| BackgroundGastric cancer is one of the most common tumors,with its incidence ranking second and mortality third in China.Recently,with the influence of dietary changes,obesity,gastroesophageal reflux disease and other factors,the incidence of esophagogastric junction cancer(AEG)has shown a significant upward trend worldwide.The incidence rate of AEG in China is also increasing year by year,and most of them are Siewert II and III.Due to the special location of the tumor,and the diagnosis of the local stage of progression is mostly.It is easy to cause metastasis and recurrence due to residual lesions.The overall prognosis is poor and the long-term survival rate is generally low,which is attracting more and more scholars’attention.Comprehensive treatment with surgery as the core is the only radical treatment for esophagogastric junction carcinoma,and the surgical methods mainly include traditional open surgery,laparoscopic surgery and robotic surgery.In recent years,laparoscopic radical gastrectomy has developed rapidly and has become one of the standard treatment options for early gastric cancer.Recent studies on advanced gastric cancer have shown that laparoscopic surgery has certain advantages over open surgery in terms of short-term efficacy.With the popularization and promotion of minimally invasive technology,more and more surgeons try to apply minimally invasive in AEG surgery,reflecting the advantages of less bleeding,less trauma,quick recovery and fewer complications,but the improvement of minimally invasive surgery technology has not improved the long-term efficacy of patients.At present,accumulating evidence indicates that neoadjuvant chemotherapy can reduce the stage of gastric cancer and improve the R0 resection rate,thus improving the long-term efficacy.However,at the same time,neoadjuvant chemotherapy can also cause gastric tissue edema and fibrosis,which may increase the difficulty of surgery.In recent years,endoscopy has been applied to the surgical treatment of locally advanced esophagogastric junction carcinoma after NACT,but there have been few reports on the study of neoadjuvant chemotherapy combined with laparoscopically assisted radical resection for esophagogastric junction carcinoma.To this end,this study conducted a retrospective controlled study on the clinical efficacy of laparoscopic D2 radical resection after neoadjuvant chemotherapy for locally advanced esophagogastric junction adenocarcinoma,in order to evaluate the safety and effectiveness of neoadjuvant chemotherapy combined with endoscopic radical resection for locally advanced Siewert II and III AEG,in order to provide evidence-based medical basis for NACT combined with laparoscopic D2 radical resection of locally advanced esophageal and gastric junction adenocarcinoma.ObjectiveMeta-analysis was conducted to compare the short-term outcome of laparoscopic gastrectomy versus open gastrectomy in the treatment of advanced gastric cancer after neoadjuvant chemotherapy,and to explore the safety of laparoscopy in the treatment of gastric cancer after neoadjuvant chemotherapy.At the same time,retrospective cohort study and propensity score matching analysis were used to compare the short-term and long-term efficacy of neoadjuvant chemotherapy combined with laparoscopic gastrectomy with directly gastrectomy surgery in Siewert II and III type adenocarcinoma of esophagogastric junction,as well as the influencing factors of complications and survival,in order to provide evidence-based medical evidence for laparoscopic surgery for adenocarcinoma of esophagogastric junction after neoadjuvant chemotherapy.MethodPub Med,Embase,The Cochrane Library,China National Knowledge Infrastructure(CNKI),China Biomedicine,Wanfang Data and VIP were searched for the literature on the comparation of the short-term efficacy of laparoscopic with open gastrectomy for advanced gastric cancer after neoadjuvant chemotherapy.The retrieval period is until April2020.The literature was screened according to the inclusion criteria and the quality of the literature was evaluated.The basic data,intraoperative results,postoperative results and other indicators of the study were extracted,and meta-analysis was conducted by using Rev Man5.3software.The heterogeneity was quantitatively analyzed by calculating I~2according to which the data were combined using fixed or random effects models.Counting data were represented by odds ratio(OR)and 95%confidence interval(95%CI),while measurement data were represented by weighted mean difference(WMD)and 95%CI.The funnel plot was used to test the potential publication bias if the studies included≥5 and no test was conducted if the included studies<5.2.The clinical data of Siewert II and III Adenocarcinoma of the esophagogastric junction treated by laparoscopic gastrectomy at the Department of General Surgery the First Affiliated Hospital of Army Medical University from May 2011 to October 2020 were retrospectively analyzed in a cohort study.Patients were screened according to the criteria of arrangement,and R software 3.5.0 1:3 nearest method was used to match the propensity score of patients in the neoadjuvant chemotherapy combined with laparoscopic gastrectomy group(hereinafter referred to as the neoadjuvant chemotherapy group or NACT group)and patients in the direct laparoscopic gastrectomy group(hereinafter referred to as the laparoscopic gastrectomy group or LG group)to reduce the selection bias of patients.NACT group and the LG group to reduce the selection bias of patients,and the surgical results,pathological results and incidence of postoperative complications in the two groups were compared and analyzed.The measurement data with normal distribution were expressed as mean±standard deviation(mean±SD)and compared by T test.Measurement data with skewness distribution were expressed by median(IQR),and non-parametric test was used for comparison.Statistical data were represented in absolute numbers or percentages,and chi-square test was used for comparison.SPSS 26.0 software was used for data statistical analysis.Logistics regression model was used to analyze the risk factors of complications.Factors with P value less than 0.1in univariate analysis were included in multivariate analysis.P value<0.05 was considered statistically significant.The cut-off value of intraoperative blood loss and operation time were determined by receiver Operating Characteristic Curve(ROC).3.The survival data of the patients after PSM in the two groups were followed up.The difference of OS and DFS between the neoadjuvant chemotherapy group and the laparoscopic group after PSM was compared by log-rank method of Graph Pad Prism 9.0 software,and the survival curve was drawn to P<0.05(bilateral)was recognized as significant difference.At the same time,the differences of OS and DFS between the two groups in each subgroup were compared and the forest map was drawn with R 3.5.0 software.SPSS 26.0 Cox proportional risk model was used for univariate regression and multivariate analysis of the possible prognostic variables.Factors of P<0.10 were included in multivariate analysis,and P<0.05(bilateral)was statistically significant in the multivariate regression analysis.X-tile 3.6.1software was used to determine the optimal cut-off value for predicting the total number of dissected lymph nodes in OS.The number and percentage of cases of each type of recurrence and metastasis in the two groups were counted,and the difference in recurrence rate of each type was compared between the two groups by Chi-square test.P<0.05(bilateral)was considered statistically significant.Result1.According to the inclusion criteria,2 RCTS and 5 non-randomized controlled studies were included in the meta-analysis,with a cumulative sample size of 762 gastric cancer patients,292 in the LG group and 470 in the OG group.The meta-analysis results showed that the operation time in the LG group was significantly longer than that in the OG group(WMD=29.24,95%CI:24.88～33.60,P<0.05),the amount of intraoperative blood loss was significantly lower than that of the OG group(WMD=-45.92,95%CI:-78.85～13.00,P<0.05),and the time to first flatus(WMD=-0.45,95%CI:-0.77～0.12,P<0.05)and postoperative hospital stay(WMD=-5.40,95%CI:-7.11～3.68,P<0.05)were significantly shorter than those in the open group,and there was no difference in the number of resected lymph nodes between the two groups.The incidence of postoperative total complications(OR=0.51,95%CI:0.31～0.84,P<0.05)and infectious complications(OR=0.44,95%CI:0.23～0.85,P<0.05)in LG group was significantly lower than that in open group.There was no significant difference in wound infection complications,pulmonary infection complications and anastomotic leakage complications.2.After propensity score matching,a total of 164 patients were enrolled:41 patients in the NACT group and 123 patients in the direct LG group.The baseline characteristics of the two groups showed no statistical difference.Compared with the laparoscopic group,tumor volume in the neoadjuvant chemotherapy group was significantly smaller,and the pathological T stage and N stage were significantly reduced.The time to first flatus in the NACT group was significantly shorter than the LG group,but the length of hospital stay was significantly longer in the NACT group.There were no statistical difference in the total complications(29.3%vs.25.2%,P=0.683),systemic complications(24.4%vs.21.1%,P=0.663),local complications(12.2%vs.9.8%,P=0.767),minor complications(19.5%vs.19.5%,P=1.000)or severe complications(9.8%vs.5.7)between the two groups.Subgroup analysis showed no significant differences in all stratification parameters.Operation time greater than or equal to 300 min was identified as an independent risk factor for total complications.Age greater than or equal to 60 years was identified as an independent risk factor for severe complications.3.Among the 164 matched cases,8 cases were lost to follow-up,including 1 case in NACT group and 7 cases in LG group.The mean follow-up time after matching was 39.6months,42.3 months in the NACT group and 38.7 months in the LG group.The three-year overall survival rate and five-year overall survival rate in the NACT group were 71.0%and62.4%,respectively;the three-year overall survival rate and five-year overall survival rate in the LG group were 54.2%and 35.7%,respectively.The hazard ratio for cumulative survival in the NACT versus LG group was 0.484(95%CI,0.305～0.768,P=0.010).The 3-year disease-free survival rate and 5-year disease-free survival rate in the NACT group were61.5%and 53.3%,respectively,while the 3-year disease-free survival rate and 5-year disease-free survival rate in the LG group were 47.3%and 35.5%,respectively.The risk ratio of cumulative survival was 0.585(95%CI,0.372～0.921,P=0.041).The results of subgroup analysis showed that each subgroup showed the long-term survival advantage of the NACT group.The results of the analysis of survival risk factors showed that whether neoadjuvant chemotherapy,whether to switch to open surgery,and the number of dissected lymph nodes greater than or equal to 25 were the prognostic factors and independent prognostic factors for OS and DFS.There was no significant difference in recurrence types between the two groups.Conclusion1.The meta-analysis results of this study showed that compared with OG,LG was safe and feasible for radical treatment of advanced gastric cancer patients after neoadjuvant chemotherapy,with fast postoperative recovery,low incidence of complications and satisfactory short-term efficacy.2.Compared with directly laparoscopic surgery,neoadjuvant chemotherapy significantly reduced stage and tumor volume,and neoadjuvant chemotherapy combined with laparoscopic treatment of Siewet type II and III AEG did not increase the risk of postoperative complications and mortality.Operation time greater than or equal to 300 minutes was identified as an independent risk factor for total complications.Age greater than or equal to 60years was identified as an independent risk factor for severe complications.3.The OS and DFS of the NACT group were significantly better than those of the LG group,and the results of multivariate analysis suggested that whether neoadjuvant chemotherapy,whether to convert to open gasrectomy,and the number of resected lymph nodes were independent prognostic factors for Siewert II and III AEG treated by laparoscopic gastrectomy.Neoadjuvant chemotherapy combined with laparoscopic surgery is a safe and effective surgical method for Siewert II and III adenocarcinoma of the esophagogastric junction. |
PDF Full Text Request