Comparison of prognostic impact of anatomic location of the pancreas on postoperative pancreatic fistula in laparoscopic and open gastrectomy.

BACKGROUND: Postoperative pancreatic fistula (POPF) is a serious complication after gastric cancer surgery. The current study aimed to investigate the significance of the anatomic location of the pancreas as a predictor for POPF in both laparoscopic gastrectomy (LG) and open gastrectomy (OG). METHODS: In total, 233 patients with gastric cancer were assessed retrospectively. We measured the maximum vertical (P-L height; PLH) and horizontal length (P-L depth; PLD) between the upper border of pancreas and the root of left gastric artery on a preoperative CT in the sagittal direction. The maximum length of the vertical line between the surface of the pancreas and the aorta (P-A length), previously reported as prognostic factor of POPF, was also measured. We investigated the correlations between these parameters and the incidence of POPF in LG and OG groups. RESULTS: Among the patients in this study, 118 underwent OG and 115 underwent LG. In LG, the median PLH and P-A length in patients with POPF were significantly longer compared with those without POPF (p = 0.026, 0.034, respectively), but not in OG. There was no significant difference in the median PLD between the patients with or without POPF in both LG and OG. The multivariate analysis demonstrated that PLH (odds ratio [OR] 4.19, 95% confidence interval [CI] 1.57-11.3, P = 0.004) and P-A length (OR 4.06, 95%CI 1.05-15.7, P = 0.042] were independent factors for predicting POPF in LG. However, intraoperative blood loss (OR 2.55, 95%CI 1.05-6.18, P = 0.038) was extracted as an independent factor in OG. The median amylase level in the drained fluid (D-Amy) were significantly higher in patients with high PLH(≥12.4 mm) or high P-A length (≥45 mm) compared with those with low PLH or low P-A length in LG. However, there were no differences in the D-Amy levels by PLH or P-A length in OG patients. CONCLUSIONS: The anatomic location of the pancreas is a specific and independent predictor of POPF in LG but not in OG. PLH is a simple parameter that can evaluate the anatomic position of the pancreas, and it may be useful for preventing POPF after LG.

Laparoscopic versus open gastrectomy for gastric cancer.

BACKGROUND: Compared with open gastrectomy (OG), laparoscopic gastrectomy (LG) for gastric cancer has achieved rapid development and popularities in the past decades. However, lack of comprehensive analysis in long-term oncological outcomes such as recurrence and mortality hinder its full support as a valid procedure. Therefore, there are still debates on whether one of these options is superior. AIM: To evaluate the primary and secondary outcomes of laparoscopic versus open gastrectomy for gastric cancer patients METHODS: Two authors independently extracted study data. Risk ratio (RR) with 95% confidence interval (CI) was calculated for binary outcomes, mean difference (MD) or the standardized mean difference (SMD) with 95% CI for continuous outcomes, and the hazard ratio (HR) for time-to-event outcomes. Review Manager 5.3 and STATA software were used for the meta-analysis. RESULTS: Seventeen randomized controlled trials (RCTs) involving 5204 participants were included in this meta-analysis. There were no differences in the primary outcomes including the number of lymph nodes harvested during operation, severe complications, short-term and long-term recurrence, and mortality. As for secondary outcomes, compared with the OG group, longer operative time was required for patients in the LG group (MD = 58.80 min, 95% CI = [45.80, 71.81], P < 0.001), but there were less intraoperative blood loss (MD = - 54.93 ml, 95% CI = [- 81.60, - 28.26], P < 0.001), less analgesic administration (frequency: MD = - 1.73, 95% CI = [- 2.21, - 1.24], P < 0.001; duration: MD = - 1.26 days, 95% CI = [- 1.40, - 1.12], P < 0.001), shorter hospital stay (MD = - 1.37 days, 95% CI = [- 2.05, - 0.70], P < 0.001), shorter time to first flatus (MD = - 0.58 days, 95% CI = [- 0.79, - 0.37], P < 0.001), ambulation (MD = - 0.50 days, 95% CI = [- 0.90, - 0.09], P = 0.02) and oral intake (MD = - 0.64 days, 95% CI = [- 1.24, - 0.03], P < 0.04), and less total complications (RR = 0.81, 95% CI = [0.71, 0.93], P = 0.003) in the OG group. There was no difference in blood transfusions (number, quantity) between these two groups. Subgroup analysis, sensitivity analysis, and the adjustment of Duval's trim and fill methods for publication bias did not change the conclusions. CONCLUSION: LG was comparable to OG in the primary outcomes and had some advantages in secondary outcomes for gastric cancer patients. LG is superior to OG for gastric cancer patients.

Clinical Application of Indocyanine Green Fluorescence Technology in Laparoscopic Radical Gastrectomy.

Background: This study aimed to observe the application and evaluate the feasibility and safety of indocyanine green (ICG) fluorescence technology in laparoscopic radical gastrectomy (LRG). Methods: Patients who underwent LRG & D2 lymphadenectomy at Qilu Hospital of Shandong University were included between January 2018 and August 2019. According to whether endoscopic injection of ICG was performed, patients were assigned to the ICG group (n=107) and the control group (n=88). The clinicopathologic features, retrieved lymph nodes, postoperative recovery, and follow-up data were compared between the two groups. Results: Baseline characteristics are comparable. The ICG group had a significantly larger number of lymph nodes retrieved (49.55 ± 12.72 vs. 44.44 ± 10.20, P<0.05), shorter total operation time (min) (198.22 ± 13.14 vs. 202.50 ± 9.91, P<0.05), shorter dissection time (min) (90.90 ± 5.34 vs. 93.74 ± 5.35, P<0.05) and less blood loss (ml) (27.51 ± 12.83 vs. 32.02 ± 17.99, P<0.05). The median follow-up time was 29.0 months (range 1.5-43.8 months), and there was no significant difference between the ICG group and the control group in 2-year OS (87.8% vs. 82.9%, P>0.05) or DFS (86.0% vs. 80.7%, P>0.05). Conclusions: ICG fluorescence technology in laparoscopic radical gastrectomy has advantages in LN dissection, operation time, and intraoperative blood loss. The 2-year OS and 2-year DFS rates between the two groups were comparable. In conclusion, ICG fluorescence technology is feasible and safe.

Laparoscopic Gastrectomy for Cancer: Cut Down Complications to Unveil Positive Results of Minimally Invasive Approach.

Several randomized controlled trials and meta-analyses have confirmed the advantages of laparoscopic surgery in early gastric cancer, and there are indications that this may also apply in advanced distal gastric cancer. The study objective was to evaluate the safety and effectiveness of laparoscopic gastrectomy (LG), in comparison to open gastrectomy (OG), in the management of locally advanced gastric cancer. The single-center, case-control study included 204 patients, in conveyance sampling, who underwent radical gastrectomy for locally advanced gastric cancer. Out of 204 patients, 102 underwent LG, and 102 patients underwent OG. The primary endpoints were safety endpoints, i.e., complication rates, reoperation rates, and 30-day mortality rates. The secondary endpoints were efficacy endpoints, including perioperative characteristics and oncological outcomes. Even though the overall complication rate was higher in the OG group compared to the LG group (30.4% and 19.6%, respectively), the difference between groups did not reach statistical significance (p = 0.075). No significant difference was identified in reoperation rates and 30-day mortality rates. Time spent in the intensive care unit (ICU) and overall hospital stay were shorter in the LG group compared to the OG group (p < 0.001). Although the number of retrieved lymph nodes is oncologically adequate in both groups, the median number is higher in the OG group (35 vs. 29; p = 0.024). Resection margins came out to be negative in 92% of patients in the LG group and 73.1% in the OG group (p < 0.001). The study demonstrated statistically longer survival rates for the patients in the laparoscopic group, which particularly applies to patients in the most prevalent, third stage of the disease. When patients with the Clavien-Dindo grade ≥II were excluded from the survival analysis, further divergence of survival curves was observed. In conclusion, LG can be safely performed in patients with locally advanced gastric cancer and accomplish the oncological standard with short ICU and overall hospital stay. Since postoperative complications could affect overall treatment results and diminish and blur the positive effect of the minimally invasive approach, further clinical investigations should be focused on the patients with no surgical complications and on clinical practice to cut down the prevalence of complications.

The Comparison of Short- and Long-Term Outcomes for Laparoscopic Versus Open Gastrectomy for Patients With Advanced Gastric Cancer: A Meta-Analysis of Randomized Controlled Trials.

Objectives: The effect of laparoscopic gastrectomy (LG) for the treatment of advanced gastric cancer (AGC) is still controversial. The aim of this meta-analysis was to contrast the short- and long-term outcomes of laparoscopic versus conventional open gastrectomy (OG) for patients with AGC. Methods: Databases including PubMed, Embase, Scopus, and Cochrane Library were systematically searched until December 2021 for randomized controlled trial-enrolled patients undergoing LG or OG for the treatment of AGC. Short-term outcomes were overall postoperative complications, anastomotic leakage, number of retrieved lymph node, surgical time, blood loss, length of hospital stay, and short-term mortality. Long-term outcomes were survival rates at 1, 3, and 5 years. Results: A total of 12 trials involving 4,101 patients (2,059 in LG group, 2,042 in OG group) were included. No effect on overall postoperative complications (OR 0.84, 95% CI 0.67 to 1.05, p = 0.12, I2 = 34%) and anastomotic leakage (OR 1.26, 95% CI 0.82 to 1.95, p = 0.30, I2 = 0%) was found. Compared with the open approach, patients receiving LG had fewer blood loss (MD -54.38, 95% CI -78.09 to -30.67, p < 0.00001, I2 = 90%) and shorter length of hospital stay (MD -1.25, 95% CI -2.08 to -0.42, p = 0.003, I2 = 86%). However, the LG was associated with a lower number of retrieved lymph nodes (MD -1.02, 95% CI -1.77 to -0.27, p = 0.008, I2 = 0%) and longer surgical time (MD 40.87, 95% CI 20.37 to 54.44, p < 0.00001, I2 = 94%). Furthermore, there were no differences between LG and OG groups in short-term mortality and survival rate at 1, 3, and 5 years. Conclusions: LG offers improved short-term outcomes including shorter hospital stays and fewer blood loss, with comparable postoperative complications, short-term mortality, and survival rate at 1, 3, and 5 years when compared to the open approach. Our results support the implementation of LG in patients with AGC. Systematic Review Registration: PROSPERO (CRD 42021297141).

Pre-operative Weight Loss Program for Obese Patients Undergoing Laparoscopic Gastrectomy.

Background : The aim of this study was to investigate the influence of obesity and the usefulness of a pre-operative weight loss program (PWLP) for obese patients undergoing laparoscopic gastrectomy (LG) for gastric cancer (GC). Materials and Methods : Study1 : 219 patients who underwent laparoscopic distal gastrectomy (LDG) for GC were divided into 2 groups : body mass index (BMI) ≧ 28 and BMI < 28kg / m2. The influence of BMI in LG surgery was investigated. Study2 : The BMI ≧ 28 kg / m2 patients with a planned LG (n = 8) undertook a PWLP including calorie restriction and exercise. The effects of this program were evaluated. Results : Study1 :  The BMI ≧ 28kg / m2 group showed significantly longer operation times, more blood loss and a higher frequency of post-operative complications than that of the BMI < 28kg / m2 group. Study 2 : The patients achieved a weight loss of 4.2%. The visceral fat area (VFA) was significantly decreased by 10.6%, whereas skeletal muscle mass was unaffected. The PWLP group showed shorter operation times, less blood loss and a lower frequency of post-operative complications compared with that of the BMI ≧ 28kg / m2 group. Conclusion : Obesity is an important risk factor and a pre-operative weight loss program is useful for obese patients undergoing a LG. J. Med. Invest. 68 : 165-169, February, 2021.

Educational system of laparoscopic gastrectomy for trainee-how to teach, how to learn.

The feasibility of laparoscopic gastrectomy (LG) has been gradually proven by several scientific works, however, proper training method for this kind of surgery are still under investigation and debate. Here we report our educational system of LG to enhance the skill of young surgeons in our hospital. Our training program for trainee consists of 3 years of junior residency and 2 years of senior residency programs, requiring 5 years in total. In order to master LG, three following factors seem to be essential: learning, practice and experience. Learning means that trainee study techniques and concepts by educational materials, such as operative videos, lectures, or textbook. Practice means animal laboratory training or dry box training to acquire hand-eye coordination or bi-hand coordination, leading to precise movement of surgical devices. Experience means actual on-site training, participating in clinical LG as scopist, assistant or operator. In the actual surgery, we have some common principles for scopist, assistant and operator, respectively, and these principles are shared by entire surgical team. These principles are transmitted from trainer to trainee using simple keywords repeatedly. In conclusion, combination and balance of the three factors, learning, practice and experience are necessary to efficiently advance education of LG for trainee and may leads to benefits for gastric cancer patients.

Laparoscopic distal gastrectomy with D2 lymphadenectomy followed by intracorporeal gastroduodenostomy for advanced gastric cancer: technical guide and tips.

In 1994, Kitano and colleagues first reported laparoscopy-assisted Billroth I gastrectomy. Since then, laparoscopic gastrectomy (LG) has been associated with earlier patient recovery compared with open surgery, and has gained increasing international acceptance. Japan Society of Endoscopic Surgery biennial surveys confirm the increasing use of laparoscopic procedures for treatment of gastric cancer in Japan. Its thirteenth national survey indicates that of 31,264 patients treated at Japanese institutions in 2015, approximately 9,500 (30.3%) underwent LG, and laparoscopic distal gastrectomy (LDG) was the procedure most commonly performed. Despite evidence supporting the efficacy of LDG for gastric cancer in the short term, however, uncertainty remains concerning the efficacy of LG. Today, phase III randomized control trials on this procedure are ongoing in East Asian countries. Distal gastrectomy (DG) is the most commonly performed mode of resection, and as appropriate surgical techniques need to be acquired by gastric surgeons, here we describe a 'gold standard' method to perform total LDG.