Laparoscopic D2 plus complete mesogastrium excision using the "enjoyable space" approach versus conventional D2 total gastrectomy for local advanced gastric cancer: short-term outcomes

Short-Term Outcomes after D2 Gastrectomy with Complete Mesogastric Excision in Patients with Locally Advanced Gastric Cancer: A Systematic Review and Meta-Analysis of High-Quality Studies

Complete mesogastric excision (CME) has been advocated to allow for a more extensive retrieval of lymph nodes, as well as lowering loco-regional recurrence rates. This study aims to analyze the short-term outcomes of D2 radical gastrectomy with CME compared to standard D2 gastrectomy. A systematic review of the literature was conducted according to the Cochrane recommendations until 2 July 2023 (PROSPERO ID: CRD42023443361). The primary outcome, expressed as mean difference (MD) and 95% confidence intervals (CI), was the number of harvested lymph nodes (LNs). Meta-analyses of means and binary outcomes were developed using random effects models to assess heterogeneity. The risk of bias in included studies was assessed with the RoB 2 and ROBINS-I tools. There were 13 studies involving 2009 patients that were included, revealing a significantly higher mean number of harvested LNs in the CME group (MD: 2.55; 95% CI: 0.25-4.86; 95%; p = 0.033). The CME group also experienced significantly lower intraoperative blood loss, a lower length of stay, and a shorter operative time. Three studies showed a serious risk of bias, and between-study heterogeneity was mostly moderate or high. Radical gastrectomy with CME may offer a safe and more radical lymphadenectomy, but long-term outcomes and the applicability of this technique in the West are still to be proven.

Intracorporeal bi-directional pouch jejunojejunostomy following Roux-en-Y anastomosis: a simple reconstruction technique using an endoscopic linear stapler

Introduction

Intracorporeal pouch jejunojejunostomy (JJ) is a technically challenging procedure during totally laparoscopic gastrectomy (TLG).

Aim

This study introduced a new method involving the construction of an intracorporeal bi-directional pouch JJ using an endoscopic linear stapler and analyzed the surgical outcomes of this method, including JJ complications.

Material and methods

We retrospectively reviewed the medical records of 168 patients who underwent laparoscopic gastrectomy with intracorporeal bi-directional pouch JJ between November 2017 and October 2018 at Asan Medical Center.

Results

The construction of an intracorporeal bi-directional pouch JJ took an average of 10 min. No postoperative bleeding or anastomotic strictures related to JJ reconstruction occurred after this procedure. No mortality occurred during follow-up.

Conclusions

Intracorporeal bi-directional pouch JJ using an endoscopic linear stapler is a safe and simple procedure. It is a feasible option to reduce JJ stricture after TLG in patients with gastric cancer.

Comparison of short-term outcomes of robotic-assisted and laparoscopic-assisted D2 gastrectomy for gastric cancer: a meta-analysis

Aim

The aim of the study was to compare the outcomes of robot-assisted (RAGD2) and laparoscopy-assisted gastrectomy with D2 lymphadenectomy (LAGD2) for patients with gastric cancer.

Material and methods

Relevant articles published up to September 2020 were searched. The weighted mean difference (WMD) was used to pool continuous variables, while risk ratio (RR) was calculated for dichotomous outcomes.

Results

RAGD2 required a longer operating time (WMD = 29.78, 95% confidence interval (CI): 15.97-43.59) and had less operative blood loss (WMD = -31.93, 95% CI: -44.03 to -19.83), shorter time to first flatus (WMD = -0.13, 95% CI: -0.22 to -0.04), shorter time to liquid diet (WMD = -0.20, 95% CI: -0.28 to 0.12), and fewer severe complications (RR = 0.62, 95% CI: 0.43-0.90) and overall complications (RR = 0.75, 95% CI: 0.62-0.91) than LAGD2.

Conclusions

RAGD2 could be beneficial in reducing operative blood loss and postoperative complications relative to LAGD2.

First experience of junior surgeons with laparoscopic distal gastrectomy: in view of comparison with experienced surgeons

Introduction

Laparoscopic surgery is not easily performed by junior surgeons who have limited experience.

Aim

To investigate the safety and feasibility of the first experience of junior surgeons with laparoscopic distal gastrectomy (LDG) who were trained in super high-volume centers.

Material and methods

Clinicopathological data from the first 85 LDG cases performed by three gastric cancer surgeons were collected. All three surgeons were trained for > 1 year in super high-volume centers. The surgical and postoperative outcomes of the first experiences of junior surgeons were compared with the short-term outcomes reported in a multicenter randomized controlled trial (Korean Laparoendoscopic Gastrointestinal Surgery Study, KLASS-01 trial), conducted by the KLASS group, which is composed of experienced surgeons who practice in a high-volume center.

Results

A significantly greater number of older patients with longer operation times and lower estimated blood loss was observed for the junior surgeons than in the KLASS data. Although junior surgeons performed significantly more Billroth II anastomoses with D1+ lymph node dissection, there was no difference between the two groups in terms of hospital stay, number of retrieved lymph nodes, or postoperative morbidity.

Conclusions

The surgical outcomes of early gastric cancer managed by laparoscopic surgery performed by well-trained beginners were similar to the outcomes reported in the large-scale trial. Therefore, with regard to the surgical training system, training at super high-volume centers may be considered to provide some assurance in terms of surgical technique-related safety.