Advances in Gastric Cancer Surgical Management

The goal of a gastric cancer operation is a microscopically negative resection margin and D2 lymphadenectomy. Minimally invasive techniques (laparoscopic and robotic) have been proven to be equivalent for oncologic care, yet with faster recovery. Endoscopic mucosal resection can be used for T1a N0 tumor resection. Better understanding of hereditary gastric cancer and molecular subtypes has led to specialized recommendations for MSI-high tumors and patients with pathogenic CDH1 mutations. In the future, surgical management will support minimally invasive approaches and personalized cancer care based on subtype.

Assessment of diagnostic Value of Indocyanine Green (ICG) for lymph node metastasis in laparoscopic subtotal gastrectomy with D2 lymphadenectomy for gastric cancer. A prospective single-center study

PURPOSE

Evaluation of diagnostic value for lymph node metastasis and lymph node identification using Indocyanine Green (ICG) fluorescence in laparoscopic subtotal gastrectomy for gastric cancer.

METHODS

A prospective study on 79 patients who underwent radical subtotal gastrectomy with the use of ICG-guided lymph node dissection. The sensitivity and specificity of the ICG fluorescence lymphography method in detecting metastatic lymph nodes were evaluated.

RESULTS

A total of 79 patients underwent surgery. The number of lymph nodes (LNs) were retrieved: 2.992 LNs, of which 2.392 were fluorescent (79.9%) and 600 were non-fluorescent (20.1%). The average number of lymph nodes dissected was 37.7 ± 11.8 LNs, and the average number of fluorescent lymph nodes was 30.3 ± 11.1; the LN metastasis rate in the total lymph nodes and in the ICG group were 6.79% and 7.34%, respectively. The median number of retrieved LNs in patients with LN metastases [32 (IQR 26-44)] was higher than in patients without LN metastases [26 (IQR 21-36)], (p=0.348). The median number of fluorescent LNs was significantly higher in patients with LN metastases [32 (IQR 26-44)] than in those without LN metastases [26 (IQR 21-36); p<0.001]. The sensitivity of ICG in metastasis detection was 75.86% (22 out of 29 patients), with a false-negative (FN) rate of 24.14% (7 out of 29 patients). For the identification of metastatic LNs, the sensitivity of ICG was 90.7%, with the specificity of 20.8%. The negative predictive value of non-fluorescent LNs was 97%.

CONCLUSION

ICG fluorescence lymphography-guided lymphadenectomy can clearly visualize the lymphatic system and the lymph nodes alongside the tumor. The high sensitivity in detecting metastatic lymph nodes and the high negative predictive value of a non-fluorescent lymph nodes suggest that this is an effective method for clinically radical gastrectomy for gastric cancer.

Feasibility of laparoscopic/robot-assisted surgery for Borrmann type 4 gastric cancer: a comparison study with conventional open surgery

BACKGROUND

Laparoscopic surgery for early gastric cancer is regarded as a standard of care because of robust evidences obtained by several phase-III trials. Furthermore, the efficacy of laparoscopic radical surgery for advanced gastric cancer has been also reported. Meanwhile, the feasibility of laparoscopic surgery for Bormann type 4 gastric cancer, special type with unfavorable prognosis, remains unclear since excluded from eligibility of these trials.

METHODS

This study included 100 patients with type 4 gastric cancer who underwent laparoscopic/robot-assisted (minimally invasive surgery (MIS) group; n = 32) or open (Open group; n = 68) curative surgery between 2008 and 2021. After propensity score matching, 30 patients in each group were extracted for analysis. Clinical data, including surgical and midterm survival outcomes, were retrospectively compared between the two groups.

RESULTS

Incidences of postoperative complication (≥ Clavien-Dindo grade III) were recorded in 23.3% in the MIS group and 13.3% in the Open group, but no statistical significance was demonstrated (P = 0.50). The 3-year overall survival rate in the MIS group was better than that in the Open group (80.2% vs. 53.5%, log-rank, P = 0.03). The trend of recurrence site was similar. Multivariate analysis showed that adjuvant chemotherapy was an independent favorable prognostic factor (hazard ratio, 0.33, 95% confidence interval 0.11-0.93) for overall survival. MIS was indicated as a favorable prognostic factor (hazard ratio, 0.39, 95% confidence interval 0.39-1.07), but without statistical difference.

CONCLUSION

While multidisciplinary treatment is mainstay of treatment because of the poor prognosis of this disease, minimally invasive surgery may play an important role in treatment if appropriate patient selection is done. Further analyses with larger sample size are necessary to reach a final conclusion regarding oncological efficacy.

Modified Q-type purse-string suture duodenal stump embedding method for laparoscopic gastrectomy for gastric cancer

OBJECTIVE

This study introduced the modified Q-type purse-string suture duodenal stump embedding method, a convenient way to strengthen the duodenum, and compared it to the conventional one to assess its efficacy and safety.

METHODS

This retrospective analysis examined 612 patients who received laparoscopic gastrectomy for gastric Cancer at a single center. The patients were divided into Not Reinforced Group (n = 205) and Reinforced Group (n = 407) according to the surgical approach to the duodenal stump. The reinforced group was further divided into a modified Q-type purse-string suture embedding method group (QM, n = 232) and a conventional suture duodenal stump embedding method group (CM, n = 175) according to the methods of duodenal stump enhancement. Clinicopathological characteristics, operative variables, and short-term complications were documented and analyzed.

RESULTS

The incidence of duodenal stump leakage(DSL) in the Not Reinforced Group was higher compared to the Reinforced Group, although the difference was not statistically significant [2.4% (5/205) vs 0.7% (3/407), p = 0.339]. Additionally, the Not Reinforced Group exhibited a higher rate of Reoperation due to DSL compared to the Reinforced Group [2 (1.0%) vs. 0, p = 0.046], with one patient in the Not Reinforced Group experiencing mortality due to DSL [1 (0.5%) vs 0, p = 0.158]. Subgroup analysis within the Reinforced Group revealed that the modified Q-type purse-string suture embedding group (QM) subgroup demonstrated statistically significant advantages over the conventional suture embedding group (CM) subgroup. QM exhibited shorter purse-string closure times (4.11 ± 1.840 vs. 6.05 ± 1.577, p = 0.001), higher purse-string closure success rates (93.1% vs. 77.7%, p = 0.001), and greater satisfaction with purse-string closure [224 (96.6%) vs 157 (89.7%), p = 0.005]. No occurrences of duodenal stump leakage were observed in the QM subgroup, while the CM subgroup experienced two cases [2 (1.1%)], though the difference was not statistically significant. Both groups did not exhibit statistically significant differences in secondary surgery or mortality related to duodenal stump leakage.

CONCLUSION

Duodenal Stump Leakage (DSL) is a severe but low-incidence complication. There is no statistically significant relationship between the reinforcement of the duodenal stump and the incidence of DSL. However, laparoscopic reinforcement of the duodenal stump can reduce the severity of fistulas and the probability of Reoperation. The laparoscopic Q-type purse-string suture duodenal stump embedding method is a simple and effective technique that can, to some extent, shorten the operation time and enhance satisfaction with purse-string closure. There is a trend towards reducing the incidence of DSL, thereby improving patient prognosis to a certain extent.

The outcomes of laparoscopic omentum-preserving gastrectomy compared to open surgery with omentectomy in gastric cancer patients: a propensity score matched study of 249 UICC stage 0-IV gastric cancer patients

BACKGROUND

We performed a propensity score matched study comparing patients' short- and long-term results after laparoscopic omentum-preserving gastrectomy and open surgery with omentectomy with UICC stages 0-IV.

METHODS

Between 2015 and 2022, 311 patients with gastric cancer underwent surgery at the University Clinical Centre Maribor. Of these, 249 met the inclusion criteria and 198 were included in the study group after PSM.

RESULTS

Patients in both groups were well-balanced in demographic and pathological characteristics after PSM. There was no significant difference in the 5-year survival between groups (LAP: 62.2% vs. OPN: 54.4%; p = 0.950). The Cox regression model identified UICC stage and age as significant predictors for survival. In both groups, peritoneal dissemination was the most common site of recurrence. The multivariate analysis identified the UICC stage as a significant predictor for peritoneal recurrence, while omental preservation was not associated with a higher risk of peritoneal dissemination. Omentum preservation was not associated with more intestinal obstruction. Patients in the LAP group had significantly shorter hospital stays (LAP: 9(6) vs. OPN: 10(5); p = 0.009), less postoperative morbidity (LAP: 17% vs. OPN: 23.4%; p = 0.009), and significantly more extracted LNs per operation compared to open surgery (LAP: 31 ± 11 LNs vs. OPN: 25 ± 12 LNs; p = 0.002).

CONCLUSION

Based on our results, we recommend the use of laparoscopic omentum-preserving gastrectomy in patients with early and advanced gastric cancer.

Increased postoperative complications after laparoscopic gastrectomy in patients with preserved ratio impaired spirometry

BACKGROUND

Preserved ratio impaired spirometry (PRISm), defined as decreased forced expiratory volume in the first second in the setting of normal ratio, is associated with an increased risk of respiratory disease and systemic comorbidities. Unlike severe obstructive pulmonary disease, little is known about the impact of PRISm on short-term outcomes in patients undergoing laparoscopic gastrectomy (LG) and its association with small airway dysfunction (SAD).

METHODS

This study enrolled 830 patients who underwent preoperative spirometry and LG between January 2021 and August 2023. Of these, 228 patients were excluded. Participants were categorized into 3 groups based on their baseline lung function, and postoperative outcomes were subsequently analyzed. Potential associations between postoperative outcomes and various clinical variables were examined using univariate and multivariate analyses.

RESULTS

PRISm was identified in 16.6% of the patients, whereas SAD was present in 20.4%. The incidence of postoperative pulmonary complications (PPCs) was notably higher in the SAD group (20.3% vs 9.8%, P = .002) and the PRISm group (28.0% vs 9.8%, P < .001) than the normal group. Among the 3 groups, pneumonia was the most frequently observed PPC. Multivariate analysis revealed that both SAD (odds ratio [OR], 2.34; 95% CI, 1.30-4.22; P = .005) and PRISm (OR, 3.26; 95% CI, 1.80-5.90; P < .001) independently constituted significant risk factors associated with the occurrence of PPCs. Univariate analysis showed that female was a possible risk factor for PPCs in PRISm group.

CONCLUSION

Our study showed that PRISm and SAD were associated with the increased PPCs in patients undergoing LG for gastric cancer.

Evaluation of factors influencing long-term and textbook outcomes in laparoscopic gastrectomy

BACKGROUND

Textbook outcome (TO) in gastric cancer surgery is a multidimensional measure of surgical quality. However, its impact on long-term survival after laparoscopic gastrectomy (LG) is unclear. This study aims to evaluate TO in LG, assess its hospital-level relevance, and examine its association with long-term survival.

METHODS

In this retrospective cohort study, we analyzed 2278 consecutive gastric cancer patients who underwent laparoscopic gastrectomy (LG) from January 2004 to December 2017. We determined TO achievement rates, compared preoperative and intraoperative variables between TO and non-TO groups, identified independent predictors of TO, and assessed long-term oncologic outcomes using Kaplan-Meier analysis and Cox regression.

RESULTS

A total of 1540 LG patients were analyzed, with 994 (64.5%) achieving TO. The least frequently achieved metric was 'hospital stays ≤21 days' (83.4%), followed by 'lymph nodes retrieved ≥15' (84.0%). Factors independently associated with reduced TO likelihood included age ≥65 years, BMI ≥25, ASA III, conversion to open surgery, operation time ≥260 min, and estimated blood loss ≥150 ml. Furthermore, TO was independently linked to improved 5-year overall survival (OS) and disease-free survival (DFS) (HR 0.519 [0.443-0.609] and HR 0.517 [0.443-0.604], respectively).

CONCLUSION

Implementing the TO concept in LG provides a benchmark for achieving improved prognoses and empowers surgeons to devise strategies for enhancing surgical care quality.

6 lymphadenectomy in laparoscopic gastrectomy

BACKGROUND

Laparoscopic gastrectomy (LG) requires a long learning curve because of the complicated surgical procedures. Infrapyloric (No. 6) lymph node dissection (LND) is one of the difficult procedures in LG, especially for trainees. This study investigated the impact of the prediction of the difficulty of No. 6 LND.

METHODS

We retrospectively reviewed the preoperative computed tomography (CT) images and individual operative video records of 57 patients who underwent LG with No. 6 LND to define and predict the No. 6 LND difficulty. To evaluate whether prediction of the difficulty of No. 6 LND could improve surgical outcomes, 48 patients who underwent laparoscopic distal gastrectomy were assessed (30 patients without prediction by a qualified surgeon and 18 patients with prediction by a trainee).

RESULTS

The anatomical characteristic that LND required > 2 cm of dissection along the right gastroepiploic vein was defined as difficulty of No. 6 LND. Of the 57 LG patients, difficulty was identified intraoperatively in 21 patients (36.8%). Among the several evaluated anatomical parameters, the length between the right gastroepiploic vein and the right gastroepiploic artery in the maximum intensity projection in contrast-enhanced CT images was significantly correlated with the intraoperative difficulty of No. 6 LND (p < 0.0001). Surgical outcomes, namely intraoperative minor bleeding, postoperative pancreatic fistula, and drain amylase concentration were not significantly different between LG performed by a trainee with prediction compared with that by a specialist without prediction.

CONCLUSIONS

Preoperative evaluation of the difficulty of No. 6 LND is useful for trainees, to improve surgical outcomes.

The short- and long-term outcomes of laparoscopic D2 lymphadenectomy plus complete mesogastrium excision for lymph node-negative gastric cancer

BACKGROUND

Patients with T1-3N0M0 gastric cancer (GC) who undergo radical gastrectomy maintain a high recurrence rate. The free cancer cells in the mesogastric adipose connective tissue (Metastasis V) maybe the reason for recurrence in these individuals. We aimed to evaluate whether D2 lymphadenectomy plus complete mesogastrium excision (D2 + CME) was superior to D2 lymphadenectomy with regard to safety and oncological efficacy for T1-3N0M0 GC.

METHODS

Patients with T1-3N0M0 GC who underwent radical resection from January 2014 to July 2018 were retrospectively analyzed; there were 323 patients, of whom 185 were in the D2 + CME group and 138 in the D2 group. The primary endpoint was 5-year disease-free survival (DFS). Secondary endpoints include the 5-year overall survival (OS), recurrence pattern, morbidity, mortality, and surgical outcomes.

RESULTS

D2 + CME was associated with less intraoperative bleeding loss, a greater number of lymph nodes harvested, and less time to first postoperative flatus, but the postoperative morbidity was similar. The 5-year DFS was 95.6% (95% CI 92.7-98.5%) and 90.4% (95% CI 85.5-95.3%) in the D2 + CME group and the D2 group, respectively, with a hazard ratio (HR) of 0.455 (95% CI 0.188-1.097; p = 0.071). In terms of recurrence patterns, local recurrence was more prone to occur in the D2 group (p = 0.031). Subgroup analysis indicated that for patients with T1b-3N0M0 GC, the 5-year DFS in the D2 + CME group was considerably greater than that in the D2 group (95.3% [95% CI 91.6-99.0%] vs. 87.6% [95% CI 80.7-94.5%], HR 0.369, 95% CI 0.138-0.983; log-rank p = 0.043).

CONCLUSION

Laparoscopic D2 + CME for T1-3N0M0 GC is safe and feasible. Furthermore, it not only reduces the local recurrence rate but also improves the 5-year DFS in cases of T1b-3N0M0 GC.

Laparoscopic radical gastrectomy for gastric cancer: Long-term outcome in a teaching center

BACKGROUND

Laparoscopic gastrectomy for gastric cancer (GC) are increasing, yet the evidence of the relationship between the learning curve and long-term outcomes is limited.

AIMS

To analyze the relationship between the learning curve and survival in GC patients over a 10-year period.

METHODS

This retrospective cohort study studied 3674 patients who underwent laparoscopic radical gastrectomy for gastric cancer. Cusum and Cox regression analysis were used to assess the association between the surgeon's experience and the 3 years overall survival (OS).

RESULTS

The 3-year OS of all patients was 71.8 %. This increase of 3-year OS was associated with laparoscopic cases (r = 0.638, p = 0.047). Analysis of the CUSUM curve showed a significant change in the 3-year OS of 1400 cases. Further propensity score matching (PSM) of patients during and after the learning curve (<1400 and ≥ 1400 cases) showed a significant difference in the 3-year OS between the two groups (68.5 % vs. 72.3 %, p = 0.045). Cox regression analysis verified that in ≥1400 cases, prior laparoscopic surgery (p = 0.045), textbook outcome (TO) and the number of retrieved lymph nodes (LNs) were independent protective factors. The LN non-compliance rate was an independent risk factor. In contrast, the rate of TO and the median number of retrieved LNs were significantly higher after the learning curve (≥1400 cases). Furthermore, the rates of LN non-compliance were significantly lower (p < 0.05).

CONCLUSIONS

Increasing laparoscopic surgical experience is associated with surgical quality and prognostic improvement in patients with gastric cancer. But improvements in outcomes accrued slowly over a long period.

Laparoscopic prophylactic total gastrectomy with limited lymphadenectomy for CDH1 gene carriers

BACKGROUND

CDH1 gene mutations are the leading etiology of hereditary diffuse gastric cancer with cumulative lifetime risk ranging up to 83%. Prophylactic total gastrectomy (PTG) is, therefore, recommended for CDH1 carriers. A laparoscopic approach may reduce operative risk versus an open operation, thus leading more patients with CDH1 mutations to pursue PTG prior to cancer development. However, more experience and oncologic outcome data are needed for a laparoscopic approach and indicated lymphadenectomy.

METHODS

A retrospective descriptive cohort study of adult patients with CDH1 mutations who underwent laparoscopic PTG with D1 lymphadenectomy between 2012 and 2022 was conducted at a single institution. All patients had preoperative EGD screening, and those with visible tumor lesions on surveillance EGD were excluded and not considered prophylactic. Demographics, family history, pathology, and operative course were obtained. Outcomes included complications, readmission, and postoperative weight change.

RESULTS

Among 23 patients, median age was 48 years (IQR 37, 53) and 15 (65%) were female. Family history for gastric and/or lobular breast cancer was present in 22 (96%) patients. The median [IQR] time from positive genetic testing to PTG was 347 days [140, 625]. Pathologic evaluation showed five (22%) patients with foci of gastric cancer on pre-operative EGD biopsies, 10 (44%) in resected stomach specimens. All lymph nodes were negative. To address early postoperative complications, EJ anastomotic technique changed from EEA to GIA over the course of the study and feeding jejunostomy was no longer placed during PTG with minimal change in postoperative weight loss.

CONCLUSIONS

This is the largest series, spanning 10 years at a single institution, dedicated solely to a laparoscopic approach for risk-reducing PTG. A laparoscopic approach with limited lymphadenectomy resulted in acceptable surgical and oncologic outcomes. Despite no visible cancer, over half of our patients had foci of early gastric cancer. Therefore, CDH1 carriers should consider laparoscopic PTG.

Short- and long-term outcomes of laparoscopic versus open gastrectomy after neoadjuvant chemotherapy: A case-control study using a propensity score matching method

Background

Neoadjuvant chemotherapy (NACT) is increasingly becoming the recommended treatment for locally advanced gastric cancer (LAGC) with promising results. According to previous reports, few studies have evaluated the benefits of laparoscopic gastrectomy (LG) after NACT.

Methods

135 patients from our center who underwent gastrectomy with NACT were available, including 41 patients of LG and 94 OG between July 2018 and July 2022. To reduce selection bias, we used the nearest neighbor method and set caliper = 0.2 for 3:1 matching between LG and OG groups for propensity score matching method (PSM). After PSM, the matched 41 patients with LG and 80 patients with OG formed the cohort, respectively. Univariate and multivariate Cox analyses were performed on all variables to determine independent risk factors associated with survival.

Results

LG had a longer operating time compared to OG [260.00 min (220.00 min, 300.00 min) vs. 200.00 min (160.00 min, 260 min), P < 0.001]. The estimated blood loss, metastatic lymph nodes (LN), total LN examined, postoperative hospital stays, blood transfusion (P>0.05) and the incidence of postoperative complications did not show statistical differences from the OG group (P = 0.084). The type of surgery (LG vs. OG) did not show a significant risk propensity in the univariate and multivariate Cox analysis (HR = 0.69, P = 0.36, 95 % CI: 0.31-1.53). Through the Kaplan-Meier curves, a certain trend showed that the LG group had a better long-term survival outcomes than the OG group, although there was no statistical difference between two groups (P>0.05).

Conclusion

LG is a promising treatment option for LAGC patients receiving NACT and had an acceptable safety and efficacy compared to OG.

Laparoscopic gastrectomy for gastric cancer: A single cancer center experience

Objectives

Laparoscopic gastrectomy (LG) was challenging to most surgeons due to the two-dimensional view, difficult manipulations of the instruments, ergonomic discomfort, and the associated muscular spasm and effort. Technological advances with improved surgical experience, have made LG a more feasible and favorable approach for gastric cancer (GC) patients.

Material and Methods

LG was performed in 44 patients with GC between July 2015 to June 2022, in the Department of Surgical Oncology, Oncology Center, Mansoura University, Egypt, and we assessed the surgical outcomes of this approach as an initial experience of a single cancer center.

Results

Twenty-seven patients underwent laparoscopic distal gastrectomy, and seventeen underwent laparoscopic total gastrectomy. Two cases had combined resection. Operative time was 339.2 ± 76.73 min, while blood loss was 153.86 ± 57.51 mL. The patients were ambulant on postoperative day 0, oral intake was started within three days (range 1-5 days) and the hospital stay was six days (range 3-9 days).

Conclusion

LG for GC is a feasible approach for both early and advanced GC patients as it allows for adequate diagnosis of the peritoneal disease, meticulous dissection, and identification of the lymph nodes with minimal blood loss and decrease surgery-related problems and encourage the early patients' discharge from hospital and return to daily life activities.

Efficacy and safety of laparoscopic vs open gastrectomy after neoadjuvant therapy for locally advanced gastric cancer

BACKGROUND

Laparoscopic gastrectomy (LG) is widely accepted as a minimally invasive approach for the treatment of early gastric cancer. However, its role in locally advanced gastric cancer (LAGC) after neoadjuvant therapy (NAT) remains controversial. This study aimed to compare the efficacy and safety of LG vs open gastrectomy (OG) after NAT for the treatment of LAGC.

AIM

To compare the efficacy and safety of LG vs OG after NAT for LAGC.

METHODS

We conducted a prospective study of 76 patients with LAGC who underwent NAT followed by LG (n = 38) or OG (n = 38) between 2021 and 2023. The primary endpoint was overall survival (OS), and the secondary endpoints were disease-free survival (DFS), surgical complications, and quality of life (QOL).

RESULTS

The two groups had comparable baseline characteristics, with a median follow-up period of 24 mo. The 3-year OS rates in the LG and OG groups were 68.4% and 60.5%, respectively (P = 0.42). The 3-year DFS rates in the LG and OG groups were 57.9% and 50.0%, respectively (P = 0.51). The LG group had significantly less blood loss (P < 0.001), a shorter hospital stay (P < 0.001), and a lower incidence of surgical site infection (P = 0.04) than the OG group. There were no significant differences in other surgical complications between the groups, including anastomotic leakage, intra-abdominal abscess, or wound dehiscence. The LG group had significantly better QOL scores than the OG group regarding physical functioning, role functioning, global health status, fatigue, pain, appetite loss, and body image at 6 months postoperatively (P < 0.05).

CONCLUSION

LG after NAT is a viable and safe alternative to OG for the treatment of LAGC, with similar survival outcomes and superior short-term recovery and QOL. LG patients had less blood loss, shorter hospitalizations, and a lower incidence of surgical site infections than OG patients. Moreover, the LG group had better QOL scores in multiple domains 6 mo postoperatively. Therefore, LG should be considered a valid option for patients with LAGC who undergo NAT, particularly for those who prioritize postoperative recovery and QOL.

Efficacy and safety of patient-controlled thoracic epidural analgesia alone versus patient-controlled intravenous analgesia with acetaminophen after laparoscopic distal gastrectomy for gastric cancer: a propensity score-matched analysis

BACKGROUND

Laparoscopic gastrectomy is a common procedure for early gastric cancer treatment. Improving postoperative pain control enhances patient recovery after surgery. The use of multimodal analgesia can potentially enhance the analgesic effect, minimize side effects, and change the postoperative management. The purpose of this study was to evaluate and compare the efficacies of the use of patient-controlled intravenous analgesia with regular acetaminophen (PCIA + Ace) and patient-controlled thoracic epidural analgesia (PCEA) for postoperative pain control.

METHODS

We retrospectively collected the data of 226 patients who underwent laparoscopic distal gastrectomy (LDG) with delta-shaped anastomosis between 2016 and 2019. After 1:1 propensity-score matching, we compared 83 patients who used PCEA alone (PCEA group) with 83 patients who used PCIA + Ace (PCIA + Ace group). Postoperative pain was assessed using a numeric rating scale (NRS) with scores ranging from 0 to 10. An NRS score ≥ 4 was considered the threshold for additional intravenous rescue medication administration.

RESULTS

Although NRS scores at rest were comparable between the PCEA and PCIA + Ace groups, NRS scores of patients in the PCIA + Ace group during coughing or movement were significantly better than those of patients in the PCEA group on postoperative days 2 and 3. The frequency of additional rescue analgesic use was significantly lower in the PCIA + Ace group than in the PCEA group (1.1 vs. 2.7, respectively, p < 0.001). The rate of reduction or interruption of the patient-controlled analgesic dose was higher in the PCEA group than in the PCIA + Ace group (74.6% vs. 95.1%, respectively, p = 0.0002), mainly due to hypotension occurrence in the PCEA group. Physical recovery time, postoperative complication occurrence, and liver enzyme elevation incidence were not significantly different between groups.

CONCLUSIONS

PCIA + Ace can be safely applied without an increase in complications or deterioration in gastrointestinal function; moreover, PCIA + Ace use may provide better pain control than PCEA use in patients following LDG.

Minimally invasive surgery for gastro-oesophageal junction adenocarcinoma: Current evidence and future perspectives

Minimally invasive surgery is increasingly indicated in the management of malignant disease. Although oesophagectomy is a difficult operation, with a long learning curve, there is actually a shift towards the laparoscopic/thoracoscopic/ robotic approach, due to the advantages of visualization, surgeon comfort (robotic surgery) and the possibility of the whole team to see the operation as well as and the operating surgeon. Although currently there are still many controversial topics, about the surgical treatment of patients with gastro-oesophageal junction (GOJ) adenocarcinoma, such as the type of open or minimally invasive surgical approach, the type of oesophago-gastric resection, the type of lymph node dissection and others, the minimally invasive approach has proven to be a way to reduce postoperative complications of resection, especially by decreasing pulmonary complications. The implementation of new technologies allowed the widening of the range of indications for this type of surgical approach. The short-term and long-term results, as well as the benefits for the patient - reduced surgical trauma, quick and easy recovery - offer this type of surgical treatment the premises for future development. This article reviews the updates and perspectives on the minimally invasive approach for GOJ adenocarcinoma.

Pain and Opioid Consumption After Laparoscopic Versus Open Gastrectomy for Gastric Cancer: A Secondary Analysis of a Multicenter Randomized Clinical Trial (LOGICA-Trial)

BACKGROUND

Laparoscopic gastrectomy could reduce pain and opioid consumption, compared to open gastrectomy. However, it is difficult to judge the clinical relevance of this reduction, since these outcomes are reported in few randomized trials and in limited detail.

METHODS

This secondary analysis of a multicenter randomized trial compared laparoscopic versus open gastrectomy for resectable gastric adenocarcinoma (cT1-4aN0-3bM0). Postoperative pain was analyzed by opioid consumption in oral morphine equivalents (OME, mg/day) at postoperative day (POD) 1-5, WHO analgesic steps, and Numeric Rating Scales (NRS, 0-10) at POD 1-10 and discharge. Regression and mixed model analyses were performed, with and without correction for epidural analgesia.

RESULTS

Between 2015 and 2018, 115 patients in the laparoscopic group and 110 in the open group underwent surgery. Some 16 patients (14%) in the laparoscopic group and 73 patients (66%) in the open group received epidural analgesia. At POD 1-3, mean opioid consumption was 131, 118, and 53 mg OME lower in the laparoscopic group, compared to the open group, respectively (all p < 0.001). After correcting for epidural analgesia, these differences remained significant at POD 1-2 (47 mg OME, p = 0.002 and 69 mg OME, p < 0.001, respectively). At discharge, 27% of patients in the laparoscopic group and 43% patients in the open group used oral opioids (p = 0.006). Mean highest daily pain scores were between 2 and 4 at all PODs, < 2 at discharge, and did not relevantly differ between treatment arms.

CONCLUSION

In this multicenter randomized trial, postoperative pain was comparable between laparoscopic and open gastrectomy. After laparoscopic gastrectomy, this was generally achieved without epidural analgesia and with fewer opioids.

TRIAL REGISTRATION

NCT02248519.

Long-term oncologic and surgical outcomes of robotic and laparoscopic gastrectomy for Siewert II/III esophagogastric junction carcinoma: A propensity score-matched retrospective cohort study

BACKGROUND

This study aimed to investigate the short-term surgical and long-term survival outcomes after robotic gastrectomy (RG) or laparoscopic gastrectomy (LG) for patients with Siewert type II and III adenocarcinoma of the esophagogastric junction (AEG).

METHODS

We retrospectively analyzed 84 and 312 patients with Siewert type II/III AEG who underwent RG or LG between January 2005 and September 2016 in our center. We performed a 1:2 matched propensity score matching (PSM) analysis between the RG and LG group for clinical features to reduce confounding bias. Additionally, the long- and short-term outcomes between the RG and LG group were compared.

RESULTS

The clinicopathological characteristics of 246 patients (RG group: n = 82; LG group: n = 164) were well balanced after PSM. Patients in the RG group showed less estimated blood loss, less time to first flatus, less time to first ambulation, less drainage tube removed time, and retrieved more lymph nodes than the LG group. The overall complication rate was comparable between the RG and LG groups. The 5-year overall survival (OS) was 44.4% in the RG group and 43.7% in the LG group (p = 0.898). The 5-year disease-free survival (DFS) was 43.2% in the RG group and 43.2% in the LG group (p = 0.990). The RG and LG groups exhibited a similar recurrence rate and pattern within 5 years after surgery.

CONCLUSION

Robotic gastrectomy could be a feasible and safe option for patients with Siewert II/III AEG in terms of surgical and oncologic outcomes.

Laparoscopic compared to open approach for distal gastrectomy may reduce pneumonia risk for patients with gastric cancer

Background

Whether laparoscopic approach to gastrectomy for gastric cancer (GC) reduces the risk of pneumonia remains unknown. In this study, we compared pneumonia outcomes for patients with GC who underwent either laparoscopic gastrectomy (LG) or open gastrectomy (OG).

Methods

The ACS NSQIP database was queried to identify patients with GC who underwent LG or OG between Jan 2012 - Dec 2018. Outcomes were compared using regression models. A post-hoc analysis was performed for elderly patients.

Results

The study cohort included 2661 patients, 23.4 % undergoing LG. Laparoscopic approach lowered pneumonia risk (OR 0.47, p = .028) and reduced hospital length of stay, (5.3 vs 7.1 days, p < .001). Elderly patients undergoing LG demonstrated similar benefits. Risk factors for pneumonia included advanced age, dyspnea and weight-loss, whereas laparoscopic approach reduced this risk.

Conclusions

LG in patients with GC has both statistically and clinically significant advantages over OG with respect to pneumonia. Further studies are needed to validate the relationship between postoperative pneumonia and surgical approach for gastrectomy.

Comparisons of perioperative and long-term outcomes of laparoscopic versus open gastrectomy for advanced gastric cancer after neoadjuvant therapy: an updated pooled analysis of eighteen studies

BACKGROUND

Outcomes of laparoscopic surgery in advanced gastric cancer patients who received neoadjuvant therapy represent a controversial issue. We performed an updated meta-analysis to evaluate the perioperative and long-term survival outcomes of laparoscopic gastrectomy (LG) versus conventional open gastrectomy (OG) in this subset of patients.

METHODS

Electronic databases including PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials and China National Knowledge Infrastructure were comprehensively searched up to May 2023. The short-term and long-term outcomes of LG versus OG in advanced gastric cancer patients undergoing neoadjuvant therapy were evaluated. Effect sizes with 95% confidence intervals were always assessed using random-effects model. The prospective protocol was registered with PROSPERO (CRD42022359126).

RESULTS

Eighteen studies (2 randomized controlled trials and 16 cohort studies) involving 2096 patients were included. In total, 933 patients were treated with LG and 1163 patients were treated with OG. In perioperative outcomes, LG was associated with less estimated blood loss (MD = - 65.15; P < 0.0001), faster time to flatus (MD = - 0.56; P < 0.0001) and liquid intake (MD = - 0.42; P = 0.02), reduced hospital stay (MD = - 2.26; P < 0.0001), lower overall complication rate (OR = 0.70; P = 0.002) and lower minor complication rate (OR = 0.69; P = 0.006), while longer operative time (MD = 25.98; P < 0.0001). There were no significant differences between the two groups in terms of proximal margin, distal margin, R1/R2 resection rate, retrieved lymph nodes, time to remove gastric tube and drainage tube, major complications and other specific complications. In survival outcomes, LG and OG were not significantly different in overall survival, disease-free survival and recurrence-free survival.

CONCLUSION

LG can be a safe and feasible technique for the treatment of advanced gastric cancer patients receiving neoadjuvant therapy. However, more high-quality randomized controlled trials are still needed to further validate the results of our study.

Reinforcement methods of duodenal stump after laparoscopic gastrectomy for gastric cancer: A review

Duodenal stump fistula is a rare but dangerous complication of gastric cancer surgery. Reinforcement of the duodenal stump was suggested as a useful method to prevent the occurrence of duodenal stump fistula. Although laparoscopic surgery has been established as a safe procedure for gastric cancer, it is acknowledged that the application of duodenal stump reinforcement is a demanding process in laparoscopic radical gastrectomy. This review aims to provide a concise description of the proposed reinforcement methods of duodenal stump after laparoscopic radical gastrectomy for gastric cancer by summarizing the relevant literature written in English. The thorough knowledge of these reinforcement techniques may help surgeons to find the most suitable reinforcement method of duodenal stump for patients.

Distribution of splenic artery lymph nodes and splenic hilar lymph nodes

BACKGROUND

Total gastrectomy with splenectomy is the standard treatment for advanced proximal gastric cancer with greater-curvature invasion. As an alternative to splenectomy, laparoscopic spleen-preserving splenic hilar lymph node (LN) dissection (SPSHLD) has been developed. With SPSHLD, the posterior splenic hilar LNs are left behind.

AIM

To clarify the distribution of splenic hilar (No. 10) and splenic artery (No. 11p and 11d) LNs and to verify the possibility of omitting posterior LN dissection in laparoscopic SPSHLD from an anatomical standpoint.

METHODS

Hematoxylin & eosin-stained specimens were prepared from six cadavers, and the distribution of LN No. 10, 11p, and 11d was evaluated. In addition, heatmaps were constructed and three-dimensional reconstructions were created to visualize the LN distribution for qualitative evaluation.

RESULTS

There was little difference in the number of No. 10 LNs between the anterior and posterior sides. For LN No. 11p and 11d, the anterior LNs were more numerous than the posterior LNs in all cases. The number of posterior LNs increased toward the hilar side. Heatmaps and three-dimensional reconstructions showed that LN No. 11p was more abundant in the superficial area, while LN No. 11d and 10 were more abundant in the deep intervascular area.

CONCLUSION

The number of posterior LNs increased toward the hilum and was not neglectable. Thus, surgeons should consider that some posterior No. 10 and No. 11d LNs may remain after SPSHLD.

Five-year long-term comparison of robotic and laparoscopic gastrectomy for gastric cancer: a large single-center cohort study

BACKGROUND

Robotic gastrectomy (RG) has been reported to be technically feasible and safe for patients with gastric cancer. However, 5-year long-term survival and recurrence outcomes for advanced gastric cancer have rarely been reported. This study aimed to compare the long-term oncologic outcomes between RG and laparoscopic gastrectomy (LG) for gastric cancer.

METHODS

The general clinicopathological data of 1905 consecutive patients who underwent RG and LG were retrospectively collected at the Chinese People's Liberation Army General Hospital between November 2011 and October 2017. Propensity score matching (PSM) was used to match groups. The primary endpoints were 5-year disease-free survival (DFS) and overall survival (OS).

RESULTS

After PSM, a well-balanced cohort of 283 patients in the RG group and 701 patients in the LG group were included in the analysis. The 5-year cumulative DFS rates were 67.28% in the robotic group and 70.41% in the laparoscopic group. The 5-year OS rate was 69.01% in the robotic group and 69.58% in the laparoscopic group. No significant differences in Kaplan-Meier survival curves for DFS (HR = 1.08, 95% CI 0.83-1.39, Log-rank P = 0.557) and OS (HR = 1.02, 95% CI 0.78-1.34, Log-rank P = 0.850) were observed between the 2 groups. In the subgroup analyses for potential confounding variables, there were no significant differences in 5-year DFS and 5-year OS survival between the 2 groups (P > 0.05), except for patients with pathological stage III and pathological stage N3 (P < 0.05).

CONCLUSION

For patients with early gastric cancer, robotic and laparoscopic approaches have similar long-term survival. For patients with advanced gastric cancer, further studies need to be conducted to assess the long-term survival outcomes of RG.

Clinical Impact of Laparoscopic Surgery on the Long-term Survival of Advanced Gastric Cancer Patients With Regard to Facilitating Doublet Adjuvant Chemotherapy

BACKGROUND/AIM

The impact of laparoscopic gastrectomy (LG), a standard gastric cancer (GC) management strategy, in advanced GC cases involving doublet adjuvant chemotherapy remains unclear. This study was aimed at comparing short- and long-term LG and open gastrectomy (OG) results.

PATIENTS AND METHODS

Patients who underwent gastrectomy with D2 lymph node dissection for stage II/III GC between 2013 and 2020 were retrospectively analyzed. Patients were divided into two groups: patients undergoing LG (n=96, LG-group) and OG (n=148, OG-group). The primary outcome was relapse-free survival (RFS).

RESULTS

Compared with the OG group, the LG group was associated with a longer operation time (373 vs. 314 min, p<0.001), less blood loss (50 vs. 448 ml, p<0.001), fewer grade 3-4 complications (5.2 vs. 17.1%, p=0.005), and a shorter hospital stay (12 vs. 15 days, p<0.001). More lymph nodes were dissected in the LG group (49 vs. 40, p<0.001). The intergroup difference in prognosis was insignificant [5-year RFS: 60.4% (LG) vs. 63.1% (OG), p=0.825]. The LG group more frequently received doublet adjuvant chemotherapy (46.8 vs. 12.7%, p<0.001) and started treatments within 6 weeks after surgery (71.1% vs. 38.9%, p=0.017), and the completion rate of doublet AC was significantly higher in the LG group (85.4% vs. 58.8%, p=0.027). Compared to OG, LG for stage III GC tended to be associated with improved prognosis (HR=0.61, 95%CI=0.33-1.09, p=0.096).

CONCLUSION

LG for advanced GC may facilitate doublet regimens due to favorable postoperative outcomes and its intervention may contribute to survival benefits.

A sandwiching method that simplifies hepatic left lateral segment inversion to secure an optimal surgical view around the esophageal hiatus in laparoscopic and robotic gastrectomy for upper gastric and esophagogastric junction cancers

PURPOSE

In laparoscopic surgery for upper gastric and esophagogastric junction (EGJ) cancer, it is important to achieve optimal exposure of the esophageal hiatus to secure an appropriate workspace. In recent years, hepatic left lateral segment (HLLS) inversion has been used to achieve an optimal surgical field. We present a simple technique to perform a modified HLLS inversion.

METHODS

As a simple modified method, suturing a 2-0 straight needle to the peritoneum of the round ligament and pulling it to the outside of the abdominal cavity, the falciform, left triangular, and coronary ligaments were dissected. The HLLS was inverted by moving it to the right through the space of the transected falciform ligament. By ligating the thread through the round ligament, the HLLS was sandwiched between the rest of the liver and abdominal wall. The short-term surgical outcomes of patient who underwent simple modified HLLS inversion were retrospectively reviewed.

RESULTS

This study investigated consecutive 24 patients who underwent laparoscopic proximal and total gastrectomies using the simple modified HLLS inversion technique between June 2021 and April 2022. This series of procedures could be completed in approximately 16 min. A Nathanson liver retractor was used in three patients due to difficulties in completing the HLLS inversion in our institution. Postoperative serum liver enzyme levels indicated there was a small effect on the liver.

CONCLUSIONS

The simple modified HLLS inversion technique may be a safe and useful procedure and can provide an enhanced surgical field during laparoscopic surgery for upper gastric and EGJ cancers.

Pancreatic thickness as a predictor of postoperative pancreatic fistula after laparoscopic or robotic gastrectomy

BACKGROUND

Despite technical advances in minimally invasive gastrectomy for gastric cancer, an increased incidence of postoperative pancreatic fistula (POPF) has been reported. POPF can cause infectious and bleeding complications, which could lead to surgery-related death; therefore, reduction of the post-gastrectomy POPF risk is crucial. This study aimed to investigate the importance of pancreatic anatomy as a predictor of POPF in patients undergoing laparoscopic or robotic gastrectomy.

METHODS

Data were collected from 331 consecutive patients who underwent laparoscopic or robotic gastrectomy for gastric cancer. The thickness of the pancreas anterior to the most ventral level of the splenic artery (TPS) was measured. The correlation between TPS and POPF incidence was investigated using univariate and multivariate analyses.

RESULTS

The cutoff value of TPS was 11.8 mm, which predicted a high drain amylase concentration on postoperative day 1, and patients were categorized into thin (Tn group) and thick TPS groups (Tk group). There was no significant difference in the background characteristics between the two groups, except for sex (P = 0.009) and body mass index (P < 0.001). The incidences of POPF grade B or higher (2% vs. 16%, P < 0.001), all postoperative complications of grade II or higher (12% vs. 28%, P = 0.004), and postoperative intra-abdominal infections of grade II or higher (4% vs. 17%, P = 0.001) were significantly higher in the Tk group. Multivariable analysis identified that high TPS was the only independent risk factor for grade B or higher POPF and grade II or higher postoperative intra-abdominal infectious complications.

CONCLUSIONS

The TPS is a specific predictive factor for POPF and postoperative intra-abdominal infectious complications in patients undergoing laparoscopic or robotic gastrectomy. Careful pancreatic manipulation during suprapancreatic lymphadenectomy is necessary for patients with increased TPS (> 11.8 mm) to avoid postoperative complications.

Skill-qualified surgeons positively affect short-term outcomes after laparoscopic gastrectomy for gastric cancer: a survey of the National Clinical Database of Japan

BACKGROUND

Proficiency of the operating surgeon is one of the most critical factors potentially associated with reductions in complications and surgery-related mortality. With video-rating systems having shown potential for assessing laparoscopic surgeons' proficiency, the Endoscopic Surgical Skill Qualification System (ESSQS) was developed by the Japan Society for Endoscopic Surgery to subjectively assess the proficiency of laparoscopic surgeons by rating applicants' non-edited case videos. We conducted a study to evaluate how ESSQS skill-qualified (SQ) surgeon involvement influences short-term outcomes of laparoscopic gastrectomy performed for gastric cancer.

METHODS

Data from the National Clinical Database regarding laparoscopic distal and total gastrectomy performed for gastric cancer between January 2016 and December 2018 were analyzed. Operative mortality, defined as 30-day mortality or 90-day in-hospital mortality, and anastomotic leakage rates were compared per involvement vs. non-involvement of an SQ surgeon. Outcomes were also compared per involvement of a gastrectomy-, colectomy-, or cholecystectomy-qualified surgeon. The association between the area of qualification and operative mortality/anastomotic leakage was also analyzed with a generalized estimating equation logistic regression model used to account for patient-level risk factors and institutional differences.

RESULTS

Of 104,093 laparoscopic distal gastrectomies, 52,143 were suitable for inclusion in the study; 30,366 (58.2%) were performed by an SQ surgeon. Of 43,978 laparoscopic total gastrectomies, 10,326 were suitable for inclusion; 6501 (63.0%) were performed by an SQ surgeon. Gastrectomy-qualified surgeons outperformed non-SQ surgeons in terms of both operative mortality and anastomotic leakage. They also outperformed cholecystectomy- and colectomy-qualified surgeons in terms of operative mortality or anastomotic leakage in distal and total gastrectomy, respectively.

CONCLUSION

The ESSQS appears to discriminate laparoscopic surgeons who can be expected to achieve significantly improved gastrectomy outcomes.

Improved survival after laparoscopic compared to open gastrectomy for advanced gastric cancer: a Swedish population-based cohort study

BACKGROUND

Laparoscopic gastrectomy is increasingly used for the treatment of locally advanced gastric cancer but concerns remain whether similar results can be obtained compared to open gastrectomy, especially in Western populations. This study compared the short-term postoperative, oncological and survival outcomes following laparoscopic versus open gastrectomy based on data from the Swedish National Register for Esophageal and Gastric Cancer.

METHODS

Patients who underwent surgery with curative intent for adenocarcinoma of the stomach or gastroesophageal junction Siewert type III from 2015 to 2020 were identified, and 622 patients with cT2-4aN0-3M0 tumors were included. The impact of surgical approach on short-term outcomes was assessed using multivariable logistic regression. Long-term survival was compared using multivariable Cox regression.

RESULTS

In total, 350 patients underwent open and 272 laparoscopic gastrectomy, of which 12.9% were converted to open surgery. The groups were similar regarding distribution of clinical disease stage (27.6% stage I, 46.0% stage II, and 26.4% stage III). Neoadjuvant chemotherapy was administered to 52.7% of the patients. There was no difference in the rate of postoperative complications, but laparoscopic approach was associated with lower 90 day mortality (1.8 vs 4.9%, p = 0.043). The median number of resected lymph nodes was higher after laparoscopic surgery (32 vs 26, p < 0.001), while no difference was found in the rate of tumor-free resection margins. Better overall survival was observed after laparoscopic gastrectomy (HR 0.63, p < 0.001).

CONCLUSIONS

Laparoscopic gastrectomy can be safely preformed for advanced gastric cancer and is associated with improved overall survival compared to open surgery.

Comparison of laparoscopic and open radical gastrectomy for gastric cancer patients with GLIM-defined malnutrition

PURPOSE

Malnutrition is common in the patients with gastric cancer. Radical gastrectomy remained the primary strategy of curable treatment for gastric cancer. This study is performed to explore the effect of laparoscopic radical gastrectomy on clinical outcomes in gastric cancer patients with malnutrition.

METHODS

Gastric cancer patients with GLIM-defined malnutrition between 2014 and 2019 at our center were enrolled. The patients were divided into two groups according to the different type of surgery. Propensity score match analysis was used to balance the clinicopathologic characteristics of two groups. Postoperative outcomes and survival were compared. Multivariate analysis was used to independent risk factors of complication, overall survival (OS), and disease-free survival (DFS).

RESULTS

Compared with patients underwent open radical gastrectomy, patients who underwent laparoscopic radical gastrectomy had lower rate of total, surgical and severe complications. They also had shorter postoperative hospital stay with better OS and DFS. Hypoalbuminemia (P = 0.003) was the independent risk factor of complications. Old age (≥75, P = 0.035) and TNM stage (III: P < 0.001, II: P = 0.015) were the independent risk factors of OS. Combined resection (P = 0.003) and TNM stage (III: P < 0.001, II: P = 0.001) posed independent risk factors of lacking DFS. Laparoscopic surgery proved to be the independent protective factor of complications (P = 0.014), OS (P < 0.001) and DFS (P < 0.001).

CONCLUSION

Laparoscopic radical gastrectomy was relative safe and showed favorable outcomes in malnourished gastric cancer patients.

Evolution of laparoscopic gastrectomy for cancer in the East and West

Laparoscopic gastrectomy has evolved differently in Eastern and Western countries. Feasibility, safety and oncological outcomes of laparoscopic gastrectomy were addressed step-by-step by several randomized controlled trials from the East. Few phase III studies were published from the West that largely did not show a difference between the laparoscopic and open approach. Despite this, laparoscopic gastrectomy is seen as the standard for the surgical treatment of early and advanced gastric cancer in many European countries. Here, we review and comment on some important studies on laparoscopic gastrectomy for gastric cancer from Eastern and Western countries and also comment on current and future challenges.

Short-and long-term outcomes of laparoscopic versus open gastrectomy in patients with gastric cancer: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Laparoscopic gastrectomy (LG) for gastric cancer has rapidly developed and become more popular in recent decades. Additional high-quality randomized controlled trial (RCT) studies comparing LG versus open gastrectomy (OG) for gastric cancer (GC) have been published in recent years. An updated systematic review is warranted. The aim of our meta-analysis was to comprehensively evaluate the short- and long-term outcomes of LG versus OG for GC.

MATERIALS AND METHODS

The PubMed, Embase, Web of Science, and Cochrane Center Register of Controlled Trials databases were comprehensively searched to identify RCTs comparing LG versus OG for GC published between January 1994 and December 7, 2021. This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Cochrane Collaboration and the Quality of Reporting of Meta-analyses (QUORUM) guidelines. All RCTs comparing the short- and long-term outcomes of LG with those of OG were included. A random effects model was adopted with significant heterogeneity (I² > 50%), while a fixed effects model was employed in all other cases (I² ≤ 50%).

RESULTS

A total of 26 RCTs with 8301 patients were included in this meta-analysis. The results indicated that the intraoperative complication rate was comparable between the LG group and the OG group (OR=1.14, 95% CI [0.76, 1.70], I²=0%, p=0.53). The LG group had fewer postoperative complications than the OG group (OR=0.65, 95% CI [0.57, 0.74], I²=26%, p<0.00001). However, the severe postoperative complication rate and perioperative mortality were comparable between the two groups (OR=0.83, 95% CI [0.67, 1.04], I²=10%, p=0.10; OR=1.11, 95% CI [0.59, 2.09], I²=0%, p=0.74, respectively). The number of lymph nodes retrieved by the LG group was less than that of the OG group (MD=-1.51, 95% CI [-2.29, -0.74], I²=0%, p<0.0001). The proximal resection margin distance in the LG group was shorter than that in the OG group (MD=-0.34, 95% CI [-0.57, -0.12], I²=23%, p=0.003), but the distal resection margin distance in the two groups was comparable (MD=-0.21, 95% CI [-0.47, 0.04], I²=0%, p=0.10). The time to first ambulation was shorter in the LG group than in the OG group (MD=-0.14, 95% CI [-.26, -0.01], I²=40%, p=0.03). The time to first flatus was also shorter in the LG group than in the OG group (MD=-0.15, 95% CI [-0.23, -0.07], I²=4%, p=0.0001). However, the first time on a liquid diet was comparable between the two groups (MD=-0.30, 95% CI [-0.64, 0.04], I²=88%, p=0.09). Furthermore, the postoperative length of stay was shorter in the LG group than in the OG group (MD=-1.26, 95% CI [-1.99, -0.53], I²=90%, p=0.0007). The 5-year overall survival (OS) was comparable between the two groups (HR=0.97, 95% CI [0.80, 1.17], I²=0%, p=0.73), and the 5-year disease-free survival (DFS) was also similar between the LG group and OG group (HR=1.08, 95% CI [0.77, 1.52], I²=0%, p=0.64).

CONCLUSION

LG is a technically safe and feasible alternative to OG with the advantages of a fewer postoperative complication rate, faster recovery of gastrointestinal function, and greater cosmetic benefit for patients with GC. Meanwhile, LG has comparable long-term outcomes to OG for GC.

Benefit of laparoscopic compared to standard open gastric cancer surgery for sarcopenic patients: a propensity score-matching analysis

BACKGROUND

Laparoscopic gastrectomy (LG) is performed widely, but whether LG is the optimal treatment for sarcopenic gastric cancer patients is unclear. This study aimed to determine whether LG is particularly beneficial for gastric cancer patients with sarcopenia.

METHODS

We collected data concerning 604 consecutive patients who underwent gastrectomy for gastric cancer between January 2003 and December 2019. After adjustment using one-to-one propensity score matching, short-term and long-term outcomes were compared between LG and open gastrectomy (OG) groups among patients with sarcopenia and those without.

RESULTS

Among patients with and without sarcopenia, the LG group had a significantly longer operative time but less blood loss than the OG group. The two groups showed no significant differences regarding complications. Although 5-year overall and disease-specific survival were similar between LG and OG groups among patients with and without sarcopenia, LG was associated with greater 5-year non-gastric cancer-related survival than OG among patients with sarcopenia (88.3% vs. 78.1%, P = 0.048), but not those without.

CONCLUSION

LG for resectable gastric cancer was not inferior to OG regarding complications and outcomes in patients with or without sarcopenia. No difference in overall survival was evident between these approaches, but LG may lessen mortality from conditions unrelated to gastric cancer in sarcopenic patients.

Comprehensive evaluation of three-dimensional anatomy of perigastric vessels using enhanced multidetector-row computed tomography

BACKGROUND

To perform laparoscopic gastrectomy safely, we aimed to comprehensively re-evaluate perigastric vessel anatomies using a three-dimensional angiography reconstructed from enhanced multidetector-row computed tomography data.

METHODS

Perigastric vessel anatomy was preoperatively analyzed using a multidetector-row computed tomography-based three-dimensional angiography reconstructed in 127 patients undergoing gastric surgery.

RESULTS

Of the 67 left gastric veins that ran along the dorsal side of the arteries, 59 (88.1%) ran along the dorsal side of the common hepatic artery and flowed into the portal vein. In 18 cases, a common trunk of one to three left gastric arteries and the replaced left hepatic artery was observed. The left inferior phrenic artery ramified from the left gastric artery in 5.5% of the cases. The right gastric artery was classified into distal (73.2%), caudal (18.1%), and proximal (8.7%) types. The infra-pyloric artery was also classified into distal (64.6%), caudal (26.0%), and proximal (9.4%) types. The posterior gastric artery branched as a common trunk with the superior polar artery in the proximal (37.9%) and distal (18.4%) regions of the splenic artery. The left gastroepiploic artery ramified from the splenic (18.1%) and inferior terminal arteries (81.9%). No, one, and two gastric branches of the left gastroepiploic artery, which ramified between the roots of the left gastroepiploic artery and its omental branch, were found in 36.5%, 49.2%, and 14.3% of the cases, respectively.

CONCLUSIONS

Preoperative 3D angiography is useful for the precise evaluation of perigastric vessel anatomies, and may help us to perform laparoscopic gastrectomy and robotic surgery safely.

Laparoscopic distal gastrectomy for gastric cancer in a patient with situs inversus: a case report

Background

Situs inversus (SI) is a rare congenital condition characterized by organ transposition from their normal positions. Careful preoperative planning is important for the safe operation of patients with SI because only a few surgeons have operated on such patients. Here, we report the case of a patient with SI who underwent laparoscopic distal gastrectomy (LDG) with D2 lymph node dissection (LND) for advanced gastric cancer (GC).

Case presentation

The patient was a 72-year-old man diagnosed with GC. Upper endoscopy revealed a type 3 tumor in the anterior wall of the stomach body. Multidetector computed tomography showed no obvious GC metastasis or inverted organs. The preoperative diagnosis was cStage IIB (i.e., cT3, cN0, and cM0) GC with SI. Although liver retracting and intracorporeal suturing required special attention, LDG with D2 LND and Billroth-I reconstruction were safely performed by reversing the usual procedure. The patient was discharged 10 days after the surgery.

Conclusions

To safely perform laparoscopic surgery for GC in patients with SI, sufficient preoperative preparation is necessary. In particular, a reversible method of liver retraction should be prepared.

Laparoscopic single-layer running "trapezoid-shaped" suture versus mechanical stapling for esophagojejunostomy after total gastrectomy for gastric cancer: cost-effect analysis of propensity score-matched study cohorts

OBJECTIVES

Totally laparoscopic total gastrectomy has been developed with difficulty in intracorporeal esophagojejunostomy. Although mechanical stapling has been widely used for intracorporeal esophagojejunostomy, manual suture holds great promise with the emergence of high-resolution 3D vision and robotic surgery. After exploration of how to improve the safety and efficiency of intracorporeal suture for esophagojejunostomy, we recommended the technique of single-layer running "trapezoid-shaped" suture. The cost-effectiveness was analyzed by comparing with conventional mechanical stapling.

METHODS

The study retrospectively reviewed the patients undergoing laparoscopic gastrectomy for gastric cancer from January 2010 to December 2021. The patients were divided into two cohorts based on the methods of intracorporeal esophagojejunostomy: manual suture versus stapling suture. Propensity score matching was performed to match patients from the two cohorts at a ratio of 1:1. Then group comparison was made to determine whether manual suture was non-inferior to stapling suture in terms of operation time, anastomotic complications, postoperative hospital stay, and surgical cost.

RESULTS

The study included 582 patients with laparoscopic total gastrectomy. The manual and stapling suture for esophagojejunostomy were performed in 50 and 532 patients, respectively. In manual suture cohort, the median time for the whole operation and digestive tract reconstruction were 300 min and 110 min. There was no anastomotic bleeding and stenosis but two cases of anastomotic leak which occurred at 3 days after surgery. The median length of postoperative hospital stay was 11 days. After propensity score matching, group comparison yielded two variables with statistical significance: time for digestive tract reconstruction and surgery cost. The manual suture cohort spent less money but more time for esophagojejunostomy. Intriguingly, the learning curve of manual suture revealed that the time for digestive tract reconstruction was declined with accumulated number of operations.

CONCLUSIONS

Laparoscopic single-layer running "trapezoid-shaped" suture appears safe and cost-effective for intracorporeal esophagojejunostomy after total gastrectomy. Although the concern remains about prolonged operation time for beginners of performing the suture method, adequate practice is expected to shorten the operation time based on our learning curve analysis.

Comparison of short-term outcomes between robotic-assisted and laparoscopic gastrectomy guided by carbon nanoparticle suspension injection in gastric cancer

Background

The clinical application of robotic-assisted gastrectomy remains controversial, especially as clinical studies of this operation navigated by carbon nanoparticle suspension injection (CNSI) have not been conducted. This study aims to assess the perioperative safety and efficacy of CNSI-guided robotic-assisted gastrectomy in patients with gastric cancer by focusing on short-term outcomes.

Methods

A retrospective analysis of patients who underwent CNSI-guided laparoscopic or robotic-assisted gastrectomy with a pathological diagnosis of gastric cancer was conducted. Data on demographics, surgical management, clinical-pathological results and short-term outcomes were compared among the groups.

Results

A total of 126 eligible patients were separated into the robotic-assisted gastrectomy (RAG) group (n = 16) and the laparoscopic gastrectomy (LG) group (n = 110) in total. The operation time of the RAG group is longer than the LG group (p = 0.0000). When it comes to perioperative and short-term complications, there exists no statistical difference between the two groups.

Conclusion

The time required for CNSI-guided robotic-assisted gastrectomy is longer than that for CNSI-guided laparoscopic gastrectomy. CNSI-guided robotic-assisted gastrectomy is safe and effective.

Quantitative Comparison of Surgical Device Usage in Laparoscopic Gastrectomy Between Surgeons' Skill Levels: an Automated Analysis Using a Neural Network

BACKGROUND

Whether surgical device usage in laparoscopic gastrectomy differs with respect to operator's skill levels is unknown. Further, device usage analysis using artificial intelligence has not been reported to date. Herein, we compared the patterns of surgical device usage during laparoscopic gastrectomy for gastric cancer among surgeons at different skill levels. The data of device usage was acquired from laparoscopic video recordings using an automated surgical-instrument detection system.

METHODS

In total, 100 video recordings of infrapyloric lymphadenectomy and 33 of D2 suprapancreatic lymphadenectomy during laparoscopic gastrectomy for gastric cancer were analyzed in this retrospective study. The system's accuracy was evaluated by comparing the automatic and the manual usage time. Surgical device usage patterns were compared between qualified and nonqualified surgeons of The Japan Society for Endoscopic Surgery Endoscopic Surgical Skill Qualification System.

RESULTS

For every device, the automatic detection time and manual detection time were consistent with each other. In infrapyloric lymphadenectomy, the usage time proportions of dissector forceps and clip applier were higher among nonqualified operators than among qualified operators (dissector, 5.1% vs. 2.3%, P < 0.001; clip applier, 1.6% vs. 1.3%, P < 0.01). In suprapancreatic lymphadenectomy, the usage time proportions of energy devices, clip applier, and grasper forceps were significantly different (energy devices, 59.6% vs. 50.6%, P < 0.001; clip applier, 1.4% vs. 0.9%, P < 0.001; only grasper forceps; 18.3% vs. 27.9%, P = 0.022).

CONCLUSIONS

Quantitative analysis of laparoscopic device usage using the automated surgical device detection system showed that the patterns of device usage during laparoscopic gastrectomy differed depending on surgeons' skill levels. These differences could suggest how the qualified and nonqualified surgeons performed the procedures.

Effectiveness of Intraoperative Endoscopy for Localization of Early Gastric Cancer during Laparoscopic Distal Gastrectomy

INTRODUCTION

Intraoperative localization of tumors has been considered crucial in determining adequate resection margins during laparoscopic gastrectomy for early gastric cancer (EGC). This study has evaluated the effectiveness of intraoperative endoscopy for localization of EGC during the totally laparoscopic distal gastrectomy.

METHODS

Patients with EGC who received totally laparoscopic distal gastrectomy from January 2018 to March 2020 were included in this study. Except the tumors located in the antrum, the patients were categorized into two groups: no localization procedure (n = 144) and intraoperative endoscopy (n = 65). To evaluate the effectiveness of the localization procedure, proximal resection margin (PRM) involvement by the tumor and approximation of optimal PRM were compared, including their postoperative outcomes.

RESULTS

There were 3 patients (2.1%) with tumor involvement of the PRM at the initial gastric resection in the no localization group. Distance from the tumor to the PRM was determined to be not significantly different between the no localization group and intraoperative endoscopy group. The PRM distribution pattern and reconstruction method were also not significantly different between the two groups.

DISCUSSION/CONCLUSION

Intraoperative endoscopy for localization of EGC is an effective method to avoid tumor involvement at the resection margin during the laparoscopic gastrectomy with intracorporeal gastric resection and reconstruction.

Advantages of a robotic approach compared with laparoscopy gastrectomy for patients with high visceral fat area

BACKGROUND

Gastric cancer surgery for obese patients is regarded as a technically challenging procedure. The morbidity after gastrectomy has been reported to be significantly higher in patients with high visceral fat area (VFA). Robotic gastrectomy (RG) is expected to be advantageous for complicated operations. However, whether RG is superior to conventional laparoscopic gastrectomy (LG) for patients with visceral fat obesity remains unclear. The present study aimed to clarify the impact of RG on the short- and long-term outcomes of patients with high VFAs.

METHODS

This study included 1306 patients with clinical stage I/II gastric cancer who underwent minimally invasive gastrectomy between January 2012 and December 2020. The patients were subclassified according to VFA. The short- and long-term outcomes of RG were compared with those of LG in two VFA categories.

RESULTS

This study included 394 (high-VFA, 151; low-VFA, 243) and 882 patients (high-VFA, 366; low-VFA, 516) in the RG and LG groups, respectively. RG was associated with a significantly longer operative time than LG (high-VFA, P < 0.001; low-VFA, P < 0.001). The incidence rates of overall and intra-abdominal infectious complications in the high-VFA patients were lower in the RG group than in the LG group (P = 0.019 and P = 0.048, respectively) but not significantly different from those in the low-VFA patients. In the multivariate analysis, LG was identified as the only independent risk factor of overall (odds ratio [OR] 3.281; P = 0.012) and intra-abdominal infectious complications (OR 3.462; P = 0.021) in the high-VFA patients. The overall survival of high-VFA patients was significantly better in the RG group than in the LG group (P = 0.045).

CONCLUSIONS

For patients with visceral fat obesity, RG appears to be advantageous to LG in terms of reducing the risk of complications and better long-term survival.

Pancreas-contactless gastrectomy for gastric cancer prevents postoperative inflammation

BACKGROUND

Pancreas-related complications after laparoscopic gastrectomy (LG) for gastric cancer can be fatal. We developed a gastrectomy procedure with no pancreas contact to prevent such complications and herein report the surgical outcomes.

METHODS

We retrospectively reviewed 182 consecutive patients with gastric cancer who underwent LG at Kitasato University Hospital from January 2017 to January 2020. These patients were divided into a pancreas-contact group (C group) and pancreas-contactless group (CL group) for comparison of postoperative complications, and inflammatory parameters such as body temperature (BT) and C-reactive protein (CRP).

RESULTS

Postoperative complications of CDc grade ≧ IIIa were significantly fewer in the CL group than in the C group [0/76 (0%) vs. 6/106 (5.7%), P = 0.035]. The median drain amylase (drain-AMY) on postoperative day 1 (POD1) was significantly lower in the CL group than in the C group (641 vs. 1162 IU/L, P = 0.02), as was BT at POD1 (37.4 °C vs. 37.7 °C, P = 0.04), the patient group with a BT above 37.5 °C at POD3 [5/76 (6.5%) vs. 18/106 (17%), P = 0.037], and those showing a CRP above 20.0 mg/dL at POD3 [5/76 (6.5%) vs. 20/106 (19%), P = 0.018].

CONCLUSIONS

Our technique to prevent pancreas contact during supra-pancreatic lymph node dissection during LG could minimize the inflammatory response and prevent further postoperative complications. Further large-scale, prospective studies are now required.

Risk factors and oncological impact of positive resection margins in gastrectomy for cancer: are they salvaged by an additional resection?

BACKGROUND

The situation of positive resection margins (PRMs) varies notably between Western and Asian countries. In the West, PRMs are associated with advanced disease and R1, whereas in Asia, PRMs are also considered in early disease because stomach preservation was recently prioritized. Furthermore, PRMs are usually resected to obtain R0. However, the oncological impact of PRMs and additional resection remains unclear. The aim of this study is to evaluate the oncological impact of PRMs in laparoscopic gastrectomy (LG) for clinical stage (cStage) I gastric cancer.

METHODS

A total of 2121 patients who underwent LG for cStage I gastric cancer between 2007 and 2015 were enrolled. Survival outcomes were compared between patients with PRMs (group P) and those without (group N). Furthermore, prognostic factors were analyzed using multivariate analysis.

RESULTS

Twenty-seven patients (1.3%) had PRMs. Patients in group P had upper and more advanced disease, and the 5-year relapse-free survival (RFS) rate was worse in group P compared with group N (76.3% vs. 95.1%, P = 0.003). The 5-year RFS of patients with pT2 or deeper (pT2-4) disease in group P was significantly worse than that of patients in group N (66.7% vs. 89.5%, P = 0.030) although that of patients with pT1 was not. Likelihood ratio tests showed that there was a significant interaction between pT status and PRM (P = 0.005).

CONCLUSION

PRM in cStage I gastric cancer is associated with advanced upper disease. It remains an independent prognostic factor in pT2-4 disease even after an additional resection to obtain R0.

Laparoscopic gastrectomy for gastric cancer: has the time come for considered it a standard procedure?

Radical gastrectomy with an adequate lymphadenectomy is the main procedure which makes it possible to cure patients with resectable gastric cancer. 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 gastric cancer. At present, laparoscopic gastrectomy is considered a standard procedure for early-stage gastric cancer, especially in Asian countries. On the other hand, 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. Additional high-quality studies comparing laparoscopic gastrectomy versus open gastrectomy for gastric cancer have been recently published, in particular concerning the latest results obtained by laparoscopic approach to advanced gastric cancer. It seems very useful to update the review of literature in light of these new evidences for this subject and draw some considerations.

Implementation of Multimodality Therapy and Minimally Invasive Surgery: Short- and Long-term Outcomes of Gastric Cancer Surgery in Medium-Volume Center

BACKGROUND

Multimodal treatment of gastric cancer includes careful preoperative staging, perioperative oncological treatment, and selective minimally invasive approach. The aim was to evaluate whether this approach improves short- and long-term outcomes in operable gastric cancer.

METHODS

This study included 181 gastric cancer patients who underwent curative intent surgery in Central Finland Central Hospital between years 2005 and 2021 for gastric or esophagogastric junction adenocarcinoma. Those 65 patients in group 1 operated between years 2005-2010 had open surgery with possible adjuvant therapy. During the second period including 58 patients (2011-2015), perioperative chemotherapy and minimally invasive surgery were implemented. The period, when these treatments were standard practise, was years 2016-2021 including 58 patients (group 3). Outcomes were lymph node yield, major complications and 1- and 3-year survival rates.

RESULTS

Median lymph node yield increased from 17 in group 1 and 20 in group 2 to 23 in group 3 (p < 0.001). Major complication rates in groups 1-3 were 12.3%, 32.8%, and 15.5% (group 1 vs. group 2, p = 0.007; group 2 vs. group 3, p = 0.018), respectively. Overall 1-year survival rates between study groups 1-3 were 78.5% vs. 69.0% vs. 90.2% (p = 0.018) and 3-year rates 44.6% vs. 44.8% vs. 68.1% (p = 0.016), respectively. For overall 3-year mortality, adjusted hazard ratio (HR) was 1.02 (95%CI 0.63-1.66) in group 2 and HR 0.37 (95%CI 0.20-0.68) in group 3 compared to group 1.

CONCLUSIONS

In medium-volume center, modern multimodal therapy in operable gastric cancer combined with minimally invasive surgery increased lymph node yield and improved long-term survival without increasing postoperative morbidity.

Effect of preoperative CT angiography examination on the clinical outcome of patients with BMI ≥ 25.0 kg/m2 undergoing laparoscopic gastrectomy: study protocol for a multicentre randomized controlled trial

BACKGROUND

Gastric cancer, which is the fifth most common malignancy and the third most common cause of cancer-related death, is particularly predominant in East Asian countries, such as China, Japan and Korea. It is a serious global health issue that causes a heavy financial burden for the government and family. To our knowledge, there are few reports of multicentre randomized controlled trials on the utilization of CT angiography (CTA) for patients who are histologically diagnosed with gastric cancer before surgery. Therefore, we planned this RCT to verify whether the utilization of CTA can change the short- and long-term clinical outcomes.

METHOD

The GISSG 20-01 study is a multicentre, prospective, open-label clinical study that emphasises the application of CTA for patients who will undergo laparoscopic gastrectomy to prove its clinical findings. A total of 382 patients who meet the inclusion criteria will be recruited for the study and randomly divided into two groups in a 1:1 ratio: the CTA group (n = 191) and the non-CTA group (n = 191). Both groups will undergo upper abdomen enhanced CT, and the CTA group will also receive CT angiography. The primary endpoint of this trial is the volume of blood loss. The second primary endpoints are the number of retrieved lymph nodes, postoperative recovery course, hospitalization costs, length of hospitalization days, postoperative complications, 3-year OS and 3-year DFS.

DISCUSSION

It is anticipated that the results of this trial will provide high-level evidence and have clinical value for the application of CTA in laparoscopic gastrectomy.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT04636099. Registered November 19, 2020.

Surgical and survival outcomes after laparoscopic and open gastrectomy for serosa-invasive Siewert type II/III esophagogastric junction carcinoma: a propensity score matching analysis

BACKGROUND

The potential advantage of laparoscopic gastrectomy (LG) compared with open gastrectomy (OG) for serosa-invasive (pT4a) Siewert type II and III adenocarcinoma of the esophagogastric junction (AEG) remains uncertain. Thus, the purpose of this study was to investigate the short- and long-term outcomes of LG compared to OG for pT4a Siewert type II/III AEG cancers.

METHODS

We retrospectively evaluated 283 patients with pathological confirmed T4a Siewert type II and type III AEG who underwent LG or OG in our center between January 2004 and September 2015. The short- and long-term outcomes were compared between the groups using a 1:1 matched propensity score matching method (PSM).

RESULTS

The LG group had a longer operation time, less estimated blood loss, less time to first flatus, less time to start liquid diet, less time to first ambulation, and shorter length of incision than the OG group. The conversion rates were 5.4% in the LG groups. There was no significant difference in the overall complication rate between the LG and OG groups. The 5-year overall survival (OS) and the 5-year disease-free survival (DFS) were comparable between the LG and OG groups (35.4% vs 32.1%, p = 0.541; 34.1% vs 31.0%, p = 0.523, respectively). There was no significant difference in the recurrence rate and pattern between the LG and OG groups.

CONCLUSIONS

Laparoscopic gastrectomy is associated with better short-term outcomes and similar long-term outcomes for pT4a Siewert type II/III AEG. This study reveals that LG could be a safe and feasible option for pT4a Siewert type II/III AEG compared to OG.

Impact of laparoscopic gastrectomy on relapse-free survival for locally advanced gastric cancer patients with sarcopenia: a propensity score matching analysis

BACKGROUND

Recent gastric cancer reports have shown that preoperative sarcopenia worsens long-term prognosis after gastrectomy. We investigated the impact of laparoscopic surgery on the long-term prognosis of locally advanced gastric cancer patients with sarcopenia.

METHODS

This retrospective study included consecutive patients who underwent radical gastrectomy for primary c-stage II or III advanced gastric cancer, between April 2008 and April 2017, with computed tomography records of skeletal muscle mass. The skeletal muscle mass index was calculated, and sarcopenia was defined when values were below the cut-off. The patients were divided into a laparoscopy group and open group, in which the background was adjusted using propensity score matching; the relapse-free survival and overall survival were compared between them. The prognostic factors for relapse-free survival and overall survival were investigated by multivariate analyses.

RESULTS

This study included 141 patients with sarcopenia (laparoscopy group, n = 69 [48.9%]; open group, n = 72 [51.1%]). After matching, there were 50 patients in both groups, with no significant differences in patient background. The median follow-up period was 38 months. Relapse-free survival was worse in the open group (hazard ratio: 1.662, 95% confidence interval: 0.910-3.034; P = 0.098), but there was no difference in the overall survival (P = 0.181). Multivariate analysis concluded that open surgery is an independent prognostic factor of relapse-free survival (hazard ratio: 3.219, 95% confidence interval: 1.381-7.502; P = 0.007) but not of OS.

CONCLUSION

Compared with the open surgery group, the laparoscopy group had a better RFS, although the difference was not statistically significant.

Effectiveness and safety of robotic gastrectomy versus laparoscopic gastrectomy for gastric cancer: a meta-analysis of 12,401 gastric cancer patients

Advanced minimally invasive techniques, such as robotic surgeries, are applied increasingly frequently around the world and are primarily used to improve the surgical outcomes of laparoscopic gastrectomy (LG). Against that background, we conducted a meta-analysis to evaluate the feasibility, safety, and effectiveness of robotic gastrectomy (RG). Studies comparing surgical outcomes between LG and RG patients were retrieved from medical databases, including RCTs and non-RCTs. The primary outcome of this study was overall survival, which was obtained by evaluating the 3-year survival rate and the 5-year survival rate. In addition, postoperative complications, mortality, length of hospital stay, and harvested lymph nodes were also assessed. We also conducted subgroup analyses stratified by resection type, body mass index, age, depth of invasion and tumour size. Ultimately, 31 articles met the criterion for our study through an attentive check of each text, including 1 RCT and 30 non-RCTs. A total of 12,401 patients were included in the analysis, with 8127 (65.5%) undergoing LG and 4274 (34.5%) undergoing RG. Compared with LG, RG was associated with fewer postoperative complications (OR 0.81; 95% CI 0.71-0.93; P = 0.002), especially pancreas-related complications (OR 0.376; 95% CI 0.156-0.911; P = 0.030), increased harvested lymph nodes (WMD 2.03; 95% CI 0.95-3.10; P < 0.001), earlier time to first flatus (WMD - 0.105 days; 95% CI - 0.207 to - 0.003; P = 0.044), longer operation time (WMD 40.192 min, 95% CI 32.07-48.31; P < 0.001), less intraoperative blood loss (WMD - 20.09 ml; 95% CI - 26.86 to - 13.32; P < 0.001), and higher expense (WMD 19,141.68 RMB; 95% CI 11,856.07-26,427.29; P < 0.001). There was no significant difference between RG and LG regarding 3-year overall survival (OR 1.030; 95% CI 0.784-1.353; P = 0.832), 5-year overall survival (OR 0.862; 95% CI 0.721-1.031; P = 0.105), conversion rate (OR 0.857; 95% CI 0.443-1.661; P = 0.648), postoperative hospital stay (WMD - 0.368 days; 95% CI - 0.75-0.013; P = 0.059), mortality (OR 1.248; 95% CI 0.514-3.209; P = 0.592), and reoperation (OR 0.855; 95% CI 0.479-1.525; P = 0.595). Our study revealed that postoperative complications, especially pancreas-related complications, occurred less often with RG than with LG. However, long-term outcomes between the two surgical techniques need to be further examined, particularly regarding the oncological adequacy of robotic gastric cancer resections.

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.

Circular versus linear stapling oesophagojejunostomy after laparoscopic total gastrectomy. A systematic review and meta-analysis

BACKGROUND

To assess which anastomosis technique is the most appropriate after laparoscopic total gastrectomy, a systematic review with meta-analysis has been performed to evaluate safety and efficacy of the linear versus circular stapler performing the oesophagojejunostomy.

METHODS

A systematic search was performed using the string: total AND gastrectomy AND (circular OR linear OR stapler). Extracted data were patients' number, gender, age, BMI, ASA Score, tumor stage. Outcomes were leakages, stenoses and bleedings, number of overall anastomotic complications, mortality, operative time, time to first flatus and diet resumption and length of stay of each group. A meta-analysis among the included studies was performed. A subgroup analysis, including the studies in which the Authors considered a single technique to perform each type of anastomosis (LS and CS), was performed. Meta-regression analyses were performed to assess if one or more demographic and clinical variables significantly impacted on the obtained results.

RESULTS

12 articles were included in the final analysis. A significant difference was observed in terms of "overall anastomotic complications" in favour of linear stapling (RD = 0.06, p = 0.01). No significant differences were observed in terms of postoperative complications anastomosis-related, even if a trend towards advantages of linear stapling have been found (stenosis: RD = 0.04, p = 0.06; bleeding: RD = 0.02, p = 0.05). However, all the study was retrospective and there was high heterogeneity among the studies.

CONCLUSION

Linear stapler seems to be related with lesser number of complication if compared with circular stapler. However, further high-quality studies are needed to obtain definitive conclusions.