Search

Key Points Question What are the 3-year outcomes after laparoscopic total gastrectomy combined with spleen-preserving splenic hilar lymphadenectomy for patients with locally advanced proximal gastric cancer? Findings In this nonrandomized clinical trial of 251 patients with clinically staged, locally advanced upper-third gastric cancer, the 3-year overall survival was 79.1%. The 3-year therapeutic value index of lymph node 10 dissection was 4.5, exceeding the index for the partial D2 lymph node group. Meaning The findings of this study suggest the utility of laparoscopic total gastrectomy combined with spleen-preserving splenic hilar lymphadenectomy for clinically staged, locally advanced upper-third gastric cancer., Importance The long-term survival of patients with laparoscopic total gastrectomy combined with spleen-preserving splenic hilar lymphadenectomy (LSTG) for advanced upper-third gastric cancer (AUTGC) and the association of splenic hilar lymph node (LN-10) metastasis with survival remain controversial. Objective To evaluate the long-term outcomes of LSTG and the value index of LN-10 metastasis for patients with AUTGC. Design, Setting, and Participants The Chinese Laparoscopic Gastrointestinal Surgery Study 4 (CLASS-04) was a prospective, multicenter, single-arm trial that involved 19 centers in China. A total of 251 eligible patients with clinical stage T2, T3, or T4a upper-third gastric cancer without distant metastases were enrolled from September 1, 2016, to October 31, 2017. The final follow-up was on December 31, 2020. Interventions All patients were enrolled to undergo LSTG. Main Outcomes and Measures The main outcomes were the 3-year overall survival (OS) and disease-free survival (DFS). Multivariate analyses were used to explore the association of LN-10 metastasis with survival. Results Among the 251 patients, 246 (98.0%; mean [SD] age, 60.1 [9.4] years; 197 [80.1%] male) underwent LSTG and completed the study. The 3-year OS was 79.1% (95% CI, 74.0%-84.2%), and the 3-year DFS was 73.1% (95% CI, 67.4%-78.8%). In addition, the 3-year therapeutic value index of LN-10 dissection was 4.5, exceeding the indexes for the partial D2 LN group (including LNs 5, 6, 11d, and 12a). Nineteen patients (7.7%) with LN-10 metastasis had significantly worse survival than the nonmetastasis group, and multivariate analysis revealed that splenic LN-10 metastasis was an independent risk factor (OS: hazard ratio [HR], 2.38; 95% CI, 1.08-5.26; P = .03; DFS: HR, 2.28; 95% CI, 1.12-4.63; P = .02). Moreover, patients with LN-10 metastasis were more likely to have recurrence (42.1% vs 20.7%, P = .03), especially when multiple site metastasis was present (21.1% vs 4.4%, P = .01). However, patients with LN-10 metastasis who received adjuvant chemotherapy had significantly better OS and DFS than those without adjuvant chemotherapy and achieved the same oncologic effect as those without LN-10 metastasis. Conclusions and Relevance This results of this study suggest that LSTG for AUTGC has feasible long-term outcomes. In addition, patients with LN-10 metastasis may have worse survival and may be more prone to recurrence., This nonrandomized clinical trial of patients with advanced upper-third gastric cancer assesses the outcomes of patients with laparoscopic total gastrectomy combined with spleen-preserving splenic hilar lymphadenectomy and the association of splenic hilar lymph node metastasis with survival.

To explore the risk factors for relapse of hyperglycemia in obese patients with type II diabetes mellitus (T2DM) who received laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery. A retrospective analysis was performed on all obese patients with T2DM who underwent a LRYGB during the period 2011–2013. Demographics, preoperative body mass index (BMI), preoperative glycated hemoglobin A1c (HbA1c), adherence to lifestyle intervention, preoperative medication of insulin, and the time interval between surgery and diagnosis of T2DM were investigated and compared. A total of 24 patients were included in our study. The median age was 45.5 years, the median BMI was 29.9 kg/m2, and the median HbA1c was 7.9%. Out of 24 patients, 54.2% (13/24) experienced a relapse of hyperglycemia. The 1-year, 3-year, and 5-year relapse rates were 4.2%, 12.5%, and 50.0%, respectively. The preoperative HbA1c level, C-peptide (2 h) level, and C-peptide (3 h) level were identified as independent variables for the relapse of hyperglycemia (8.11 ± 0.48 vs 7.72 ± 0.37 kg/m2, p = 0.036; 4.35 ± 1.46 vs 7.13 ± 4.10 ng/ml, p = 0.032; 3.76 ± 0.61 vs 5.99 ± 3.39 ng/ml, p = 0.029). Lifestyle intervention could reduce the hyperglycemia relapse rate (66.7 vs 41.7%) after LRYGB surgery. The preoperative HbA1c level and C-peptide level at surgery have an important significance in predicting the relapse of hyperglycemia after LRYGB surgery; lifestyle intervention is crucial for these patients.

Background This study aims to assess the learning curve of robotic distal gastrectomy (RDG) and robotic total gastrectomy (RTG) for gastric cancer. Methods Data on consecutive patients who underwent robotic gastrectomy for gastric cancer by five surgeons between March 2010 and August 2019 at two high-volume institutions were collected. The learning curve was determined based on the analyses of operation time and postoperative complications within 30 days. Cumulative sum analysis (CUSUM) and risk-adjusted-CUSUM (RA-CUSUM) were applied to identify the turning points (TPs). Results A total of 899 consecutive patients were included. The mean number of patients needed to overcome the learning curve for operation time of RDG and RTG were 22 and 20, respectively. The number of patients needed to overcome the learning curve for postoperative complications after RDG and RTG were 23 and 18, respectively. The surgical outcomes in the post-TP group were better than in the pre-TP group and improved as surgeons’ experience increased. Also, increased case numbers in RDG promoted the RTG learning process. Conclusion The present study demonstrated a substantial influence of surgical cumulative volume on improved surgical outcomes in robotic gastrectomy. Increased experience in RDG may help surgeons to achieve proficiency faster in RTG.

Purpose: To evaluate the effectiveness of the comprehensive post-operative management including low-frequency endo-anal electrical stimulation and daily suppository usage on post-operative anal functional recovery for low rectal cancer patients who underwent robotic total intersphincteric resection (ISR). Methods: A retrospective analysis was performed on 42 low rectal cancer patients who underwent robotic total ISR, of which 23 patients received comprehensive post-operative management, including biofeedback low-frequency endo-anal electrical stimulation and daily suppository usage (management group). Wexner score and anorectal manometric values, including resting pressure (RP), maximum squeeze pressure (MSP), initial perceived volume (IPV), and maximum tolerated volume (MTV), were assessed and compared. Results: A total of 42 low rectal cancer patients were included in our study. The RP at 6 months after ISR (40.95 ± 6.95 mmHg vs. 33.29 ± 5.40 mmHg, p = 0.002) and MSP at 3 and 6 months after ISR (72.05 ± 10.16 mmHg vs. 69.05 ± 8.67 mmHg, p = 0.031; 91.57 ± 15.47 mmHg vs. 84.05 ± 12.94 mmHg, p = 0.039, respectively) were significantly higher in the management group. The median IPV at 1 and 3 months after ISR (17.81 ± 3.61 ml vs. 15.43 ± 5.08 ml, p = 0.038; 20.19 ± 4.35 ml vs. 17.67 ± 5.16 ml, p = 0.044, respectively) and MTV at 3 months after ISR (83.71 ± 5.44 ml vs. 76.10 ± 8.42 ml, p = 0.012) were significantly higher in the management group. Wexner scores at 1 and 3 months after closure of stoma (COS) in the management group were significantly lower (11.3 ± 2.9 vs. 13.4 ± 3.0, p = 0.041; 8.9 ± 2.0 vs. 10.6 ± 2.4, p = 0.036, respectively). Conclusions: Comprehensive post-operative management could accelerate the recovery of sphincteric function and anal sensitivity after robotic total ISR and could also contribute to treatment of fecal incontinence followed by COS.

Robotic distal gastrectomy (RDG) has been increasingly used for the treatment of gastric cancer in recent year. However, whether RDG could reduce the morbidity when compared to laparoscopic distal gastrectomy (LDG) remains controversial. This study aimed to compare the morbidity and short-term surgical outcomes of RDG and LDG for gastric cancer and identify the related risk factors.Between March 2010 and August 2019, consecutive patients undergoing RDG or LDG (519 and 957 patients, respectively) at our institution were included in this study. Postoperative complications were stratified according to the Clavien-Dindo (C-D) classification. We performed one-to-one propensity score matching (PSM) analysis, and evaluated postoperative morbidity and short-term surgical outcomes in PSM 1032 patients undergoing RDG or LDG.After PSM, the two groups were well-balanced. The mean blood loss of the RDG group was about 27 mL less than that of the LDG group (112.1 vs 139.0 mL, P 0.001). The RDG group had more retrieved lymph nodes than that in the LDG group (32.7 v 30.2, P 0.001). The RDG group showed a similar overall (9.9% vs 10.7%, P = 0.682), severe (2.7% vs 3.7%, P = 0.376), local (5.6% vs 5.2%, P = 0.783), and systemic complication rates (5.4% vs 6.0%, P = 0.688). There were no significant differences in mortality between the two groups (RDG 0% vs LDG 0.2%, P = 1.000). Subgroup analyses showed no significant differences in most stratified parameters. Age 65 years and ASA III were identified as two major risk factors for complications.RDG could be a safe and feasible in treating gastric cancer compared to LDG. However, we did not observe significant reduction in postoperative complications of RDG compared with LDG, although the use of robotic system is assumed to provide a technically superior operative environment.

This study was designed to compare robot-assisted gastrectomy with laparoscopy-assisted gastrectomy in surgical performance and short-term clinical outcomes for gastric cancer and evaluate the safety and feasibility of robotic surgery. A retrospective database of patients who underwent robotic or laparoscopic gastrectomy for gastric cancer between March 2010 and May 2013 was examined. After screening, 514 patients who underwent gastrectomy for gastric cancer were enrolled in this study: 120 robotic and 394 laparoscopic surgery. Patient demographics, surgical performance, and short-term clinical outcomes were examined. All operations were performed successfully. The clinicopathologic characteristics were similar between the two groups. Compared with the laparoscopic group, the robotic group had less intraoperative blood loss (118.3 ± 55.8 vs. 137.6 ± 61.6 ml, P

Laparoscopy-assisted gastrectomy (LAG) has gained international acceptance for the treatment of early gastric cancer (EGC). However, the use of laparoscopic surgery in the management of advanced gastric cancer (AGC) has not attained widespread acceptance. This retrospective large-scale patient study in a single center for minimally invasive surgery assessed the feasibility and safety of LAG for T2 and T3 stage AGC. A total of 628 patients underwent LAG and 579 patients underwent open gastrectomy (OG) from Jan 2004 to Dec 2011. All cases underwent radical lymph node (LN) dissection from D1 to D2+. This study compared short- and long-term results between the 2 groups after stratifying by pTNM stages, including the mean operation time, volume of blood loss, number of harvested LNs, average days of postoperative hospital stay, mean gastrointestinal function recovery time, intra- and post-operative complications, recurrence rate, recurrence site, and 5-year survival curve. Thirty-five patients (5.57%) converted to open procedures in the LAG group. There were no significant differences in retrieved LN number (30.4 ± 13.4 vs 28.1 ± 17.2, P = 0.43), proximal resection margin (PRM) (6.15 ± 1.63 vs 6.09 ± 1.91, P = 0.56), or distal resection margin (DRM) (5.46 ± 1.74 vs 5.40 ± 1.95, P = 0.57) between the LAG and OG groups, respectively. The mean volume of blood loss (154.5 ± 102.6 vs 311.2 ± 118.9 mL, P

The aim of this study was to assess the complications associated with the laparoscopic treatment of gastric cancer and to discuss their management. From March 2004 to June 2007, 302 patients affected by gastric adenocarcinoma underwent laparoscopy-assisted gastrectomy. Of the 302 gastric malignancy cases, distal gastrectomy was performed in 161 cases, proximal gastrectomy in 62 cases, and total gastrectomy in 79 cases. In all cases, D1 or D2 lymph node dissection was performed according to the recommended procedures of the Japanese Gastric Cancer Association. Duration of surgery ranged from 180 to 310 min (median 230 min). There were no deaths during surgery and no anesthesiology complications in our series. We recorded 15 (4.97%) intraoperative complications: one transverse colon perforation, one lesion of the liver, two cases of splenic laceration, one injury of cystic artery leading to gangrene of the gallbladder, nine cases of hemorrhage, and one biliary tract injury. Conversion to open surgery was necessary in only five cases (1.7%). We recorded 21 (7.0%) postoperative complications: four cases of intra-abdominal bleeding, seven cases of duodenal stump leakage, one case of duodenal stump leakage followed by arteriole hemorrhage due to fundus of the stomach, two cases of acute pancreatitis, one case of lymphatic fistula, one case of anastomotic fistula, three cases of delayed gastric emptying, and two cases of obstruction of afferent loop. Six patients underwent reoperation, of whom two died after the procedure while the other four recovered postoperatively; other postoperative complications were treated conservatively. The overall operative morbidity and mortality rates were 11.9% and 0.7%, respectively. Our results show that laparoscopic-assisted gastrectomy is an adequate treatment for gastric cancer as long as the indications are controlled and only suitable cases are enrolled in the series. The complication rate is low enough to be acceptable. Most complications can be treated effectively via conservative treatment, and only a small number of cases require reoperation.

The feasibility and safety of laparoscopically assisted gastrectomy with extended lymphadenectomy for advanced gastric cancer has rarely been studied. This study aimed to investigate the feasibility, safety, and cancer clearance of laparoscopically assisted distal gastrectomy with D2 lymphadenectomy.Of the 44 patients with distal gastric cancer who underwent radical distal gastrectomy from March 2004 to May 2005, 35 were treated with D2/D2(+) lymphadenectomy. These patients were compared with 58 patients who, during the same period, underwent a conventional open radical distal gastrectomy.The mean total number of retrieved lymph nodes (30.11 +/- 16.97) and the mean tumor margin were comparable with those in the open group. The mean operative time for laparoscopically assisted distal gastrectomy was significantly longer than for open surgery (282.84 +/- 32.81 min vs 223.75 +/- 23.25 min). The patients in the laparoscopic surgery group had less blood loss, shorter times of analgesic injection, and a faster recovery. The rates of complications were comparable between two groups.Although laparoscopically assisted radical gastrectomy with D2 lymphadenectomy is more time consuming than open surgery, it is a safe, feasible procedure that achieves cancer clearance similar to open surgery and leads to a quick postoperative recovery.

To compare the short-term outcomes of gastric cancer patients treated with robotic gastrectomy (RG) or laparoscopic gastrectomy (LG).Robotic gastrectomy (RG) has been used for gastric cancer since 2002. This meta-analysis evaluates the safety and efficacy of robotic gastrectomy (RG) and conventional laparoscopic gastrectomy (LG) for gastric cancer.Pubmed, Embase and The Cochrane Library were searched, and manual searches were performed up to March 31, 2013. Five non-randomized control trials that reported RG and LG for gastric cancer were included. Outcomes evaluated were operation time, number of retrieved LN, blood loss, the length of the resection margin, complications, length of postoperative hospital stay.Of 1796 patients in five studies, 551 were allocated to RG and 1245 to LG. Operation time was significantly shorter in the latter group (weighted mean difference 42.9; 95 % confidence interval 20.87 to 64.92 min; p0.05). Blood loss weighted mean difference was -16.07 (95 % confidence interval -32.78 to 0.64 mL; p0.05) and postoperative stay weighted mean difference was -1.98 (95 % confidence interval -3.66 to -0.3 days; p0.05); both were less in the RG group. LN, length of the resection margin, and postoperative complications were similar in both groups.It may be concluded that RG is a safe and comfortable alternative to LG and is justifiable in the light of clinical trials.

Objectives: This study investigated the expression of Sonic Hedgehog (Shh) protein in gastric cancer, and correlated it with clinicopathological parameters. The prognostic significance of Shh protein was analyzed. Methods: Shh protein expression was evaluated in 113 cases of gastric cancer and 60 cases of normal gastric mucosa. The immunoreactivity was scored semi quantitatively as: 0 = absent; 1 = weak; 2 = moderate; and 3 = strong. All cases were further classified into two groups, namely non-overexpression group with score 0 or 1, and overexpression group with score 2 or 3. The overexpression of Shh protein was correlated with clinicopathological parameters. Survival analysis was then performed to determine the Shh protein prognostic significance in gastric cancer. Results: In immunohistochemistry study, nineteen (31.7%) normal gastric mucosa revealed Shh protein overexpression, while eighty-one (71.7%) gastric cancer revealed overexpression. The expression of Shh protein were significantly higher in gastric cancer tissues than in normal gastric mucosa (P < 0.001), which was statistically correlated with age (P = 0.006), tumor differentiation (P < 0.001), depth of invasion (P = 0.042), pathologic staging (P = 0.017), and nodal metastasis (P = 0.019). We found no significant difference in both overall and disease free survival rates between Shh overexpression and non-expression groups P = 0.168 and 0.071). However, Shh overexpression emerged as a significant independent prognostic factor in multivariate Cox regression analysis (hazard ratio 1.187, P = 0.041). Conclusions: Shh protein expression is upregulated and is statistically correlated with age, tumor differentiation, depth of invasion, pathologic staging, and nodal metastasis. The Shh protein overexpression is a significant independent prognostic factor in multivariate Cox regression analysis in gastric cancer.