Minimally Invasive Surgery For Gastric Cancer

Background Radical gastrectomy is the dominant treatment for patients with resectable gastric cancer.High-quality studies have confirmed that laparoscopic gastrectomy(LG)is a safe and feasible procedure for early gastric cancer(EGC)in terms of short-and long-term outcomes when compared to those undergoing open gastrectomy(OG).In China,more than 80% of the Chinese patients are diagnosed at advanced stage.Long-term oncologic outcome after LG is a major concern of surgeons and patients.Studies reported the long-term outcomes after LG for advanced gastric cancer(AGC)were always limited by small sample size,inadequate follow-up or unmatched groups.Meanwhile,it has been unclear whether LG is suitable for patients with serosa-positive(p T4a)gastric cancer.To date,the optimal resection extent for middle-third AGC still remains controversial.Additionally,postoperative complication is a major concern in clinical practice.For patients with gastric cancer,previous studies have reported that the occurrence of postoperative complications is a negative predictor of long-term survival outcomes.However,the correlation between the severity of complications and long-term survival outcomes after curative resection for gastric cancer still remains unclear.Enhanced recovery after surgery(ERAS)programs or fast-track surgery(FTS)has been widely used in various surgeries in past decade.The clinical efficacy of combination of the ERAS programs and laparoscoic surgery still remains unclear.In light of these controversial topics,the present study was conducted from the following five parts around the theme “Minimally invasive surgery for gastric cancer”.Part one Long-term outcomes of laparoscopic versus open D2 gastrectomy for advanced gastric cancer: A propensity score-matched analysisPurpose The purpose of this part was to compare the long-term outcomes of LG versus OG for AGC using a propensity score matching(PSM)analysis.Methods The data of patients with gastric cancer who underwent LG or OG with D2 lymph node dissection at our institution between June 2007 and June 2012 were retrieved.1:1 PSM was performed to compensate for heterogeneity between groups.The 5-year overall survival(OS),disease-free survival(DFS)and recurrence of these matched groups were compared.Results In the propensity score-matched cohort,no significant differences were observed in 5-year OS(52.0% vs.53.4%,P = 0.805)and DFS(46.8% vs.47.3%,P = 0.963)between the LG group and the OG group.Stratified analysis showed that the 5-year OS and DFS rates were also comparable between the two groups in each tumor stage(P > 0.05).Multivariate analysis revealed that the surgical method was not an independent prognostic factor for OS.Conclusions LG is a feasible surgical procedure for AGC in terms of long-term prognosis,although the results should be confirmed by the ongoing RCTs.Part two Surgical and long-term oncologic outcomes of laparoscopic and open gastrectomy for serosa-positive(p T4a)gastric cancer: A propensity score-matched analysisPurpose The purpose of this study was to compare the surgical and long-term oncologic outcomes of LG and OG for p T4 a gastric cancer.Methods We prospectively collected data from patients with pathological confirmed p T4 a gastric cancer who underwent LG or OG at our institution between June 2009 and May 2015.A 1:1 matched PSM analysis was performed to reduce confounding bias.The primary outcome was 5-year OS rate.Results After PSM,202 patients were included in each group for the analysis.The LG group showed a longer operation time(236.63 vs.176.52 min,P < 0.001),less blood loss(164.64 vs.203.22 ml,P < 0.001),and shorter postoperative hospital stay(7.39 vs.8.03 days,P = 0.023).The overall complication rate was 14.4% in the LG group and 16.3% in the OG group(P = 0.581).The minor(grade II)and severe(grade ? IIIa)complication rates were similar(6.9% vs.9.9%,P = 0.282;7.4% vs.6.4%,P = 0.695,respectively).The LG and OG groups showed similar survival 5-year OS and 5-year DFS rates(44.6% vs.42.1%,P = 0.403;40.1% vs.37.6%,P = 0.321,respectively).The recurrence rate and pattern did not differ between the two groups(P > 0.05).Conclusions For patients with p T4 a gastric cancer,LG with D2 lymph node dissection can be a safe and feasible procedure in terms of surgical and long-term oncologic outcomes.Part three Laparoscopic distal gastrectomy versus laparoscopic total gastrectomy with D2 lymph node dissection for middle-third advanced gastric cancerPurpose The aim of this study was to compare the technical feasibility and long-term outcomes of laparoscopic distal gastrectomy(LDG)versus laparoscopic total gastrectomy(LTG)for middle-third AGC and to determine the optimal surgical procedure.Methods In this study,data of patients with gastric cancer who underwent LDG or LTG with D2 lymph node dissection between April 2005 and June 2014 were analyzed retrospectively.The primary outcomes were 5-year OS and postoperative complications.Results The LDG group had a significantly shorter operation time(212.74 vs.241.79 min,P < 0.001),less estimated blood loss(114.38 vs.181.51 ml,P < 0.001),shorter time to first flatus(3.0 vs.3.4 d,P = 0.039)and postoperative hospital stay(7.6 vs.8.6 d,P = 0.023).Additionally,the total cost of hospitalization was significantly higher in the LTG group than those in the LDG group(71187.58 vs.65783.25 RMB,P < 0.001).There were no significant differences in postoperative complications rate between the LDG group and the LTG group.The 5-year OS rate in the LDG group was non-inferior to that in the LTG group(64.4% vs.61.0%,P = 0.548).The extent of resection was not an independent prognostic factor for OS.Conclusions LDG with D2 lymph node dissection is a feasible treatment strategy for middle-third AGC with better short-term outcomes and similar long-term survival rates when compared with LTG.We recommended that LDG should be the optimal surgical procedure for middle one-third AGC under the premise of negative proximal resection margin.Part four Relationship between the severity of complications and long-term survival outcomes after curative resection for gastric cancerStudy I Severity of complications and long-term survival after laparoscopic total gastrectomy with D2 lymph node dissection for advanced gastric cancer: A propensity score-matched analysisPurpose This study aimed to explore the relationship between the severity of complications and long-term survival outcomes after LTG for AGC.Methods The study analyzed 571 patients with AGC who underwent LTG in our institution between April 2008 and June 2015.Patients were divided into two groups based on the occurrence or absence of postoperative complications which were recorded using the Clavien–Dindo classification.The primary outcomes were 5-year OS and cancer-specific survival(CSS).Results The complication group was associated with decreased 5-year CSS(65.1% vs.76.2%,P = 0.049).Subgroup analysis showed that the severe complication(Clavien–Dindo grade > II)group was associated with decreased 5-year OS(46.3% vs.65.9%,P = 0.042)and CSS(53.7% vs.74.4%,P = 0.030).However,a comparative analysis of 5-year OS and CCS showed no significant differences between the minor complication(Clavien-Dindo grade II)group and matched no complication group(68.9% vs.72.2%,P = 0.578;75.6% vs.77.8%,P = 0.649;respectively).Multivariate analysis confirmed severe complication was an independent risk factor for decreased OS.Age of 60 years old or more,low BMI,and combined resection were independent risk factors for the occurrence of severe complications.Conclusions Severe complications adversely affected long-term survival outcomes after LTG withD2 lymph node dissection for AGC.More attention should be paid to patients at high riskfor severe complications in preoperative assessment and postoperative management.Study II Relationship between Clavien–Dindo classification and long-term survival outcomes after curative resection for gastric cancerPurpose The purpose of this study was to evaluate the relationship between the severity of complications and long-term survival outcomes after curative resection for gastric cancer.Methods The study analyzed patients who underwent curative resection for gastric cancer in our center between June 2009 and June 2015.Patients were divided into two groups based on the occurrence or absence of postoperative complications which were recorded using the Clavien–Dindo classification.The primary outcomes were 5-year OS,DFS and CSS.Results Complications group were associated with decreased 5-year OS(51.7% vs.67.5%,P < 0.001),DFS(49.9% vs.65.6%,P < 0.001),and DSS(53.9% vs.68.8%,P < 0.001).Increasing Clavien–Dindo grades from II to IV was significantly associated with a corresponding decrease in OS(60%,48.3%,34%,P = 0.010),DFS(58.3%,46.3%,32.1%,P < 0.001)and DSS(62.9%,50.3%,34%,P < 0.001).Multivariate analysis confirmed postoperative complication was an independent prognostic factor for decreased OS,DFS,and DSS(all P < 0.05).Conclusions Postoperative complications had negative effects on long-term survival outcomes after curative resection for gastric cancer.The negative effects were also increased with higher Clavien–Dindo grades.Part five ERAS programs in the era of minimally invasive surgeryStudy I ERAS programs for laparoscopic gastrectomy: A meta-analysisPurpose The purpose of this study was to evaluate the safety and feasibility of ERAS programs for gastric cancer patients undergoing LG.Methods We performed a meta-analysis of randomized control trials(RCTs)involving ERAS/fast-track surgery(FTS)for patients underwent LG.EMBASE,Pubmed,Web of science,and Cochrane Library databases were searched from January 1995 to July 2017.The primary outcomes included the length of postoperative hospital stay,cost of hospitalization,postoperative complications,and readmission rate.Results5 RCTs were eligible for analysis.There were 159 cases in ERAS group and 156 cases in conventional care group.Compared with conventional care group,ERAS group showed shorter postoperative hospital stay(WMD =-2.16,95% CI:-3.05 to-1.26,P < 0.05),less cost of hospitalization(WMD =-4.72,95% CI:-6.88 to-2.55,P < 0.05),shorter time to first flatus(WMD =-9.78,95% CI:-13.75 to-5.81,P < 0.05),lower level of C-reaction protein on postoperative days 3 or 4(WMD =-19.66,95% CI:-28.98 to-10.34,P < 0.05),higher level of albumin on postoperative day 4(WMD = 3.45,95% CI:2.01 to 4.89,P < 0.05),and postoperative day 7(WMD = 5.63,95% CI: 1.01 to 10.24,P < 0.05).Regarding postoperative complications,no significant differences were observed between ERAS group and conventional care group(OR = 0.63,95% CI:0.37 to 1.09,P > 0.05).The readmission rate of ERAS group was comparable to conventional care group(OR = 3.14,95% CI:0.12 to 81.35,P > 0.05).Conclusions ERAS programs for LG is safe and effective.The combined effects of the two methods could further accelerate clinical recovery of patients with gastric cancer.Study II ERAS programs for Laparoscopic abdominal surgery: A meta-analysisPurpose The purpose of this study was to evaluate the role of ERAS protocols in laparoscopic abdominal surgery.Methods We searched the Pub Med,Embase,and the Cochrane Library databases for all the relevant studies from January 1990 to October 2017.The primary outcomes were postoperative hospital stay,postoperative complications,and readmission rate.Results In the present meta-analysis,the outcomes of 34 comparative studies(15 RCTs and 19 non-randomized controlled studies)enrolling 3615 patients(1749 in the ERAS group and 1866 in the control group)were pooled.The ERAS group was associated with shorter hospital stay(WMD=-2.37,95% CI:-3.25 to-1.73,P < 0.05)and earlier time to first flatus(WMD =-0.63,95% CI:-0.90 to-0.36,P < 0.05).Meanwhile,lower overall postoperative complication rate(OR = 0.62,95% CI:0.51 to 0.76,P < 0.05)and less hospital cost(WMD =-801.52,95% CI:-918.15 to-684.89,P < 0.05)were observed in the ERAS group.Similar readmission rate(OR = 0.73,95% CI:0.52 to 1.03,P > 0.05)and perioperative mortality(OR = 1.33,95% CI: 0.53 to 3.34,P > 0.05)were found between the two groups.Conclusions ERAS programs for laparoscopic abdominal surgery is safe and effective.The combination of ERAS programs and laparoscopic technique is associated with faster postoperative recovery without increasing readmission rate and perioperative mortality.