ABSTRACT
Objective:To analyze the interim clinical efficacy of laparoscopic and open distal gastrectomy for gastric cancer in elderly patients.Methods:The prospective randomized controlled study was conducted. The clinicopathological data of 102 patients aged ≥65 years who underwent distal gastrectomy for gastric cancer in the Nanfang Hospital of Southern Medical University from September 2014 to May 2018 were collected. After excluding 6 patients, 96 patients were finally included. Based on random number table, patients were allocated into two groups. Patients undergoing laparoscopic distal gastrectomy were allocated into laparoscopic group, and patients undergoing open distal gastrectomy were allocated into open group, respectively. Obser-vation indicators: (1) grouping situations of the enrolled patients; (2) intraoperative situations; (3) postoperative situations; (4) follow-up. Follow-up using outpatient examination and telephone interview was conducted to detect complications in the postoperative 30 days up to July 2018. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was analyzed using the t test. Measurement data with skewed distribution were represented as M( P25, P75) or M(range), and comparison between groups was analyzed using the Mann-Whitney U test. Count data were described as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test. Comparison of ordinal data was analyzed using the non-parameter Mann-Whitney U test. Results:(1) Grouping situations of the enrolled patients: a total of 96 patients were selected for eligibility. There were 66 males and 30 females, aged from 65 to 85 years, with a median age of 69 years. There were 49 of 96 patients in the laparoscopic group and 47 patients in the open group. (2) Intraoperative situations: patients in the two groups underwent distal gastrectomy successfully with D 2 lymphadenectomy, without intra-operative conversion to laparotomy. The volume of intraoperative blood loss and surgical incision length were 50 mL(50 mL,100 mL) and (7.1±1.7)cm for the laparoscopic group, respectively, versus 100 mL(100 mL,200 mL) and (19.1±1.7)cm for the open group, showing significant differences between the two groups ( Z=?3.779, t=?34.880, P<0.05) . (3) Postoperative situations: the number of lymph node dissected, time to postoperative initial out-of-bed activities, time to postoperative first flatus, time to postoperative first liquid food intake, time to postoperative first semi-liquid food intake, time to drainage tube removal, duration of postoperative hospital stay were 49(35,62), 1.9 days(1.3 days,2.9 days), 2.6 days(2.2 days,2.9 days), 3.4 days(2.7days,4.0 days), 5.9 days(4.7 days,7.7 days), 4.9 days(3.5 days,6.8 days), 7.7 days(6.7 days,8.9 days) for the laparoscopic group, respectively, versus 40(27,51), 2.5 days (1.8 days,3.3 days), 2.6 days(2.2 days,2.9 days), 3.9 days(2.9 days,5.7 days), 4.9 days(3.9 days, 5.9 days), 6.3 days(4.7 days,8.9 days), 8.7 days(6.9 days,11.7 days), showing significant differences between the two groups ( Z=?2.354, ?2.210, ?2.743, ?2.474, ?2.906, ?2.503, ?2.359, P<0.05). (4) Follow-up: patients in the two groups received 30 days of follow-up. During the follow-up, 8 patients in the laparoscopic group had postoperative complications, including 1 case with Clavien-Dindo grade Ⅰ complications, 7 cases with Clavien-Dindo grade Ⅱ complications, and no patient with Clavien-Dindo grade Ⅲ complications. Thirteen patients in the open group had postoperative complications, including 2 cases with Clavien-Dindo grade Ⅰ complications, 10 cases with Clavien-Dindo grade Ⅱ complications, and 1 case with Clavien-Dindo grade Ⅲ complications. There was no significant difference in the above indicators between the two groups ( χ2=1.135, 1.973, 1.054, P>0.05). The overall complication rate was 16.3%(8/49) and 27.7%(13/47) for the laparoscopic group and open group, respectively, showing no significant difference between the two groups ( χ2=1.803, 99.7% confidence interval as ?∞ to 2.4%, P>0.05). The upper limit of 99.7% confidence interval was less than non-inferiority level of 15%, interim analysis of which showed that the complication rate of the laparoscopic group was non-inferior to the open group. Conclusion:For elderly patients undergoing laparoscopic or open distal gastrectomy for gastric cancer, laparoscopic surgery does not increase intraoperative or postoperative complications, and has advantages of minimally invasiveness, fine operation, quicker recovery, and shorter hospital stay. Registry: this study was registered at clinicaltrials.gov in United States, with the registry number of NCT02246153.
ABSTRACT
The insufficiency of the examined number of lymph nodes after surgery for gastric cancer may undermine the stage of lymph node metastasis, which would have a significant impact on prognostic evaluation and strategy formulation of adjuvant therapy. Under the premise of standard D2 lymphadenectomy, the number of harvested lymph nodes is mainly dependent on the procedures of lymph node examination. Since 2013, our center has set up a special lymph node examination team. In the same year, the average number of harvested lymph nodes in each sample was 46, which was significantly higher than before (average 18 nodes/case in 2004-2012). After continuous quality improvement and regular quality control in 2014, average number of retrieved lymph nodes was 64 per specimen. Therefore, this paper summarizes the methods and experience of lymph node examination in gastric cancer specimens of general surgery in Southern Hospital. The overall construction of the lymph node examination team of gastric cancer in our center mainly includes three parts: establishment of a specialized lymph node examination team, effective standard operating procedures (SOP), and long-term and sustained quality control. The specialized lymph node examination team consists of postgraduate students who are not involved in surgery but have been trained by surgeons. Standard procedures include theoretical reserve of gastric anatomy, surgical observation to correspond to specimens in vitro and in vivo, and standardized specimen processing procedures. Long-term and sustained quality control requires periodic report of lymph node examination data and continuous feedback optimization of the process. Intraoperative lymph node tracing navigation and specimen lymph node intensification are carried out with nanocarbon and indocyanine green dye staining, and then lymph nodes are harvested based on the traditional methods, which can improve the examination rate of lymph nodes, especially for small lymph nodes. Research on lymph node tracing methods, requires multidisciplinary cooperation in particular, will become a hot topic.
ABSTRACT
Advanced gastric cancer (AGC) has a high recurrence rate (especially peritoneal relapse) and a poor prognosis. Systematic chemotherapy or targeted therapy have not been able to significantly reduce the major cause of an unfavorable prognosis, namely the high peritoneal AGC recurrence rate post-surgery. Further studies concerning the application of hyperthermic intraperitoneal chemotherapy (HIPEC) post curative surgery for AGC patients, namely the prophylactic HIPEC (P-HIPEC), have involved a prophylactic approach to prevent peritoneal relapse following curative gastrectomy in high-risk patients. Theoretically, breaking the "plasma-peritoneal barrier" increases cytotoxic chemotherapy activity via a synergistic hyperthermic effect; therefore, HIPEC can eradicate free cancer cells and micro-metastasis within the peritoneal cavity intraoperatively or soon after curative gastrectomy to reduce peritoneal recurrence. Many clinical trials have shown that P-HIPEC can reduce peritoneal recurrence and improve prognosis of AGC patients. However, some studies applying HIPEC at an early stage have revealed a high rate of complications that limited generalizability. This procedure has been increasingly adopted, given the complication rate has now been reduced and safety has been proven. Recently, for assessing the important role of HIPEC, many high-quality prospective randomized controlled clinical trials have been conducted to further investigate the best guidance for P-HIPEC and to demonstrate its effectiveness and safety with a higher grade of evidence. With theory development, the technique, equipment, and management of HIPEC and the role of P-HIPEC for AGC continues to evolve. This study summarizes the progress of P-HIPEC for high-risk AGC patients.
Subject(s)
Humans , Antineoplastic Combined Chemotherapy Protocols , Therapeutic Uses , Chemotherapy, Cancer, Regional Perfusion , Combined Modality Therapy , Hyperthermia, Induced , Neoplasm Recurrence, Local , Peritoneal Neoplasms , Drug Therapy , Randomized Controlled Trials as Topic , Stomach Neoplasms , Drug TherapyABSTRACT
<p><b>OBJECTIVE</b>To evaluate the feasibility and safety of intracorporeal Roux-en-Y esophagojejunostomy via the transoral anvil(OrVil) by mini-laparotomy anastomosis during laparoscopic total gastrectomy (LTG) for gastric cancer.</p><p><b>METHODS</b>From March 2010 to December 2016, 414 consecutive gastric adenocarcinoma patients underwent either intracorporeal Roux-en-Y esophagojejunostomy (n=43) via the OrVil or extracorporeal circular anastomosis (n=371) via auxiliary incision during LTG. After generating propensity scores with six covariates, including gender, age, body mass index (BMI), neoadjuvant chemotherapy, tumor location, and tumor size, 43 patients undergoing OrVil method (OrVil group) were matched with 43 patients undergoing extracorporeal circular anastomosis approach (extracorporeal anastomosis group). Operation-associated parameters and safety were compared between the two groups.</p><p><b>RESULTS</b>Both groups were balanced regarding baseline variables (all P > 0.05). The total operative time [(235.6±49.8) minutes vs. (221.1±46.5) minutes, t=1.397, P=0.166] and anvil insertion time [(10.0±3.2) minutes vs. (10.6±4.5) minutes, t=-0.671, P=0.504] were not significantly different between the two group, whereas the duration of reconstruction and the mean length of minilaparotomy [(48.3±12.0) minutes vs. (55.9±12.3) minutes, t=-2.899, P=0.005; (5.6±0.6) cm vs. (8.1±2.2) cm, t=-7.118, P=0.001] in the OrVil group were significantly shorter. The number of retrieved lymph nodes, mean blood loss and proximal resection margin were not significantly different between two groups (all P > 0.05). As a whole, OrVil group had advantages over extracorporeal anastomosis group during the postoperative recovery course. The time to liquid intake [(3.7±1.8) days vs. (6.2±7.2) days, t=-2.236, P=0.030], time to fluid diet [(4.8±2.3) days vs. (7.2±7.1) days, t=-2.013, P=0.048], and time to semi-fluid diet [(6.7±2.9) days vs. (10.2±9.6) days, t=-2.245, P=0.029] were significantly shorter in the OrVil group. The first ambulatory time, time to first flatus and length of hospital stay were not significantly different between two groups(all P>0.05). The morbidity of intraoperative complication [7.0%(3/43) vs. 4.7%(2/43), χ²=0.000, P=1.000] and postoperative complication [30.2%(13/43) vs. 20.9%(9/43), χ²=1.484, P=0.223], and even the distribution of severity (χ²=0.013, P=0.990) between the two groups were not significantly different. The incidence of anastomotic leakage (AL) was 9.3% (4/43) and 18.6% (8/43) in the OrVil group and extracorporeal anastomosis group respectively without significant difference (χ²=1.550, P=0.213). Multivariate analysis showed that the OrVil anastomosis was not a risk factor of AL(HR=0.663, 95%CI:0.120-3.674, P=0.638).</p><p><b>CONCLUSIONS</b>Intracorporeal esophagojejunostomy using the OrVil system is more minimally invasive and convenient to operate without increasing the risk of operation-related complication. Thus it may be a potential safe approach to optimize the reconstruction for LTG.</p>