Comparison efficacy and safety of total laparoscopic gastrectomy and laparoscopically assisted total gastrectomy in treatment of gastric cancer

BACKGROUND The development of laparoscopic technology has provided a new choice for surgery of gastric cancer(GC),but the advantages and disadvantages of laparoscopic total gastrectomy(LTG)and laparoscopic-assisted total gastrectomy(LATG)in treatment effect and safety are still controversial.The purpose of this study is to compare the efficacy and safety of the two methods in the treatment of GC,and to provide a basis for clinical decision-making.AIM To compare the efficacy of totally LTG(TLTG)and LATG in the context of radical gastrectomy for GC.Additionally,we investigated the safety and feasibility of the total laparoscopic esophagojejunostomy technique.METHODS Literature on comparative studies of the above two surgical methods for GC(TLTG group and LATG group)published before September 2022 were searched in the PubMed,Web of Science,Wanfang Database,CNKI,and other Chinese and English databases.In addition,the following search keywords were used:Gastric cancer,total gastrectomy,total laparoscopy,laparoscopy-assisted,esophagojejunal anastomosis,gastric/stomach cancer,total gastrectomy,totally/completely laparoscopic,laparoscopic assisted/laparoscopy assisted/laparoscopically assisted,and esophagojejunostomy/esophagojejunal anastomosis.Review Manager 5.3 software was used for the meta-analysis after two researchers independently screened the literature,extracted the data,and evaluated the risk of bias in the included studies.RESULTS After layer-by-layer screening,258 pieces of literature were recovered,and 11 of those pieces were eventually included.This resulted in a sample size of 2421 instances,with 1115 cases falling into the TLTG group and 1306 cases into the LATG group.Age or sex differences between the two groups were not statistically significant,according to the meta-analysis,however the average body mass index of the TLTG group was considerably higher than that of the LATG group(P=0.01).Compared with those in the LATG group,the incision length in the TLTG group was significantly shorter(P<0.001),the amount of intraoperative blood loss was significantly lower(P=0.003),the number of lymph nodes removed was significantly greater(P=0.04),and the time of first postoperative feeding and postoperative hospitalization were also significantly shorter(P=0.03 and 0.02,respectively).There were no significant differences in tumor size,length of proximal incisal margin,total operation time,anastomotic time,postoperative pain score,postoperative anal exhaust time,postoperative anastomosis-related complications(including anastomotic fistula,anastomotic stenosis,and anastomotic hemorrhage),or overall postoperative complication rate(P>0.05).CONCLUSION TLTG and esophagojejunostomy are safe and feasible.Compared with LATG,TLTG has the advantages of less trauma,less bleeding,easier access to lymph nodes,and faster postoperative recovery,and TLTG is also suitable for obese patients.

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 1^(st),3^(rd),and 5^(th) 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.

Short- and long-term outcomes associated with enhanced recovery after surgery protocol vs conventional management in patients undergoing laparoscopic gastrectomy

BACKGROUND At present,the enhanced recovery after surgery(ERAS)protocol is widely implemented in the field of gastric surgery.However,the effect of the ERAS protocol on the long-term prognosis of gastric cancer has not been reported.AIM To compare the effects of ERAS and conventional protocols on short-term outcomes and long-term prognosis after laparoscopic gastrectomy.METHODS We retrospectively analyzed the data of 1026 consecutive patients who underwent laparoscopic gastrectomy between 2012 and 2015.The patients were divided into either an ERAS group or a conventional group.The groups were matched in a 1:1 ratio using propensity scores based on covariates that affect cancer survival.The primary outcomes were the 5-year overall and cancer-specific survival rates.The secondary outcomes were the postoperative short-term outcomes and inflammatory indexes.RESULTS The patient demographics and baseline characteristics were similar between the two groups after matching.Compared to the conventional group,the ERAS group had a significantly shorter postoperative hospital day(7.09 d vs 8.67 d,P<0.001),shorter time to first flatus,liquid intake,and ambulation(2.50 d vs 3.40 d,P<0.001;1.02 d vs 3.64 d,P<0.001;1.47 d vs 2.99 d,P<0.001,respectively),and lower medical costs($7621.75 vs$7814.16,P=0.009).There was a significantly higher rate of postoperative complications among patients in the conventional group than among those in the ERAS group(18.1 vs 12.3,P=0.030).Regarding inflammatory indexes,the C-reactive protein and procalcitonin levels on postoperative day 3/4 were significantly different between the two groups(P<0.001 and P=0.025,respectively).The ERAS protocol was associated with significantly improved 5-year overall survival and cancer-specific survival rates compared with conventional protocol(P=0.013 and 0.032,respectively).When stratified by tumour stage,only the survival of patients with stage III disease was significantly different between the two groups(P=0.044).CONCLUSION Adherence to the ERAS protocol improves both the short-term outcomes and the 5-year overall survival and cancer-specific survival of patients after laparoscopic gastrectomy.

Digestive tract reconstruction options after laparoscopic gastrectomy for gastric cancer

In addition to the popularity of laparoscopic gastrectomy(LG),many reconstructive procedures after LG have been reported.Surgical resection and lymphatic dissection determine long-term survival;however,the election of a reconstruction procedure determines the postoperative quality of life for patients with gastric cancer(GC).Presently,no consensus exists regarding the optimal reconstructive procedure.In this review,the current state of digestive tract reconstruction after LG is reviewed.According to the determining influence of the tumor site on the procedures of surgical resection and reconstruction,we divide these reconstruction procedures into three categories consistent with the resection procedures.We focus on the technical tips of every reconstruction procedure and examine the surgical outcomes(length of surgery and blood loss)and postoperative complications(anastomotic leakage and stricture)to facilitate gastrointestinal surgeons to understand the merits and demerits of every reconstruction procedure.

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.

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.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.

Evolution of laparoscopic gastrectomy for cancer in the East and West

Laparoscopic gastrectomy has evolved differently in Eastern and Western countries.Feasibility,safety and oncological outcomes of laparoscopic gastrectomy were addressed step-by-step by several randomized controlled trials from the East.Few phase III studies were published from the West that largely did not show a difference between the laparoscopic and open approach.Despite this,laparoscopic gastrectomy is seen as the standard for the surgical treatment of early and advanced gastric cancer in many European countries.Here,we review and comment on some important studies on laparoscopic gastrectomy for gastric cancer from Eastern and Western countries and also comment on current and future challenges.

Machine learning identifies the risk of complications after laparoscopic radical gastrectomy for gastric cancer

BACKGROUND Laparoscopic radical gastrectomy is widely used,and perioperative complications have become a highly concerned issue.AIM To develop a predictive model for complications in laparoscopic radical gastrectomy for gastric cancer to better predict the likelihood of complications in gastric cancer patients within 30 days after surgery,guide perioperative treatment strategies for gastric cancer patients,and prevent serious complications.METHODS In total,998 patients who underwent laparoscopic radical gastrectomy for gastric cancer at 16 Chinese medical centers were included in the training group for the complication model,and 398 patients were included in the validation group.The clinicopathological data and 30-d postoperative complications of gastric cancer patients were collected.Three machine learning methods,lasso regression,random forest,and artificial neural networks,were used to construct postoperative complication prediction models for laparoscopic distal gastrectomy and laparoscopic total gastrectomy,and their prediction efficacy and accuracy were evaluated.RESULTS The constructed complication model,particularly the random forest model,could better predict serious complications in gastric cancer patients undergoing laparoscopic radical gastrectomy.It exhibited stable performance in external validation and is worthy of further promotion in more centers.CONCLUSION Using the risk factors identified in multicenter datasets,highly sensitive risk prediction models for complications following laparoscopic radical gastrectomy were established.We hope to facilitate the diagnosis and treatment of preoperative and postoperative decision-making by using these models.

Association between operative position and postoperative nausea and vomiting in patients undergoing laparoscopic sleeve gastrectomy

BACKGROUND Bariatric surgery is one of the most effective ways to treat morbid obesity,and postoperative nausea and vomiting(PONV)is one of the common complications after bariatric surgery.At present,the mechanism of the high incidence of PONV after weight-loss surgery has not been clearly explained,and this study aims to investigate the effect of surgical position on PONV in patients undergoing bariatric surgery.AIM To explore the effect of the operative position during bariatric surgery on PONV.METHODS Data from obese patients,who underwent laparoscopic sleeve gastrectomy(LSG)in the authors’hospital between June 2020 and February 2022 were divided into 2 groups and retrospectively analyzed.Multivariable logistic regression analysis and the t-test were used to study the influence of operative position on PONV.RESULTS There were 15 cases of PONV in the supine split-leg group(incidence rate,50%)and 11 in the supine group(incidence rate,36.7%)(P=0.297).The mean operative duration in the supine split-leg group was 168.23±46.24 minutes and 140.60±32.256 minutes in the supine group(P<0.05).Multivariate analysis revealed that operative position was not an independent risk factor for PONV(odds ratio=1.192,95%confidence interval:0.376-3.778,P=0.766).CONCLUSION Operative position during LSG may affect PONV;however,the difference in the incidence of PONV was not statistically significant.Operative position should be carefully considered for obese patients before surgery.

Efficacy and safety of laparoscopic vs open gastrectomy after neoadjuvant therapy for locally advanced gastric cancer

BACKGROUND Laparoscopic gastrectomy(LG)is widely accepted as a minimally invasive approach for the treatment of early gastric cancer.However,its role in locally advanced gastric cancer(LAGC)after neoadjuvant therapy(NAT)remains controversial.This study aimed to compare the efficacy and safety of LG vs open gastrectomy(OG)after NAT for the treatment of LAGC.AIM To compare the efficacy and safety of LG vs OG after NAT for LAGC.METHODS We conducted a prospective study of 76 patients with LAGC who underwent NAT followed by LG(n=38)or OG(n=38)between 2021 and 2023.The primary endpoint was overall survival(OS),and the secondary endpoints were diseasefree survival(DFS),surgical complications,and quality of life(QOL).RESULTS The two groups had comparable baseline characteristics,with a median follow-up period of 24 mo.The 3-year OS rates in the LG and OG groups were 68.4%and 60.5%,respectively(P=0.42).The 3-year DFS rates in the LG and OG groups were 57.9%and 50.0%,respectively(P=0.51).The LG group had significantly less blood loss(P<0.001),a shorter hospital stay(P<0.001),and a lower incidence of surgical site infection(P=0.04)than the OG group.There were no significant differences in other surgical complications between the groups,including anastomotic leakage,intra-abdominal abscess,or wound dehiscence.The LG group had significantly better QOL scores than the OG group regarding physical functioning,role functioning,global health status,fatigue,pain,appetite loss,and body image at 6 months postoperatively(P<0.05).CONCLUSION LG after NAT is a viable and safe alternative to OG for the treatment of LAGC,with similar survival outcomes and superior short-term recovery and QOL.LG patients had less blood loss,shorter hospitalizations,and a lower incidence of surgical site infections than OG patients.Moreover,the LG group had better QOL scores in multiple domains 6 mo postoperatively.Therefore,LG should be considered a valid option for patients with LAGC who undergo NAT,particularly for those who prioritize postoperative recovery and QOL.

State of art on the mechanisms of laparoscopic sleeve gastrectomy in treating type 2 diabetes mellitus

Obesity and type-2 diabetes mellitus(T2DM)are metabolic disorders.Obesity increases the risk of T2DM,and as obesity is becoming increasingly common,more individuals suffer from T2DM,which poses a considerable burden on health systems.Traditionally,pharmaceutical therapy together with lifestyle changes is used to treat obesity and T2DM to decrease the incidence of comorbidities and allcause mortality and to increase life expectancy.Bariatric surgery is increasingly replacing other forms of treatment of morbid obesity,especially in patients with refractory obesity,owing to its many benefits including good long-term outcomes and almost no weight regain.The bariatric surgery options have markedly changed recently,and laparoscopic sleeve gastrectomy(LSG)is gradually gaining popularity.LSG has become an effective and safe treatment for type-2 diabetes and morbid obesity,with a high cost-benefit ratio.Here,we review the mechanism associated with LSG treatment of T2DM,and we discuss clinical studies and animal experiments with regard to gastrointestinal hormones,gut microbiota,bile acids,and adipokines to clarify current treatment modalities for patients with obesity and T2DM.

Meta analysis of safety and effectiveness of anastomosis of esophagus and jejunum overlap in total laparoscopic total gastrectomy

Objective:To systematically evaluate and compare the safety and effectiveness of esophagojejunostomy and traditional esophagojejunostomy in total laparoscopic total gastrectomy in the treatment of gastric cancer,providing evidence-based medical evidence for clinical practice.Methods:PubMed,Embase,Cochrane Library,Web of Science,CNKI,Wanfang and VIP databases were searched by computer,and the retrieval time was up to December 2021.Relevant literatures were obtained,and eligible studies were gradually screened and included.Cochrane ROB bias risk assessment tool and NOS scale were used to evaluate the quality of the articles,and required data were extracted from high-quality literatures.Finally,meta-analysis was performed using Review Manager 5.3 software.Results:Eleven studies were finally included,including 1398 patients,including 566 patients receiving overlap anastomosis and 832 patients receiving traditional anastomosis.The results show that overlap anastomosis and traditional anastomosis had the advantages of operation time(MD=0.63,95%CI=7.22,8.48,P=0.88),postoperative first exhaust time(MD=-0.13,95%CI=0.43,0.18,P=0.42),postoperative first feeding time(MD=0.02,95%CI=0.33,0.37,P=0.91),anastomotic leakage(OR=1.38,95%CI=0.73,2.63,P=0.32),and postoperative hospital stay(MD=-0.16,95%CI=0.82,0.51,P=0.64)had no significant differences(all P>0.05).Compared with traditional anastomosis,overlap anastomosis had longer anastomosis time(MD=5.60,95%CI=0.59,10.62,P=0.03),higher incidence of anastomotic bleeding(OR=2.48,95%CI=1.08,5.69,P=0.03),less intraoperative bleeding(MD=-6.42,MD=-6.42,OR=2.48,95%CI=1.08,P=0.03).95%CI=10.28,-2.56,P=0.001)and anastomotic stenosis(OR=0.17,95%CI=0.06,0.46,P=0.0006).Conclusion:Overlap esophagojejunostomy is a safe,effective and prognostic surgical method,and is expected to become the standard esophagojejunostomy in total laparoscopic total gastrectomy.

Effect of laparoscopic sleeve gastrectomy on related variables of obesity complicated with polycystic ovary syndrome

BACKGROUND Polycystic ovary syndrome(PCOS)is closely related to obesity,and weight loss can significantly improve the metabolic,endocrine and reproductive functions of obese individuals with PCOS.However,the efficacy of laparoscopic sleeve gastrectomy(LSG)for obesity with PCOS are unclear.AIM The purpose of the study was to investigate the effect of LSG on related variables in obese patients with PCOS.METHODS A retrospective analysis was performed on 32 obese patients with PCOS who received LSG treatment at the Third Hospital of Shanxi Medical University from 2013 to 2020.The changes in anthropometric indices,insulin,testosterone,estradiol,follicle stimulating hormone(FSH),luteinizing hormone(LH),menstrual cycle and LH/FSH ratio before and 1 mo,3 mo,6 mo and 12 mo after the operation were statistically analyzed.RESULTS At 1 mo,3 mo,6 mo and 12 mo after surgery,the anthropometric indices,such as body weight and body mass index,of all patients were lower than those before the operation.The percentage excess weight loss(EWL%)at 1 mo,3 mo,6 mo and 1 year of follow-up were 25,40,46 and 65,respectively.The PCOS-related indices,such as insulin,testosterone,estradiol,follicle stimulating hormone(FSH),luteinizing hormone(LH)and menstrual cycle,were improved to varying degrees.During the 1-year follow-up,the average serum testosterone decreased from preoperative 0.72 ng/mL to 0.43 ng/mL(P<0.05),average fasting insulin level(9.0 mIU/mL,preoperative 34.2 mil,LH level,4.4 mIU/mL,preoperative 6.1 mIU/mL).The level of FSH(3.8 U/L,4.8 U/p0.05)and the ratio of LH/FSH(0.7,1.3/p0.05)were more relieved than those before surgery.During the postoperative follow-up,it was found that the menstrual cycle of 27 patients(nasty 27)returned to normal,and 6 patients(18%)who intended to become pregnant became pregnant within 1 year after surgery.CONCLUSION The weight loss effect of LSG is obvious and affirmative,and the endocrine index of obese patients with PCOS is also improved to some extent,although the mechanism is not clear.Laparoscopic sleeve gastrectomy is expected to become a backup choice for patients with polycystic ovaries in the future.

Laparoscopic and robot-assisted gastrectomy for gastric cancer: Current considerations

Radical gastrectomy with an adequate lymphadenectomy is the main procedure which makes it possible to cure patients with resectable gastric cancer (GC). A number of randomized controlled trials and meta-analysis provide phase III evidence that laparoscopic gastrectomy is technically safe and that it yields better short-term outcomes than conventional open gastrectomy for early-stage GC. While laparoscopic gastrectomy has become standard therapy for early-stage GC, especially in Asian countries such as Japan and South Korea, the use of minimally invasive techniques is still controversial for the treatment of more advanced tumours, principally due to existing concerns about its oncological adequacy and capacity to carry out an adequately extended lymphadenectomy. Some intrinsic drawbacks of the conventional laparoscopic technique have prevented the worldwide spread of laparoscopic gastrectomy for cancer and, despite technological advances in recent year, it remains a technically challenging procedure. The introduction of robotic surgery over the last ten years has implied a notable mutation of certain minimally invasive procedures, making it possible to overcome some limitations of the traditional laparoscopic technique. Robot-assisted gastric resection with D2 lymph node dissection has been shown to be safe and feasible in prospective and retrospective studies. However, to date there are no high quality comparative studies investigating the advantages of a robotic approach to GC over traditional laparoscopic and open gastrectomy. On the basis of the literature review here presented, robot-assisted surgery seems to fulfill oncologic criteria for D2 dissection and has a comparable oncologic outcome to traditional laparoscopic and open procedure. Robot-assisted gastrectomy was associated with the trend toward a shorter hospital stay with a comparable morbidity of conventional laparoscopic and open gastrectomy, but randomized clinical trials and longer follow-ups are needed to evaluate the possible influence of robot gastrectomy on GC patient survival.

Laparoscopic gastrectomy for elderly gastric-cancer patients:comparisons with laparoscopic gastrectomy in non-elderly patients and open gastrectomy in the elderly

Background:The benefits of laparoscopic gastrectomy(LG)in elderly gastric-cancer patients still remain unclear.The purpose of this study was to evaluate the feasibility and safety of LG in elderly gastric-cancer patients.Methods:We retrospectively evaluated patients who underwent LG or open gastrectomy(OG)between June 2009 and July 2015 in a single high-volume center.We compared surgical,short-term,and long-termsurvival outcomes among an elderly(-70 years old)LG(ELG)group(n=114),a non-elderly(<70 years old)LG(NLG)group(n=740),and an elderly OG(EOG)group(n=383).Results:Except for extended time to first flatus,the surgical and short-term outcomes of the ELG group were similar to those of the NLG group.The ELG group revealed comparable disease-specific survival(DSS)rates to the NLG group(64.9%vs 66.2%,P=0.476),although the overall survival(OS)rate was lower(57.0%vs 65.5%,P<0.001)in the ELG group than in the NLG group.The ELG group showed longer operation time than the EOG group(236.4677.3 vs 179652.2 min,P<0.001).The ELG group had less estimated blood loss(174.0688.4 vs 209.36133.8,P=0.008)and shorter post-operative hospital stay(8.362.5 vs 9.264.5,P=0.048)than the EOG group.The severity of complications was similar between the ELG and NLG groups.Multivariate analysis confirmed that LG was not a risk factor for post-operative complications.Conclusions:LG is a feasible and safe procedure for elderly patients with acceptable short-and long-term survival outcomes.

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.

Digestive tract reconstruction using isoperistaltic jejunumlater-cut overlap method after totally laparoscopic total gastrectomy for gastric cancer: Short-term outcomes and impact on quality of life

AIM To evaluate the short-term outcomes and quality of life(Qo L) in gastric cancer patients undergoing digestive tract construction using the isoperistaltic jejunum-latercut overlap method(IJOM) after totally laparoscopic total gastrectomy(TLTG).METHODS A total of 507 patients who underwent laparoscopic gastrectomy(D2) from January 2014 to March 2016 were originally included in the study. The patients were divided into two groups to undergo digestive tract construction using either IJOM after TLTG(group T, n = 51) or Roux-en-Y anastomosis after laparoscopic-assisted total gastrectomy(LATG)(group A, n = 456). The short-term outcomes and Qo L were compared between the two groups after 1:2 propensity-score matching(PSM). We used a questionnaire to assess Qo L.RESULTS Before matching, age, sex, tumor size, tumor location, preoperative albumin and blood loss were significantly different between the two groups(P < 0.05). After PSM, the patients were well balanced in terms of their clinicopathological characteristics, although both blood loss and in-hospital postoperative days in group T were significantly lower than those in group A(P < 0.05). After matching, group T reported better Qo L in the domains of pain and dysphagia. Among the items evaluating pain and dysphagia, group T tended to report better Qo L("Have you felt pain" and "Have you had difficulty eating solid food")(P < 0.05).CONCLUSION The IJOM for digestive tract reconstruction after TLTG is associated with reduced blood loss and less pain and dysphagia, thus improving Qo L after laparoscopic gastrectomy.

Totally laparoscopic total gastrectomy using the modified overlap method and conventional open total gastrectomy:A comparative study

BACKGROUND Although several methods of totally laparoscopic total gastrectomy(TLTG)have been reported.The best anastomosis technique for LTG has not been established.AIM To investigate the effectiveness and surgical outcomes of TLTG using the modified overlap method compared with open total gastrectomy(OTG)using the circular stapled method.METHODS We performed 151 and 131 surgeries using TLTG with the modified overlap method and OTG for gastric cancer between March 2012 and December 2018.Surgical and oncological outcomes were compared between groups using propensity score matching.In addition,we analyzed the risk factors associated with postoperative complications.RESULTS Patients who underwent TLTG were discharged earlier than those who underwent OTG[TLTG(9.62±5.32)vs OTG(13.51±10.67),P<0.05].Time to first flatus and soft diet were significantly shorter in TLTG group.The pain scores at all postoperative periods and administration of opioids were significantly lower in the TLTG group than in the OTG group.No significant difference in early,late and esophagojejunostomy(EJ)-related complications or 5-year recurrence free and overall survival between groups.Multivariate analysis demonstrated that body mass index[odds ratio(OR),1.824;95%confidence interval(CI):1.029-3.234,P=0.040]and American Society of Anaesthesiologists(ASA)score(OR,3.154;95%CI:1.084-9.174,P=0.035)were independent risk factors of early complications.Additionally,age was associated with≥3 Clavien-Dindo classification and EJrelated complications.CONCLUSION Although TLTG with the modified overlap method showed similar complication rate and oncological outcome with OTG,it yields lower pain score,earlier bowel recovery,and discharge.Surgeons should perform total gastrectomy cautiously and delicately in patients with obesity,high ASA scores,and older ages.

Novel method for esophagojejunal anastomosis after laparoscopic total gastrectomy:Semi-end-to-end anastomosis

AIM: To test a new safe and simple technique for circular-stapled esophagojejunostomy in laparoscopic total gastrectomy (LATG).

Comparative study of outcomes following laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy in morbidly obese patients: A case control study

To compare the impact of laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) on weight loss and obesity related comorbidities over two year follow-up via case control study design. METHODSForty patients undergoing LRYGB, who completed their two year follow-up were matched with 40 patients undergoing LSG for age, gender, body mass index and presence of type 2 diabetes mellitus (T2DM). Data of these patients was retrospectively reviewed to compare the outcome in terms of weight loss and improvement in comorbidities, i.e., T2DM, hypertension (HTN), obstructive sleep apnea syndrome (OSAS), hypothyroidism and gastroesophageal reflux disease (GERD). RESULTSPercentage excess weight loss (EWL%) was similar in LRYGB and LSG groups at one year follow-up (70.5% vs 66.5%, P = 0.36) while it was significantly greater for LRYGB group after two years as compared to LSG group (76.5% vs 67.9%, P = 0.04). The complication rate after LRYGB and LSG was similar (10% vs 7.5%, P = 0.99). The median duration of T2DM and mean number of oral hypoglycemic agents were higher in LRYGB group than LSG group (7 years vs 5 years and 2.2 vs 1.8 respectively, P < 0.05). Both LRYGB and LSG had significant but similar improvement in T2DM, HTN, OSAS and hypothyroidism. However, GERD resolved in all patients undergoing LRYGB while it resolved in only 50% cases with LSG. Eight point three percent patients developed new-onset GERD after LSG. CONCLUSIONLRYGB has better outcomes in terms of weight loss two years after surgery as compared to LSG. The impact of LRYGB and LSG on T2DM, HTN, OSAS and hypothyroidism is similar. However, LRYGB has significant resolution of GERD as compared to LSG.