Laparoscopic Gastrectomy Patients Research Articles

Beyond scalpels: A meta-analysis of robotic and laparoscopic gastrectomy in long-term oncological outcomes in gastric cancer.

e16125 Background: Gastric cancer persists as a substantial worldwide health concern, serving as a prominent contributor to both the incidence and fatalities associated with cancer. In this context, robotic gastrectomy (RG) and laparoscopic gastrectomy (LG) in patients with gastric cancer is a subject of extensive scientific investigation, reflecting the ongoing evolution of minimally invasive surgical techniques. RG has been posited as a potentially advantageous alternative to LG, as it is associated with improved precision and maneuverability, particularly in complex anatomical scenarios. Conversely, LG, with its established history and widespread adoption, is characterized by a shorter learning curve and potential cost advantages. Scientific literature suggests comparable outcomes between the two techniques, while others report divergent results in terms of operative time, blood loss, and complication rates. However, the impact of both techniques in long-term oncological outcomes remains unclear. Therefore, we aimed to perform a systematic review and meta-analysis for RG and LG for oncological outcomes in patients with gastric cancer. Methods: A systematic search was performed in PubMed, Cochrane and Embase in January 2024 for randomized controlled trials or observational studies comparing RG with LG in patients with gastric cancer. Risk ratios (RR) for binary outcomes with a 95% confidence interval (CI) were pooled and a p-value < 0.05 was considered statistically significant. Rayyan and Review Manager 5.3 software were selected, respectively, to manage the reported references and perform the statistical analysis of this study. Results: A total of 3727 results were screened, of which 13 were included in the meta-analysis, totalizing 25428 patients. There were no differences between RG and LG for 3-year overall survival (RR 1.03, 95% CI 1.00 - 1.06, I2 = 50%, p = 0.06), 3-year disease free survival (RR 1.01, 95% CI 0.95 - 1.06, I2 = 45%, p = 0.82), recurrence free survival (RR 0.51, 95% CI 0.22 - 1.20, I2 = 100%, p = 0.12), 5-year disease free survival (RR 1.02, 95% CI 0.99 - 1.05, I2 = 0%, p = 0.23), and ≥ 3-year overall survival (RR 1.02, 95% CI 1.00 - 1.05, I2 = 38%, p = 0.03). Conclusions: These findings from this comprehensive meta-analysis reveal a lack of discernible disparity between RG and LG in terms of oncological outcomes. The collective evidence suggests comparable results, emphasizing the need for continued research to refine our understanding and guide clinical decision-making in the pursuit of optimized patient care. These results contribute to the ongoing dialogue surrounding optimal treatment strategies for the assessed condition.

Increased postoperative complications after laparoscopic gastrectomy in patients with preserved ratio impaired spirometry

BackgroundPreserved ratio impaired spirometry (PRISm), defined as decreased forced expiratory volume in the first second in the setting of normal ratio, is associated with an increased risk of respiratory disease and systemic comorbidities. Unlike severe obstructive pulmonary disease, little is known about the impact of PRISm on short-term outcomes in patients undergoing laparoscopic gastrectomy (LG) and its association with small airway dysfunction (SAD). MethodsThis study enrolled 830 patients who underwent preoperative spirometry and LG between January 2021 and August 2023. Of these, 228 patients were excluded. Participants were categorized into 3 groups based on their baseline lung function, and postoperative outcomes were subsequently analyzed. Potential associations between postoperative outcomes and various clinical variables were examined using univariate and multivariate analyses. ResultsPRISm was identified in 16.6% of the patients, whereas SAD was present in 20.4%. The incidence of postoperative pulmonary complications (PPCs) was notably higher in the SAD group (20.3% vs 9.8%, P = .002) and the PRISm group (28.0% vs 9.8%, P < .001) than the normal group. Among the 3 groups, pneumonia was the most frequently observed PPC. Multivariate analysis revealed that both SAD (odds ratio [OR], 2.34; 95% CI, 1.30–4.22; P = .005) and PRISm (OR, 3.26; 95% CI, 1.80–5.90; P < .001) independently constituted significant risk factors associated with the occurrence of PPCs. Univariate analysis showed that female was a possible risk factor for PPCs in PRISm group. ConclusionOur study showed that PRISm and SAD were associated with the increased PPCs in patients undergoing LG for gastric cancer.

Usefulness of robotic camera control assisted duet laparoscopic gastrectomy in patients with gastric cancer

Usefulness of robotic camera control assisted duet laparoscopic gastrectomy in patients with gastric cancer

Laparoscopic vs. Robotic Gastrectomy in Patients with Situs Inversus Totalis: A Systematic Review.

Situs inversus totalis (SIT) is a rare genetic anomaly involving the mirror-image transposition of organs. This transposition can potentially make surgical treatments difficult because of the reversed anatomy and intraoperative confusion. The aim of this systematic review is to compare the perioperative outcomes and safety of robotic and laparoscopic gastrectomy in patients with SIT. We included full-text case reports with brief reviews and standalone case studies on SIT patients age ≥21, undergoing laparoscopic or robotic gastrectomy. We excluded case studies focusing on procedures other than laparoscopic and robotic gastrectomy, namely, open gastrectomy, gastric banding, and gastric bypass. English was selected as the language and articles published in the last 10 years were selected with a date range from Jan, 2011, to Aug, 2021. We focused on intraoperative and postoperative outcomes including blood loss, vascular aberrancy, operation duration, mortality, operative complications, duration of hospitalization, and follow-up interval. Online databases included Clinical Key, Embase, ScienceDirect, Ovid, and Google Scholar. The last search was conducted on Aug 15, 2021. For all eligible articles, risk of bias assessment was carried out using JBI critical appraisal checklist (Table 1). Continuous data were analyzed using t-test with p value of 0.05. From our search, we retained 29 case reports which reported information from 30 cases. The results reported in each study were summarized (Table 2). The laparoscopic procedure was used in 21 cases and robot-assisted surgery was used in 9 cases. Operative time was mentioned in 24 out of the 30 cases and the average operative time was 205.67 min. Blood loss was reported in 16 out of the 30 cases, with an average blood loss of 51.9 mL. Hospital stay information was provided in 26 out of the 30 cases, with an average length of stay of 8.5 days. A statistically significant difference was not found for the operative time, length of hospitalization, or age of the patient. However, intraoperative blood loss in robot-assisted gastrectomy was lower compared to laparoscopic gastrectomy, with a p value of 0.0293. Perioperative death was not reported in any of the cases. Only three cases of postoperative complications were reported in laparoscopic surgery. Only one of the three cases suggested that the complication was due to an anomaly, whereas the other two of them reported complications due to procedural errors. Laparoscopic and robotic gastrectomy can be safely used for SIT patients if performed cautiously. Some precautions include thoroughly assessing anatomical aberrations using preoperative imaging, adjusting the operative set up, and having experienced surgeons. The robotic approach may have a few advantages over laparoscopic procedures that may enhance the surgical safety for SIT patients and need to be further explored in future research. Advantages of the robotic approach may include improved surgical safety with better visualization of the surgical field, promoting the stability of surgical instruments and perhaps allowing ease of surgical orientation and positioning when operating on patients with SIT. Further research in this field is merited.

Short-term outcomes of robotic gastrectomy vs laparoscopic gastrectomy for patients with gastric cancer: A randomized clinical trial.

344 Background: Robotic gastrectomy (RG) procedure for gastric cancer (GC) patients may be associated with decreased incidence of intra-abdominal infectious complications. Prospective randomized controlled trials (RCTs) comparing laparoscopic gastrectomy (LG) and RG are required, however. We completed an RCT to compare short-term surgical outcomes of LG and RG for GC patients. Methods: This was a randomized, two-center clinical trial. All included patients are adults with primary carcinoma of the stomach, in whom the tumor is considered surgically resectable (cStage I-III). Included in this trial were 240 patients with GC. The primary endpoint was to assess the incidence of postoperative intra-abdominal infectious complications including pancreatic fistula, intra-abdominal abscess, and anastomotic leakage. Secondary endpoints included incidence of postoperative complications, surgical results, postoperative course, and oncological outcomes. Lymphadenectomy without touching the pancreas was basically performed during robotic gastrectomy using assisting articulating forceps. Results: A total of 241 patients were randomly assigned to the LG group (n = 122) or the RG group (n = 119), and 236 patients (LG119 RG117) were analyzed for ITT population. Overall incidence of intra-opereative infectious complications higher than Clavien-Dindo grade II were not significantly different (LG 8.4%, RG 6%). However, overall incidence of any complications higher than grade II were significantly lower in the RG group (19.3 vs 8.5% P = .019). In RG group, postoperative pancreatic fistula was not found. Amylase levels in drainage fluid on POD 1 were significantly lower in the RG group (893IU/L) than in the LG group (438 IU/L) ( P = 0.039). Conclusions: Regarding short-term surgical outcomes, RG is feasible, safe and ideal treatment procedure for GC. Our RG procedure without touching the pancreas may be associated with decreased incidence of postoperative pancreatic fistula. Clinical trial information: UMIN000031536 .

Relationship Between Fat Mass Indices and Postoperative Complications After Laparoscopic Gastrectomy in Patients With Gastric Cancer: A Propensity Score Matching Analysis.

Visceral adipose tissue index (VAI) and visceral-to-subcutaneous adipose tissue area ratio (VSR) are indices related to visceral fat mass, and intramuscular adipose tissue content (IMAC) is an index related to intramuscular fat. We investigated the impact of fat mass-related indices on the incidence of postoperative complications. Patients who underwent radical laparoscopic gastrectomy for c-stage I primary gastric cancer between April 2014 and December 2020 were included. We investigated the relationship between both VAI, VSR, IMAC and postoperative complications. For each value, the median was used as a cut-off point, the patients were divided into high- and low-fat groups, and background adjustments using propensity score matching analysis were used to compare these two groups. Of the 490 patients, 245 (50.0%) were in the high-VAI group, 243 (49.6%) in the high-VSR group, and 239 (48.8%) in the high-IMAC group. After matching, intra-abdominal abscess and pancreatic fistula were greater in the high-VAI group than those in the low-VAI group (p=0.081 and p=0.081, respectively), and were also significantly greater in the high-VSR group (p=0.012 and p=0.025, respectively). However, anastomotic leakage was greater in the high-IMAC group than in the low-IMAC group (p=0.050). VAI and VSR, which reflect visceral fat mass, were useful in predicting intra-abdominal infections, whereas IMAC, which reflects intramuscular fat, was useful in predicting anastomotic leakage. Preoperative prediction using a combination of these factors may aid clinical assessment of complication risk.

Impact of postoperative NSAIDs (IV-PCA) use on short-term outcomes after laparoscopic gastrectomy for the patients of gastric cancer.

Further data are necessary to evaluate the risk of complications associated with the use of non-steroidal anti-inflammatory drugs (NSAIDs) postoperatively. This study aimed to determine the correlation between the use of NSAIDs in intravenous patient-controlled analgesia (IV-PCA) and postoperative complications after laparoscopic gastrectomy in patients with gastric cancer. This retrospective, single-center study was conducted. The study population comprised 2150 patients who underwent laparoscopic gastrectomy for gastric cancer treatment. They were divided into two groups: non-NSAIDs (n = 1215) and NSAIDs (n = 935) according to their use of the drugs. Clinicopathologic characteristics, operative details, postoperative complications within 30days, risk factors for complications, and survival were analyzed. Of the 2150 patients, 935 (43.49%) used NSAIDs. The overall complication rate showed no significant difference between the NSAIDs and non-NSAIDs groups (22.7% vs. 20.7%, p = 0.280), while the rates of anastomotic leakage and duodenal leakage were higher in the NSAID group (2.4% vs. 0.7%, p = 0.002 and 1.8% vs. 0.6%, p = 0.007, respectively). The rates of intra-abdominal bleeding and intra-abdominal abscess were significantly higher in the NSAID group (2.1% vs. 0.7%, p = 0.005 and 1.5% vs. 0.4%, p = 0.008, respectively). However, postoperative ileus occurred more frequently in the non-NSAID group (3.0% vs. 1.4%, p = 0.015). On multivariate analysis, NSAID use was an independent risk factor for early postoperative complications (1.303 [1.042-1.629], p = 0.020). Meanwhile, the NSAID group showed no differences in overall survival at each pathological stage. Postoperative NSAID use by IV-PCA is associated with anastomotic leakage, duodenal stump leakage, intra-abdominal bleeding, and intra-abdominal abscess in patients who underwent laparoscopic gastrectomy for gastric cancer. Caution is advised when NSAIDs are used peri-operatively.

The safety and efficacy of laparoscopic gastrectomy for patients with locally advanced gastric cancer following neoadjuvant chemotherapy

Limited researches focused on the application of laparoscopic gastrectomy (LG) in locally advanced gastric cancer (LAGC) patients following neoadjuvant chemotherapy (NACT). In this study, we aimed at illustrating the surgical and survival outcome of LG in LAGC patients following NACT. We performed a retrospective study of patients with LAGC who received either LG following NACT or upfront LG at Fujian Provincial Hospital between March 2013 and October 2018. Perioperative parameters, short-term and long-term outcomes were compared. The Kaplan–Meier estimator was used to describe the survival curves, and the differences were examined by the log-rank test. In total, 76 consecutive patients were enrolled into the NACT-LG (41 patients) and LG (35 patients) group. The postoperative hospital stay was significantly longer for LG than for NACT-LG (11.0 vs. 12.0 day, P = 0.031). Significant difference was found in Grade ≥ III severe postoperative complications in two groups (0 vs. 17.1%, P = 0.001). No patient died of postoperative complications in the NACT-LG group, and one patient (1/35, 2.9%) died of postoperative complications in the LG group. A forest plot revealed that most subgroups of LG group were at great risks of postoperative complications. Compared with the LG group, the NACT-LG group had a significantly better DFS (14.4% vs. 5.7%, P = 0.0299) and better OS (34.1% vs. 8.6%, P = 0.0061) at 3 years. NACT increased the safety of LG for patients with LAGC and offer better disease-free and overall survival. For patients with LAGC, LG following NACT should be the priority treatment.

Gastric electric stimulator versus gastrectomy for the treatment of medically refractory gastroparesis.

Gastric electrical stimulation (GES) and laparoscopic gastrectomy (LG) are known therapeutic options for medically refractory gastroparesis (MRG) although there are limited data comparing their outcomes. We aim to compare clinical outcomes between patients undergoing GES vs upfront LG for the treatment of MRG while examining factors associated with GES failure and conversion to LG. We retrospectively analyzed 181 consecutive patients who underwent GES or LG for MRG at our institution from January 2003 to December 2017. Data collection consisted of chart review and follow-up telephone survey. Statistical analysis utilized Chi-squared, ANOVA, and multivariable logistic regression. Overall, 130 (72%) patients underwent GES and 51 (28%) LG as primary intervention. GES patients were more likely to have diabetic gastroparesis (GES 67% vs LG 39%, p &lt; 0.001), while primary LG patients were more likely to have post-surgical gastroparesis (GES 5% vs LG 43%, p &lt; 0.001). Postoperatively, primary LG patients had higher rates of major in-hospital morbidity events (GES 5% vs LG 18%, p = 0.017) and longer hospital stays (GES 3 vs LG 9days, p &lt; 0.001). However, over a mean 35-month follow-up period, there were no differences in the rates of major morbidity, readmissions, or mortality. Multivariable regression analysis revealed patients undergoing GES as a primary intervention were less likely to report improvement in symptoms on follow-up compared to primary LG patients OR 0.160 (95% CI 0.048-0.532). Additionally, patients who converted to LG from GES were more likely to have post-surgical gastroparesis as the primary etiology. GES as a first-line surgical treatment of MRG was associated with worse outcomes compared to LG. Post-surgical etiology was associated with an increased likelihood of GES failure, and in such patients, upfront gastrectomy may be a superior alternative to GES. Further studies are needed to determine patient selection for operative treatment of MRG.

Gastric cancer: Russian clinical guidelines

Gastric cancer remains one of the most common malignancies in Russia. Despite steady decrease of gastric cancer incidence it still reaches 24.65 per 100 000 population (crude rate) in 2019 with about 36 000 new cases annually. More than 29 000 people die of gastric cancer every year. High mortality rate is mostly caused by an extremely significant proportion of patients with metastatic disease which reached 40.1% in 2019. The majority of cases is related to Helicobacter pylori infection, salty diet, tobacco exposure as well as hereditary syndromes. Staging of locally advanced gastric cancer includes contrast-enhanced computed tomography of the thorax, abdomen and pelvis as well as diagnostic laparoscopy with peritoneal washings. In patients with inoperable or disseminated cancer of the stomach additional analysis for HER2, microsatellite instability and PD-L1 status is recommended. Endoscopic or laparoscopic resection remains the mainstay of treatment in patients with early cancer. Laparoscopic gastrectomy in patients with locally advanced cancer is reserved for high-volume centers with extensive experience with the procedure. Recently, perioperative cytotoxic therapy became the standard of treatment in patients with locally advanced gastric cancer. FLOT regimen is recommended while FOLFOX6 or XELOX are considered possible in the elderly or frail patients. Drug therapy includes standard doublet or triplet chemotherapy regimens for metastatic disease with trastuzumab for HER2(+++) patients. Patients with MSI-H tumors can be treated with pembrolizumab starting with 2nd line while nivolumab is reserved for the 3rd and further lines regardless of PD-L1 status. Importantly, this year guidelines include multimodal prehabilitation including physical exercise, nutritional support and psychological counselling as a possibility in all patients in need of surgery. Also standardized enhanced recovery protocols are recommended for usage during the perioperative period.

Effectiveness and safety of robotic gastrectomy versus laparoscopic gastrectomy for gastric cancer: a meta-analysis of 12,401 gastric cancer patients.

Advanced minimally invasive techniques, such as robotic surgeries, are applied increasingly frequently around the world and are primarily used to improve the surgical outcomes of laparoscopic gastrectomy (LG). Against that background, we conducted a meta-analysis to evaluate the feasibility, safety, and effectiveness of robotic gastrectomy (RG). Studies comparing surgical outcomes between LG and RG patients were retrieved from medical databases, including RCTs and non-RCTs. The primary outcome of this study was overall survival, which was obtained by evaluating the 3-year survival rate and the 5-year survival rate. In addition, postoperative complications, mortality, length of hospital stay, and harvested lymph nodes were also assessed. We also conducted subgroup analyses stratified by resection type, body mass index, age, depth of invasion and tumour size. Ultimately, 31 articles met the criterion for our study through an attentive check of each text, including 1 RCT and 30 non-RCTs. A total of 12,401 patients were included in the analysis, with 8127 (65.5%) undergoing LG and 4274 (34.5%) undergoing RG. Compared with LG, RG was associated with fewer postoperative complications (OR 0.81; 95% CI 0.71-0.93; P = 0.002), especially pancreas-related complications (OR 0.376; 95% CI 0.156-0.911; P = 0.030), increased harvested lymph nodes (WMD 2.03; 95% CI 0.95-3.10; P < 0.001), earlier time to first flatus (WMD -0.105days; 95% CI -0.207 to -0.003; P = 0.044), longer operation time (WMD 40.192min, 95% CI 32.07-48.31; P < 0.001), less intraoperative blood loss (WMD -20.09ml; 95% CI -26.86 to -13.32; P < 0.001), and higher expense (WMD 19,141.68 RMB; 95% CI 11,856.07-26,427.29; P < 0.001). There was no significant difference between RG and LG regarding 3-year overall survival (OR 1.030; 95% CI 0.784-1.353; P = 0.832), 5-year overall survival (OR 0.862; 95% CI 0.721-1.031; P = 0.105), conversion rate (OR 0.857; 95% CI 0.443-1.661; P = 0.648), postoperative hospital stay (WMD -0.368days; 95% CI -0.75-0.013; P = 0.059), mortality (OR 1.248; 95% CI 0.514-3.209; P = 0.592), and reoperation (OR 0.855; 95% CI 0.479-1.525; P = 0.595). Our study revealed that postoperative complications, especially pancreas-related complications, occurred less often with RG than with LG. However, long-term outcomes between the two surgical techniques need to be further examined, particularly regarding the oncological adequacy of robotic gastric cancer resections.

Safe implementation of robotic gastrectomy for gastric cancer under the requirements for universal health insurance coverage: a retrospective cohort study using a nationwide registry database in Japan.

BackgroundRobotic gastrectomy (RG) has increased since being covered by universal health insurance in 2018. However, to ensure patient safety the operating surgeon and facility must meet specific requirements. We aimed to determine whether RG has been safely implemented under the requirements for universal health insurance in Japan.MethodsData of consecutive patients with primary gastric cancer who underwent minimally invasive total or distal gastrectomy—performed by a surgeon certified by the Japan Society for Endoscopic Surgery (JSES) endoscopic surgical skill qualification system (ESSQS) between October 2018 and December 2019—were extracted from the gastrointestinal surgery section of the National Clinical Database (NCD). The primary outcome was morbidity over Clavien–Dindo classification grade IIIa. Patient demographics and hospital volume were matched between RG and laparoscopic gastrectomy (LG) using propensity score-matched analysis (PSM), and the short-term outcomes of RG and LG were compared.ResultsAfter PSM, 2671 patients who underwent RG and 2671 who underwent LG were retrieved (from a total of 9881), and the standardized difference of all the confounding factors reduced to 0.07 or less. Morbidity rates did not differ between the RG and LG patients (RG, 4.9% vs. LG, 3.9%; p = 0.084). No difference was observed in 30-day mortality (RG, 0.2% vs. LG, 0.1%; p = 0.754). The reoperation rate was greater following RG (RG, 2.2% vs. LG, 1.2%; p = 0.004); however, the duration of postoperative hospitalization was shorter (RG, 10 [8–13] days vs. LG, 11 [9–14] days; p < 0.001).ConclusionsInsurance-covered RG has been safely implemented nationwide.

Impact of non-curative endoscopic submucosal dissection on short- and long-term outcome of subsequent laparoscopic gastrectomy for pT1 gastric cancer

The feasibility and oncological safety of non-curative endoscopic submucosal dissection (ESD) prior to additional gastrectomy for early gastric cancer (EGC) are still unclear. The aim of this study was to evaluate the impact of non-curative ESD on short- and long-term outcomes of subsequent laparoscopic gastrectomy (LG) for pathological T1 (pT1) EGC. We retrospectively investigated 422 patients who underwent LG for pT1 EGC between January 2007 and December 2017 at our center. Eighty-five of these patients underwent ESD with curative intent before surgery. Using propensity-score matching for sex, age, body mass index, American society of anesthesiologists score, history of previous abdominal surgery, tumor location, mucosal/submucosal infiltration, histology, lymph node metastasis, extent of lymph node dissection, operative method, lymphatic invasion, and venous invasion, the clinicopathologic and survival data of these patients were compared. The median follow-up period was 60 (range 2-168) months. Using propensity-score matching from a total of 422 patients, 75 patients were selected in the Non-ESD and the ESD cohorts each. There were no significant differences in terms of characteristics and clinicopathological findings between the two groups. Furthermore, there were no significant differences in postoperative morbidity (13.3% vs. 17.3%; P = 0.497) and mortality (1.3% vs. 0%; P = 0.316). Both the 5-year overall survival ratio (88.8% vs. 86.9%; P = 0.757) and 5-year disease-specific survival ratio (97.1% vs. 98.4%; P = 0.333) were similar in the two groups. Short- and long-term outcomes of LG in patients with pT1 EGC are not related to preoperative ESD history. Even for non-curative resections, ESD prior to surgery is feasible in terms of oncological and surgical outcomes in pT1 EGC.

Short-term Outcomes of Robotic Gastrectomy vs Laparoscopic Gastrectomy for Patients With Gastric Cancer

Robotic gastrectomy (RG) for gastric cancer may be associated with decreased incidence of intra-abdominal infectious complications, including pancreatic fistula, leakage, and abscess. Prospective randomized clinical trials comparing laparoscopic gastrectomy (LG) and RG are thus required. To compare the short-term surgical outcomes of RG with those of LG for patients with gastric cancer. In this phase 3, prospective superiority randomized clinical trial of RG vs LG regarding reduction of complications, 241 patients with resectable gastric cancer (clinical stages I-III) were enrolled between April 1, 2018, and October 31, 2020. LG vs RG. The primary end point was the incidence of postoperative intra-abdominal infectious complications. Secondary end points were incidence of any complications, surgical results, postoperative courses, and oncologic outcomes. The modified intention-to-treat population excluded patients who had been randomized and met the postrandomization exclusion criteria. There was also a per-protocol population for analysis of postoperative complications. This study enrolled 241 patients, with 236 patients in the modified intention-to-treat population (150 men [63.6%]; mean [SD] age, 70.8 [10.7] years). There was no significant difference in the incidence of intra-abdominal infectious complications (per-protocol population: 10 of 117 [8.5%] in the LG group vs 7 of 113 [6.2%] in the RG group). Of 241 patients, 122 were randomly assigned to the LG group, and 119 patients were randomly assigned to the RG group. Two of the 122 patients (1.6%) in the LG group converted from LG to open surgery, and 4 of 119 patients (3.4%) in the RG group converted from RG to open or laparoscopic surgery, with no significant difference. Finally, 117 patients in the LG group completed the procedure, and 113 in the RG group completed the procedure; these populations were defined as the per-protocol population. The overall incidence of postoperative complications of grade II or higher was significantly higher in the LG group (23 [19.7%]) than in the RG group (10 [8.8%]) (P = .02). Even in analysis limited to grade IIIa or higher, the complication rate was still significantly higher in the LG group (19 [16.2%]) than in the RG group (6 [5.3%]) (P = .01). This study found no reduction of intra-abdominal infectious complications with RG compared with LG for gastric cancer. umin.ac.jp/ctr Identifier: UMIN000031536.

Impact of chronic kidney disease on the short- and long-term outcomes of laparoscopic gastrectomy for gastric cancer patients

BackgroundsThis study was undertaken to investigate the impact of coexisting chronic kidney disease (CKD) on short- and long-term outcomes of laparoscopic gastrectomy in patients with gastric cancer (GC).MethodsWe reviewed the data of 798 patients treated for GC by laparoscopic gastrectomy. All procedures took place between January 2010 and December 2017. Patients were divided into three groups according to their estimated glomerular filtration rate (eGFR): severe CKD group, 44 patients with eGFR < 45 mL/min/1.73 m2; moderate CKD group, 117 patients with 45 ≤ eGFR < 60; control group, 637 patients with eGFR ≥ 60.ResultsBased on multivariate analysis, severe CKD (eGFR < 45) emerged as an independent predictor of anastomotic leak (Hazard ratio 4.63, 95% confidence interval [CI] 1.62–11.54). The 5-year overall survival (OS) rates by group were 46.3% (severe CKD), 76.6% (moderate CKD), and 81.5% (control). Multivariate analysis likewise identified severe CKD (eGFR < 45) as an independent correlate of poor 5-year OS. The 5-year cancer-specific survival (CSS) rates did not differ significantly by group.ConclusionsAn eGFR value less than 45 mL/min/1.73 m2 is a useful factor for predicting both anastomotic leak and 5-year OS in GC patients undergoing laparoscopic gastrectomy. Clinical care to improve eGFR should be reinforced before and after gastrectomy for GC patients with severe CKD.

Randomized controlled phase III trial to investigate superiority of robot-assisted gastrectomy over laparoscopic gastrectomy for clinical stage T1-2N0-2 gastric cancer patients: Japan Clinical Oncology Group study JCOG1907 (MONA LISA study).

TPS254 Background: Postoperative complications reportedly affect oncological outcomes in various cancers according to the timing of adjuvant chemotherapy and by influencing the immune function. Particularly, postoperative intra-abdominal infectious complications, including intra-abdominal abscess, pancreatic fistula, and anastomotic leakage, have been identified as prognostic factors for gastric cancer. Given the negative impact of such complications on patient survival, considering the short- and long-term outcomes, it is important to develop surgical procedures with fewer complications. In Japan, laparoscopic gastrectomy is a standard treatment modality for early gastric cancer. Randomized controlled trials have shown that laparoscopic gastrectomy is relatively less invasive and has similar postoperative complications and non-inferior patient survival rates when compared with open gastrectomy. However, several challenges associated with the procedure need to be overcome, such as the limited movement of the forceps. Robot-assisted gastrectomy allows surgeons to perform more meticulous surgical interventions with articulated devices; therefore, reducing the possibility of postoperative complications, as demonstrated by a few prospective studies performed in Japan. However, a non-randomized controlled trial conducted in Korea reported that there were no benefits of robot-assisted gastrectomy in terms of postoperative complications. Furthermore, no randomized controlled trials have directly compared robot-assisted and laparoscopic gastrectomy to provide solid evidence regarding the merits of the former. Methods: To confirm the superiority of robot-assisted gastrectomy over laparoscopic gastrectomy for patients with cT1-2N0-2M0 gastric cancer, we designed JCOG1907 (UMIN000039825) as a multicenter randomized phase III trial. In the standard arm, we performed laparoscopic gastrectomy with lymphadenectomy, while in the experimental arm, we performed robot-assisted gastrectomy with lymphadenectomy. The primary endpoint is the incidence of postoperative intra-abdominal infectious complications of Clavien–Dindo classification grade ≥II. Major secondary endpoints are relapse-free survival, overall survival, overall postoperative complications, and short-term clinical outcomes after gastrectomy. The planned sample size is 1040 participants, with a one-sided alpha of 5% and a power of 70%, with an expected 3% decrease in postoperative intra-abdominal infectious complications (6% vs. 3%). Over the period of 5 years, patients will be enrolled from 35 Japanese institutions. Enrollment has started in March 2020, and as of August 2020, 30 patients have already been enrolled. Clinical trial information: UMIN000039825.

Long-Term Oncological Outcomes of Reduced Three-Port Laparoscopic Gastrectomy for Early-Stage Gastric Carcinoma: a Retrospective Large-Scale Multi-Institutional Study.

PurposeWith advances in surgical techniques, reduced-port laparoscopic surgery is increasingly being performed for the treatment of gastric carcinoma. Many studies have reported satisfactory short-term outcomes after reduced 3-port laparoscopic gastrectomy (LG). The aim of this study was to investigate the long-term oncological outcomes of 3-port LG in patients with gastric carcinoma.Materials and MethodsWe reviewed the medical records of 1,117 patients who underwent LG for gastric carcinoma in three major institutions between 2012 and 2015. The data showed that 460 patients underwent 3-port LG without assistance, and 657 underwent conventional 5-port LG. We compared the overall and disease-free survival rates between the 2 groups.ResultsThere were 642 male and 475 female patients with a mean age of 56.1 years. Among them, 1,028 (92.0%) underwent distal gastrectomy and 89 (8.0%) underwent total gastrectomy. In the final pathologic examination, 1,027 patients (91.9%) were stage I, 73 (6.5%) were stage II, and 17 (1.5%) were stage III, and there were no significant difference in the pathologic stage between groups. The 3- and 5-port LG groups showed no significant differences in the 5-year overall survival (94.3% vs. 96.7%, P=0.138) or disease-free survival (94.3% vs. 95.9%, P=0.231). Stratified analyses according to pT and pN stages also showed no significant differences in overall or disease-free survival between the two groups.ConclusionsLong-term survival after 3- and 5-port LG was comparable in patients with early-stage gastric carcinoma. The 3-port technique requiring limited surgical assistance may be an appropriate surgical option for this patient population.

Propensity-score-matching-based analysis of laparoscopic gastrectomy with neoadjuvant chemotherapy for gastric carcinoma.

Neoadjuvant chemotherapy (NAC) is widely accepted as a potential treatment for advanced gastric cancer (AGC). Laparoscopic gastrectomy (LG) has recently been performed for advanced gastric cancer and could lead to improved adherence to multimodal treatment. In the present study, we compared the feasibility and outcomes of LG in patients with or without NAC in our institution. We assessed patients who underwent LG with (n=185) or without (n=1204) NAC between 1997 and 2013. We used propensity score matching to evaluate perioperative short-term outcomes and long-term outcome. We used propensity score matching by patient background and treatment-rerated factors to establish two groups of 157 patients with or without NAC. There were no significant differences in perioperative short-term outcomes or long-term outcome between the groups. LG for selected patients with NAC is feasible and safe but has no long-term survival benefit.

Pooled analysis of the oncological outcomes in robotic gastrectomy versus laparoscopic gastrectomy for gastric cancer.

Aim:Robotic gastrectomy (RG) is more and more widely used in the treatment of gastric cancer. However, the long-term oncological outcomes of RG have not been well evaluated. The aim of this study was to evaluate the long-term oncological outcomes of RG and laparoscopic gastrectomy (LG) in the treatment of gastric cancer.Materials and Methods:PubMed, China National Knowledge Infrastructure, Cochrane Library and EMBASE electronic databases were searched until August 2019. Eligible studies were analysed for comparison of oncological outcomes between RG and LG in patients with gastric cancer.Results:Eleven retrospective comparative studies, which included 1347 (32.52%) patients in the RG group and 2795 (67.48%) patients in the LG group, were selected for the analysis. Meta-analysis of the 11 included studies showed that there was no statistically significant difference in the OS between the RG and LG groups (hazard ratios [HRs] = 0.97, 95% confidence intervals [CIs] = 0.80–1.19, P = 0.80). Six studies evaluated disease-free survival (DFS), and pooled analysis showed that there was no statistically significant difference in DFS between RG group and LG group (HR = 0.94, 95% CIs = 0.72–1.23, P = 0.65). According to the odds ratio (OR) analysis, there was no significant difference in 3-year OS, 5-year OS, 3-year DFS and 5-year DFS between the RG and LG groups. Nine articles reported the recurrence rate, and the meta-analysis showed that there was no statistically significant difference between the RG and LG groups (OR = 0.88, 95% CIs = 0.69–1.12, P = 0.31).Conclusions:This meta-analysis indicated that the long-term oncological outcomes in the RG group were similar to that in the LG group.

Laparoscopic approach to early gastric cancer in a patient with a prior history of open right hepatectomy: a case report

BackgroundLaparoscopic gastrectomy is regarded a standard treatment procedure for early gastric cancer and is widely used in clinical practice. However, the feasibility of laparoscopic gastrectomy for patients with a prior history of open surgery, especially in the case of a complicated operation, remains unclear. Here, we report a laparoscopic gastrectomy case with a prior history of right hepatectomy.Case presentationA 70-year-old man was diagnosed with early gastric cancers preceding a right hepatectomy for a solitary hepatocellular carcinoma at risk of rupture. An additional gastrectomy, after non-curative endoscopic submucosal dissection, was planned after the hepatectomy. Extensive adhesions were found around the liver. Rigid adherence of the duodenum to the adjacent hepatoduodenal ligament had formed. In addition, identification of the hepatic artery was difficult due to stiffening of the mesentery. Peeling off the adhesions from the ventral side of the duodenum revealed the supra-pyloric vessels and enabled us to transect the duodenum safely. Further, exposing the proper hepatic artery via the dorsal side of the mesentery and subsequent supra-pancreatic dissection on the outermost layer allowed effective identification of the right gastric artery. The postoperative course was uneventful.ConclusionsWe successfully performed total laparoscopic distal gastrectomy on a patient with a prior history of major hepatectomy.