| BackgroundGastric cancer is one of the most common malignant tumors.The morbidity of gastric cancer ranks the second among malignant tumors,and the mortality ranks the third among malignant tumors in China.In recent years,with the change of people's dietary habits and effective control of Helicobacter pylori,the incidence rate of gastric cancer has been decreasing worldwide.However,the incidence rate of adenocarcinoma of esophagogastric junction(AEG)is increasing.The statistical results in China show that the proportion of AEG in all gastric adenocarcinoma has increased from 22.3%in the early 1990s to 35.7%.The incidence rate of Siewert type?and?AEG increased significantly.Most of the patients were diagnosed at advanced stage,the operation was difficult and the overall prognosis was poor.The comprehensive treatment based on surgical resection is the main treatment strategy of locally advanced Siewert type?and?AEG.The traditional open surgery is a standard operation for locally advanced Siewert type?and?AEG with mature technical route and definite clinical effect.Since Kitano first reported laparoscopic assisted distal gastrectomy in 1994,laparoscopic radical gastrectomy has been widely used and achieved satisfactory short and long-term results.Therefore,more surgeons started trying to use laparoscopic gastrectomy(LG)to treat Siewert type?and?AEG and reported the preliminary results.Compared with open gastrectomy(OG),LG has the advantages of less intraoperative bleeding,less postoperative pain,rapid recovery of intestinal function,short hospitalization time for Siewert type?and?AEG.The short-term effect of LG is satisfactory,but there are few reports on the long-term effect.In recent years,with the rapid development of minimally invasive surgery technology,robot surgery has been gradually applied to the treatment of gastric cancer.Compared with laparoscopic surgery,robot surgery system has the advantages of clearer imaging,larger magnification,stable three-dimensional field of vision,tremor filtering function and 7degrees of freedom simulation wrist.At present,researches at home and abroad show that robotic gastrectomy(RG)has achieved satisfactory clinical effect in the treatment of gastric cancer,but it is mostly focused on the distal radical gastrectomy,while the application of it in Siewert type?and?AEG is rarely reported.In order to evaluate the safety,feasibility and effectiveness of RG in the treatment of locally advanced Siewert type?and?AEG,the clinical effects of RG,LG and OG were compared in this study.ObjectiveThe purpose of this study is to evaluate the safety and feasibility of LG in the treatment of Siewert type?and?AEG through the meta-analysis of the literature about the clinical effect of LG versus OG for Siewert type?and?AEG.Moreover,in order to evaluate the safety,feasibility and effectiveness of RG for locally advanced Siewert type?and?AEG,the retrospective cohort study and propensity score matching were used to compare the short and long-term efficacy indicators of RG,LG and OG for locally advanced Siewert type?and?AEG,with a view to providing evidence-based medical evidence for RG in the treatment of locally advanced Siewert type?and?AEG.Methods1.A systemic search and review was performed in PubMed,MEDLINE,EMBASE,Cochrane Library,Clinical-Trials.gov and the web of science and other databases up to December 31,2018.Terms,such as"adenocarcinoma of the esophagogastric junction","esophagogastric junctional adenocarcinoma","laparoscopic","open"and"gastrectomy",were used searched the English literature which comparing the clinical efficacy of LG and OG for Siewert type?and?AEG.Two researchers independently performed literature screening and data extraction.The Newcastle-Ottawa scale(NOS)was used to evaluate the quality of the literature.The Rev Man 5.3 statistical software was used for meta-analysis.The weighted mean difference(WMD)and odds ratio(OR)were applied to compare the intraoperative and postoperative conditions of the LG and OG.Literature heterogeneity was assessed using I~2 values,and funnel charts were used to assess potential publication bias for the literature.2.We retrospectively collected clinical and pathological data of patients with locally advanced Siewert type?and?AEG who underwent gastrotomy at department of general surgery,the First Affiliated Hospital of Army Military Medical University from January2009 to April 2019.The patients were screened according to the inclusion and exclusion criteria.The propensity score matching(PSM)was used to balance the baseline of the patients in RG group,LG group and OG group.The surgical indicators of the three groups after PSM such as operation time,intraoperative blood loss,number of lymph node dissections,proximal resection margin,distal resection margin,postoperative recovery indicators such as time to first flatus,time to ambulation,postoperative hospital stay,postoperative complications and long-term efficacy indicators such as 5-year overall survival(5-year OS),5-year disease-free survival(5-year DFS)and recurrence rate were compared and analyzed.The PSM was performed using SPSS 23.0 and R software 3.6.1Match It.The measurement data conforming to the normal distribution are expressed in(±s),the one-way ANOVA analysis is used for the intergroup comparison.The measurement data conforming to the skew distribution and the grade data are expressed in M(range),the nonparametric test is used for the intergroup comparison.The absolute number or percentage is used for the count data,and the?2 test is used for the intergroup comparison.The survival analysis was performed by the Kaplan-Meier method,the OS rate and DFS rate of the three groups were compared by Log-rank test.The difference was statistically significant(P<0.05).Results1.Meta-analysis for the Clinical efficacy of LG versus OG for Siewert type?and?AEGSeven studies of 1915 patients were included for meta-analysis.The estimated blood loss(WMD=-77.49,95%CI-111.84 to-43.15;P<0.05)was significantly less and the postoperative hospital stay(WMD=-1.98,95%CI-2.14 to-1.83;P<0.05)was significantly shorter in the LG group than in the OG group,while the operation time,number of retrieved lymph node,time to first flatus,and time to ambulation showed no significant difference between LG and OG groups.The overall postoperative complications[OR=0.78,95%CI 0.60-1.02;P=0.07]in LG group were less than those in OG group,although the difference was not significant between the two groups.2.The clinical efficacy of RG,LG and OG for locally advanced Siewert type?and?AEGA total of 404 patients with locally advanced Siewert type?and?AEG were included in this study.312 patients were matched successfully after matching the baseline characteristics of the three groups with a 1:2:1 propensity score,including 78 in the RG group,156 in the LG group and 78 in the OG group.There were significant differences in age,histopathological grade and surgical resection range among the three groups before PSM.After PSM,there was no significant difference in the above indexes among the three groups.Compared with OG,the RG and LG groups had less bleeding[137.5(50.0-400.0),150.0(40.0-800.0)and 200.0(55.0-800.0)ml,P<0.05],smaller incision[6.0(3.0-12.0),6.0(3.0-12.0)and 20.0(18.0-25.0)cm,P<0.05],longer proximal margin[2.5(1.5-5.5),3.0(1.0-5.0)and 2.0(1.0-5.5)cm,P<0.05],shorter time to first flatus[3.0(2.0-5.0),3.0(2.0-8.0)and 4.0(2.0-10.0)days,P<0.05],shorter time to first ambulation[2.0(1.0-4.0),2.0(1.0-7.0)and 4.0(2.0-10.0)days,P<0.05]and shorter postoperative hospitalization days[9.0(5.0-20.0),9.0(6.0-56.0)and 11.0(8.0-41.0)days,P<0.05].However,the operation time of the RG and LG group was longer and the total cost of the RG group was higher.There was no significant difference among the three groups in the distal margin.The number of lymph nodes in the 2nd station[9.0(2.0-30.0),6.5(0.0-25.0)and 6.5(0-19.0),P<0.05]and upper region of pancreas[9.0(2.0-30.0),7.0(0-25.0)and 6.5(0-19.0),P<0.05]in the RG group were significantly higher than that in the LG and OG groups.There was no significant difference in the total number of lymph nodes detected,the number of lymph nodes in the first station and around diaphragm and esophagus among the three groups.There was no significant difference among the three groups in the incidence of overall postoperative complications and major complications.The 5-year OS of the RG,LG and OG groups were 46.4%,45.4%,and 39.2%(P=0.223),and the 5-year DFS was 46.4%,44.5%,and 39.4%(P=0.320),respectively.The difference of 5-year OS and 5-year DFS among the three groups was not statistically significant.In the p TNM subgroup analysis,there was no statistically significant difference in the 5-year OS and 5-year DFS rates among the RG,LG and OG group for stage?,?,and?.In the Siewert subgroup analysis,the 5-year OS of the RG,LG,and OG groups for Siewert type?AEG patients were:50.3%,46.6%,and 34.8%(P=0.026),and the 5-year DFS were:55.1%,47.1%and 37.6%(P=0.021),respectively.the long-term survival indicators of the RG and LG group were significantly higher than those of the OG group,but no statistically significant in the 5-year OS and 5-year DFS for patients with Siewert type?AEG among the three surgical methods(P=0.925 and P=0.878).The total tumor recurrence rates in the RG,LG,and OG groups were 37.2%,44.2%,and 47.4%,respectively.There was no significant difference in the total recurrence rates among the three groups(P=0.409).Conclusion1.The meta-analysis of this study show that compared with OG,LG for Siewert type?and?AEG has less blood loss,shorter hospital stays,and no significant difference in the incidence of complications.LG are safe and feasible for Siewert type?and?AEG.2.RG and LG has less bleeding,shorter surgical incisions,faster postoperative recovery,and satisfactory short-term results compared with OG for locally advanced Siewert type?and?AEG.Moreover,RG is safe and feasible for locally advanced Siewert type?and?AEG with more minimally invasive advantage over LG.The number of lymph node dissections in the 2nd station and the upper pancreas is more in RG group when compared with than LG and OG.The long-term efficacy of RG is equivalent to that of LG and OG,but for Siewert type?AEG,the long-term efficacy of RG and LG is better than that of OG.3.This study provides evidence-based medical evidence for RG in the treatment of locally advanced Siewert type?and?AEG. |
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