

This CPG can lead to optimum care for patients and populations by providing up-to-date medical information. We intend this CPG for widespread adoption to increase the standard of prevention, screening, diagnosis, treatment, and follow-up of early gastric cancer; thereby, contributing to improving national health care and patient quality of life.

Laparoscopic versus Open Surgery for Gastric Cancer in Western Countries: A Systematic Review and Meta-Analysis of Short- and Long-Term Outcomes

Background. The advantages of a laparoscopic approach for the treatment of gastric cancer have already been demonstrated in Eastern Countries. This review and meta-analysis aims to merge all the western studies comparing laparoscopic (LG) versus open gastrectomies (OG) to provide pooled results and higher levels of evidence. Methods. A systematic literature search was performed in MEDLINE(PubMed), Embase, WebOfScience and Scopus for studies comparing laparoscopic versus open gastrectomy in western centers from 1980 to 2021. Results. After screening 355 articles, 34 articles with a total of 24,098 patients undergoing LG (5445) or OG (18,653) in western centers were included. Compared to open gastrectomy, laparoscopic gastrectomy has a significantly longer operation time (WMD = 47.46 min; 95% CI = 31.83−63.09; p < 0.001), lower blood loss (WMD = −129.32 mL; 95% CI = −188.11 to −70.53; p < 0.0001), lower analgesic requirement (WMD = −1.824 days; 95% CI = −2.314 to −1.334; p < 0.0001), faster time to first oral intake (WMD = −1.501 days; 95% CI = −2.571 to −0.431; p = 0.0060), shorter hospital stay (WMD = −2.335; 95% CI = −3.061 to −1.609; p < 0.0001), lower mortality (logOR = −0.261; 95% the −0.446 to −0.076; p = 0.0056) and a better 3-year overall survival (logHR 0.245; 95% CI = 0.016−0.474; p = 0.0360). A slight significant difference in favor of laparoscopic gastrectomy was noted for the incidence of postoperative complications (logOR = −0.202; 95% CI = −0.403 to −0.000 the = 0.0499). No statistical difference was noted based on the number of harvested lymph nodes, the rate of major postoperative complication and 5-year overall survival. Conclusions. In Western centers, laparoscopic gastrectomy has better short-term and equivalent long-term outcomes compared with the open approach, but more high-quality studies on long-term outcomes are required.

Laparoscopic gastrectomy for early and advanced gastric cancer in a western center: a propensity score-matched analysis

The employment of laparoscopic gastrectomy (LG) in the management of gastric cancer (GC) is increasing. Despite recent results from randomized trials, its effectiveness and oncological results in different scenarios remain controversial, especially in western centers. The aim of this study was to compare the short-term outcomes and survival of LG with open gastrectomy (OG) for GC. We reviewed all GC patients who underwent curative gastrectomy from a prospective database. Propensity score-matched (PSM) analysis including 10 variables was conducted to reduce patient selection bias using a 1:1 case-control match. A total of 530 GC were eligible for inclusion (438 OG and 92 LG). Older age, lower hemoglobin levels, total gastrectomy, larger tumor size, greater depth of tumor invasion and advanced pTNM stage was more frequent in the OG group. After PMS analysis, 92 patients were matched in each group. All variables assigned in the score were well matched. LG group had a slightly higher number of retrieved lymph nodes (42.3 vs 37.6), however, without reaching statistical significance (p = 0.072). No differences were recorded about the frequency of major postoperative complications (POC) and mortality rates between OG and LG groups (12% vs 15.2%, p = 0.519, respectively). In survival analysis, after matching, there was no difference in survival between the two groups. Multivariate analysis showed that only ASA and pN stage were independent factor associated with survival after PSM. In conclusion, laparoscopic gastrectomy was a safe and effective surgical technique for gastric cancer, with short-term and oncological outcomes comparable to open surgery.

Laparoscopic vs Open Gastrectomy: an Updated Meta-analysis of Randomized Control Trials for Short-Term Outcomes

The aim of this meta-analysis was to compare short-term outcomes of laparoscopic and open gastrectomy for gastric cancer. EMBASE, MEDLINE, PubMed, and the Cochrane Database were searched for randomized control trials comparing outcomes in patients undergoing laparoscopic gastrectomies with those patients undergoing open gastrectomies. The primary outcome was 30-day morbidity and mortality. Secondary outcomes studied included length of stay, blood loss, d2 gastrectomies, lymph node retrieval, operative time, wound complications, and intraabdominal complications. Systemic review and meta-analysis were done according to MOOSE and PRISMA guidelines. Eleven RCTs consisting of 4614 patients were included in the study. A total of 2452 patients were there in laparoscopic gastrectomy group while 2162 patients were included in open gastrectomy group. Morbidity was significantly low in laparoscopic group (p = 0.003). There was no significant difference in mortality between the two groups (P = 0.75). There were fewer wound complications in laparoscopic group and no difference intra-abdominal complications in both groups. Blood loss was significantly lesser in laparoscopic group (p < 0.001). Hospital stay was similar in both groups (p = 0.30). Operative time was significantly higher in laparoscopic group (p < 0.001). Laparoscopic group patients had a lesser number of lymph node retrieval compared to open group (p = 0.002). Laparoscopic group also contained similar advanced staged gastric cancer than open gastrectomies (p = 0.64). Laparoscopic gastrectomies were associated with lesser wound-related complications without decreasing hospital stay with a smaller number of lymph nodes retrieval.

A case report of diffuse hyperplastic gastropathy with multiple polypoid formations in a patient with pernicious anemia, Helicobacter pylori infection, hypergastrinemia and hypoalbuminaemia: Do not forget of Ménétrier's disease

INTRODUCTION

Ménétrier's disease is a rare condition, frequently associated with Helicobacter pylori infection, hypergastrinemia and hypoalbuminaemia.

PRESENTATION OF THE CASE

A case of a 55 years-old female patient with a previous diagnosis of pernicious anemia complaining of epigastric discomfort, hyporexia, vomiting, and weight loss is reported. Endoscopy showed multiple gastric polyploid formations and Helicobacter pylori infection was detected. Laboratory tests showed elevated gastrin serum levels and presence of antibodies antiparietal cells, as well as microcytic hypochromic anemia compatible with chronic iron deficiency. Albumin serum level was slightly decreased. Full thickness biopsy performed via echoendoscopy reported gastritis cystica/polyposa profunda. Given the association of diffuse involvement of the entire stomach, the possibility of developing malignant disease and the clinical symptoms, the patient underwent laparoscopic total gastrectomy with Roux-en-Y reconstruction. The surgical specimen showed the mucosa hyperemic and swollen, with prominent gastric folds. Hyperplastic elongation of gastric foveolas associated with disappearance of oxyntic glands was compatible with Ménétrier's disease.

DISCUSSION

The Ménétrier's disease diagnosis may be tricky, especially when an unusual endoscopic presentation is associated with other conditions that may mislead the diagnostic evaluation. The differential diagnoses were gastric malignancies, Zollinger-Ellison syndrome, massive gastric polyposis and gastritis cystica/polyposa profunda.

CONCLUSION

Clinical, laboratory, endoscopic and histopathological findings are paramount for reaching the diagnosis of Ménétrier's disease, but it should be suspected in all cases of upper gastrointestinal symptoms and hypertrophied gastric mucosa.

RISK FACTORS FOR SEVERE POSTOPERATIVE COMPLICATIONS AFTER GASTRECTOMY FOR GASTRIC AND ESOPHAGOGASTRIC JUNCTION CANCERS

BACKGROUND

Gastrectomy is the main treatment for gastric and Siewert type II-III esophagogastric junction (EGJ) cancer. This surgery is associated with significant morbidity. Total morbidity rates vary across different studies and few have evaluated postoperative morbidity according to complication severity.

AIM

To identify the predictors of severe postoperative morbidity.

METHODS

This was a retrospective cohort study from a prospective database. We included patients treated with gastrectomy for gastric or EGJ cancers between January 2012 and December 2016 at a single center. Severe morbidity was defined as Clavien-Dindo score ≥3. A multivariate analysis was performed to identify predictors of severe morbidity.

RESULTS

Two hundred and eighty-nine gastrectomies were performed (67% males, median age: 65 years). Tumor location was EGJ in 14%, upper third of the stomach in 30%, middle third in 26%, and lower third in 28%. In 196 (67%), a total gastrectomy was performed with a D2 lymph node dissection in 85%. Two hundred and eleven patients (79%) underwent an open gastrectomy. T status was T1 in 23% and T3/T4 in 68%. Postoperative mortality was 2.4% and morbidity rate was 41%. Severe morbidity was 11% and was mainly represented by esophagojejunostomy leak (2.4%), duodenal stump leak (2.1%), and respiratory complications (2%). On multivariate analysis, EGJ location and T3/T4 tumors were associated with a higher rate of severe postoperative morbidity.

CONCLUSION

Severe postoperative morbidity after gastrectomy was 11%. Esophagogastric junction tumor location and T3/T4 status are risk factors for severe postoperative morbidity.

ADJUVANT CHEMORADIOTHERAPY AFTER SUBTOTAL OR TOTAL GASTRECTOMY AND D2 LIMPHADENECTOMY INCREASES SURVIVAL IN ADVANCED GASTRIC CANCER?

BACKGROUND

The treatment of advanced gastric cancer with curative intent is essentially surgical and chemoradiotherapy is indicated as neo or adjuvant to control the disease and prolong survival.

AIM

To assess the survival of patients undergoing subtotal or total gastrectomy with D2 lymphadenectomy followed by adjuvant chemoradiotherapy.

METHODS

Were retrospectively analyzed 87 gastrectomized patients with advanced gastric adenocarcinoma, considered stages IB to IIIC and submitted to adjuvant chemoradiotherapy (protocol INT 0116). Tumors of the esophagogastric junction, with peritoneal implants, distant metastases, and those that had a compromised surgical margin or early death after surgery were excluded. They were separated according to the extention of the gastrectomy and analyzed for tumor site and histopathology, lymph node invasion, staging, morbidity and survival.

RESULTS

The total number of patients who successfully completed the adjuvant treatment was 45 (51.7%). Those who started treatment and discontinued due to toxicity, tumor-related worsening, or loss of follow-up were 10 (11.5%) and reported as incomplete adjuvant. The number of patients who refused or did not start adjuvant treatment was 33 (48.3%). Subtotal gastrectomy was indicated in 60 (68.9%) and total in 27 (31.1%) and this had a shorter survival. The mean resected lymph nodes was 30.8. Staging and number of lymph nodes affected were predictors of worse survival and the more advanced the tumor. Patients undergoing adjuvant therapy with complete chemoradiotherapy showed a longer survival when compared to those who did it incompletely or underwent exclusive surgery. On the other hand, comparing the T4b (IIIB + IIIC) staging patients who had complete adjuvance with those who underwent the exclusive operation or who did not complete the adjuvant, there was a significant difference in survival.

CONCLUSION

Adjuvant chemoradiotherapy presents survival gain for T4b patients undergoing surgical treatment with curative intent.