Surgical,Oncological Efficacy And Learning Curve Of Laparoscopic-Assisted Total Gastrectomy

ObjectiveDespite a slight drop of incidence,gastric cancer remains the fifth most common malignancy and the third main causes of cancer death worldwide.Radical surgery plays an essential role in gastric cancer treatment for resectable cases.How to speed up the rapid recovery after surgery,reduce the incidence of postoperative complications,and improve the quality of life of patients,as long as the quality of surgical outcomes,have been one of the main focus.In the recent years,minimally invasive surgery has gained popularity due to its less invasive nature and its faster postoperative recovery.To date,several international cooperative multicenter randomized controlled trials(RCTs)have demonstrated the short-term safety and long-term efficacy of laparoscopic-assisted distal gastrectomy for distal gastric cancer.In many experienced institutions,laparoscopic surgery is a mature technique and optional approach,instead of conventional open surgery,for distal gastrectomy.Nevertheless,compared with laparoscopic-assisted distal gastrectomy(LADG),studies which provide convincing data to prove the feasibility and safety of laparoscopic-assisted total gastrectomy(LATG)remain insufficient.No RCTs have been launched to evaluate the feasibility and oncological efficacy of LATG for AGC till now.Therefore,more studies are still needed to confirm the non-inferiority of LATG to OTG,especially for AGC patients.Part ? Surgical and oncological efficacy of laparoscopic-assisted total gastrectomy versus open total gastrectomy for gastric cancer:a systematic review and meta-analysisMethods:We searched PubMed,EMBASE,and the Cochrane library databases from Jan 1994 to Jan 2021.Newcastle Ottawa scale and Cochrane system were used to evaluate the quality of the literature.The evidence of outcomes was evaluated using the GRADE approach and GRADE Profiler.Review Manager 5.3 and Stata 14.0 were used to analyze the outcomes.Results:A total of 21 papers were included.LATG showed advantages with respect to less blood loss in surgery,shorter time to whole liquid diet intake and postoperative hospital stay.But LATG had a longer time of operation.No significant differences were found between the two groups with regard to postoperative complications as well as overall survival.ConclusionLATG appears to have comparable surgical and oncological safety with OTG and faster postoperative recovery by experienced surgeons.Part ? Surgical and oncological efficacy of laparoscopic-assisted total gastrectomy versus open total gastrectomy for gastric cancer by propensity score matching:a retrospective comparative studyMethods:The data of 365 clinical stage ?-? GC cases who underwent total gastrectomy with D2 lymphadenectomy were retrospectively collected from January 2011 to April 2018 in the Department of Gastrointestinal Surgery ? of Peking University Cancer Hospital.Propensity scores were generated through taking all covariates into consideration and 131 pairs of patients receiving either LATG or OTG were matched.Intraoperative,postoperative,and survival parameters were compared in the matched groups accordingly.Risk factors for postoperative complications and overall survival were further analyzed.Results:Patient characteristics in the LATG and OTG groups were well balanced after PSM.LATG showed advantages with respect to shorter time to ambulation,first flatus,and first whole liquid diet intake.No significant differences were found between the two groups with regard to postoperative complications as well as overall survival in terms of different pathological stage.Older age was found as an independent risk factor for postoperative complications,and pathological stage for overall survival as well.ConclusionLATG appears to have comparable surgical and oncological safety with OTG by experienced surgeons.Part ? The learning curve of laparoscopic-assisted total gastrectomyMethods:The clinical data of 147 consecutive patients with gastric cancer who underwent laparoscopicassisted total gastrectomy by the same surgeon from January 2011 to April 2018 were retrospectively analyzed.Cumulative sum curve was used to analyze the learning curve based on operation time and postoperative complication rate.Regarding to different learning stages,intraoperative,postoperative recovery,postoperative complications and overall survival were compared.SPSS 25.0(IBM SPSS Inc.,Chicago,IL,USA)was used for data processing and analysis.Results:The CUSUM curve based on "operation time" showed that about 52 cases were needed to complete the learning curve.After 44 cases of stable,the learning curve further decreased and the operation quality further improved.The CUSUM curve based on "postoperative complication" showed that about 55 cases were needed to complete the learning curve.After 36 cases of stable,the learning curve further decreased and the operation quality further improved.ConclusionLaparoscopic-assisted total gastrectomy is a feasible technique with acceptable complications.An experienced gastrointestinal surgeon requires about 52-55 cases of surgery to finish the learning curve of laparoscopic-assisted total gastrectomy.