Gastrectomy For Early-stage Gastric Cancer Research Articles

Comparison of the clinical and prognosis risk factors between endoscopic resection and radical gastrectomy for early-stage gastric cancer

AimThis study aimed to explore the efficacy and safety of endoscopic submucosal dissection/endoscopic mucosal resection (ESD/EMR), laparoscopic-assisted radical gastrectomy (LARG), and open radical gastrectomy (ORG) in early-stage gastric cancer.MethodsA total of 417 patients with early-stage gastric cancer who were admitted in two hospitals from January 1, 2014 to July 31, 2017 were selected; the patients were divided into the ESD/EMR group (139 cases), LARG group (108 cases), and ORG group (170 cases) according to the operation methods used. The baseline data, economic cost of health, oncologic characteristics, postoperative complications, 5-year overall survival and disease-free survival, and risk factors of death were compared and analyzed.ResultsNo significant difference was observed in the baseline data among the three patient groups (P > 0.05). The total hospitalization days, operation time, postoperative fluid intake time, hospitalization expenses, and proportion of antibiotic use rate in the ESD/EMR group were lesser than those in other groups (P < 0.05). The LARG group has a longer operation time and higher hospitalization expenses compared with the ORG group (P < 0.05), but the total hospitalization days, postoperative fluid intake time, proportion of antibiotic use, and lung infection status were consistent. The ESD/EMR group had a lower incidence of incision site infection and postoperative abdominal distension compared with that of the surgery groups (P < 0.05). Five patients required radical surgery after undergoing ESD/EMR (The patients had residual tissue margin cancer), while none of the patients had switched to ORG during LARG. Surgery had advantages over ESD/EMR in terms of lymph node dissection (P < 0.05). No significant differences were observed in the postoperative complications such as upper gastrointestinal bleeding, perforation, incision hernia, reoperation and recurrence (P > 0.05). The 5-year postoperative survival rates of patients in the three groups were 94.2% (ESD/EMR), 93.5% (LARG), and 94.7% (ORG), respectively, with no significant differences (P > 0.05). The binary logistics multivariate analysis showed that the tumor size, invasion depth, vascular invasion, and differentiated degree were risk factors for death in patients with gastric cancer.ConclusionsNo significant difference was observed between ESD/EMR and radical surgery. However, standardized criteria for excluding metastatic lymph nodes should be established to promote ESD/EMR.

A desmoid tumor with fluorodeoxyglucose accumulation arising from the anastomotic site of postoperative gastric cancer: a case report

BackgroundDesmoid tumors are extremely rare borderline benign and malignant tumors that do not exhibit accumulation on fluorodeoxyglucose positron emission tomography–computed tomography. In the present study, we report a rare case of a desmoid tumor with fluorodeoxyglucose accumulation at the anastomotic postoperative gastric cancer site.Case presentationA 68-year-old Japanese man underwent robot-assisted laparoscopic distal gastrectomy for early-stage gastric cancer in 2019. The pathological diagnosis was stage IA cancer, and no adjuvant chemotherapy was administered. Two years after surgery, a soft mass appeared on the greater curvature side of the anastomosis on computed tomography. Fluorodeoxyglucose positron emission tomography–computed tomography revealed fluorodeoxyglucose accumulation, which suggested a malignancy; therefore, surgery was performed for diagnostic treatment. The histopathological findings led to the diagnosis of a desmoid tumor. The patient has not experienced recurrence to date.ConclusionsIn the present study, we encountered a desmoid tumor arising from the anastomotic site of a postoperative gastric cancer. This case is rare as fluorodeoxyglucose positron emission tomography–computed tomography showed fluorodeoxyglucose accumulation in the desmoid tumor, and a preoperative diagnosis could not be reached. We hope that further studies will improve the accuracy of preoperative diagnosis.

Robot-assisted laparoscopic subtotal gastrectomy for early-stage gastric cancer: Case series of initial experience

BackgroundIn the last decade's robotic gastrectomy (RG) has increasingly widespread as a valid minimally invasive option for treatment of gastric cancer. In literature, evidence of its routine use is not yet well established. The aims of this study are to report our initial experience and to present possible advantages of our hybrid operative technique for subtotal gastrectomy. Materials and methodsRetrospectively, we analyzed data from 41 patients (22 male and 19 female) who underwent robot-assisted laparoscopic subtotal gastrectomy (RALG) with D2 lymphadenectomy using the da Vinci XI robotic system. Inclusion criteria were gastric cancer in the middle or lower portion of the stomach amenable of radical subtotal gastrectomy without preoperative suspicion of positive lymph-nodes or other organs involving and distant metastasis. All the procedures were performed by attending surgeons. ResultsThe mean operative time was 270 min with one case of conversion to open surgery. The mean age was 71.4 (IQR 68.2–76.8) with 43.9% of patients classified as ASA (American Society of Anesthesiologists) score ≥3. The median of lymph-nodes retrieved was 25 (IQR 19–35). No intra-operative complications occurred. Time to resume a soft diet was 5 days. Patients were hospitalized a median of 7 days. According to pathological AJCC-TNM, 21 patients were classified as advanced gastric cancer. Post-operative morbidity was recorded in 9 patients (21.9%) with major complications requiring surgical operation in 4 patients (9.8%). Elevated ASA score, fewer lymph-nodes retrieved and ICU recovery requirements were significant increased in patients with major complications. ConclusionThe preliminary results demonstrated that robot-assisted laparoscopic subtotal gastrectomy is safe and feasible. In particular, we found that the da Vinci platform improves surgeon abilities to perform an adequate lymphadenectomy and digestive reconstruction. Further studies are necessary to better clarify the role of this high-cost technology in minimally invasive treatment of gastric cancer.

Effect of Laparoscopic vs Open Distal Gastrectomy on 3-Year Disease-Free Survival in Patients With Locally Advanced Gastric Cancer

Laparoscopic distal gastrectomy is accepted as a more effective approach to conventional open distal gastrectomy for early-stage gastric cancer. However, efficacy for locally advanced gastric cancer remains uncertain. To compare 3-year disease-free survival for patients with locally advanced gastric cancer after laparoscopic distal gastrectomy or open distal gastrectomy. The study was a noninferiority, open-label, randomized clinical trial at 14 centers in China. A total of 1056 eligible patients with clinical stage T2, T3, or T4a gastric cancer without bulky nodes or distant metastases were enrolled from September 2012 to December 2014. Final follow-up was on December 31, 2017. Participants were randomized in a 1:1 ratio after stratification by site, age, cancer stage, and histology to undergo either laparoscopic distal gastrectomy (n = 528) or open distal gastrectomy (n = 528) with D2 lymphadenectomy. The primary end point was 3-year disease-free survival with a noninferiority margin of -10% to compare laparoscopic distal gastrectomy with open distal gastrectomy. Secondary end points of 3-year overall survival and recurrence patterns were tested for superiority. Among 1056 patients, 1039 (98.4%; mean age, 56.2 years; 313 [30.1%] women) had surgery (laparoscopic distal gastrectomy [n=519] vs open distal gastrectomy [n=520]), and 999 (94.6%) completed the study. Three-year disease-free survival rate was 76.5% in the laparoscopic distal gastrectomy group and 77.8% in the open distal gastrectomy group, absolute difference of -1.3% and a 1-sided 97.5% CI of -6.5% to ∞, not crossing the prespecified noninferiority margin. Three-year overall survival rate (laparoscopic distal gastrectomy vs open distal gastrectomy: 83.1% vs 85.2%; adjusted hazard ratio, 1.19; 95% CI, 0.87 to 1.64; P = .28) and cumulative incidence of recurrence over the 3-year period (laparoscopic distal gastrectomy vs open distal gastrectomy: 18.8% vs 16.5%; subhazard ratio, 1.15; 95% CI, 0.86 to 1.54; P = .35) did not significantly differ between laparoscopic distal gastrectomy and open distal gastrectomy groups. Among patients with a preoperative clinical stage indicating locally advanced gastric cancer, laparoscopic distal gastrectomy, compared with open distal gastrectomy, did not result in inferior disease-free survival at 3 years. ClinicalTrials.gov Identifier: NCT01609309.

Outcomes After Laparoscopic or Open Distal Gastrectomy for Early-Stage Gastric Cancer

In a large nationwide administrative database of hospitalized patients, we investigated postoperative outcomes after laparoscopic or open distal gastrectomy in Japan. The benefits of laparoscopic gastrectomy, such as decreased length of stay and morbidity, have typically been evaluated only with limited data on the basis of small samples. : Using the Japanese Diagnosis Procedure Combination Database, we identified 9388 patients who were preoperatively diagnosed with stage I and II gastric cancer and underwent laparoscopic (n = 3937) or open (n = 5451) distal gastrectomy between July and December 2010. One-to-one propensity score matching was performed to compare in-hospital mortality, postoperative complication rates, length of stay, total costs, and 30-day readmission rates between the 2 groups. Patients with younger age, lower comorbidity index, or stage I cancer were more likely to receive laparoscopic gastrectomy. In the propensity-matched analysis with 2473 pairs, the laparoscopic gastrectomy group in comparison with the open gastrectomy group showed a slight reduction in median postoperative length of stay (13 days vs 15 days, P < 0.001) but a slight increase in median total costs (US $21,510 vs $21,024, P = 0.002). There were no significant differences in in-hospital mortality (0.36% vs 0.28%, P = 0.80), overall postoperative complications (12.9% vs 12.6%, P = 0.73), or 30-day readmission rates (3.2% vs 3.2%, P = 0.94). In this large nationwide cohort of patients with early-stage gastric cancer, laparoscopic gastrectomy was associated with a statistically significant but slight reduction in postoperative length of stay, but no differences between laparoscopic gastrectomy and open gastrectomy were detected in terms of early mortality and morbidity.

Laparoscopic gastrectomy: advances enable wide clinical application

The current trend is toward laparoscopic gastrectomy. Although no level 1 randomized evidence or cost-effective analysis exists to show the superiority of laparoscopic gastrectomy over open gastrectomy, the indications and use of laparoscopic gastrectomy in clinical practice have been expanded beyond the carefully selected older patients described in the report by Singh et al. [1] in a recent issue of this journal. A current published report shows the clinical use of laparoscopic gastrectomy for early-stage gastric cancer with a trend also toward locally advanced carcinoma [2] and for carriers of CDH1 mutations to prevent hereditary diffuse gastric cancer (HDGC) syndrome [3, 4]. As laparoscopic gastrectomy currently is being applied in an environment of strong competition within various countries and among specialized institutions worldwide to attract patients, what are the benefits and risks of the laparoscopic approach? Laparoscopic gastrectomy is unlikely to improve survival or cure rates for gastric cancer patients, but evidence supports its superiority over open gastrectomy in improving quality of life (QOL). Singh et al. [1] report on a series of 20 elderly patients who underwent laparoscopic gastrectomy procedures. These patients were at risk for high morbidity and mortality with the use of conventional gastric surgery. There were no perioperative deaths. Four patients experienced significant complications, with two patients requiring reoperation. Extended D2 lymphadenectomy should be considered for patients with gastric cancer. Lee et al. [2] recently reported on laparoscopically assisted distal gastrectomy (LADG) with extended D2 lymphadenectomy for patients with early-stages gastric cancer. Two surgeons performed the procedure for 64 patients over an 8-month period, with a postoperative complication rate of only 3% and no deaths. The high-volume surgeons who performed the procedures are the key for these excellent results. The D2 lymphadenectomy compliance rate for the LADG was similar to that for open gastrectomy. Should D2 gastrectomy be the standard procedure for localized gastric cancer? Despite a long-term debate in the West [5–8], D2 surgery is a standard approach in Eastern countries [9, 10]. High cure rates have been reported with D2 surgery for early-stage gastric malignant tumors [9, 11, 12], but there still is no level 1 evidence in favor of D2 surgery [13]. The current status of the treatment for localized gastric cancer [14] includes either D2 surgery performed by experienced surgeons [15, 16] or, if this criterion is not met, limited D1 surgery plus chemoradiotherapy [17, 18]. With the randomized evidence for the safety and efficacy of the laparoscopic approach for colorectal cancer, laparoscopic gastrectomy has been growing rapidly. The advantages of laparoscopic over open gastrectomy include quicker return of gastrointestinal function, faster ambulation, and earlier discharge from the hospital, although the operating time is longer than for open gastrectomy [19]. Another important field of laparoscopic approach is the primary prevention of gastric cancer for individuals with familial susceptibility to the disease. This patient-friendly technique may increase the number of health individuals who are carriers of germ-line mutations in the CDH1 (Ecadherin) gene. For these carriers, who face a very high T. Liakakos (&) Third Surgical Department, University of Athens, Athens, Greece e-mail: theodlia@otenet.gr

Surgical results of proximal gastrectomy for early-stage gastric cancer: jejunal interposition and gastric tube reconstruction.

BACKGROUND: The frequency of tumors in the upper one-third of the stomach has been increasing. The standard operation for proximal gastric cancer has been total or proximal gastrectomy. The aim of this study was to present the pathologic and surgical results of 30 patients with early-stage proximal gastric cancer managed by proximal gastrectomy.METHODS: A consecutive series of 30 patients who underwent proximal gastrectomy for early-stage proximal gastric cancer was studied. Sixteen patients underwent jejunal interposition, while 14 underwent gastric tube reconstruction, which consisted of a direct anastomosis between the esophagus and the remnant of the tube-like stomach.RESULTS: Twenty patients (67%) had no abdominal symptoms and the lesions were detected by screening gastric fiberscopy. The tumors were mostly located along the lesser curvature (73%), were grossly depressed type (IIc) (70%), and histologically well differentiated type (63%). The depth of wall invasion was the mucosa in 12 patients, submucosa in 15, and muscularis propria in 3; lymph node metastasis was absent in 28 patients (93%). When compared with patients with jejunal interposition, patients with gastric tube reconstruction had a shorter operation time (327 vs 165 min), less blood loss (508 vs 151 g), and shorter hospital stay after operation (31 vs 17 days). Endoscopy and 24-h pH monitoring showed no evidence of reflux esophagitis, except in 1 patient with gastric tube reconstruction, and no patient died of recurrence.CONCLUSIONS: Early-stage proximal gastric cancer can be successfully treated by proximal gastrectomy. Since gastric tube reconstruction is a simple, easy, and safe procedure, proximal gastrectomy followed by gastric tube reconstruction is recommended for patients with early-stage proximal gastric cancer.