| BackgroundGastric cancer（GC）is one of the leading causes of cancer-related death worldwide.There are an estimated 679 100 new cases and 498 000 deaths of GC in China each year[1].Gastrectomy with D2-lymphadenectomy remains the gold standard of GC treatment.Laparoscopic gastrectomy（LG）has gained rapid popularity among the world and became one of the standard operations for early gastric cancer.However,for advanced gastric cancer（AGC）,although many researches affirmed the morbidity and mortality of LG with D2-lymphadenectomy[2-7],its clinical practice is still difficult to carry out.On the one hand,the operation is complicated and the technical requirements are high;On the other hand,people are concerned about the possible risk of tumor cell shedding and peritoneal implantation in AGC surgery[8].GC relapse occurs in about 30%of the patients treated with gastrectomy and D2-lymphadenectomy,mainly due to distant or peritoneal metastases（PM）[9].Once metastases appeared,median survival was 6.2 months[10].Accordingly,how to reduce risk of recurrence in peritoneal cavity has been one of the hotspots in gastric cancer research.Many methods have been tried to treat PM,such as extended resection,combination chemotherapy,intraperitoneal thermochemotherapy and immunotherapy,but the prognosis of PM patients is still very poor,and there is no recognized standard treatment.Although PM is responsible for 60%of patients with GC death,PM can be considered a local disease,unlike lymph nodes or distant metastases.Therefore,in this case,local application of multidisciplinary treatment methods can also improve the prognosis.At present,hyperthermic intraperitoneal chemotherapy（HIPEC）is the most effective means of treating PM caused by gastric cancer.Intraoperative HIPEC combines the mechanisms of surgical locoregional chemotherapy,hyperthermal therapy and large-volume abdominal perfusion washing to eradicate residual tumor nodules,micrometastases and free cancer cells.Some cohort studies have shown that open radical gastrectomy combined with HIPEC can improve the prognosis of patients with gastric cancer[12-14].There are also some non-randomized controlled studies showing that cytoreductive surgery（CRS）combined with HIPEC is superior to CRS in the treatment of gastric cancer with PM[15,16].An RCT study by Yang et al.found that the median survival（11.0 months）of GC patients with PM receiving CRS combined with HIPEC was significantly longer than the median survival of CRS alone（6.5 months）[17].MI et al.reported that radical gastrectomy with prophylaxis HIPEC in AGC patients can improve survival rate and reduce recurrence rate,and its safety is acceptable[18].The safety and clinical efficacy of intraoperative HIPEC in open gastrectomy（OG）with D2-lymphadenectomy of advanced gastric cancer have been confirmed by many studies.In theory,intraoperative HIPEC can also reduce the risk of tumor cell shedding and abdominal implantation in laparoscopic surgery for advanced gastric cancer.What’s more,laparoscopic surgery with HIPEC has also been reported to be feasible in the treatment of PM[19].Therefore,we explored the combination of LG with intraoperative HIPEC.In view of the fact that LG with D2-lymphadenectomy is different from open surgery in lymph node dissection,digestive tract reconstruction,separation and hemostasis,it is necessary to discuss the safety of HIPEC in LG with D2-lymphadenectomy for AGC,and then observe whether this treatment mode can reduce the risk of postoperative peritoneal implantation and metastasis of AGC.ObjectiveWe used the recent results of surgery（complication,recovery of gastrointestinal function,etc.）as the primary endpoint,and the rate of peritoneal metastasis after 2 years of surgery was the secondary endpoint.Patients who underwent LG with D2-lymphadenectomy and HIPEC（LG+HIPEC）during the same period were retrospectively compared with patients undergoing LG with D2-lymphadenectomy alone,or OG with D2-lymphadenectomy plus HIPEC（OG+HIPEC）respectively,to study the safety and efficacy of LG with D2-lymphadenectomy combined with HIPEC.MethodFrom October 2015 to November 2018,a total of 430 advanced gastric cancer patients were considered for enrollment.98 patients underwent LG+HIPEC,278 patients underwent LG alone,and 54 patients underwent OG+HIPEC.Baseline characteristics of study population,operative characteristics,laboratory indexes,complication characteristics and 2-year postoperative peritoneal metastasis rate were collected.Data of LG+HIPEC and those of LG alone or OG+HIPEC were statistically analyzed.Result1.Compared with OG+HIPEC,we found the pattern and Clavien-Dindo classification of complication in LG+HIPEC had no significant difference,suggesting that the safety of LG+HIPEC is similar to OG+HIPEC.Further analysis showed that LG+HIPEC had less blood loss and shorter postoperative hospital stay,suggesting that LG+HIPEC has less surgical trauma and faster postoperative recovery.In the perioperative laboratory results,WBC count,creatinine and urea nitrogen were significantly increased in the OG+HIPEC,suggesting that the inflammatory response of laparotomy was more serious,and the effect of combined HIPEC on renal function was more obvious.2.Compared with LG alone,we found the pattern and Clavien-Dindo classification of complication in LG+HIPEC also had no significant difference.When the morbidity was further analyzed,the morbidity of gastroparesis was significantly increased in LG+HIPEC.At the same time,we found that the operation time,the time to 1st flatus,hospital stay were longer and hospitalization expense was higher in LG+HIPEC,indicating a slower recovery of bowel function.3.The results of the rate of PM in 2 years after surgery were analyzed and compared.Compared with OG+HIPEC,there was no significant difference in the results of LG+HIPEC.Compared with LG alone,LG+HIPEC had no statistical difference in the rate of PM,but there was a trend that the rate in LG+HIPEC was better than in LG alone.ConclusionFor patients with AGC,LG+HIPEC is a safe and feasible method.It potentially benefit patients with a prognosis without increasing the corresponding safety risk.However,HIPEC will limit the recovery of gastrointestinal function to a certain degree. |
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