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A prospective, multicenter, randomized controlled trial (CLASS-01) of laparoscopic versus open surgery for locally advanced distal gastric cancer provides high-level evidence-based evidence for minimally invasive surgery for locally advanced gastric cancer. The findings showed that the experienced surgeons could perform laparoscopic D2 distal gastrectomy for locally advanced gastric cancer safely and effectively, with significant minimally invasive advantages, which attracting extensive attention in the academic community. In order to correctly understand and scientifically apply the results of this research in clinical practice, this paper summarized the research consensus of CLASS-01 trail for readers, including relevant definitions, surgical indications, device preparation, perioperative management, surgical principles and standards as well as the operational processes and quality control. The relevant standard procedures in this paper are the consensuses which were reached between the researchers when writing the CLASS-01 research plan. The basic principles referred to the international and domestic treatment guidelines and at the same time fully considered the actual situation of laparoscopic gastric cancer surgery in China. It has crucial guiding significance for the scientific development and rational promotion of laparoscopic surgery for gastric cancer in China.
Subject(s)
Humans , China , Consensus , Gastrectomy , Methods , Laparoscopy , Reference Standards , Prospective Studies , Stomach Neoplasms , General SurgeryABSTRACT
A prospective, multicenter, randomized controlled trial (CLASS-01) of laparoscopic versus open surgery for locally advanced distal gastric cancer provides high-level evidence-based evidence for minimally invasive surgery for locally advanced gastric cancer. The findings showed that the experienced surgeons could perform laparoscopic D2 distal gastrectomy for locally advanced gastric cancer safely and effectively, with significant minimally invasive advantages, which attracting extensive attention in the academic community. In order to correctly understand and scientifically apply the results of this research in clinical practice, this paper summarized the research consensus of CLASS-01 trail for readers, including relevant definitions, surgical indications, device preparation, perioperative management, surgical principles and standards as well as the operational processes and quality control. The relevant standard procedures in this paper are the consensuses which were reached between the researchers when writing the CLASS-01 research plan. The basic principles referred to the international and domestic treatment guidelines and at the same time fully considered the actual situation of laparoscopic gastric cancer surgery in China. It has crucial guiding significance for the scientific development and rational promotion of laparoscopic surgery for gastric cancer in China.
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Objective To explore the clinical effect of minimally invasive distal gastric cancer surgery combined with D2 lymph node dissection. Methods From September 2010 to September 2012,95 cases of gastric cancer surgically treated from our hospital were selected. Among them,2 cases were converted to laparotomy by abdominal cavity,and a total of 93 patients were included in the study. According to dif-ferent surgical methods,there were 43 cases in the observation group and 50 cases in the control group. The observation group was treated with minimally invasive distal gastric cancer surgery combined with D2 lymph node dissection,and the control group was treated with open surgery combined with D2 lymph node dissection. The bleeding volume,ambulation time,operative time,hospitalization time,lymph node dissection and postoperative complications were compared between the two groups. The recurrence,metastasis and mortality during 1 year,3 years and 5 years follow-up were also compared. Results The bleeding volume in the observation group was less than that in the control group,and the off-bed activity occurred earlier than that in the control group. The hospitalization time was shorter in the observation group than in the control group(P<0. 05),but there was no significant difference in operative time between the two groups(P>0. 05). There was no statistical differ-ence between the number of lymph nodes in the first station, the number of lymph nodes in second stations and the total number of lymph nodes in the two groups(P>0. 05). The incidence of postoperative complications in the observation group(6. 98％) was lower than that of the control group (22. 00％)(P<0. 05). The two groups were followed up for 1,3 and 5 years,and the recurrence rate and mortality rate were low(P>0. 05). Conclusion minimally invasive distal gastric cancer surgery combined with D2 lymph node dissection has significant clinical effect,less blood loss,quicker postoperative recovery and fewer complications,as well as less recurrence and metastasis and death in long-term follow-up.
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Objective To compare the short-term clinical efficacies of Da Vinci robotic surgical systemassisted and laparoscopy-assisted radical gastrectomy for locally advanced gastric cancer (GC).Methods The retrospective cohort study was conducted.The clinicopathological data of 162 patients who underwent minimally invasive radical gastrectomy for locally advanced GC in the First Affiliated Hospital of Army Medical University between September 2016 and September 2017 were collected.Of 162 patients,65 undergoing Da Vinci robotic surgical system-assisted radical gastrectomy were allocated into the robotic group and 97 undergoing laparoscopyassisted radical gastrectomy were allocated into the laparoscopic group.According to Japanese gastric cancer treatment guidelines,patients with upper GC and with middle or lower GC underwent respectively total gastrectomy + D2 lymph node dissection and distal subtotal gastrectomy + D2 lymph node dissection,and then Billroth Ⅱ or Roux-en-Y digestive tract reconstruction.Observation indicators:(1) surgical and postoperative situations;(2) detection of lymph node;(3) follow-up and survival situations.Measurement data with normal distribution were represented as x±s,and comparisons between groups were analyzed using the t test.Comparisons of count data were done using the chi-square test.Ordinal data were analyzed by the nonparametric test.Results (1) Surgical and postoperative situations:all 162 patients underwent successful surgery,without conversion to laparoscopic or open surgery,and pathological resection margins were confirmed as R0.Volume of intraoperative blood loss,levels of amylase in peritoneal drainage fluid at day 1,2 and 3 postoperatively,levels of serum amylase fluid at day 1,2 and 3 postoperatively were respectively (123±39) mL,(557± 181) U/L,(357± 127) U/L,(183±86) U/L,(181±47)U/L,(123±29)U/L,(85±22)U/L in the robotic group and (142±40)mL,(793±284)U/L,(497±199)U/L,(279±157) U/L,(218±45) U/L,(162±37) U/L,(120±31) U/L in the laparoscopic group,with statistically significant differences between groups (t =-3.015,-2.817,-2.364,-2.132,-2.372,-3.338,-3.720,P＜0.05).Cases with distal subtotal gastrectomy + D2 lymph node dissection and with total gastrectomy + D2 lymph node dissection,cases with Billroth Ⅱ and Roux-en-Y of digestive tract reconstruction,time of distal subtotal gastrectomy + D2 lymph node dissection,time of total gastrectomy + D2 lymph node dissection,cases with anastomotic leakage,pulmonary infection,wound infection or liquefaction and delayed gastric emptying,cases in grading Ⅱ,Ⅲ,Ⅳ and Ⅴ of postoperative complications,time of postoperative drainage-tube removal and duration of postoperative hospital stay were respectively 47,18,40,25,(222±37) minutes,(274±43) minutes,1,1,1,1,2,1,0,0,(6.5-± 1.5) days,(10.0±4.0) days in the robotic group and 74,23,69,28,(213±40) minutes,(262±39)minutes,2,4,1,0,4,1,0,1,(6.9±1.7)days,(10.0±5.0)days in the laparoscopic group,with no statistically significant difference between groups (x2=0.326,1.628,t =1.272,0.960,x2=2.501,Z=-1.342,t=-1.142,-0.115,P＞0.05).One and 1 patients in the robotic and laparoscopic groups who were complicated with esophagus-jejunum anastomotic leakage after total gastrectomy + Roux-en-Y anastomosis were cured by nutrition support therapy using feeding tube placement under gastroscopy,and 1 patient in the laparoscopic group who were complicated with gastrojejunal anastomosis leakage after distal subtotal gastrectomy +Billroth Ⅱ anastomosis received the second surgical exploration and jejunal feeding tube placement.Patients with pulmonary infection,wound infection or liquefaction and delayed gastric emptying were cured by conservative treatment.Levels of amylase in peritoneal drainage fluid and serum amylase fluid at day 1,2 and 3 postoperatively were not higher than 3 times of upper limit of normal,without treatment interventions.(2) Detection of lymph node:overall number of lymph nodes detected in the robotic and laparoscopic groups were respectively 36.82±13.41 and 35.21 ± 11.52,with no statistically significant difference between groups (t =0.786,P＞ 0.05).Results of further analysis showed that numbers of lymph node dissected in the 2nd station and upper region of pancreas in patients undergoing distal subtotal gastrectomy + D2 lymph node dissection were respectively 6.04±3.98,13.51±6.53 in the robotic group and 4.45±3.12,11.40±5.30 in the laparoscopic group,with statistically significant differences between groups (t=2.461,1.986,P＜0.05).Numbers of lymph node dissected in No 7 and 8 groups and upper region of pancreas in patients undergoing total gastrectomy + D2 lymph node dissection were respectively 5.44±2.63,2.92±1.87,10.81±4.78 in the robotic group and 3.11±1.82,1.62±1.33,7.76±3.34 in the laparoscopic group,with statistically significant differences between groups (t =3.340,2.689,2.522,P＜0.05).(3) Follow-up and survival situations:of 162 patients,148 were followed up for 2-14 months,with a median time of 8 months.During the follow-up,patients in the 2 groups had tumor-free survival.Conclusions Da Vinci robotic surgical system-assisted radical gastrectomy is safe and feasible.Compared with laparoscopy-assisted radical gastrectomy for locally advanced GC,it has advantages of clear vision of the local anatomy,less intraoperative bleeding,more numbers of lymph nodes dissected in the upper region of pancreas and lighter pancreatic injure,meanwhile,it has also certain operating advantages around the great vessels and in the deep and narrow spaces.
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Chemoradiotherapy is an important part in the adjuvant regimen for locally advanced gastric cancer after radical resection. Adjuvant chemoradiotherapy has demonstrated a clear local control and survival advantage for locally advanced patients with less than D2 lymph node dissection. Thus, chemoradiotherapy is recommended as standard of care in the postoperative setting. However, the role of radiotherapy for patients with more extensive D2 lymph node dissections remains controversial. Three phase III random-ized clinical trials in Asia show that adjuvant chemoradiotherapy after D2 dissection is safe and feasible and may benefit certain groups of patients. The benefit of radiotherapy in the case of more extensive surgery still warrants well-designed, fully powered randomized controlled clinical trials for verification. More studies are needed to focus on the identification of patient subgroups that are at high risk for locoregional failure and may benefit from adjuvant chemoradiotherapy. Further optimization of target volume in the radiother-apy and exploration of new modalities of radiation techniques are also necessary.
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PURPOSE: According to the 2nd English Edition of the Japanese Gastric Cancer Association (JGCA) in 1998, in case of distal gastric cancer, the 14v (superior mesenteric vein) lymph node (LN) is included in the N2 group. However, in Korea, a modified radical gastrectomy is performed, and a 14v LN dissection is not done as a routine procedure. Thus, we investigated the rate of metastatic 14v LNs, evaluated the necessity of dissection of the 14v LN, and searched for indications of 14v LN dissection. MATERIALS AND METHODS: From April 2004 to August 2005, we enrolled the patients who were diagnosed as having advanced gastric cancer in the distal third portion of the stomach. We performed a distal gastrectomy with D2 lymph node dissection as defined in the 2nd English edition of the JGCA classification. We calculated the positive rate of metastatic LNs of each station and analyzed the relationship between the positive rates of No.6 LNs and 14v LNs. We also compared the positive 14v LN group with the negative 14v LN group. RESULTS: The total number of patients was 50, the mean age was 56 (range 30~80) years, and sex ratio (Male/Female) was 1.63 : 1. In 47 (94%) cases, distal a gastrectomy with gastroduodenostomy was done, and in the remaining 3 (6%) cases, a distal gastrectomy with gastrojejunostomy was done. The most frequently metastatic LNs were nos. 3 and 6 (54%). The metastatic rate of the 14v LN was 10%, which was similar to that of LN no. 9. In the comparison of the 14v positive group with the 14v negative group, there were significant differences in the numbers of metastatic LNs (mean 25.4 vs 4.91, P<0.001) and the numbers of metastatic no. 6 LNs, (mean 6.8 vs 1.42, P<0.001), and if no. 6 LNs were metastatic, the possibility of metastasis to the 14v LN was 19.2%. In the 14v positive group, all cases were more than stage 3 by the UICC 6th edition. CONCLUSION: In cases of advanced cancer with metastasis to the no. 6 LN, there was a good chance of metastasis to the 14v LN. Thus, in the operative field, if the tumor is advanced to more than stage 3 by the UICC classification and the no. 6 LN is metastatic, a 14v LN dissection is necessary. However, the usefulness of a 14v LN dissection should be evaluated prospectively through an analysis of tumor recurrence and long-term survival.
Subject(s)
Humans , Asian People , Classification , Gastrectomy , Gastric Bypass , Korea , Lymph Node Excision , Lymph Nodes , Neoplasm Metastasis , Recurrence , Sex Ratio , Stomach , Stomach NeoplasmsABSTRACT
PURPOSE: Early gastric cancer (EGC) has an excellent prognosis compared to advanced gastric cancer. The 5-year survival rate for EGC now exceeds 90%, and EGC is recognized as a curable malignancy. The important prognostic factor in EGC is the status of lymph-node metastasis. Despite conserving surgery being suggested for EGC at present, it is of vital importance to select a surgical method appropriate to each individual case. This retrospective study was undertaken to clarify clinicopathologic features and factors related to lymph-node metastasis in submucosal gastric cancer in order to determine an appropriate therapy. MATERIALS AND METHODS: This study analyzed the clinicopathologic features for 279 patients with a submucosal gastric carcinoma (Group I) and compared with those of patients with mucosal (Group II) or muscularis proprial gastric carcinoma (Group III). All patients were operated on from 1981 to 1999 at Chonnam University Hospital. There were no statistically significant differences among the groups with respect to age, gender, tumor location, hepatic metastasis, or peritoneal dissemination. RESULTS: Positive lymph node metastasis was found in 47 (16.8%) of the 279 patients with a submucosal gastric carcinoma. The incidence of lymph-node metastasis was significantly higher in patients with a submucosal gastric carcinoma than in patients with a mucosal gastric carcinoma (16.8% vs. 3.9%; P<0.01). Therefore, depth of invasion was a significant factor affecting in lymph-node metastasis. The 5-year survival rates were 88.6% for patients in Group I, 95.2% for patients in Group II, and 72.7% for patients in Group III (P<0.01 for Group I vs. Group II; Group I vs. Group III). In patients with a submucosal gastric carcinoma, the survival rate with positive lymph nodes was significantly poorer than that of patients without lymph-node metastasis (87.3% vs. 94.2%; P<0.01). CONCLUSION: Gastrectomy with D2 lymph node dissection is an appropriate operative procedure for patients with a submucosal gastric carcinoma.
Subject(s)
Humans , Gastrectomy , Incidence , Lymph Node Excision , Lymph Nodes , Neoplasm Metastasis , Prognosis , Retrospective Studies , Stomach Neoplasms , Surgical Procedures, Operative , Survival RateABSTRACT
PURPOSE: Early gastric cancer (EGC) has an excellent prognosis compared to advanced gastric cancer. The 5-year survival rate for EGC now exceeds 90%, and EGC is recognized as a curable malignancy. The important prognostic factor in EGC is the status of lymph-node metastasis. Despite conserving surgery being suggested for EGC at present, it is of vital importance to select a surgical method appropriate to each individual case. This retrospective study was undertaken to clarify clinicopathologic features and factors related to lymph-node metastasis in submucosal gastric cancer in order to determine an appropriate therapy. MATERIALS AND METHODS: This study analyzed the clinicopathologic features for 279 patients with a submucosal gastric carcinoma (Group I) and compared with those of patients with mucosal (Group II) or muscularis proprial gastric carcinoma (Group III). All patients were operated on from 1981 to 1999 at Chonnam University Hospital. There were no statistically significant differences among the groups with respect to age, gender, tumor location, hepatic metastasis, or peritoneal dissemination. RESULTS: Positive lymph node metastasis was found in 47 (16.8%) of the 279 patients with a submucosal gastric carcinoma. The incidence of lymph-node metastasis was significantly higher in patients with a submucosal gastric carcinoma than in patients with a mucosal gastric carcinoma (16.8% vs. 3.9%; P<0.01). Therefore, depth of invasion was a significant factor affecting in lymph-node metastasis. The 5-year survival rates were 88.6% for patients in Group I, 95.2% for patients in Group II, and 72.7% for patients in Group III (P<0.01 for Group I vs. Group II; Group I vs. Group III). In patients with a submucosal gastric carcinoma, the survival rate with positive lymph nodes was significantly poorer than that of patients without lymph-node metastasis (87.3% vs. 94.2%; P<0.01). CONCLUSION: Gastrectomy with D2 lymph node dissection is an appropriate operative procedure for patients with a submucosal gastric carcinoma.