Comparison of totally robotic and totally laparoscopic gastrectomy for gastric cancer: a propensity score matching analysis.

BACKGROUND: With the improvements in laparoscopic or robotic surgical techniques and instruments, a growing number of surgeons have attempted to complete all digestive tract reconstruction intracorporeally; these procedures include totally robotic gastrectomy (TRG) and totally laparoscopic gastrectomy (TLG). This study aimed to evaluate the safety and feasibility of the TRG and compare the short-term outcomes of the TRG and TLG in patients with gastric cancer. METHODS: Between January 2018 and June 2023, 346 consecutive patients who underwent TRG or TLG at a high-volume academic gastric cancer specialty center were included. 1:1 propensity score matching (PSM) was performed to reduce confounding bias. The surgical outcomes, postoperative morbidity, and surgical burden were compared in PSM cohort. RESULTS: After PSM, a well-balanced cohort of 194 patients (97 in each group) was included in the analysis. The total operation time of the TRG group was significantly longer than that of the TLG group (244.9 vs. 213.0 min, P < 0.001). There was no significant difference in the effective operation time between the 2 groups (217.8 vs. 207.2 min, P = 0.059). The digestive tract reconstruction time of the TRG group was significantly shorter than that of the TLG group (39.4 vs. 46.7 min, P < 0.001). The mean blood loss in the TRG group was less than that in the TLG group (101.1 vs. 126.8 mL, P = 0.014). The TRG group had more retrieved lymph nodes in the suprapancreatic area than that in the TLG group (16.6 vs 14.2, P = 0.002). The TRG group had a lower surgery task load index (38.9 vs. 43.1, P < 0.001) than the TLG group. No significant difference was found in terms of postoperative morbidity between the 2 groups (14.4% vs. 16.5%, P = 0.691). CONCLUSION: This study demonstrated that TRG is a safe and feasible procedure, and is preferable to TLG in terms of invasion and ergonomics. The TRG may maximize the superiority of robotic surgical systems and embodies the theory of minimally invasive surgery.

Efficacy and safety of totally laparoscopic gastrectomy with uncut Roux-en-Y for gastric cancer: a dual-center retrospective study.

BACKGROUND: Uncut Roux-en-Y (URY) effectively alleviates the prevalent complexities connected with RY, such as Roux-en-Y stasis syndrome (RSS). Nevertheless, for gastric cancer (GC) patients, it is still controversial whether URY has an impact on long-term prognosis and whether it has fewer afferent loop recanalization. Therefore, compare whether URY and RY have differences in prognosis and long-term complications of GC patients undergoing totally laparoscopic gastrectomy (TLG). METHODS: We analyzed the data of patients who underwent TLG combined with digestive tract reconstruction from dual-center between 2016 and 2022. Only patients undergoing URY and RY were selected for analysis. Relapse-free survival (RFS) and overall survival (OS) were estimated. Bias between the groups was reduced by propensity score matching (PSM). The Cox proportional hazard regression model was used to further analyze the influence of URY on prognosis. RESULTS: Two hundred forty two GC patients were enrolled. The URY had significantly shorter operation time, liquid food intake time, and in-hospital stays than the RY (P < 0.001). The URY had fewer long-term and short-term postoperative complications than the RY, especially with regard to RSS, reflux esophagitis, and reflux gastritis. The 3-year and 5-year OS of the URY group and the RY group before PSM: 87.5% vs. 65.6% (P < 0.001) and 81.4% vs. 61.7% (P = 0.001). PSM and Cox multivariate analysis confirmed that compared to RY, URY can improve the short-term and long-term prognosis of GC patients. CONCLUSION: TLG combined with URY for GC, especially for advanced, older, and poorly differentiated patients, may promote postoperative recovery and improve long-term prognosis.

Short- and long-term oncological outcomes of totally laparoscopic gastrectomy versus laparoscopy-assisted gastrectomy for clinical stage I gastric cancer.

BACKGROUND: Totally laparoscopic gastrectomy (TLG), which involves a complete intracorporeal gastric transection and the creation of an anastomosis, has been gradually adopted. However, a potential limitation of intracorporeal transection is the lack of tactile feedback, and whether this limitation influences oncological outcomes is unclear. The aim of this study is to evaluate the short- and long-term oncological safety of TLG using endoscopy-guided intracorporeal gastric transection for clinical stage (cStage) I gastric cancer. METHODS: A total of 1875 consecutive patients who underwent laparoscopic gastrectomy for cStage I gastric cancer between January 2007 and March 2015 were enrolled in this study. Marking clips were preoperatively placed and a transection line was determined by perceiving it tactually in laparoscopy-assisted gastrectomy (LAG) or endoscopically in TLG. After propensity score matching, 1366 patients (683 each for LAG and TLG groups) were selected to primarily test the non-inferiority of TLG to that of LAG for relapse-free survival (RFS). RESULTS: In the propensity-matched population, the 5-year RFS rates of the LAG and TLG groups were 94.3% (95% confidence interval (CI) 92.2-95.8%), and 95.6% (95% CI 93.8-96.9%), respectively. The hazard ratio (TLG/LAG) was 0.77 (95% CI 0.48-1.24, P for non-inferiority < 0.01). There were no significant differences in the recurrence profiles. The incidence of the remnant of marking clips or tumor tissue did not differ (LAG: 1.0% vs. TLG: 1.9%, P = 0.177). CONCLUSIONS: TLG using preoperative markings and intraoperative endoscopic guidance provides cStage I gastric cancer patients with comparable oncological outcomes to the conventional method.

Practicality and short-term outcomes of intracorporeal gastroduodenostomy in totally laparoscopic distal gastrectomy for gastric cancer: A single-centre retrospective study.

OBJECTIVE: Totally laparoscopic distal gastrectomy (TLDG) with intracorporeal anastomosis is feasible because of improved approaches to laparoscopic surgery and the availability of a variety of surgical instruments. This study was designed to evaluate the practicality, safety and short-term operative outcomes of intracorporeal gastroduodenostomy in TLDG for gastric cancer. MATERIALS AND METHODS: Medical records of patients with primary distal gastric cancer undergoing Billroth I (B-I) (n = 37) or B-II anastomosis (n = 41) in TLDG from February 2010 to November 2015 were retrospectively analysed. Perioperative data including the extent of lymph node dissection, number of stapler cartridges used, time required to create the anastomosis, operative time, estimated blood loss, proximal and distal margin length, and number of lymph nodes harvested were collected. Short-term post-operative outcomes evaluated during the initial 30 days after surgery included time to first flatus and earliest liquid consumption, length of post-operative hospital stay and incidence of post-operative complications. RESULTS: B-I anastomosis was mainly applied to patients with carcinoma in the lower third of the gastric body (B-I, 81.08% vs. B-II, 31.71%;P < 0.001). Mean operating (B-I, 153.57 ± 18.25 min vs. B-II, 120.17 ± 11.74 min;P = 0.004) and anastomosis (B-I, 31.92 ± 6.10 min vs. B-II, 25.29 ± 3.84 min;P = 0.01) times were significantly longer for B-I anastomosis compared to B-II anastomosis. There were no significant differences in the number of stapler cartridges used, estimated blood loss, time to first flatus and liquid consumption, length of hospital stay or incidence of complications between these groups. CONCLUSIONS: TLDG with B-I or B-II anastomosis is safe and feasible for gastric cancer. B-II anastomosis may require less time than B-I anastomosis.

Intracorporeal circular-stapled anastomosis after totally laparoscopic gastrectomy: A novel, simplest u-shaped parallel purse-string suture technique.

BACKGROUND: Intracorporeal anastomoses in totally laparoscopic gastrectomy (TLG) remain technical challenges to many surgeons, although the intracorporeal jejunojejunal or gastrojejunal anastomosis is an essential procedure during TLG. Standardized, reproducible and simple circular-stapled anastomosis in open gastrectomy is limited in TLG due to the difficulties of intracorporeal purse-string suture or anvil placement. An optimal procedure for intracorporeal anastomosis in TLG remains to be established. METHODS: Between February 2018 and January 2019, 31 consecutive patients with gastric cancer underwent totally laparoscopic total gastrectomy (TLTG) or totally laparoscopic distal gastrectomy (TLDG) using the novel u-shaped parallel purse-string suture technique along the jejunum for anvil placement. The intracorporeal circular-stapled jejunojejunostomy of Roux-en-Y reconstruction in TLTG and gastrojejunostomy of Billroth II in TLDG were, respectively, performed. RESULTS: The total mean ± SD operative time was 214.7 ± 48.6 minutes. The time required for purse-string suture and anvil placement was 2.3 ± 0.5 and 4.4 ± 1.1 minutes, respectively. There were no instances of postoperative jejunojejunal or gastrojejunal anastomosis-related complications observed during the median follow-up period of 5.5 months. CONCLUSIONS: The novel procedure conceptionally and technically changes the conventional circular-shaped purse-string suture into a much simpler way, u-shaped parallel purse-string suture. This could be the simplest published intracorporeal pure-string suture technique.

Simple and reliable method for tumor localization during totally laparoscopic gastrectomy: intraoperative laparoscopic ultrasonography combined with tattooing.

We have developed a new method to localize a tumor during totally laparoscopic gastrectomy that uses intraoperative laparoscopic ultrasonography combined with preoperative clipping and tattooing. One or 2 days before the surgery, endoscopic clipping was performed just proximal to the tumor, followed by tattooing with India ink at the clipping site. Examination by intraoperative laparoscopic ultrasonography was performed at the tattooed site to detect the clips. The resection line of the stomach was determined with use of the detected clips as a marker of the proximal margin of the tumor. This method was attempted in 14 patients who underwent totally laparoscopic gastrectomy, and the clips were successfully identified in all patients. The clips were visualized as several layers of a hyperechoic bar, which was termed a "ladder sign." The mean time from insertion of the laparoscopic probe to identification of the clips was 2 min. The ladder sign is an important finding in this method.

Totally laparoscopic gastrectomy for gastric cancer after endoscopic submucosal dissection: a propensity score matching analysis.

PURPOSE: A recently developed endoscopic mucosal resection (EMR) procedure, endoscopic submucosal dissection (ESD), makes en bloc resection possible for mucosal cancer regardless of lesion size. ESD involves deeper and wider dissection of the gastric wall and may therefore increase the difficulty of subsequent totally laparoscopic gastrectomy (TLG) and the risk of complications. However, the influence of ESD on subsequent TLG has yet to be demonstrated. The purpose of the present study was to clarify the influence of ESD on subsequent TLG. METHODS: Between March 2006 and December 2013, we retrospectively collected data of 38 patients undergoing TLG with ESD (ESD group) and propensity score-matched 38 patients undergone TLG without ESD (non-ESD group) for treatment of gastric cancer at Tonan Hospital and Hokkaido University Hospital. The covariates for propensity score matching were as follows: age, sex, American Society of Anesthesiologists score, body mass index, and type of surgery. Clinicopathologic characteristics and surgical outcomes were compared between the two groups. RESULTS: Operative times for TLG in ESD group and non-ESD group were 228.2 ± 53.9 and 228.1 ± 52.7 min (P = 0.989), and blood loss was 45.7 ± 83.0 and 71.3 ± 74.5 g, respectively (P = 0.161). There were no significant differences between the groups of ESD and non-ESD in postoperative recovery and postoperative complications. In totally laparoscopic distal gastrectomy (TLDG), the patients with ESD-resected specimens of more than 50 mm in diameter had significantly longer operative times (P = 0.009). CONCLUSIONS: In this study, TLG is a feasible procedure treatment of gastric cancer regardless of ESD. However, TLDG is more difficult in cases where the ESD-resected specimen is more than 50 mm in diameter.

Safety and Feasibility of Electro-Vaporization of Ligamentum Teres Hepatis in Totally Laparoscopic Gastrectomy.

Introduction: The ligamentum teres hepatis may block the field of vision during totally laparoscopic gastrectomy (TLG), especially in patients with obesity. Aim: We used electrocautery to increase the visual field of TLG by shrinking the ligamentum teres hepatis. This procedure is termed electro-vaporization of the ligamentum teres hepatis (EVLTH). Methods: Patients with body mass index (BMI) ≥24 who underwent total laparoscopic distal gastrectomy (TLDG) or total laparoscopic total gastrectomy (TLTG) between January 2020 and December 2023 were retrospectively enrolled. According to the scope of gastrectomy and whether the patients underwent EVLTH, the patients were divided into the TLDG-EVLTH, TLDG-NEVLTH, TLTG-EVLTH, and TLTG-NEVLTH groups. The clinical characteristics, surgical outcomes, and pathological features were compared between the TLDG-EVLTH and TLDG-NEVLTH groups and the TLTG-EVLTH and TLTG-NEVLTH groups. Results: This study included 65 patients who underwent TLDG (EVLTH: NEVLTH = 29:36) and 32 patients who underwent TLTG (EVLTH:NEVLTH = 15:17). There were no significant differences in clinical characteristics, surgical outcomes, and pathological features between the TLDG-EVLTH and TLDG-NEVLTH groups. However, the operation time in the TLTG-EVLTH group was significantly shorter than that in the TLTG-NEVLTH group, and the difference was statistically significant, although differences in other data were not statistically significant. Conclusions: EVLTH is a simple and safe procedure that reduces the operation time of TLTG in patients who are overweight and enhances the field of vision of TLG.

Influence of liver function after laparoscopy-assisted vs totally laparoscopic gastrectomy.

BACKGROUND: Previously, some studies have proposed that total laparoscopic gastrectomy (TLG) is superior to laparoscopic-assisted gastrectomy (LAG) in terms of safety and feasibility based on the related intraoperative operative parameters and incidence of postoperative complications. However, there are still few studies on the changes in postoperative liver function in patients undergoing LG. The present study compared the postoperative liver function of patients with TLG and LAG, aiming to explore whether there is a difference in the influence of TLG and LAG on the liver function of patients. AIM: To investigate whether there is a difference in the influence of TLG and LAG on the liver function of patients. METHODS: The present study collected 80 patients who underwent LG from 2020 to 2021 at the Digestive Center (including the Department of Gastrointestinal Surgery and the Department of General Surgery) of Zhongshan Hospital affiliated with Xiamen University, including 40 patients who underwent TLG and 40 patients who underwent LAG. Alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), γ-glutamyltransferase (GGLT), total bilirubin (TBIL), direct bilirubin (DBIL) and indirect bilirubin (IBIL), and other liver function-related test indices were compared between the 2 groups before surgery and on the 1st, 3rd, and 5th d after surgery. RESULTS: The levels of ALT and AST in the 2 groups were significantly increased on the 1st to 2nd postoperative days compared with those before the operation. The levels of ALT and AST in the TLG group were within the normal range, while the levels of ALT and AST in the LAG group were twice as high as those in the TLG group (P < 0.05). The levels of ALT and AST in the 2 groups showed a downward trend at 3-4 d and 5-7 d after the operation and gradually decreased to the normal range (P < 0.05). The GGLT level in the LAG group was higher than that in the TLG group on postoperative days 1-2, the ALP level in the TLG group was higher than that in the LAG group on postoperative days 3-4, and the TBIL, DBIL and IBIL levels in the TLG group were higher than those in the LAG group on postoperative days 5-7 (P < 0.05). No significant difference was observed at other time points (P > 0.05). CONCLUSION: Both TLG and LAG can affect liver function, but the effect of LAG is more serious. The influence of both surgical approaches on liver function is transient and reversible. Although TLG is more difficult to perform, it may be a better choice for patients with gastric cancer combined with liver insufficiency.

Comparison of short-term efficacy between totally laparoscopic gastrectomy and laparoscopic assisted gastrectomy for elderly patients with gastric cancer.

BACKGROUND: Totally laparoscopic gastrectomy (TLG) entails both gastrectomy and gastrointestinal reconstruction under laparoscopy. Compared with laparoscopic assisted gastrectomy (LAG), TLG has been demonstrated in many studies to require a smaller surgical incision, result in a faster postoperative recovery and less pain and have comparable long-term efficacy, which has been a research hotspot in recent years. Whether TLG is equally safe and feasible for elderly patients remains unclear. AIM: To compare the short-term efficacy of and quality of life (QOL) associated with TLG and LAG in elderly gastric cancer (GC) patients. METHODS: The clinicopathological data of 462 elderly patients aged ≥ 70 years who underwent LAG or TLG (including distal gastrectomy and total gastrectomy) between January 2017 and January 2022 at the Department of General Surgery, First Medical Center, Chinese PLA General Hospital were retrospectively collected. A total of 232 patients were in the LAG group, and 230 patients were in the TLG group. Basic patient information, clinicopathological characteristics, operation information and QOL data were collected to compare efficacy. RESULTS: Compared with those in the LAG group, intraoperative blood loss in the TLG group was significantly lower (P < 0.001), and the time to first flatus and postoperative hospitalization time were significantly shorter (both P < 0.001). The overall incidence of postoperative complications in the TLG group was significantly lower than that in the LAG group (P = 0.01). Binary logistic regression results indicated that LAG and an operation time > 220 min were independent risk factors for postoperative complications in elderly patients with GC (P < 0.05). In terms of QOL, no statistically significant differences in various preoperative indicators were found between the LAG group and the LTG group (P > 0.05). Compared with the laparoscopic-assisted total gastrectomy group, patients who received totally laparoscopic total gastrectomy had lower nausea and vomiting scores and higher satisfaction with their body image (P < 0.05). Patients who underwent laparoscopic-assisted distal gastrectomy were more satisfied with their body image than patients in the totally laparoscopic distal gastrectomy group (P < 0.05). CONCLUSION: TLG is safe and feasible for elderly patients with GC and has outstanding advantages such as reducing intracorporeal blood loss, promoting postoperative recovery and improving QOL.

Efficacy and Safety of Totally Laparoscopic Gastrectomy Compared with Laparoscopic-Assisted Gastrectomy in Gastric Cancer: A Propensity Score-Weighting Analysis.

Objectives: To compare the short- and long-term outcomes of totally laparoscopic gastrectomy (TLG) with laparoscopic-assisted gastrectomy (LAG) in gastric cancer (GC) patients and evaluate the efficacy and safety of TLG. Methods: This retrospective study was based on GC patients who underwent laparoscopic radical gastrectomy in the Qilu Hospital from January 2017 to December 2020. The groups' variables were balanced by using the propensity score-based inverse probability of treatment weighting (PS-IPTW). The primary outcomes were 3-year relapse-free survival (RFS) and 3-year overall survival (OS). Postoperative recovery and complications were the secondary outcomes. Results: A total of 250 GC patients were included in the study. There were no significant differences in baseline and pathological features between the TLG and the LAG groups after the PS-IPTW. TLG took around 30 min longer than LAG, while there were more lymph nodes obtained and less blood loss throughout the procedure. TLG patients had less wound discomfort than LAG patients in terms of short-term prognosis. There were no significant differences between groups in the 3-year RFS rate [LAG vs. TLG: 78.86% vs. 78.00%; hazard ratio (HR) = 1.14, 95% confidence interval (CI), 0.55-2.35; p = 0.721] and the 3-year OS rate (LAG vs. TLG: 78.17% vs. 81.48%; HR = 0.98, 95% CI, 0.42-2.27; p = 0.955). The lymph node staging was found to be an independent risk factor for tumor recurrence and mortality in GC patients with laparoscopic surgery. The subgroup analysis revealed similar results of longer operation time, less blood loss, and wound discomfort in totally laparoscopic distal gastrectomy, while the totally laparoscopic total gastrectomy showed benefit only in terms of blood loss. Conclusion: TLG is effective and safe in terms of short- and long-term outcomes, with well-obtained lymph nodes, decreased intraoperative blood loss, and postoperative wound discomfort, which may be utilized as an alternative to LAG.

Prophylactic drains in totally laparoscopic distal gastrectomy: are they always necessary?

Prophylactic drains have always been a useful tool to detect early complications and prevent postoperative fluid collections, particularly in gastrointestinal surgery. Recently, the utilization of such drains has been debated, due to mounting evidence that they could be harmful rather than beneficial. Based on recent published articles, Liu et al reported that the routine use of prophylactic drains in total laparoscopic distal gastrectomy might not be necessary for all patients. Herein, we express our opinion regarding this interesting publication.

Intraoperative gastroscopy to determine proximal resection margin during totally laparoscopic gastrectomy for patients with upper third gastric cancer.

BACKGROUND: In totally laparoscopic gastrectomy (TLG), it is usually difficult to determine the proximal margin. Therefore, the present study evaluated the usefulness of intraoperative gastroscopy for direct marking of the tumor proximal margin during TLG for cancer in the upper third of the stomach. METHODS: This retrospective cohort study included 52 patients with gastric cancer who underwent TLG from January 2018 to May 2020. The proximal margin of tumors was determined by intraoperative gastroscopic methods. RESULTS: Patients were divided into short (1 cm) and long (2 cm) groups according to the distance to the proximal margin of the tumor. Participants consisted of 41 males and 11 females with a median age of 63.5 years. Tumors involving the esophagogastric junction (EGJ) occurred in 27 patients. Siewert type II and III tumors were present in 42 and 10 patients, respectively. The median operative time was 244 min. The long group had a statistically significant lower frequency of positive margin than the short group (0% vs. 17.4%, P=0.033). Total gastrectomy was performed in 35 patients, and 17 patients received proximal gastrectomy. No complications associated with the procedure occurred in any patient. CONCLUSIONS: Intraoperative endoscopic views for tumor proximal localization can be used effectively during TLG for patients with upper third gastric cancer. Our results indicate that a distance of ≥2 cm from the proximal resection margin to the tumor was necessary to achieve a negative resection margin. In the future, this may be used as an alternative to frozen section diagnosis.

Comparison of totally laparoscopic and laparoscopic assisted gastrectomy after neoadjuvant chemotherapy in locally advanced gastric cancer.

BACKGROUND: Neoadjuvant chemotherapy (NACT) and laparoscopic surgery have been increasingly used in the treatment of gastric cancer, however, the feasibility and safety of totally laparoscopic gastrectomy after NACT still remain unknown. MATERIALS AND METHODS: At the Gastrointestinal cancer center of Peking university cancer hospital and institute in Beijing, clinical and pathological data of patients who has received NACT, followed by radical laparoscopic gastrectomy was retrospectively reviewed between March 2011 and November 2019. Patients were divided into 2 groups according to whether intracorporeal anastomosis or extracorporeal anastomosis had been performed, short-term outcomes (post-operative recovery index and complications) and economic cost were compared between 2 groups. RESULT: All of 139 patients underwent laparoscopic gastrectomy. 87 [62.6%] patients had totally laparoscopic gastrectomy (TLG) and 52 [37.4%] patients had laparoscopic-assisted gastrectomy (LAG). Overall complication rate was 28.8% in all patients. TLG group was significantly associated with lower overall complication rate (21.8% VS 40.4%; p = 0.019) and major complication rate (3.4% VS 13.5%; p = 0.001) compared with LAG group. Overall cost was similar (p = 0.077). In subgroup analysis, totally laparoscopic total gastrectomy (TLTG) group showed lower overall postoperative complication rate (19.0% VS 56.5%; p = 0.011), as well as marginal significant differences in major complication (0% VS 21.7%; p = 0.05) than laparoscopic-assisted total gastrectomy (LATG) group. Earlier first liquid diet (4 [3.5-5] day VS 6 [4-6.5] day; p = 0.047), earlier first aerofluxus (3 [3-4] day VS 4 [3-4.5] day; p = 0.02) and a shorter hospital stay (9 [8-12] day VS 12 [10-15] day; p = 0.004) were observed in TLTG group. Overall and major complication rate were similar in totally laparoscopic distal gastrectomy (TLDG) and laparoscopic assisted distal gastrectomy (LADG) group (22.7% VS 27.6%; p = 0.611; 4.5% VS 6.9%; p = 0.639; respectively). Significant differences were found between TLDG and LADG groups regarding time to first liquid diet (4 [3-5] day VS 6 [3.75-6] day; p = 0.006), time to first aerofluxus (3 [3-3] day VS 4 [3-6] day; p< 0.001), time to first defecation (4 [4-5] day VS 5 [4-6] day; p = 0.045), time to remove all drainage (7 [6-8] day VS 8 [6-9] day; p = 0.021), white blood cell count on postoperative Day 1 (9.54 ± 2.49 109/L VS 10.91 ± 2.89 109/L; p = 0.021)and postoperative hospital stay (9 [8-10] day VS 10 [9,13] day; p = 0.009). CONCLUSION: For patients with Locally advanced gastric cancer who received NACT, totally laparoscopic gastrectomy, including TLTG and TLDG, doesn't increase complications and overall cost compared with LAG, and has advantages in gastrointestinal function recovery, incision length and postoperative hospital stay.

Totally Laparoscopic Gastrectomy Versus Laparoscopic-Assisted Gastrectomy for Gastric Cancer: A Systematic Review and Meta-Analysis.

Background: Totally laparoscopic gastrectomy (TLG) has recently been accepted as a treatment strategy for gastric cancer (GC). Aim: In this study, we conducted a meta-analysis to evaluate the safety and feasibility of TLG compared with laparoscopic-assisted gastrectomy (LAG) in GC. Methods: Feasible studies comparing the TLG and LAG published up to March 2019 were searched online. The data showing short-term and complication outcomes were extracted to be pooled and analyzed. Results: Thirty-four studies, including 7974 patients were eventually eligible. There was no statistically significant difference on operation time between the two groups (weighted mean difference [WMD] = 2.43, 95% confidence interval [CI]: -4.16 to 9.02, P = .47). The time of anvil insertion time was shorter in the TLG group compared with the LAG group (WMD = -1.87, 95% CI: -2.60 to -1.15, P < .01). The TLG was significantly superior to LAG in the comparison of less trauma. In terms of radical resection, the number of lymph nodes obtained by TLG was significantly more than that obtained by LAG (WMD = 2.65, 95% CI: 1.54-3.76, P < .01). The pooled meta-analysis suggested that the patients undergoing TLG had a quicker recovery and less pain. In the advanced gastric cancer gastrectomy, the TLG could receive a longer proximal margin compared with the LAG (WMD = 0.72, 95% CI: 0.48-0.95, P < .01). Regardless of the reconstruction method, the TLG was superior to the LAG in terms of surgical parameters and postoperative recovery. Like the LAG, the TLG was safe and advantageous. A lower risk trend of conversion to open laparotomy was observed in the TLG (relative risk [RR] = 0.72, 95% CI: 0.12-4.38, P = .72). The body mass index >25 kg/m2 patients undergoing totally laparoscopic gastrectomy (TLGA) had a lower risk of overall complications (RR = 0.88, 95% CI: 0.48-1.63, P = .69). The patients with early gastric cancer or Billroth-I anastomosis were suitable to undergo the TLG (a lower risk of anastomotic leakage [RR = 0.01, 95% CI: 0.00-0.23, P < .01] and gastralgia [RR = 0.27, 95% CI: 0.08-0.88, P = .03], respectively). Conclusions: The TLG was a safe and reliable procedure compared with the LAG with reduced trauma, faster recovery, and not more complications.

Feasibility of totally laparoscopic gastrectomy without prophylactic drains in gastric cancer patients.

BACKGROUND: Prophylactic drains have been used to remove intraperitoneal collections and detect complications early in open surgery. In the last decades, minimally invasive gastric cancer surgery has been performed worldwide. However, reports on routine prophylactic abdominal drainage after totally laparoscopic distal gastrectomy are few. AIM: To evaluate the feasibility performing totally laparoscopic distal gastrectomy without prophylactic drains in selected patients. METHODS: Data of patients with distal gastric cancer who underwent totally laparoscopic distal gastrectomy with and without prophylactic drainage at China National Cancer Center/Cancer Hospital from February 2018 to August 2019 were reviewed. The outcomes between patients with and without prophylactic drainage were compared. RESULTS: A total of 457 patients who underwent surgery for gastric cancer were identified. Of these, 125 patients who underwent totally laparoscopic distal gastrectomy were included. After propensity score matching, data of 42 pairs were extracted. The incidence of concurrent illness was higher in the drain group (42.9% vs 31.0%, P = 0.258). The overall postoperative complication rates were 19.5% and 10.6% in the drain (n = 76) and no-drain groups (n = 49), respectively; there were no significant differences between the two groups (P > 0.05). The difference between the two groups based on the need for percutaneous catheter drainage was also not significant (9.8% vs 6.4%, P = 0.700). However, patients with a larger body mass index (≥ 29 kg/m2) were prone to postoperative complications (P = 0.042). In addition, the number of days from surgery until the first flatus (4.33 ± 1.24 d vs 3.57 ± 1.85 d, P = 0.029) was greater in the drain group. CONCLUSION: Omitting prophylactic drainage may reduce surgery time and result in faster recovery. Routine prophylactic drains are not necessary in selected patients. A prophylactic drain may be useful in high-risk patients.

Safety of early oral feeding after total laparoscopic radical gastrectomy for gastric cancer (SOFTLY): Study protocol for a randomized controlled trial.

BACKGROUND: Gastric cancer is the third most common cause of cancer-related deaths and has the fifth highest incidence worldwide, especially in eastern Asia, central and Eastern Europe, and South America. Currently, surgery is the only curative treatment for gastric cancer; however, there is an increasing trend toward laparoscopic radical gastrectomy. Early oral feeding (EOF) has been shown to benefit clinical outcomes compared with open gastrectomy under conditions of enhanced recovery after surgery. There are a lack of guidelines and evidence for the safety and feasibility of EOF in patients undergoing laparoscopic radical gastrectomy. Thus, a prospective randomized trial is warranted. METHODS/DESIGN: The EOF after total laparoscopic radical gastrectomy (SOFTLY) study is a single-center, parallel-arm, non-inferiority randomized controlled trial which will enroll 200 patients who are pathologically diagnosed with gastric cancer and undergo laparoscopic radical gastrectomy. The primary endpoint, incidence of anastomotic leakage, is based on 1.9% in the control group in the CLASS-01 study. The patients will be randomized (1:1) into two groups: the EOF group will receive a clear liquid diet on post-operative day 1 (POD1) and the delayed oral feeding (DOF) group will receive a clear liquid diet on post-operative day 4 (POD4). The demographic and pathologic characteristics will be recorded. Total and oral nutritional intake, general data, total serum protein, serum albumin, blood glucose, and temperature will be recorded before surgery and at the time of hospitalization. Adverse events will also be recorded. The occurrence of post-operative fistulas, including anastomotic leakage, will be recorded as the main severe post-operative adverse event and represent the primary endpoint. DISCUSSION: The safety and feasibility of EOF after gastrectomy has not been established. The SOFTLY trial will be the first randomized controlled trial involving total laparoscopic radical gastrectomy, in which the EOF group (POD1) will be compared with the DOF group (POD4). The results of the SOFTLY trial will provide data on the safety and feasibility of EOF after total laparoscopic radical gastrectomy. TRIAL REGISTRATION: Chinese Clinical Trial Registry, ChiCTR-IOR-15007660 . Registered on 28 December 2015. The study has full ethical and institutional approval.

Totally laparoscopic D2 radical distal gastrectomy using Billroth II anastomosis: A case report.

Here, we present our first case of totally laparoscopic D2 radical distal gastrectomy using Billroth II anastomosis and evaluate its effectiveness in terms of minimal invasiveness, technical feasibility and safety for the resection of early gastric cancer. In the present case, only laparoscopic linear staplers were used for intracorporeal anastomosis. The time taken was 180 min, the anastomotic time was 15 min, the number of staples used was five, and the estimated blood loss was 30 ml. The first flatus was observed at 3 days, and a liquid diet was started at 6 days. The postoperative hospital stay was 8 days. No postoperative complications were noted with our case. In conclusion, totally laparoscopic Billroth II anastomosis using laparoscopic linear staplers for early gastric cancer is considered to be safe and feasible.

Three-dimensional fusion images combining CT gastrography and CT angiography for early gastric cancer: pilot experiences of preoperative simulation prior to totally laparoscopic gastrectomy.

We herein report two cases of gastric cancer in which preoperative 3-D CT gastrography and CT angiography fusion images enabled totally laparoscopic gastrectomy. Case 1 involved a 60-year-old woman with a superficial depressed lesion on the greater curvature of the middle gastric body. Case 2 involved a 64-year-old woman with a superficial depressed lesion on the posterior wall of the upper gastric body. In both cases, 3-D fusion images were prepared from enhanced CT scans after the area near the lesions was clipped under preoperative gastroendoscopy. Based on the relative position between the clips and nearby vessels, a resection line was preoperatively determined in each case. Totally laparoscopic distal gastrectomy and totally laparoscopic proximal gastrectomy were performed in cases 1 and 2, respectively, with safe surgical margins. Three-dimensional fusion images can help in preoperative simulation of totally laparoscopic gastrectomy.