Short-term clinical effects of selecting duodenal transection timing on laparoscopic-assisted distal gastrectomy: a multicentre retrospective study (A report of 239 cases)

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Objective To investigate the short-term clinical effects of selecting duodenal transection timing on laparoscopic-assisted distal gastrectomy (LADG). Methods The retrospective cohort study was conducted. The clinicopathological data of 239 gastric cancer (GC) patients undergoing LADG in the 5 medical centers between March 2016 and March 2018 were collected, including 104 in the First Affiliated Hospital of Xiamen University, 45 in Zhangzhou Affiliated Hospital of Fujian Medical University, 35 in Quanzhou Affiliated Hospital of Fujian Medical University, 30 in the Second Affiliated Hospital of Xiamen Medical College, 25 in Zhongshan Hospital of Xiamen University. Of 239 patients undergoing LADG + D2 lymph node dissection, 107 receiving duodenal transection and then lymph node dissection in the upper region of pancreas after lymph node dissection in the lower region of pylorus and 132 receiving lymph node dissection in the upper region of pancreas and then duodenal transection were respectively divided into anterior approach group and posterior approach group. Sixty-four, 8, 16, 14 and 5 patients in the anterior approach group and 40, 37, 19, 16 and 20 patients in the posterior group respectively came from the First Affiliated Hospital of Xiamen University, Zhangzhou Affiliated Hospital of Fujian Medical University, Quanzhou Affiliated Hospital of Fujian Medical University, Second Affiliated Hospital of Xiamen Medical College and Zhongshan Hospital of Xiamen University. Observation indicators: (1) surgical and postoperative situations; (2) postoperative complications; (3) stratified analyses of surgical and postoperative situations in patients with different TNM staging, body mass index (BMI) and maximum tumor dimension; (4) follow-up and survival. Follow-up using outpatient examination and telephone interview was performed to detect postoperative overall survival and tumor recurrence or metastasis up to April 2018. Measurement data with normal distribution were represented as ±s, and comparison between groups was analyzed using the independent-samples t test. Measurement data with skewed distribution were described as M (Q), and comparison between groups was analyzed using the nonparametric test. Comparisons of count data were analyzed using chi-square test or Fisher exact probability. Comparison of ordinal data was done by the rank-sum test. Results (1) Surgical and postoperative situations: all the patients underwent successful operation, without perioperative death. Number of lymph node dissection in the upper region of pylorus in the anterior and posterior approach groups were respectively 3.9±2.6 and 3.0±2.5, with a statistically significant difference between groups (t=2.778, P 0.05). (2) Postoperative complications: cases with overall complications, anastomotic leakage, anastomotic stenosis, anastomotic bleeding, pancreatic fistula, postoperative gastroparesis, intra-abdominal hemorrhage, incision infection, pneumonia, intra-abdominal infection, bacteremia, intestinal obstruction, endolymphatic leakage, Clavien-Dindo grade Ⅰ, Ⅱ, Ⅲa, Ⅲb and Ⅳa of postoperative complications were respectively 15, 1, 1, 1, 0, 3, 1, 2, 3, 0, 1, 3, 0, 3, 9, 1, 2, 0 in the anterior approach group and 25, 3, 0, 1, 2, 2, 2, 5, 7, 3, 2, 3, 1, 6, 14, 1, 2, 2 in the posterior approach group, with no statistically significant difference between groups (χ2=1.027, 0.643, 0.022, 0.479, 0.161, 0.765, 0.921, 0.161, 0.063, Z=-1.055, P>0.05). Patients in 2 groups with complications were cured by symptomatic treatment. (3) Stratified analyses of surgical and postoperative situations in patients with different TNM staging, BMI and maximum tumor dimension: operation time, dissected times of lymph nodes in upper region of pancreas, cases with visible port vein, number of overall lymph node dissection, numbers of lymph node dissection in upper region of pylorus and upper region of pancreas were respectively (236.0±41.0)minutes, (33.9±6.2)minutes, 32, 36.0±12.0, 3.8±3.0, 13.4±5.5 in patients of the anterior approach group with Ⅲ stage of TNM staging and (253.0±45.0)minutes, (36.5±7.0)minutes, 29, 31.0±9.0, 2.5±2.0, 11.4±4.6 in patients of the posterior approach group with Ⅲ stage of TNM staging, with statistically significant differences between groups (t=-1.988, -2.066, χ2=4.686, t=2.472, 2.757, 2.016, P 0.05). Conclusions Both of anterior approach and posterior approach are safe and feasible in LADG, with equivalent short-term efficacies. The anterior approach in LADG has an advantage of the lymph node dissection in the upper region of pylorus compared with posterior approach, and it also is better for patients with later tumor staging, higher BMI and bigger tumor. Key words: Gastric neoplasms, distal; Radical resection; Duodenal transection timing; Surgical approach; Laparoscopy; Multicenters; Retrospective researches