Efficacy analysis of laparoscopy-assisted total gastrectomy and proximal gastrectomy in treatment of adenocarcinoma of esophagogastric junction

Abstract

Objective To investigate the clinical efficacy of laparoscopy-assisted total gastrectomy (LATG) and laparoscopy-assisted proximal gastrectomy (LAPG) in treatment of adenocarcinoma of esophago-gastric junction (AEG). Methods The retrospective cohort study was conducted. The clinicopathological data of 130 patients with AEG who underwent laparoscopy-assisted radical gastrectomy at the Peking University Cancer Hospital between May 2009 and February 2016 were collected. Among 130 patients, 91 undergoing LATG were allocated into the LATG group and 39 undergoing LAPG were allocated into the LAPG group. D2 lymph node dissection was applied to patients in the 2 groups according to the Japanese gastric cancer treatment guidelines. Patients received digestive tract reconstruction though a small midline incision in the epigastric region after laparoscopy-assisted lymph node dissection: patients in the LATG group and LAPG group received respectively Roux-en-Y esophagojejunostomy and residual stomach-esophagus anastomosis. Observation indicators included: (1) intra- and post-operative situations: overall surgical situation, number of patients with conversion to open surgery, operation time, volume of intraoperative blood loss, number of patients with intraoperative blood transfusion, number of lymph node dissected, time to anal exsufflation and duration of postoperative hospital stay. (2) Occurrence of complications: overall complications, surgery-related complications (slight and severe complications), reoperation, medical complications and death from surgery-related complication within 30 days postoperatively. Severity of complications was evaluated according to Clavien-Dindo classification. (3) Follow-up situations. Patients were followed up by outpatient examination, telephone interview and correspondence up to August 31, 2016. Follow-up included the tumor recurrence and metastasis. Overall survival time was counted from operation date to end of follow-up or time of death. Because follow-up time of 48 patients who underwent surgery from September 2014 to February 2016 was less than 2 years, survival analysis of the other 82 patients who underwent surgery from May 2009 to August 2014 was done. Measurement data with normal distribution were represented as ±s and comparison between groups was analyzed using the independent-sample t test. Measurement data with skewed distribution were represented as M (range) and comparison between groups was analyzed using the nonparametric test. Comparison of count data was analyzed using the chi-square test, and ranked data was analyzed using the nonparametric test. Survival curve was drawn by the Kaplan-Meier method, and survival analysis was done using the Log-rank test. Results (1) Intra- and post-operative situations: all the 130 patients underwent successful radical gastrectomy, and 7 patients converted to open surgery due to local tumor progression invading adjacent organs, abdominal adhesions and obesity. Operation time and number of lymph node dissected were (280±46)minutes, 28 (range, 14-80) in the LATG group and (258±57)minutes, 23 (range, 14-46) in the LAPG group, respectively, with statistically significant differences between the 2 groups (t=-2.305, Z=-4.168, P 0.05). The same patients may have multiple complications. Patients with complications received reoperation or corresponding treatment, 1 with anastomotic bleeding and 1 with intra-abdominal bleeding died and other patients had a smooth recovery. (3) Follow-up situations: 128 of 130 patients were followed up for 1-82 months with a median time of 39 months. During the follow-up, 28 patients died, including 25 dying of tumor recurrence and 3 dying of non-tumor causes. Of 82 patients in survival analysis, 3-year overall survival rate was 77.9% in 45 patients of LATG group and 72.2% in 37 patients of LAPG group, showing no statistically significant difference between the 2 groups (χ2=1.432, P>0.05). Conclusion Safety of LATG in treatment of AEG is equal to that of LAPG, and LATG can dissect more lymph nodes. Key words: Esophagogastric junction neoplasms, adenocarcinoma; Gastrectomy; Laparoscopy; Safety; Long-term outcomes