Minimally invasive surgery for gastric cancer: A comparison between robotic, laparoscopic and open surgery

AIM To investigate the role of minimally invasive surgery for gastric cancer and determine surgical, clinical, and oncological outcomes.METHODS This is a propensity score-matched case-control study, comparing three treatment arms: robotic gastrectomy(RG), laparoscopic gastrectomy(LG), open gastrectomy(OG). Data collection started after sharing a specific study protocol. Data were recorded through a tailored and protected web-based system. Primary outcomes: harvested lymph nodes, estimated blood loss, hospital stay, complications rate. Among the secondary outcomes, there are: operative time, R0 resections, POD of mobilization, POD of starting liquid diet and soft solid diet. The analysis includes the evaluation of type and grade of postoperative complications. Detailed information of anastomotic leakages is also provided.RESULTS The present analysis was carried out of 1026 gastrectomies. To guarantee homogenous distribution of cases, patients in the RG, LG and OG groups were 1:1:2 matched using a propensity score analysis with a caliper = 0.2. The successful matching resulted in a total sample of 604 patients(RG = 151; LG = 151; OG = 302). The three groups showed no differences in all baseline patients characteristics, type of surgery(P = 0.42) and stage of the disease(P = 0.16). Intraoperative blood loss was significantly lower in the LG(95.93 ± 119.22) and RG(117.91 ± 68.11) groups compared to the OG(127.26 ± 79.50, P = 0.002). The mean number of retrieved lymph nodes was similar between the RG(27.78 ± 11.45), LG(24.58 ± 13.56) and OG(25.82 ± 12.07) approach. A benefit in favor of the minimally invasive approaches was found in the length of hospital stay(P < 0.0001). A similar complications rate was found(P = 0.13). The leakage rate was not different(P = 0.78) between groups.CONCLUSION Laparoscopic and robotic surgery can be safely performed and proposed as possible alternative to open surgery. The main highlighted benefit is a faster postoperative functional recovery.

Liver resection versus radiofrequency ablation in the treatment of cirrhotic patients with hepatocellular carcinoma

BACKGROUND: Hepatocellular carcinoma is the most common type of primary liver tumor and its incidence is increasing worldwide. The study aimed to compare patients subjected to liver resection or radiofrequency ablation. METHODS: One hundred and forty cirrhotic patients in stage A or B of Child-Pugh with single nodular or multinodular hepatocellular carcinoma were included in this retrospective study. Among them, 87 underwent surgical resection, and 53 underwent percutaneous radiofrequency ablation. Patient charac-teristics, survival, and recurrence-free survival were analyzed. RESULTS: Recurrence-free survival was longer in the resection group in comparison to the radiofrequency group with a median recurrence-free time of 36 versus 26 months, respectively (P=0.01, HR=1.52, 95% CI: 1.05-2.25). In the resection group, median survival was 46 months, with the 1-, 3- and 5-year survival rates of 89.7%, 72.4% and 40.2%. In the radiofrequency group, median survival was 32 months, with the 1-, 3- and 5-year survival rates of 83.0%, 43.4% and 22.6% (P【0.01). CONCLUSIONS: Surgical resection improves the overall survival and recurrence-free survival in comparison with radiofrequency ablation. New evidences are needed to define the real role of the percutaneous technique as an alternative to surgery.

New totally intracorporeal reconstructive approach after robotic total gastrectomy: Technical details and short-term outcomes

AIM To show outcomes of our series of patients that underwent a total gastrectomy with a robotic approach and highlight the technical details of a proposed solution for the reconstruction phase.METHODS Data of gastrectomies performed from May 2014 to October 2016, were extracted and analyzed. Basic characteristics of patients, surgical and clinical outcomes were reported. The technique for reconstruction(Parisi Technique) consists on a loop of bowel shifted up antecolic to directly perform the esophago-enteric anastomosis followed by a second loop, measured up to 40 cm starting from the esojejunostomy, fixed to the biliary limb to create an enteroenteric anastomosis. The continuity between the two anastomoses is interrupted just firing a linear stapler, so obtaining the Roux-en-Y by avoiding to interrupt the mesentery.RESULTS Fifty-five patients were considered in the present analysis. Estimated blood loss was 126.55 ± 73 m L, no conversions to open surgery occurred, R0 resections were obtained in all cases. Hospital stay was 5(3-17) d, no anastomotic leakage occurred. Overall, a fast functional recovery was shown with a median of 3(3-6) d in starting a solid diet.CONCLUSION Robotic surgery and the adoption of a tailored reconstruction technique have increased the feasibility and safety of a minimally invasive approach for total gastrectomy. The present series of patients shows its implementation in a western center with satisfying short-term outcomes.

Fluorescence image-guided lymphadenectomy using indocyanine green and near infrared technology in robotic gastrectomy

In recent years, some researchers have tried to find a way to improve the surgical identification of the lymphatic drainage routes and lymph node stations during radical gastrectomy, thus starting a new research frontier in this field called ＂navigation surgery＂. Among the different reported solutions, the introduction of the indocyanine green （ICG） has drawn attention for its characteristics, a fluorescence dye that can be detected in the near infrared spectral band （NIR）. A fluorescence imaging technology has been integrated in the latest version of the Da Vinci robotic system and surgeons have extensively reported their experiences in colorectal and hepato-biliary surgery for tumors, vascular and lymphatic structures visualization. However, up to date, the combined use of fluorescence imaging and robotic technology has not been adequately investigated during lymphadenectomy in gastric cancer.

Long-term survival of patients with stage Ⅱ and Ⅲgastric cancer who underwent gastrectomy with inadequate nodal assessment

BACKGROUND Gastric cancer is an aggressive disease with frequent lymph node(LN)involvement.The NCCN recommends a D2 lymphadenectomy and the harvesting of at least 16 LNs.This threshold has been the subject of great debate,not only for the extent of surgery but also for more appropriate staging.The reclassification of stage IIB through IIIC based on N3b nodal staging in the eighth edition of the American Joint Committee on Cancer(AJCC)staging system highlights the efforts to more accurately discriminate survival expectancy based on nodal number.Furthermore,studies have suggested that pathologic assessment of 30 or more LNs improve prognostic accuracy and is required for proper staging of gastriccancer.AIM To evaluate the long-term survival of advanced gastric cancer patients who deviated from expected survival curves because of inadequate nodal evaluation.METHODS Eligible patients were identified from the Surveillance,Epidemiology,and End Results database.Those with stage II-III gastric cancer were considered for inclusion.Three groups were compared based on the number of analyzed LNs.They were inadequate LN assessment(ILA,<16 LNs),adequate LN assessment(ALA,16-29 LNs),and optimal LN assessment(OLA,≥30 LNs).The main outcomes were overall survival(OS)and cancer-specific survival.Data were analyzed by the Kaplan-Meier product-limit method,log-rank test,hazard risk,and Cox proportional univariate and multivariate models.Propensity score matching(PSM)was used to compare the ALA and OLA groups.RESULTS The analysis included 11607 patients.Most had advanced T stages(T3=48%;T4=42%).The pathological AJCC stage distribution was IIA=22%,IIB=18%,IIIA=26%,IIIB=22%,and IIIC=12%.The overall sample divided by the study objective included ILA(50%),ALA(35%),and OLA(15%).Median OS was 24 mo for the ILA group,29 mo for the ALA group,and 34 mo for the OLA group(P<0.001).Univariate analysis showed that the ALA and OLA groups had better OS than the ILA group[ALA hazard ratio(HR)=0.84,95%confidence interval(CI):0.79-0.88,P<0.001 and OLA HR=0.73,95%CI:0.68-0.79,P<0.001].The OS outcome was confirmed by multivariate analysis(ALA HR=0.68,95%CI:0.64-0.71,P<0.001 and OLA:HR=0.48,95%CI:0.44-0.52,P<0.001).A 1:1 PSM analysis in 3428 patients found that the OLA group had better survival than the ALA group(OS:OLA median=34 mo vs ALA median=26 mo,P<0.001,which was confirmed by univariate analysis(HR=0.81,95%CI:0.75-0.89,P<0.001)and multivariate analysis:(HR=0.71,95%CI:0.65-0.78,P<0.001).CONCLUSION Proper nodal staging is a critical issue in gastric cancer.Assessment of an inadequate number of LNs places patients at high risk of adverse long-term survival outcomes.

新辅助化疗期间肌肉指数变化值预测胃癌根治术预后的临床价值

目的探讨新辅助化疗期间肌肉指数变化值预测胃癌根治术预后的临床价值。方法采用回顾性队列研究方法。收集2010年1月至2017年12月3家医学中心收治的362例(福建医科大学附属协和医院163例、青海大学附属医院141例、圣玛丽亚医院58例)行新辅助化疗联合胃癌根治术病人的临床病理资料;男270例,女92例;中位年龄为61岁,年龄范围为26~79岁。362例病人中,福建医科大学附属协和医院与青海大学附属医院收治的304例病人设为建模组;圣玛丽亚医院收治的58例病人设为验证组。观察指标:(1)建模组病人行新辅助化疗期间身体成分、肿瘤标志物及应激状态指标变化情况。(2)随访及生存情况。(3)影响建模组病人预后因素分析。(4)预后预测模型的构建与比较。(5)预后预测模型评价。采用门诊、电话、信件方式进行随访,了解病人术后生存情况。随访时间截至2021年4月。正态分布的计量资料以x±s表示。偏态分布的计量资料以M(范围)表示。计数资料以绝对数表示。单因素和多因素分析采用COX比例风险模型。采用Kaplan-Meier法计算生存时间,采用Log-rank检验进行生存分析。结果(1)建模组病人行新辅助化疗期间身体成分、肿瘤标志物及应激状态指标变化情况。建模组304例病人行新辅助化疗前皮下脂肪指数、内脏脂肪指数、肌肉指数、癌胚抗原(CEA)、CA19-9、体质量指数(BMI)、预后营养指数(PNI)、修正全身炎症评分(mSIS)分别为31.2 cm^(2)/m^(2)(0.6~96.0 cm^(2)/m^(2)),25.1 cm^(2)/m^(2)(0.1~86.3 cm^(2)/m^(2)),47.1 cm^(2)/m^(2)(27.6~76.6 cm^(2)/m^(2)),43.2μg/L(0.2~1000.0μg/L),108.7 U/mL(0.6~1000.0 U/mL),21.9 kg/m^(2)(15.6~29.7 kg/m^(2)),46.8(28.6~69.0),(1.0±0.8)分;行胃癌根治术前上述指标分别为32.5 cm^(2)/m^(2)(5.1~112.0 cm^(2)/m^(2)),25.4 cm^(2)/m^(2)(0.2~89.0 cm^(2)/m^(2)),47.0 cm^(2)/m^(2)(16.8~67.0 cm^(2)/m^(2)),17.0μg/L(0.2~1000.0μg/L),43.9 U/mL(0.6~1000.0 U/mL),21.6 kg/m^(2)(31.1~29.0 kg/m^(2)),47.7(30.0~84.0),(1.0±0.8)分;行新辅助化疗期间上述指标变化值分别为1.4 cm^(2)/m^(2)(-31.0~35.1 cm^(2)/m^(2)),0.2 cm^(2)/m^(2)(-23.5~32.6 cm^(2)/m^(2)),-0.1 cm^(2)/m^(2)(-18.2~15.9 cm^(2)/m^(2)),-26.2μg/L(-933.5~89.9μg/L),-64.9 U/mL(-992.1~178.6 U/mL),-0.3 kg/m^(2)(-9.7~7.1 kg/m^(2)),0.9(-27.1~38.2),(0.0±0.8)分。(2)随访及生存情况。建模组304例病人中,284获得随访,随访时间为3~130个月,中位随访时间为36个月;随访期间,130例病人因肿瘤复发转移死亡,9例病人因非肿瘤原因死亡,病人5年总体生存率为54.6%。验证组58例病人中,52例获得随访,随访时间为2~91个月,中位随访时间为29个月;随访期间,21例病人死亡,病人5年总体生存率为63.8%。(3)影响建模组病人预后因素分析。单因素分析结果显示:术后病理学类型、术后病理学分期是影响建模组304例胃癌病人行胃癌根治术后5年总体生存率[风险比=1.685,2.619,95%可信区间(CI)为1.139~2.493,1.941~3.533,P<0.05]和5年疾病无进展生存率的相关因素(风险比=1.468,2.577,95%CI为1.000~2.154,1.919~3.461,P<0.05)。多因素分析结果显示:术后病理学类型、术后病理学分期是建模组304例病人行胃癌根治术后5年总体生存率的独立影响因素(风险比=1.508,2.287,95%CI为1.013~2.245,1.691~3.093,P<0.05);术后病理学分期是建模组304例病人行胃癌根治术后5年疾病无进展生存率的独立影响因素(风险比=2.317,95%CI为1.719~3.123,P<0.05)。(4)预后预测模型的构建与比较。304例建模组胃癌病人皮下脂肪指数变化值、内脏脂肪指数变化值、CEA变化值、CA19-9变化值、BMI变化值、PNI变化值、mSIS变化值预后预测模型受试者工作特征曲线下面积(AUC)分别为0.549(95%CI为0.504~0.593)、0.501(95%CI为0.456~0.546)、0.566(95%CI为0.521~0.610)、0.519(95%CI为0.474~0.563)、0.588(95%CI为0.545~0.632)、0.553(95%CI为0.509~0.597)、0.539(95%CI为0.495~0.584),与肌肉指数变化值预后预测模型AUC[0.661(95%CI为0.623~0.705)]比较,差异均有统计学意义(Z=3.960,5.326,3.353,4.786,2.455,3.448,3.987,P<0.05)。肌肉指数变化值预后预测模型最佳截点值为0.7 cm^(2)/m^(2),Kaplan-Meier生存曲线结果显示:建模组肌肉指数变化值<0.7 cm^(2)/m^(2)胃癌病人与肌肉指数变化值≥0.7 cm^(2)/m^(2)胃癌病人总体生存率和疾病无进展生存率比较,差异均有统计学意义(χ2=27.510,21.830,P<0.05)。选取肌肉指数变化值、术后病理学类型、术后病理学分期为预后指标,在建模组病人中构建肌肉指数变化值+术后病理学类型+术后病理学分期列线图预后预测模型,其在建模组和验证组的AUC分别为0.762(95%CI为0.708~0.815)和0.788(95%CI为0.661~0.885),术后病理学分期预后预测模型在建模组和验证组的AUC分别为0.706(95%CI为0.648~0.765)和0.727(95%CI为0.594~0.835),列线图预后预测模型与术后病理学分期预后预测模型建模组和验证组AUC比较,差异均有统计学意义(Z=3.522,1.830,P<0.05)。(5)预后预测模型评价。肌肉指数变化值+术后病理学类型+术后病理学分期列线图预后预测模型结果显示:列线图风险评分0~6分为低风险,评分>6分且≤10分为中低风险,评分>10分且≤13分为中高风险,评分>13分为高危风险。Kaplan-Meier生存曲线结果显示:建模组及验证组低风险、中低风险、中高风险、高风险病人总体生存率比较,差异均有统计学意义(χ^(2)=75.276,14.989,P<0.05)。决策曲线分析结果显示:在建模组和验证组中,肌肉指数变化值+术后病理学类型+术后病理学分期列线图预后预测模型预测性能优于术后病理学分期预后预测模型。结论新辅助化疗期间病人肌肉指数变化值可作为胃癌根治术后病人预后预测指标,肌肉指数变化值+术后病理学类型+术后病理学分期列线图风险评分可评估病人行胃癌根治术后生存预后。