Minimally Invasive Gastrectomy for Borrmann Type IV Gastric Cancer: An Oncologically Sound Alternative to Open Surgery.

357 Background: Remnant gastric cancer (RGC) is defined as a cancer arising in the remnant stomach after initial gastrectomy, regardless of the previous disease or surgical procedure. Despite growing evidence of the effectiveness of minimally invasive surgery (MIS) for primary gastric cancer, MIS for RGC remains controversial due to the rarity of the disease. This study aimed to evaluate the surgical and oncological outcomes of MIS for radical resection of RGC. Methods: We collected the data of patients with RGC who underwent surgery with curative intent between 2005 and 2020 from 17 institutions in Japan, and performed a propensity score (PS) matching analysis to compare the short- and long-term outcomes of MIS with open surgery. Results: A total of 327 patients were included in this study and 186 patients were analyzed after matching. The risk ratios for overall and severe complications were 0.76 (95% confidence interval [CI]: 0.45–1.27) and 0.65 (95% CI: 0.32–1.29), respectively. The MIS group had significantly less blood loss (50 ml vs. 361 ml, P<0.001) and a shorter hospital stay (13 days vs. 16 days, P=0.009) than the open surgery group, while the operative time was longer in the MIS group (344 min vs. 273 min, P<0.001). The median follow-up duration of this cohort was 4.6 years, and the 3-year overall survival rates were 77.9% in the MIS group and 76.2% in the open surgery group (hazard ratio [HR], 0.78; 95% CI: 0.45–1.36). The 3-year relapse-free survival rates were 71.9% in the MIS group and 62.2% in the open surgery group (HR, 0.71; 95% CI: 0.44–1.16). Locoregional recurrence occurred in three patients (3.2%) in the MIS group and four patients (4.3%) in the open surgery group. There were also no differences in the other patterns of recurrence between the groups. Conclusions: MIS for RGC showed favorable short- and long-term outcomes compared to open surgery. MIS is a promising option for radical surgery for RGC.

Despite growing evidence of the effectiveness of minimally invasive surgery (MIS) for primary gastric cancer, MIS for remnant gastric cancer (RGC) remains controversial due to the rarity of the disease. This study aimed to evaluate the surgical and oncological outcomes of MIS for radical resection of RGC. Patients with RGC who underwent surgery between 2005 and 2020 at 17 institutions were included, and a propensity score matching analysis was performed to compare the short- and long-term outcomes of MIS with open surgery. A total of 327 patients were included in this study and 186 patients were analyzed after matching. The risk ratios for overall and severe complications were 0.76 [95% confidence interval (CI): 0.45, 1.27] and 0.65 (95% CI: 0.32, 1.29), respectively. The MIS group had significantly less blood loss [mean difference (MD), -409 mL; 95% CI: -538, -281] and a shorter hospital stay (MD, -6.5 days; 95% CI: -13.1, 0.1) than the open surgery group. The median follow-up duration of this cohort was 4.6 years, and the 3-year overall survival were 77.9% and 76.2% in the MIS and open surgery groups, respectively [hazard ratio (HR), 0.78; 95% CI: 0.45, 1.36]. The 3-year relapse-free survival were 71.9% and 62.2% in the MIS and open surgery groups, respectively (HR, 0.71; 95% CI: 0.44, 1.16). MIS for RGC showed favorable short- and long-term outcomes compared to open surgery. MIS is a promising option for radical surgery for RGC.

Standardized comparison of open vs minimally invasive surgery in patients undergoing hepatectomy through the textbook outcome.

Whether minimally invasive surgery (MIS) is safe and effective for patients with N2M0 colorectal cancer (CRC) remains controversial. This study aimed to compare short- and long-term outcomes between MIS and open surgery (Open) groups for patients with pathological (p)N2M0 CRC, and evaluate the oncological outcomes of MIS for pN2M0 CRC. We retrospectively analyzed 125 consecutive patients with pN2M0 CRC who underwent curative surgery between 2010 and 2017, using propensity score-matching (PSM) analysis. Median follow-up was 59.4months. After PSM, we enrolled 68 patients (n=34 in each group). The conversion rate was 9.6% for the entire patient cohort and 5.9% for the matched cohort. In colon cancer (CC), short-term outcomes were similar between groups. On the other hand, in rectal cancer (RC), estimated blood loss, rate of anastomosis leakage, and length of postsurgical stay were lower in the MIS group than the Open group. R0 resection was achieved in all patients with MIS. No surgical mortality was encountered in any group. No significant differences were found between groups in terms of 3-year local recurrence rate, overall survival, cancer-specific survival, or recurrence-free survival among the entire patient cohort or the matched cohort, regardless of the primary tumor site (CC or RC). Surgical approach (MIS vs Open) had no significant influence on survival outcomes. MIS is a safe and effective option for patients with pN2M0 CRC, with acceptable short- and long-term outcomes comparable to the open approach. MIS can be considered for patients with pN2M0 CRC.

As minimally invasive techniques advances, minimally invasive surgery (MIS) has emerged as an alternative modality for advanced gastric cancer. In this study, we compared the short- and long-term surgical outcomes of MIS and conventional open surgery for gastric cancer liver metastasis (GCLM) in terms of safety, feasibility, and efficacy. This retrospective study used data from a prospective database at the Chinese People's Liberation Army General Hospital. From January 2006 to June 2016, 53 gastric cancer patients with synchronous liver metastasis accepted radical gastrectomy combined with either or both hepatectomy and radiofrequency ablation for liver metastases. The 53 patients enrolled in the study were divided into two groups: a conventional open surgery group (n=42) and an MIS group (n=11). Propensity score matching (PSM) analysis was performed to overcome possible bias. With PSM performed at a 1:3 ratio, 11 patients who received MIS were compared with 33 open surgery cases. Mean operation time was significantly longer for the MIS group compared with the open surgery group (301 vs. 236min, P=0.032), while the open surgery group had a larger estimated blood loss than the MIS group (421 vs. 196ml, P=0.019). Time to first flatus and postoperative complications, including Clavien-Dindo classification, were similar in the two groups. However, patients undergoing MIS had a significantly shorter time to first sips of water (P=0.020) and soft diet (P=0.020) compared with open surgery counterparts. Long-term outcomes were comparable between groups (P=0.090) after adjustment by PSM analysis. MIS achieved superior short-term outcomes and comparable long-term outcomes compared with open surgery in GCLM patients. For experienced surgeons, both laparoscopic and robotic methods of MIS are reasonable approaches for the management of highly selected GCLM patients.

Intersphincteric resection (ISR) is a surgical technique intended to avoid abdominoperineal resection (APR) in patients diagnosed with low-lying rectal cancer. However, the oncologic outcomes of minimally invasive ISR are still controversial. We analyzed the long-term oncologic outcomes of open and minimally invasive ISR. A total of 313 rectal cancer patients who underwent ISR between 2000 and 2014 were analyzed, including 147 in the open surgery group and 166 in the minimally invasive surgery (MIS) group. This study also analyzed 113 patients who received neoadjuvant chemoradiotherapy (nCRT) for advanced lower rectal cancer. Propensity score matching (PSM) was used to correct for differences between the two groups. 5-year disease-free survival (DFS) rate was the primary end point. The length of hospital stay was significantly shorter in the MIS group (9.6 vs. 11.8 days, p < 0.001). Differences in overall postoperative morbidity rates between the groups were not significant; however, the rate of surgical site infection was significantly lower in the MIS group (1.2 vs. 10.9%, p < 0.001). The 5-year DFS associated with all stages combined in the matched patients were not significantly different: 75.2% in the open group vs. 64.2% in the MIS group (p = 0.214). Similar results were found in matched patients treated with nCRT, with 72.0% in the open group and 61.3% in the MIS group (p = 0.078) showing DFS. Both minimally-invasive and open ISR for rectal cancer yielded similar 5-year oncologic outcomes. MIS showed statistically significant advantages in some postoperative outcomes such as reduced surgical site infection and shorter hospital stay, and similar long-term outcomes compared with open ISR. This study also suggests that MIS after nCRT for advanced rectal cancer represents a surgical option with similar oncological results.

Objective: This study aims to investigate the efficacy and safety of minimally invasive surgery (MIS) in gastric cancer and to compare MIS versus open gastrectomy (OG) in terms of early mortality and morbidity, long-term oncological outcomes, and recurrence rates.Methods: A total of 75 patients who underwent MIS or OG for gastric cancer at Koç University School of Medicine between December 2014 and December 2019 were retrospectively analyzed. Postoperative complications and disease-specific survival were compared between surgical approaches.Results: Of the patients, 44 were treated with MIS and 31 with OG. In the MIS group, 33 patients underwent laparoscopic surgery, and 11 patients underwent robotic gastrectomy. Duration of operation was significantly longer in the MIS group than in the OG group (p<0.0001). The median amount of blood loss was 142.5 (range, 110 to 180) mL in the MIS group and 180.4 (range, 145 to 230) mL in the OG group (p<0.706). The median number of lymph node dissection was 38.9 (range, 15 to 66) and 38.7 (range, 12 to 70) in the MIS and OG groups, respectively (p<0.736). The median length of hospitalization, twelve days in the OG group and nine days in the MIS group. Median follow-up was 19.1 (range, 2 to 61) months in the MIS group and 22.1 (range, 2 to 58) months in the OG group. The median OS and DFS rates were 56.8 months and 39.6 months in the MIS group, respectively (log-rank; p=0.004) and 31.6 months and 23.1 months in the OG group, respectively (log-rank; p=0.003).Conclusion: Our study results suggest that, despite its technical challenges, MIS is an effective and safe method in treating gastric cancer with favorable early mortality and morbidity rates and long-term oncological outcomes, and acceptable recurrence rates.

Minimally invasive surgery versus percutaneous radiofrequency ablation for early-stage hepatocellular carcinoma: Results from a high-volume liver surgery center in East Asia

BACKGROUNDThe safety and feasibility of the simultaneous resection of primary colorectal cancer (CRC) and synchronous colorectal liver metastases (SCRLM) have been demonstrated in some studies. Combined resection is expected to be the optimal strategy for patients with CRC and SCRLM. However, traditional laparotomy is traumatic, and the treatment outcome of minimally invasive surgery (MIS) is still obscure.AIMTo compare the treatment outcomes of MIS and open surgery (OS) for the simultaneous resection of CRC and SCRLM.METHODSA systematic search through December 22, 2018 was conducted in electronic databases (PubMed, EMBASE, Web of Science, and Cochrane Library). All studies comparing the clinical outcomes of MIS and OS for patients with CRC and SCRLM were included by eligibility criteria. The meta-analysis was performed using Review Manager Software. The quality of the pooled study was assessed using the Newcastle-Ottawa scale. The publication bias was evaluated by a funnel plot and the Begg’s and Egger’s tests. Fixed- and random-effects models were applied according to heterogeneity.RESULTSTen retrospective cohort studies involving 502 patients (216 patients in the MIS group and 286 patients in the OS group) were included in this study. MIS was associated with less intraoperative blood loss [weighted mean difference (WMD) = -130.09, 95% confidence interval (CI): -210.95 to -49.23, P = 0.002] and blood transfusion [odds ratio (OR) = 0.53, 95%CI: 0.29 to 0.95, P = 0.03], faster recovery of intestinal function (WMD = -0.88 d, 95%CI: -1.58 to -0.19, P = 0.01) and diet (WMD = -1.54 d, 95%CI: -2.30 to -0.78, P < 0.0001), shorter length of postoperative hospital stay (WMD = -4.06 d, 95%CI: -5.95 to -2.18, P < 0.0001), and lower rates of surgical complications (OR = 0.60, 95%CI: 0.37 to 0.99, P = 0.04). However, the operation time, rates and severity of overall complications, and rates of general complications showed no significant differences between the MIS and OS groups. Moreover, the overall survival and disease-free survival after MIS were equivalent to those after OS.CONCLUSIONConsidering the studies included in this meta-analysis, MIS is a safe and effective alternative technique for the simultaneous resection of CRC and SCRLM. Compared with OS, MIS has less intraoperative blood loss and blood transfusion and quicker postoperative recovery. Furthermore, the two groups show equivalent long-term outcomes.

Prospective propensity score-matched study. To compare the outcomes of minimal invasive surgery (MIS) and conventional open surgery for spinal metastasis patients. There is lack of knowledge on whether MIS is comparable to conventional open surgery in treating spinal metastasis. Patients with spinal metastasis requiring surgery from January 2008 to December 2010 in two spine centers were recruited. The demographic, preoperative, operative, perioperative and postoperative data were collected and analyzed. Thirty MIS patients were matched with 30 open surgery patients using propensity score matching technique with a match tolerance of 0.02 based on the covariate age, tumor type, Tokuhashi score, and Tomita score. Both groups had significant improvements in Eastern Cooperative Oncology Group (ECOG), Karnofsky scores, visual analogue scale (VAS) for pain and neurological status postoperatively. However, the difference comparing the MIS and open surgery group was not statistically significant. MIS group had significantly longer instrumented segments (5.5 ± 3.1) compared with open group (3.8 ± 1.7). Open group had significantly longer decompressed segment (1.8 ± 0.8) than MIS group (1.0 ± 1.0). Open group had significantly more blood loss (2062.1 ± 1148.0 mL) compared with MIS group (1156.0 ± 572.3 mL). More patients in the open group (76.7%) needed blood transfusions (with higher average units of blood transfused) compared with MIS group (40.0%). Fluoroscopy time was significantly longer in MIS group (116.1 ± 63.3 s) compared with open group (69.9 ± 42.6 s). Open group required longer hospitalization (21.1 ± 10.8 days) compared with MIS group (11.0 ± 5.0 days). This study demonstrated that MIS resulted in comparable outcome to open surgery for patients with spinal metastasis but has the advantage of less blood loss, blood transfusions, and shorter hospital stay. 3.

Although surgeons normally use minimally invasive surgery (MIS) for patients with early gastric cancer, in Korea and Japan the procedure is also indicated for serosa-negative tumors. Serosal invasion is regarded to be a potential risk factor for peritoneal dissemination as a result of the effect of pneumoperitoneum and tumor manipulation during the operation. We compared operative outcomes between MIS and conventional open surgery for serosa-involved advanced gastric cancer patients who had a preoperative diagnosis of cancer without serosal invasion. A total of 61 patients (39 patients treated by MIS and 22 by open surgery) treated between 2003 and 2009 who were first diagnosed preoperatively as serosa negative on the basis of computed tomography, endoscopy, and endoscopic ultrasound but then diagnosed as serosa positive upon final pathology were studied. We retrospectively compared recurrence and survival between the two treatment groups. Clinicopathologic characteristics, clinical stage, extent of surgery, and short-term operative outcome did not differ between the groups. 5-year overall survival (73.5 vs. 67.5 %, p = 0.518, respectively) and disease-free survival (67.8 vs. 54.2 %, p = 0.296, respectively) were comparable between the MIS and open surgery groups. There were recurrences in 12 patients in the MIS group and 11 patients in the open surgery group, with a median follow-up period of 64 months. Recurrence patterns did not differ between the groups; moreover, MIS did not increase peritoneal recurrences compared to open surgery (42.0 vs. 54.5 %, p = 0.537, respectively). In multivariate analyses, the type of surgery was not an independent prognostic factor. Similar survival and recurrence patterns were observed in advanced gastric cancer patients preoperatively diagnosed as serosa negative who were treated either by MIS or open surgery. MIS may be safely applied in patients with serosa-positive tumors.

PurposeThe association between minimally invasive surgery (MIS) for hematoma evacuation and late seizures after intracerebral hemorrhage (ICH) remains uncertain. We aimed to investigate whether MIS increases the risk of late seizures after ICH and identify the risk factors for late seizures in this patient subgroup.MethodsWe retrospectively included consecutive inpatients diagnosed with ICH at two tertiary hospitals in China. The subjects were divided into the MIS group (ICH patients who received MIS including hematoma aspiration and thrombolysis) and conservative treatment group (ICH patients who received conservative medication). Propensity score matching was performed to balance possible risk factors for late seizures between the MIS and conservative treatment groups. Before and after matching, between-group comparisons of the incidence of late seizures were performed between the MIS and conservative treatment groups. Univariate and multivariate logistic regression analyses were used to identify independent risk factors for late seizures in MIS-treated patients.ResultsA total of 241 and 1,689 patients were eligible for the MIS and conservative treatment groups, respectively. After matching, 161 ICH patients from the MIS group were successfully matched with 161 ICH patients from the conservative treatment group (1:1). Significant differences (p < 0.001) were found between the MIS group (31/241, 12.9%) and conservative treatment group (69/1689, 4.1%) in the incidence of late seizures before matching. However, after matching, no significant differences (p = 0.854) were found between the MIS group (17/161, 10.6%) and conservative treatment group (16/161, 9.9%). Multivariate logistic regression analysis revealed that cortical involvement (OR = 2.547; 95% CI = 1.137–5.705; p value = 0.023) and higher National Institutes of Health Stroke Scale (NIHSS) scores (OR = 1.050; 95% CI = 1.008–1.094; p value = 0.019) were independent risk factors for late seizures.ConclusionOur study revealed that receiving MIS did not increase the incidence of late seizures after ICH. Additionally, cortical involvement and NIHSS scores were independent risk factors for late seizures in MIS-treated patients.

Completion total gastrectomy for remnant gastric cancer (RGC) is technically challenging, especially using the minimally invasive approach. Only a few small case series have reported the technical feasibility of completion total gastrectomy by minimally invasive surgery (MIS). The aim of this study was to compare the efficacy and safety of MIS and open surgery for RGC. We retrospectively analyzed 76 completion total gastrectomies for RGC between 2005 and 2012. Indications for MIS were limited to no evidence of serosa invasion or lymph node metastasis to extraperigastric areas on preoperative evaluation. We compared patient characteristics, intraoperative factors, post-operative outcomes, and survival for the MIS and open surgery groups. Eighteen patients underwent completion total gastrectomy with MIS (10 laparoscopic, 8 robotic) and 58 patients underwent open surgery. Operation time was longer in the MIS than the open group (266 vs. 203min, P=0.004), but the groups had similar estimated blood loss, frequency of unplanned other organ resection, and number of retrieved lymph nodes. The MIS group had a significantly earlier initiation of soft diet, shorter hospital stay, and fewer pain medication injections. Complication rates, recurrence, and overall 5-year survival were similar for the two groups. When we compared laparoscopy with robotic, similar result was shown in all parameters except operation time. Compared to open surgery, MIS for RGC demonstrated better short-term outcome and comparable oncologic results. MIS for RGC is feasible and safe and maintains advantages of minimal invasiveness. Both laparoscopic and robotic approaches are reasonable to the management of RGC.

We used a population-based database to: (1) compare clinical and economic outcomes between minimally invasive surgery (MIS) and open surgery (OS) for colectomy; and (2) evaluate contemporary trends in MIS rates. Retrospective Premier Healthcare Database review of patients undergoing elective inpatient colectomy between January 1, 2010 and September 30, 2017 (first = index admission). Patients were classified into MIS (laparoscopic/robotic) or OS groups, and by left or right colectomy. Propensity score matching (1:1 ratio) of MIS and OS groups was used to address potential confounding from patient/hospital/provider characteristics. Study outcomes, measured during index admission, included major perioperative complications [anastomotic leak (AL), bleeding, infection, and a composite of infection/AL], operating room time (ORT), length of stay (LOS), and total hospital costs. Among 134,970 study-eligible patients, MIS rates increased from ~ 2% (2010) to 19-23% (2017), driven by a > tenfold increase in robotic surgery. The matched MIS and OS colectomy groups comprised 46,708 (left) and 44,560 (right) total patients. Risks of AL, bleeding, and infection were lower for MIS versus OS (all p < 0.001). In left: AL occurred in 7.9% of MIS versus 9.9% of OS; bleeding 7.8% versus 9.7%; infection 3.3% versus 5.8%; infection/AL 9.8% versus 13.3%. In right: AL 8.9% versus 11.1%; bleeding 9.8% versus 10.8%; infection 3.0% versus 5.1%; infection/AL 10.5% versus 10.4%. Although ORTs were longer with MIS (left: 240.8 vs. 216.2min; right: 192.8 vs. 178.0min), LOS was shorter (left: 5.4 vs. 7.1days; right: 5.5 vs. 7.1days), and total hospital costs were lower (left: $18,564 vs. $19,960; right: $17,375 vs. $19,417) versus OS (all p < 0.001). Compared with OS, MIS was associated with significantly lower risk of major perioperative complications (including AL), lower LOS, and lower total hospital costs, despite longer OR times. MIS colectomy rates have increased over time; recent gains appear to be due to uptake of robotic surgery.

Introduction:This study aimed to investigate whether the incidence, patterns, and surgical outcomes of small bowel obstruction (SBO) have changed in the era of minimally invasive surgery (MIS) for primary colorectal cancer (CRC).Methods:Consecutive patients who underwent laparotomy for SBO were divided into MIS and traditional open surgery (TOS) groups based on the previous colorectal cancer operation technique used. The MIS group was selected from 1544 consecutive patients who underwent MIS as a treatment for primary CRCs between 2014 and 2022, while the TOS group was selected from 1604 consecutive patients who underwent TOS as a treatment for primary CRCs between 2004 and 2013. The demographics, clinicopathological features, and surgical outcomes were compared between the two groups.Results:The SBO incidence in patients who underwent MIS for primary CRC was significantly lower than that in patients who underwent TOS (4.4%, n=68/1544 vs. 9.7%, n=156/1604, P<0.0001). Compared with the TOS group, the MIS group had significantly different (P<0.0001) SBO patterns: adhesion (48.5 vs. 91.7%), internal herniation (23.5 vs. 2.6%), external herniation (11.8 vs. 1.9%), twisted bowel limbs (4.4 vs. 0.6%), ileal volvulus with pelvic floor adhesion (5.9 vs. 1.9%), and nonspecific external compression (5.9 vs. 1.3%). A subset analysis of patients with adhesive SBO (ASBO) showed that the MIS group tended to (P<0.0001) have bands or simple adhesions (75.8%), whereas the TOS group predominantly had matted-type adhesions (59.4%). Furthermore, SBO in the MIS group had an acute (<3 months) or early (3–12 months) onset (64.7%), while that in the TOS group (P<0.0001) had an intermediate or a late onset. When the surgical outcomes of SBO were evaluated, the TOS group had significantly more (P<0.0001) blood loss and longer operation time; however, no significant difference was observed in the surgical morbidity/mortality (Clavien–Dindo classification ≧3, 11.8 vs. 14.1%, P=0.6367), hospitalization, and readmission rates between the two groups. Postoperative follow-up showed that the estimated 3-year (11.37 vs. 18.8%) and 6-year (25.54 vs. 67.4%) recurrence rates of SBO were significantly lower (P=0.016) in the MIS group than in the TOS group.Conclusions:The wide adoption of MIS to treat primary CRC has led to a lower incidence, altered patterns, and reduced recurrence rates of SBO. Awareness of this new trend will help develop surgical techniques to prevent incomplete restoration of anatomical defects and bowel malalignments specifically associated with MIS for CRC, as well as facilitate timely and appropriate management of SBO complications whenever they occur.