Open Distal Gastrectomy Research Articles

Long-Term Outcomes of Open Versus Laparoscopic Distal Gastrectomy for T4a Gastric Cancer: A Propensity Score-Matched Cohort Study.

Laparoscopic gastrectomy for advanced gastric cancer (GC) has been applied more frequently worldwide but is still controversial for patients with serosal invasion (T4a). This study compared short- and long-term outcomes of laparoscopic distal radical gastrectomy (LDG) with open distal gastrectomy (ODG) for T4a GC. We retrospectively studied 472 patients with T4a gastric adenocarcinoma in the lower or middle third of the stomach: 231 underwent LDG and 241 underwent ODG between 2013 and 2020. Short-term outcomes included operative characteristics and complications. Long-term outcomes included overall survival (OS) and disease-free survival (DFS). Propensity score-matched (PSM) analysis was used to adjust for imbalances in baseline characteristics between groups. The PSM strategy resulted in 294 patients (147 in each group). The LDG group had a significantly longer operating time (mean: 200 vs 190 min, p = 0.001) but reduced blood loss (mean: 50 vs 100 ml, p = 0.001). The LDG group had a higher rate of any postoperative complication (23.1% vs 12.2%, p = 0.021) but most were classified as grades I-II according to Clavien-Dindo classification. Grade III-V complications were similar between groups. Five-year OS was 69% versus 60% (p = 0.109) and 5-year DFS was 58% vs 53% (p = 0.3) in LDG and ODG groups, respectively. For tumor size < 5 cm, LDG was better in reduction of blood loss, postoperative hospital length of stay, and OS. LDG is feasible and safe for patients with T4a GC and is comparable to ODG regarding short- and long-term outcomes. Furthermore, LDG can be a favorable option for T4a GC smaller than 5 cm.

Laparoscopic versus open distal gastrectomy for elderly patients with advanced gastric cancer: a retrospective comparative study

BackgroundLaparoscopic radical distal gastrectomy (LDG) has been more frequently performed for locally advanced distal gastric cancer (AGC) than open distal gastrectomy (ODG). However, the benefits of LDG for elderly AGC patients (AGC-lap) remain unclear.MethodsPatients aged ≥ 70 years who underwent D2 distal gastrectomy from July 2014 to July 2021 were enrolled consecutively. Perioperative parameters, pathological features, and oncological outcomes of AGC-lap patients (n = 39) were compared with those of elderly AGC patients receiving ODG (AGC-open; n = 37) and elderly early gastric cancer patients receiving LDG (EGC-lap; n = 41) respectively.ResultsThe median age of all AGC patients was 77 years, and 28% of them had an Eastern Cooperative Oncology Group score ≥ 2. Most of the perioperative and pathological features (including the number of lymph nodes harvested) were similar between the AGC-lap and AGC-open groups. AGC-lap patients had longer median operative times (215 min versus 192 min) but significantly less surgical complications (10.3% versus 37.8%) and shorter median hospital stays (11 days versus 13 days) than did AGC-open patients (all p < 0.05). The 3-year recurrence-free and overall survival was 66.2% and 88.8% in the AGC-lap group and 51% and 66.3% in the AGC-open group (both p = 0.1). The perioperative features, including operative time, number of lymph nodes harvested, hospital stay, and complication rates, were similar between the AGC- and EGC-lap groups.ConclusionsLDG was safely and effectively performed in elderly AGC patients, resulting in faster recovery and a lower complication rate than ODG, without compromising oncological outcomes.

Laparoscopic vs Open Distal Gastrectomy for Locally Advanced Gastric Cancer

The long-term safety of laparoscopic distal gastrectomy for locally advanced gastric cancer (AGC) remains uncertain given the lack of 5-year follow-up results. To compare the 5-year follow-up results in patients with clinically AGC enrolled in the Korean Laparoendoscopic Gastrointestinal Surgery Study (KLASS)-02 randomized clinical trial who underwent laparoscopic or open distal gastrectomy. The KLASS-02, a multicenter randomized clinical trial, showed that laparoscopic surgery was noninferior to open surgery for patients with locally AGC. The present study assessed the 5-year follow-up results, including 5-year overall survival (OS) and relapse-free survival (RFS) rates and long-term complications, in patients enrolled in KLASS-02. From November 21, 2011, to April 29, 2015, patients aged 20 to 80 years diagnosed preoperatively with locally AGC were enrolled. Final follow-up was on June 15, 2021. Data were analyzed June 24 to September 9, 2021. Patients were treated with R0 resection either by laparoscopic gastrectomy or open gastrectomy as the full analysis set of the KLASS-02 trial. Five-year OS and RFS rates, recurrence patterns, and long-term surgical complications were evaluated. This study enrolled a total of 1050 patients. A total of 974 patients were treated with R0 resection; 492 (50.5%) in the laparoscopic gastrectomy group (mean [SD] age, 59.8 [11.0] years; 351 men [71.3%]) and 482 (49.5%) in the open gastrectomy group (mean [SD] age, 59.4 [11.5] years; 335 men [69.5%]). In patients who underwent laparoscopic and open distal gastrectomy, the 5-year OS (88.9% vs 88.7%) and RFS (79.5% vs 81.1%) rates did not differ significantly. The most common types of recurrence were peritoneal carcinomatosis (73 of 173 [42.1%]), hematogenous metastases (36 of 173 [20.8%]), and locoregional recurrence (23 of 173 [13.2%]), with no between-group differences in types of recurrence at each cancer stage. The correlation between 3-year RFS and 5-year OS at the individual level was highest in patients with stage III gastric cancer (ρ = 0.720). The late complication rate was significantly lower in the laparoscopic than in the open surgery group (32 of 492 [6.5%] vs 53 of 482 [11.0%]). The most common type of complication in both groups was intestinal obstruction (13 of 492 [2.6%] vs 24 of 482 [5.0%]). The 5-year outcomes of the KLASS-02 trial support the 3-year results, which is the noninferiority of laparoscopic surgery compared with open gastrectomy for locally AGC. The laparoscopic approach can be recommended in patients with locally AGC to achieve the benefit of low incidence of late complications. ClinicalTrials.gov Identifier: NCT01456598.

Extramedullary hematopoiesis in gastric wall under early gastric cancer in a man with a myeloproliferative disorder: a case report

Extramedullary hematopoiesis (EMH) is the proliferation of hematopoietic stem cells outside the bone marrow and often observed in the liver, spleen in association with myeloproliferative disorders. On the other hand, EMH in the gastric wall is extremely rare. We report a rare case of EMH foci coexisting with early gastric cancer, which resulted in severe gastrointestinal bleeding. A 70-year-old male was diagnosed with myelofibrosis 4 years ago and visited our emergency room with a complaint of hematemesis and tarry stools. Upper gastrointestinal endoscopy revealed three early-stage gastric cancers in the lower gastric body and antrum, and biopsy was performed. Persistent bleeding at the biopsy site of the hypogastric lesion led to the consideration of surgical intervention. An open distal gastrectomy was performed. Postoperative histopathological examination revealed the tumor of the lower gastric body had EMH foci associated with myelofibrosis.

The Influences of Obesity in Laparoscopic and Open Distal Gastrectomy for Patients with Early Gastric Cancer.

A recent increase in the number of surgeries performed on obese patents has raised several issues. In this study, we examined the effects of obesity on laparoscopic and open distal gastrectomy. A total of 262 patients with gastric cancer (cStage I) who underwent distal gastrectomy were classified into open distal gastrectomy (ODG) (145 patients) and laparoscopic distal gastrectomy (LDG) (117 patients) groups. According to their body mass index (BMI), they were subdivided into obese (BMI ≥ 25) and non-obese patients (BMI < 25) to examine the duration of surgery, blood loss, the number of lymph node dissections, postoperative hospital stay, and incidence of postoperative complications. The duration of surgery was longer and blood loss was higher for obese patients than for non-obese patients in both groups. The results for these two endpoints were significantly reduced in the LDG group than in the ODG group both in obese and non-obese patients. Furthermore, the number of lymph nodes dissected tended to be higher in the LDG group than in the ODG group in obese patients. Postoperative hospital stay was not significantly different between obese and non-obese patients in both groups, but was significantly shorter in the LDG group than in the ODG group regardless of the body weight. The incidence of postoperative complications was significantly higher in obese patients than in non-obese patients, although the difference between the groups was not significant. These findings indicate that LDG may be useful for obese patients with cStage I gastric cancer.

137: LAPAROSCOPIC DISTAL GASTRECTOMY: JUST AN OPTION OR THE NEW GOLD STANDARD FOR ELDERLY PATIENTS?

Abstract Background and aim The application of laparoscopy in elderly patients with gastric cancer is controversial, especially in Western population. The aim of the study is to evaluate the feasibility of a laparoscopic approach and compare short-term outcomes with results obtained using traditional open surgery. Methods Data concerning 52 elderly patients (≥70 years), who underwent distal gastrectomy at our institution from January 2017 to August 2020, were retrospectively analyzed. We divided the population into two cohorts according to the surgical technique (laparoscopic or open surgery) and we compared the short-term outcomes. The open and laparoscopic cohorts were compared in terms of demographics, ASA score, pTNM stage, the pathological pattern according to Lauren classification, time of surgery, selected type of gastrointestinal reconstruction, the extension of lymphadenectomy and number of lymph nodes resected, postoperative complications classified according to modified Clavien-Dindo system, length of stay (LOS), postoperative mortality within 30 days. Univariate and multivariate analyses were performed for length of stay, including age, sex, duration of surgery, BMI, technique, tumor localization, grading, reconstruction, ASA, Lauren stage, extension of lymphadenectomy, TNM stage, and neoadjuvant chemotherapy as variables. Results Demographics, pathological characteristics and surgical outcomes were comparable in both cohorts, except for the length of hospital stay (LOS) that was significative longer in the open cohort (12,31 vs 8,42 P = 0.02). Number of harvested lymph nodes and complete resection (R0) rate were similar, leading to comparable oncological results. Based on the univariate analysis, in addition to the approach, ASA score was another factor significantly associated to LOS (ASA 2 8,4 ± 2,1 days vs ASA 3 13,5 ± 7,8 days). A multiple regression was run to predict LOS from ASA and surgical approach. The multiple regression model statistically significantly predicted LOS, F(3,44) = 6,906, P &amp;lt; 0,002. The surgical approach showed a certain trend to significance in predicting LOS, P = 0,09. Conclusion Laparoscopic distal gastrectomy is effective and safe in elderly patients with similar short-term outcomes compared to open distal gastrectomy. The main advantage of laparoscopic technique is a shorter length of hospital stay.

Comparison of estimated treatment effects between randomized controlled trials, case-matched, and cohort studies on laparoscopic versus open distal gastrectomy for advanced gastric cancer: a systematic review and meta-analysis.

In actual surgical research, case-matched studies are frequently conducted as an alternative to randomized controlled trials (RCTs). However, it is still unclear what differences there are between RCTs and case-matched studies in upper gastrointestinal surgery, and clarifying them is a very important clinical issue. Thus, the purpose of this study was to investigate estimated treatment effects between RCTs, case-matched studies, and cohort studies regarding laparoscopic distal gastrectomy (LDG) for advanced gastric cancer (AGC). We searched the PubMed, Cochrane Central Register of Controlled Trials, and Web of Science databases for studies that compared LDG versus open distal gastrectomy for AGC published from the inception of the databases until July 2021. A meta-analysis was performed using the Review Manager version 5.3 software program from the Cochrane Collaboration, and six short-term outcomes and three long-term outcomes were assessed. Twenty-three studies with 13698 patients were included. There was no difference in estimated treatment effects between RCTs and case-matched studies for all outcomes except for the number of retrieved lymph nodes and postoperative complications. In terms of intraoperative blood loss, postoperative hospital stay, number of retrieved lymph nodes, and recurrence, observational studies tended to overestimate the treatment effects. The estimated treatment effects of LDG for AGC in the case-matched study were almost the same as in the RCTs. However, to assess the true magnitude of the treatment effect, the design and actual implementation of the analysis must be critically evaluated.

Short- and long-term outcomes of laparoscopic distal gastrectomy versus open distal gastrectomy for gastric cancer in overweight patients.

Gastrectomy for gastric cancer in overweight patients is associated with a high incidence of postoperative complications and difficulties in achieving adequate lymph node dissection. We conducted this study to compare the outcomes of laparoscopic and open distal gastrectomy (ODG) for gastric cancer in overweight Japanese patients. This retrospective study analyzed data from 180 patients with a body mass index ≥ 25 who underwent distal gastrectomy for pStage I-III gastric cancer. Postoperative complications, the number of harvested lymph nodes, and long-term survival were compared between ODG and laparoscopic distal gastrectomy (LDG). Postoperative complications of Clavien-Dindo (CD) grade ≥ 2 and ≥ 3 were significantly higher after ODG than after LDG (p < 0.001 and p = 0.004). Multivariate analysis identified age and ODG as factors related to complications of CD ≥ 2 (p = 0.014 and 0.002). The number of harvested lymph nodes at region 4sb was significantly higher in LDG for patients with pStage III disease. The 5-year lymph node recurrence-free survival tended to be better in LDG; however, no difference was found between ODG and LDG at any pathological stage. There were no significant differences in the 5-year overall and recurrence-free survival rates after ODG vs. LDG. LDG for gastric cancer appears to be associated with a lower incidence of postoperative complications than ODG, without compromising long-term survival, even for overweight patients.

Patient with gastric cancer who underwent distal gastrectomy after treatment of COVID-19 infection diagnosed by preoperative PCR screening

BackgroundBecause of the coronavirus disease 2019 (COVID-19) pandemic, preoperative screenings for COVID-19 infection are often performed in many institutions. Some patients are diagnosed with COVID-19 infection by antigen tests or polymerase chain reaction (PCR) testing for COVID-19, even if they have no symptoms, such as fever or respiratory symptoms. We herein describe a patient with gastric cancer who underwent distal gastrectomy 6 weeks after recovering from COVID-19 infection diagnosed by preoperative PCR.Case presentationAn 86-year-old man was transferred to our hospital because of hematemesis and melena. A hemorrhagic gastric ulcer was found in the lesser curvature of the antrum by emergency endoscopy. Endoscopic hemostasis was performed, and he was discharged after recovery. A tumor-like lesion in the lesser curvature of the antrum was found on repeat endoscopy and was diagnosed as well-differentiated adenocarcinoma by biopsy. There was no evidence of lymph node metastasis or distant metastasis; therefore, we planned radical surgery. However, he was diagnosed with COVID-19 infection by preoperative PCR screening. Although he had no symptoms, such as fever or respiratory symptoms, he was hospitalized because of his advanced age. He was discharged 10 days after admission, and repeat COVID-19 PCR was negative. We planned radical surgery for the stomach tumor 6 weeks after recovery from the COVID-19 infection. A PCR-negative COVID-19 status was confirmed again before hospitalization. Open distal gastrectomy with Billroth I reconstruction was performed. We avoided ultrasonic scalpels and used a Crystal Vision 450D surgical smoke evacuator (I.C. Medical, Inc., Phoenix, AZ, USA) to reduce intraoperative surgical smoke. The postoperative course was uneventful.ConclusionBecause of the COVID-19 pandemic, some patients are diagnosed with COVID-19 infection by preoperative antigen tests or PCR, even if they have no symptoms. If possible, elective surgery should be performed 4 to 6 weeks after recovery from COVID-19 infection to maximize safety. Moreover, surgeons must consider intraoperative surgical smoke.

Comparative characteristics of laparoscopic and open distal gastrectomy in cancer of the antrum

<h3>ЦЕЛЬ ИССЛЕДОВАНИЯ</h3> Сравнительный анализ непосредственных результатов лапароскопических и лапаротомных дистальных резекций желудка при раке его антрального отдела. <h3>МАТЕРИАЛ И МЕТОДЫ</h3> <i></i> Проанализированы непосредственные результаты 42 лапароскопических резекций желудка и 45 лапаротомных резекций желудка. Средний возраст пациентов составил<i></i> 63,7±6,3 года в группе лапароскопических резекций желудка и 65,1±5,8 года в группе лапаротомных резекций желудка. <h3>РЕЗУЛЬТАТЫ</h3> Лапароскопические и лапаротомные резекции желудка не различаются по количеству удаляемых лимфатических узлов (21,2±5,1 и 21,3±5,6 соответственно; <i>t</i>=0,01; <i>p</i>=0,98). При этом лапароскопические операции сопровождаются меньшей интраоперационной кровопотерей (90,3±51,2 мл против 130±71,5 мл при лапаротомном доступе; <i>t</i>=2,45; <i>p</i>=0,04), а лапаротомные менее продолжительны (126,8±68,3 мин и 190,4±45,5 мин при лапароскопическом доступе, однако различия статистически незначимы; <i>t</i>=0,77; <i>p</i>=0,28). Период стационарного лечения короче после лапароскопических резекций (7,6±3,2 сут и 14,2±6,6 сут при лапаротомном доступе; <i>t</i>=2,9; <i>p</i>=0,04). Различия по частоте развития послеоперационных осложнений (стратифицированных в соответствии со шкалой Clavien—Dindo и составляющих 31,8% для лапароскопической резекции желудка и 35,7% для лапаротомного оперативного вмешательства) статистически незначимы (χ²=0,2; <i>p</i>=0,65). Различия по частоте наступления летальных исходов после оперативного вмешательства (4,7% для лапароскопических операций и отсутствующих в группе лапаротомных вмешательств) статистически незначимы; <i>F</i>=0,23; <i>p</i>=0,55. <h3>ЗАКЛЮЧЕНИЕ</h3> <i></i> Лапароскопическая субтотальная дистальная резекция желудка является эффективным оперативным вмешательством при раке антрального отдела желудка, характеризующаяся приемлемой частотой развития послеоперационных осложнений и послеоперационной летальности, при этом отличающейся от «традиционных» резекций желудка известными преимуществами лапароскопических технологий оперирования.

Open distal gastrectomy versus laparoscopic distal gastrectomy for early gastric cancer: a retrospective study.

Laparoscopic distal gastrectomy (LDG) is gaining popularity because its early postoperative effect has been shown to be better than open distal gastrectomy (ODG). However, to our knowledge, there are no studies demonstrating ODG is oncologically equivalent to LDG. This is a retrospective study based on the prospectively maintained database of the People's Hospital of Jinan City. Patients with operable, pathologically confirmed early-stage gastric cancer were included, while those with advanced disease or carcinoma in situ were excluded. Extracted data included age, body mass index (BMI), sex, clinical TNM stage, and pathologic stage. The primary outcome was 5-year overall survival, and the secondary outcomes included cancer-specific survival, cost-effectiveness, and quality of life. A total of 126 patients were finally enrolled and included 61 in the ODG group and 65 in the LDG group. Baseline clinical and pathological characteristics were generally balanced between the two groups. After a median follow-up of 8.31 years, the 5-year overall survival rate was estimated to be 82.8% (95% CI: 69.4-90.7%) for the ODG group and 86.7% (95% CI: 73.9-93.5%) for the LDG group and the recurrence patterns were similar between the two groups. Our data showed that the surgical results of both approaches are satisfactory, and LDG offers a reasonable option to ODG in patients with early gastric cancer.

Laparoscopic vs Open Distal Gastrectomy for Locally Advanced Gastric Cancer

It is not clear whether laparoscopic and open distal gastrectomy produce similar outcomes among patients with locally advanced gastric cancer. Data from a multicenter, randomized clinical trial (Chinese Laparoscopic Gastrointestinal Surgical Study [CLASS]-01) showed that laparoscopic distal gastrectomy did not result in inferior disease-free survival at 3 years compared with open distal gastrectomy. To report 5-year overall survival data from the CLASS-01 trial of laparoscopic vs open distal gastrectomy among patients with locally advanced gastric cancer. This was a noninferiority, open-label, randomized clinical trial conducted 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 12, 2012, to December 3, 2014. Final follow-up was on December 31, 2019. Participants were randomized in a 1:1 ratio after stratification by site, age, cancer stage, and histologic features to undergo either laparoscopic distal gastrectomy (n = 528) or open distal gastrectomy (n = 528) with D2 lymphadenectomy. The 5-year overall survival rates were updated to compare laparoscopic distal gastrectomy with open distal gastrectomy. All analyses were performed on an intention-to-treat basis. In addition, per-protocol and as-treated analyses were performed for overall survival. Data from 1039 patients (726 men [69.9%]; mean [SD] age, 56.2 [10.7] years) who received curative therapy were analyzed. At 5 years, the overall survival rates were 72.6% in the laparoscopic distal gastrectomy group and 76.3% in the open distal gastrectomy group (log-rank P = .19; hazard ratio, 1.17; 95% CI, 0.93-1.48; P = .19). After comparison for competing risk events, gastric cancer-related deaths (hazard ratio, 1.14; 95% CI, 0.87-1.49; P = .34) and deaths from other causes (hazard ratio, 1.23; 95% CI, 0.74-2.05; P = .42) did not differ significantly between groups. Overall rates of survival did not differ significantly between groups with each tumor stage. This study found that laparoscopic distal gastrectomy with D2 lymphadenectomy performed by experienced surgeons in high-volume specialized institutions resulted in similar 5-year overall survival compared with open distal gastrectomy among patients with locally advanced gastric cancer. ClinicalTrials.gov Identifier: NCT01609309.

S3196 Diagnosis and Management of Phlegmonous Gastritis in a Young Female Without Predisposing Risk Factors

Introduction: Phlegmonous gastritis (PG) is a rare, but serious, condition characterized by bacterial infection of the gastric wall. Since 1862, less than 500 cases of PG have been reported in the literature, limiting knowledge of its management. We discuss a case of PG in a previously healthy female who was successfully treated with a combination of medical and surgical therapies. Case Description/Methods: A 32-year-old female presented to the emergency department with 10 days of worsening epigastric pain, fever, chills, and nausea. Symptoms onset after consuming a seafood platter containing shrimp, scallops, crab, and crawfish from a local restaurant. She had no significant past medical history. CT demonstrated heterogeneously enhancing wall thickening of the distal stomach and the first portion of the duodenum with adjacent fat stranding. Lab work was significant for leukocytosis and elevated CRP. Following admission, the patient was empirically started on piperacillin-tazobactam with general surgery and gastroenterology consulted. On hospital day 2, an EGD was performed which showed a raised lesion in the antrum with central ulceration and an overlying yellow exudate. Biopsies of the lesion were consistent with active gastritis with cryptitis. No organisms, including H pylori, were visualized on routine stains. MRI revealed a 7.5 x 4.3 cm mass in the gastric antrum with central necrosis and multiple septations. EGD with EUS on hospital day 6 noted a mass in the antrum arising from the muscular layer with areas of necrosis. FNA was performed, showing gastric columnar cells, smooth muscle fragments, and a cluster of bland-appearing spindle cells. The following day, she underwent an open distal gastrectomy with Billroth I reconstruction. Significant adhesions and a desmoid reaction involving the distal stomach to the falciform ligament was present. Tissue pathology showed a perforated ulcer with perigastric abscess and acute serositis. No malignant cells were identified. The post-operative course was uncomplicated, and the patient was discharged home on hospital day 11. Discussion: This case highlights the need to consider PG in the differential diagnosis of persistent abdominal pain, although patients may lack classic risk factors for this condition, such as immunosuppression or recent intervention. Discussion should be prompted regarding the optimal treatment regimen for PG, as there are currently no guidelines regarding standardized therapy.Figure 1.: Fig 1A: An abdominal X-ray showing the faint outline of the trichobezoar impacted within the stomach and leading to the convoluted small intestinal tract. Fig 1B: An abdominal CT scan showing the trichobezoar compacted within the stomach and the small intestines. Fig 1C: Post-operative picture of the removed trichobezoar that shows it took on the form of the stomach shape along with the tapered, elongated end of the form of the small intestine.

Mapping of the perigastric lymphatic network using indocyanine green fluorescence imaging and tissue marking dye in clinically advanced gastric cancer

BackgroundUsing indocyanine green (ICG) fluorescence imaging and tissue marking dyes (TMDs), perigastric lymphatic mapping and their pathological correlation were examined to see whether ICG staining covers all metastatic lymph nodes (LNs) in advanced gastric cancer (AGC). MethodsPatients with AGC who underwent open distal or total gastrectomy were enrolled. ICG was serially injected intraoperatively into the subserosa along the greater and lesser curvatures. Stomach specimens were examined under a near-infrared camera. ICG-stained LNs were named, excised, and tattooed with different colored TMDs to retrace the exact location after pathological examinations. ResultsA total of 687 LNs and 69 LN stations were examined from 11 patients. The map of the perigastric lymphatic network showing the topography of ICG-stained and ICG-unstained LNs, including metastatic information, was successfully reconstructed. The average number of ICG-stained and ICG-unstained LNs were 23.6 ± 12.3 (37.8%) and 38.8 ± 17.1 (62.2%), respectively. LN metastases were present in 28 LN stations of 8 patients. Of 8 cases with LN metastases, 40% (11.1–75% per case) of metastatic LNs were stained by ICG. Of 28 metastatic LN stations, 21 (75.0%) were covered by ICG, and actual metastatic LNs were stained in 16 LN stations (57.1%). In 4/8 cases (50%), all metastatic LN stations showed ICG signals. ConclusionsICG fluorescence imaging and TMD are useful tools for visualizing the perigastric lymphatic network and retracing the exact location of ICG-stained LNs in AGC. However, ICG imaging is still not recommended for selective LN dissection in AGC because of the limited staining of perigastric LNs.

Comparison of Clinical Efficacy Between Laparoscopic and Open Distal Gastrectomy in the Treatment of Gastric Carcinoma: A Meta-Analysis

Objectives: The purpose of this article was to systematically evaluate the clinical efficacy of laparoscopy-assisted distal gastrectomy (LDG) and open distal gastrectomy (ODG) in the treatment of gastric carcinoma (GC). Methods: PubMed, Web of Science, Embase, CNKI, and Wanfang databases were systematically searched for relevant articles on surgical treatment of GC published from 2010 to 2020. GC patients in the treatment group received LDG, whereas those in the control group received ODG. The evaluation criteria of these two surgical methods included operation time, intraoperative blood loss, postoperative first exhaust time, number of dissected lymph nodes, postoperative hospital stay, and incidence of complications. Results: A total of 18 studies, with 2102 patients, which met the criteria were included in this meta-analysis. The analysis results showed that in comparison with the control group, both the incidence rate of complications (odds ratio = 0.31, 95% confidence interval, CI [0.23 to 0.41]) and intraoperative blood loss (standardized mean difference, SMD = -2.72, 95% CI [-3.43 to -2.00]) were lower in the treatment group. In addition, in comparison with the control group, LDG led to an increase in the number of dissected lymph nodes (SMD = 0.08, 95% CI [-1.10 to 0.25], P = .403) and associated with shorter hospital stay (SMD = -1.42, 95% CI [-1.90 to -0.94]) and earlier postoperative first exhaust time (SMD = -2.12, 95% CI [-2.86 to -1.38]). Conclusion: LDG can significantly reduce the incidence of complications of GC, intraoperative blood loss, postoperative exhaust time, and hospital stay, whereas increase the number of lymph node dissection. Therefore, LDG is worthy of clinical application.

Potential survival benefits of open over laparoscopic radical gastrectomy for gastric cancer patients beyond three years after surgery: result from multicenter in-depth analysis based on propensity matching

BackgroundThe oncologic efficacy of laparoscopic versus open surgery for advanced distal gastric cancer (ADGC) beyond 3 years after surgery remain obscure.MethodsA total of 1256 patients with ADGC at two teaching institutions in China from April 2007 to December 2014 were enrolled. The general data of the two groups were identified to enable rigorous estimation of propensity scores. Restricted mean survival time (RMST) and Landmark analysis was used to compare survival.ResultsAfter matching 461 patients each in the open distal gastrectomy (ODG) and laparoscopic distal gastrectomy (LDG) groups, they were included into analysis. The 3- and 5-year overall survival (OS) and disease-free survival were comparable in two groups. RMST-stratified analysis showed that the 3-year RMST of ODG group was similar to that of LDG group in patients with cT4a (− 1.38 years, p = 0.163) or with cT4a and tumor size > 5 cm, whereas the 5-year RMST had significant differences between groups in cT4a patients(− 8.36 years, P = 0.005) or cT4a and tumor size > 5 cm patients(4.67 years, P = 0.042). In patients with cT4a and tumors > 5 cm, the number of peritoneal recurrences was significantly fewer in the ODG group than in the LDG group (4 vs. 17, P = 0.033), and the peritoneal recurrence time and multiple-site recurrence time were both later in the ODG group.ConclusionBy reducing recurrence, ODG achieves a better survival for GC patients with serous infiltration and tumors larger than 5 cm beyond 3 years after surgery. The present findings can serve as a reference for surgical options and the setting of follow-up time point for clinical studies.

Systematic review and updated network meta-analysis of randomized controlled trials comparing open, laparoscopic-assisted, and robotic distal gastrectomy for early and locally advanced gastric cancer

BackgroundThe role of minimally invasive surgery for the treatment of early and locally advanced gastric cancer remains controversial. The purpose of this study was to perform a comprehensive evaluation of major surgical approaches for operable distal gastric cancer. MethodsSystematic review and network meta-analyses of randomized controlled trials were performed to compare open distal gastrectomy, laparoscopic-assisted distal gastrectomy, and robotic distal gastrectomy. Risk ratio, weighted mean difference, and 95% credible intervals were used as pooled effect size measures. ResultsSeventeen randomized controlled trials (5,909 patients) were included. Overall, 2,776 (46.8%) underwent open distal gastrectomy, 2,964 (50.1%) laparoscopic-assisted distal gastrectomy, and 141 (3.1%) robotic distal gastrectomy. Among these 3 groups, there were no significant differences in 30-day mortality, anastomotic leak, and overall complications. Compared to open distal gastrectomy, laparoscopic-assisted distal gastrectomy was associated with significantly reduced intraoperative blood loss, early postoperative pain, time to first flatus, and hospital length of stay. Similarly, robotic distal gastrectomy was associated with significantly reduced blood loss and time to first flatus compared to open distal gastrectomy. No differences were found in the total number of harvested lymph nodes, tumor-free resection margins, 5-year overall, and disease-free survival. The subgroup analysis in locally advanced gastric cancer showed trends toward reduced blood loss, time to first flatus, and hospital length of stay with minimally invasive approaches but similar overall and disease-free survival. ConclusionLaparoscopic-assisted distal gastrectomy and robotic distal gastrectomy performed by well-trained experienced surgeons, even in the setting of locally advanced gastric cancer, seem associated with improved short-term outcomes with similar overall and disease-free survival compared with open distal gastrectomy.

Results of laparoscopic and open distal gastrectomies in patients with gastric cancer. Meta-analysis of Russian and European studies.

Objective: to compare the results of laparoscopic and open distal gastrectomy in patients with gastric cancer according to Russian and European studies. Materials and methods: we searched the e-library, the Cochrane Library and PubMed. Literary references, tables of contents of specialized journals and protocols of research not yet completed have been studied. Statistical calculations (mean difference - MD, odds ratios - OR, 95 % confidence interval – 95 % CI) and meta-analysis graphs were performed using RevMan 5.4 software. Results: ten primary sources met the inclusion criteria (4 researches from the Russian Federation and 6 from other European countries). Laparoscopic and open gastric resections did not differ in the number of lymph nodes removed (MD = ‒1.31, 95 % CI from 3.51 to 0.89, p = 0.24). At the same time, laparoscopic operations are accompanied by less intraoperative blood loss (MD = –163, 95 % CI ‒268 to ‒57, p = 0.002), and open operations are shorter (MD = –38, 95 % CI –71 to ‒17, p = 0.004). The period of hospital stay is shorter after laparoscopic resections (MD = –4.1, 95 % CI –8.02 to –0.14, p = 0.04). Differences in mortality are not statistically significant (OR = 0.83, 95 % CI from 0.45 to 1.54, p = 0.55), but significantly lower after laparoscopic operations (2.3 %, 12/516) than after open (3.4 %, 92/2702), as well as the frequency of complications - 31.8 % (153/481) and 35.7 % (935/2658), respectively (OR = 1.05, 95 % CI from 0.84 to 1.37, p = 0.67). The overall five-year survival rate after laparoscopic operations varies from 48.1 % to 63.6 %, after laparotomy - from 43.4 % to 55.7 %. However, scattered and incomplete information on long-term outcomes did not allow a formal meta-analysis on comparative survival at this stage. The high level of performance of technically complex surgical techniques made it possible to significantly reduce the differences in duration between open and laparoscopic interventions (RS = ‒27, 95 % CI from 77 to 22, p = 0.28) and the duration of inpatient treatment after minimally invasive operations (RS = - 8.97, 95 % CI from ‒13.48 to ‒4.47, p &lt;0.0001) in the subgroup of domestic studies. Conclusion: the direct results of laparoscopic subtotal distal gastric resections in Russian and European studies do not differ in terms of the amount of harvested lymph nodes, the number of complications and postoperative mortality. It is difficult to reliably assess the life expectancy of patients due to the lack of sufficient information at this stage, which requires the continuation of further research.

Proctotomy leak following laparoscopic total gastrectomy with transrectal specimen extraction for gastric cancer: a case report

BackgroundDespite increasing acceptance in colorectal surgery, natural orifice specimen extraction (NOSE) surgery for the treatment of gastric cancer is still in its infancy, especially via the transrectal approach, which was barely reported. So little is known about its complications. Here we report the first case of proctotomy leak after transrectal NOSE gastrectomy, and our experience in preventive interventions.Case presentationA 62-year-old male patient complaining of upper abdominal pain who underwent open distal gastrectomy for gastric cancer one year ago was diagnosed with recurrent gastric cancer by gastroscopic biopsy. We performed laparoscopic total gastrectomy with transrectal specimen extraction on the patient. The operation was completed in a total laparoscopic approach and the specimen was extracted through a 3 cm longitudinal incision in the anterior wall of the upper rectum, then interrupted sutures were used for full-thickness closure of the rectal incision. The operative time was 470 min and intra-operative blood loss was 100 mL. The postoperative pathological examination showed pT1bN0M0 gastric adenocarcinoma. The patient developed proctotomy leak on the 10th postoperative day. We analyzed the causes of this rare complication and put forward a series of technical improvements. After failure of conservative treatment, a diverting ileostomy was created and the patient eventually recovered. We successfully prevented proctotomy leak in the subsequent 20 transrectal NOSE gastrectomies using improved techniques.ConclusionsProctotomy leak after transrectal specimen extraction should be considered among the complications of NOSE surgery and can be prevented by technical precautions.

Efficacy of minimally invasive distal gastrectomy for elderly patients with clinical stage I/IIA gastric cancer: a propensity-score matched analysis.

Phase III trials have shown the non-inferiority of minimally invasive distal gastrectomy (MIDG) comparison with open distal gastrectomy (ODG) in patients with gastric cancer; however, it remains unclear whether MIDG is also effective in the elderly. This study aimed to clarify the efficacy of MIDG in elderly gastric cancer patients. This study included 316 patients older than 75years with clinical stage I/IIA gastric cancer who underwent distal gastrectomy from August 2008 to December 2016 at the Shizuoka Cancer Centre. The long-term outcomes between MIDG and ODG were compared after propensity score matching. After propensity score matching, there were 97 patients each in the MIDG and ODG groups, with an improved balance of confounding factors between the two groups. MIDG was associated with significantly longer operative time and a lower level of blood loss than ODG. The incidence of complications was comparable between the two groups. Survival outcomes were better in the MIDG group than in the ODG group (overall survival; P = 0.034, relapse-free survival; P = 0.027). In the multivariable analysis, ODG [hazard ratio (HR) 1.971, P = 0.046], being 80years or older (HR 2.285, P = 0.018), male sex (HR 2.428, 95% P = 0.024), and poor physical status (HR 2.324, P = 0.022) were identified as independent prognostic factors for overall survival. We found that MIDG showed better efficacy than ODG in elderly gastric cancer patients. MIDG is an acceptable option for elderly patients.