Feasibility and nutritional impact of laparoscopic assisted tailored subtotal gastrectomy for middle-third gastric cancer

Short-term outcomes of distal gastrectomy versus total gastrectomy for gastric cancer under enhanced recovery after surgery: a propensity score-matched analysis

Enhanced recovery after surgery (ERAS) has been used safely and effectively in patients with gastric cancer. Our aim was to evaluate the short-term outcomes of total gastrectomy (TG) versus distal gastrectomy (DG) for gastric cancer under ERAS. A prospectively collected database of 1349 patients with gastric cancer who underwent TG or DG between January 2016 and September 2022 was retrospectively analyzed. Propensity score matching analysis was used at a ratio of 1:1 to reduce confounding effects, and perioperative clinical outcomes were compared between the two groups. The primary outcome was overall postoperative complications (POCs). Secondary outcomes comprised time to bowel function recovery, postoperative hospital stay, mortality, and 30-day readmission rate. Of 1349 identified patients, 296 (21.9%) experienced overall POCs. Before matching, multivariable analysis revealed that age, body mass index, diabetes, operation time, and extent of gastrectomy were independent risk factors for overall POCs. After matching, each group comprised 495 patients, and no significant differences were observed between the groups for all parameters except tumor location. Compared with TG, DG was associated with significantly earlier days to first flatus and to eating a soft diet, and shorter postoperative hospital stay (P < 0.05). The incidence of overall- and severe POCs (Clavien-Dindo grade ≥ IIIa) in the TG group was significantly higher vs. the DG group (P < 0.05). There was no significant difference in the number of days to eating a liquid diet, or mortality and 30-day readmission rates between the groups (P > 0.05). In the subgroup analysis for middle-third gastric cancer, the TG group experienced higher rates of overall- and severe POCs, with a longer postoperative hospital stay. Compared with DG, patients who underwent TG had higher POC rates, slower recovery of bowel function, and longer duration of hospitalization under ERAS. Therefore, caution is needed when initiating early feeding for patients who undergo TG.

Long-term Results of Totally Laparoscopic Near-total Gastrectomy for Middle-third Gastric Cancer

PURPOSE

In recent years, laparoscopic near-total gastrectomy (LnTG) has emerged as a surgical option for gastric cancer in the middle-third of the stomach. However, its application in locally advanced stages presents technical challenges. This study aims to provide a detailed analysis of the operative outcomes and long-term functional and oncological results of totally LnTG in combination with D2 lymphadenectomy for middle-third gastric cancer.

PATIENTS AND METHOD

A prospective study was conducted on 79 patients who underwent totally LnTG and D2 lymphadenectomy for middle-third gastric cancer between January 2017 and December 2021. Short-term outcomes included operative characteristics, and the evaluation of gastroesophageal reflux and gastric remnant condition using endoscopy based on the Los Angeles (LA) and Residue-Gastritis-Bile classifications. Long-term oncological outcomes included overall survival and disease-free survival.

RESULTS

Totally LnTG was successfully performed in 98.7% of patients without intraoperative complications or conversions to laparotomy. The mean operation time was 202.2±43.0 min, and the median blood loss was 50 (50;100) mL. The overall incidence of postoperative morbidities was 16.5%, with one patient experiencing a narrowing of the gastrojejunostomy, successfully treated by endoscopic balloon dilation. All patients had tumor-free resection margins, and there were no mortalities. The 5-year overall survival and disease-free survival rates were 80% and 55%, respectively.

CONCLUSIONS

Totally LnTG is an effective and feasible approach for gastric cancer in the middle-third of the stomach, yielding favorable short-term outcomes and acceptable long-term results. Routine application of totally LnTG for middle-third gastric cancer is practical and promising.

An improvement in the reconstruction of digestive tract after total gastrectomy: ultra-short cecum

Aim

This study aimed to evaluate the utility and complications of ultra-short cecum (USC) in the reconstruction of digestive tract after total gastrectomy (TG) for the alleviation of reflux esophagitis and to determine its effect on long-term nutritional status.

Methods

Patients who underwent TG with USC or normal cecum (NC) at a single institution between June 2018 and December 2020 were included in this study. The inclusion and exclusion criteria were defined, and the primary endpoints were reflux esophagitis, anastomotic leakage and postoperative nutritional status. The long-term nutritional status was evaluated by the change trend of laboratory blood tests, including total protein, prealbumin, hemoglobin, and total leukocytes.

Results

Totally 240 cases were included in the final analysis out of 496 patients who received TG with USC or NC. Postoperative reflux esophagitis was significantly higher in the NC group than in the USC group (24.7% versus 7.7%, P = 0.001), and the NC group had a higher incidence of severe esophagitis symptoms compared to the USC group (13.6% versus 0.00%, P < 0.001), and the incidence of anastomotic leakage in the USC group was similar to that in the NC group (9.0% versus 6.2%, P = 0.6). There was no significant difference in long-term nutritional status between the USC and NC groups in the two years following the surgery (P > 0.05).

Conclusion

Ultra-short cecum after total gastrectomy should be more actively recommended due to its significant reduction in reflux esophagitis and similar incidence of anastomotic leakage and nutritional status compared with normal cecum after total gastrectomy.

Cardia function-preserving surgery and anti-reflux anastomotic method after proximal gastrectomy for gastric cancer: Current status and future perspectives

The incidence and mortality of gastric cancer ranked 5th and 3rd worldwide, respectively, in 2018, and the incidence of gastroesophageal junction adenocarcinoma increased over the past 40 years. Radical resection and lymph node dissection is the preferred treatment for gastric cancer. Proximal gastrectomy or total gastrectomy is usually performed for gastroesophageal junction adenocarcinoma and upper gastric cancer. Owing to the resection of the cardia structures, the incidence of reflux esophagitis increases significantly after proximal gastrectomy and total gastrectomy, resulting in poor postoperative quality of life. To reduce the incidence of reflux esophagitis and improve patients' postoperative quality of life, various methods to preserve the function of the cardia or to perform anti-reflux reconstruction have emerged. In this manuscript, we systematically introduced the advantages and problems of various anti-reflux anastomotic method after proximal gastrectomy, and cardia-preserving gastrectomy including endoscopic resection (ER), local gastrectomy by gastroscopy combined with laparoscopy, segmental gastrectomy, subtotal gastrectomy, and cardia-preserving radical gastrectomy. Cardia-preserving radical gastrectomy has the advantage of more thorough lymph node dissection and wider indications than those for subtotal gastrectomy. However, the clinical efficacy of cardia-preserving radical gastrectomy requires verification in prospective and controlled clinical trials. Cardia-preserving radical gastrectomy is a promising approach as one of the more reasonable anti-reflux surgeries.

Surgical and oncological outcomes of distal gastrectomy compared to total gastrectomy for middle‑third gastric cancer: A systematic review and meta‑analysis

Distal gastrectomy (DG) and total gastrectomy (TG) are the most common types of radical surgery for patients with middle-third gastric cancer (MTGC). However, the indications and benefits of the two procedures still remain controversial. The present meta-analysis aimed to compare the surgical and oncological outcomes of DG and TG in the treatment of MTGC. A rigorous literature review was performed in the databases of PubMed, Embase, Web of Science, China National Knowledge Infrastructure and Chinese BioMedical Literature to retrieve studies published up to February 2022. The Newcastle-Ottawa Scale was used to assess the quality of included studies and a meta-analysis was performed using RevMan 5.3 software. A total of 12 retrospective studies performing comparisons of DG and TG were included in the present meta-analysis. For patients who underwent DG, a lower rate of overall post-operative complications, anastomosis leakage and intro-abdominal infection was determined. No significant difference was observed between DG and TG in the 5-year overall survival when the proximal resection margin ranged from 3 to 5 cm. Although DG was associated with a higher 5-year overall survival rate when compared to TG, there was no significant difference in the stratified analyses by TNM stage. In conclusion, the prognosis of MTGC did not depend on the extent of gastrectomy. With lower complications and acceptable oncological outcomes, DG was a safe and feasible surgical procedure for MTGC when a negative proximal margin was confirmed.