Laparoscopic Gastric Cancer Surgery in an Enhanced Recovery Program

Abstract

Background: Open gastrectomy with lymphadenectomy has been a preferred surgical method worldwide for a long time. However, this procedure is associated with clinically significant postoperative stress, high morbidity, rate (9.1-46.0%) and longer hospital stay. Several meta-analyses have shown better short-term results after laparoscopic gastrectomy compared to an open procedure, with similar oncological outcomes. Patients with resectable gastric cancer were included in this study. Enhanced recovery after surgery (ERAS) programs have been proposed to maintain physiological function and facilitate postoperative recovery. In the following studies, laparoscopic gastrectomy was considered to reduce the rates of morbidity and shorten the length of the hospital stay. Materials and Metods: This study was a non-randomized prospective trial. Patients with histologically proven, surgically resectable gastric cancer (T1- 4a,N1-3b, M0) and European Oncology Study Group performance status 0,1,2 were eligible to participate in this study. We applied an ERAS program in the laparoscopic surgery group and in the open gastrectomy group. The primary endpoints were operative time and morbidity rate. The second factors were length of hospital stay and cost-effectiveness. Additionally, we focused on the standardized operative technique. For the period March 1, 2014-January 31, 2015, 36 patients underwent laparoscopic gastric resection for gastric cancer. We performed 17 total D2 gastrectomies with esophagojejunal anastomosis and 12 subtotal gastrectomies with gastrojejonoanastomosis. We also performed 48 open gastrectomies (30 total and 18 subtotal ones) for this period. In all patients, the ERAS protocol was implemented. Results: The mean duration of the laparoscopic procedure was 210 min. versus 150 min in open group. There was 1 conversion due to a mesenterial lipoma as a reason for a short jejunal lооp. The mean hospital stay was 5.6 days in the laparoscopic group and 9.4 days in the open group. Two postoperative complications (7.1%) after a laparoscopic procedure (internal pancreatic fistula, leakage of oesophagojejunal anastomosis ) were reported. Three postoperative complications (7.1%) after an open surgery (duodenal stump leakage, external pancreatic fistula with bleeding, leakage from oesophagojejunal anastomosis) were found. All of patients with postoperative complication had an advanced stage gastric cancer (T3-4aN1- 3bM0).Conclusion: The implementation of the ERAS protocol in the clinical practice in combination with laparoscopy in patients with gastric cancer can result in improved post-operative care quality, shortening of the hospital stay, and quicker return to normal activity. We did not find significant differences in the morbidity rate between laparoscopic and open-operated patients. Perhaps, we have not analyzed the entire learning curve of the laparoscopic gastric surgery.