Robotic gastrectomy versus laparoscopic gastrectomy for gastric cancer: meta-analysis and trial sequential analysis of prospective observational studies.

BACKGROUND: To evaluate short- and long-term outcomes of robotic gastrectomy (RG) in patients with gastric cancer to determine whether RG is an acceptable alternative to laparoscopic gastrectomy (LG). METHODS: PubMed, Embase, the Cochrane Library, and Chinese Biomedical Database were searched for prospective observational studies (POSs) comparing RG with LG for gastric cancer until October 2017. We compared short-term and long-term outcomes using systematic review with meta-analysis and trial sequential analysis (TSA). RESULTS: Sixteen POSs including 4576 patients were included in the meta-analyses. Compared with LG, RG had longer operative time (MD 57.98 min, P < 0.00001), lesser blood loss (MD - 23.71 ml, P = 0.005), and shorter time to first post-operative flatulence (MD - 0.14 days, P = 0.03). No significant difference was found in terms of the number of harvested lymph nodes, complications, reoperation, mortality, open conversion, proximal resection margin, and distal resection margin. The meta-analyses of complications, overall survival, and disease-free survival did not yield any sign of statistically significant difference between the two treatments, and the cumulative Z-curve crossed neither the traditional boundary nor the trial sequential monitoring boundary, suggesting the lack of firm evidence. TSA demonstrated that the cumulative Z-curve crossed either the traditional boundary or the trial sequential monitoring boundary on blood loss and operative time. CONCLUSIONS: The present study demonstrates that RG is as acceptable as LG in terms of short- and long-term outcomes. The TSA demonstrated that further studies are not needed to evaluate the operative time and blood loss differences between these techniques.

Analysis on efficacy and safety of total neoadjuvant therapy in patients with locally advanced rectal cancer with high risk factors / 中华胃肠外科杂志

Objective@#To evaluate the safety and preliminary efficacy of total neoadjuvant therapy (TNT) in patients with locally advanced rectal cancer (LARC) with high risk factors.@*Methods@#Data of 101 patients who were diagnosed with stage II-III rectal cancer with high risk factors and received TNT between March 2015 and January 2018 at West China Hospital of Sichuan University were analyzed retrospectively. Inclusion criteria: (1) patients were diagnosed with stage II-III rectal cancer by high-resolution MRI combined with CT and endorectal ultrasound; (2) at least one high risk factor: cT4a, cT4b, cN2, EMVI+, CRM+ and lateral lymph node+; (3) distance from tumor to anal verge was within 15 cm; (4) Eastern Collaborative Oncology Group (ECOG) performance status score was 0-1; bone marrow function, liver function and kidney function were suitable for chemoradiotherapy; (5) patients were treated with TNT strategy; (6) the follow-up data and postoperative pathological data were complete. Patients with previous rectal cancer surgery (except prophylactic colostomy), pelvic radiotherapy, and systemic chemotherapy, those with distant metastases, those without neoadjuvant radiotherapy, those receiving less than 4 cycles of neoadjuvant chemotherapy were excluded. The regimen of TNT: 3 cycles of induction CAPOX (oxaliplatin plus capecitabine) were followed by pelvic radiotherapy and concurrent CAPOX, then 3 cycles of consolidation CAPOX were delivered after radiotherapy. Total mesorectal resection (TME) or watch-and-wait strategy was selected according to the therapeutic effect and patients' wishes. Short-term efficacy, including tumor regression grade (TRG), pathological complete response (pCR), clinical complete response (cCR), postoperative complications within 30 days of surgery, and adverse events (AE) to radiotherapy and chemotherapy (measured using CTCAE 4.0) was analyzed.@*Results@#The 101 patients included 68 males (67.3%) and 33 females (32.7%) with a median age of 54 years. The proportion of patients with cT4a, cT4b, cN2 and enlarged lateral lymph node was 13.9%, 29.7%, 56.4% and 43.6%, respectively. The mean cycle of neoadjuvant chemotherapy was 6.0±1.3. Seventy-five patients (74.3%) received at least 6 cycles of neoadjuvant chemotherapy and 100 (99.0%) completed radiotherapy. The mean cycle of induction and consolidation chemotherapy was 2.0±0.9 and 2.8±1.0 respectively. Most common grade 3 AE was leucopenia (n=13, 12.9%) and thrombocytopenia (n=7, 6.9%). Grade 3 diarrhea and radiation dermatitis were observed in 5 cases (5.0%) respectively. Grade 3 anemia and rectal pain were observed in 4 cases (4.0%) respectively. And rectal mucositis was observed in 2 cases (2.0%). Most of the AE was observed during concurrent chemoradiotherapy. No grade 4 or higher AE was observed. After TNT, 32 patients (31.7%) achieved pCR or cCR, and 62 patients (60.4%) achieved partial response (PR). Only 2 patients (2.0%) developed distant metastasis after chemoradiotherapy, while the other patients did not show disease progression. Seven patients (6.9%) with cCR refused surgery and selected watch-and-wait, while 7 patients without cCR still refused surgery. The other 87 patients (86.1%) underwent TME successfully. The mean interval from the completion of chemoradiotherapy to surgery was (20.1±8.5) weeks. The R0 resection rate was 97.7% (85/87).The morbidity of surgical complication was 16.1% (14/87), including pelvic infection or abscess in 6 cases (6.9%), anastomotic leakage in 3 (3.4%), hemorrhage in 2 (2.3%), and gastrointestinal dysfunction in 3 (3.4%). Pathological findings revealed that 24 cases (27.6%) had TRG 0, 20 (23.0%) had TRG 1, 30 (34.5%) TRG 2, and 13 (14.9%) TRG 3.@*Conclusion@#TNT is safe and has good short-term efficacy for locally advanced rectal cancer patients with high risk factors.

Laparoscopic transabdominal hiatal extended gastrectomy for type Ⅱ and m esophagogastric junction cancer / 中华消化外科杂志

The incidence of esophagogastric junction cancer (EGJC) is rising dramatically both in western countries and in China.For type Ⅱ EGJC,controversies over the optimal surgical approach still remain.More and more studies support the abdominal transhiatial extended gastrectomy to be superior to the abdominothoracic combined approach.The aim of this report is to evaluate the feasibility and safety of laparoscopic transabdominal hiatal extended gastrectomy for surgical treatment of type Ⅱ and Ⅲ esophagogastric junction cancer.Based on clinical experience of 95 patients who underwent laparoscopic tansabdominal hiatal extended gastrectomy,we conclude that laparoscopic transabdominal hiatal extended gastrectomy is feasible and safe,offering a safer and simpler way of intramediastinal dissection and digestive tract reconstruction at experienced hands as compared with open surgery.This procedure also offers the merit of longer esophageal resection length without entering the pleural cavity.