Survival prognostic analysis of laparoscopic D2 radical resection for locally advanced gastric cancer: A multicenter cohort study

BACKGROUND With the development of minimally invasive surgical techniques,the use of laparoscopic D2 radical surgery for the treatment of locally advanced gastric cancer(GC)has gradually increased.However,the effect of this procedure on survival and prognosis remains controversial.This study evaluated the survival and prognosis of patients receiving laparoscopic D2 radical resection for the treatment of locally advanced GC to provide more reliable clinical evidence,guide clinical decision-making,optimize treatment strategies,and improve the survival rate and quality of life of patients.METHODS A retrospective cohort study was performed.Clinicopathological data from 652 patients with locally advanced GC in our hospitals from December 2013 to December 2023 were collected.There were 442 males and 210 females.The mean age was 57±12 years.All patients underwent a laparoscopic D2 radical operation for distal GC.The patients were followed up in the outpatient department and by telephone to determine their tumor recurrence,metastasis,and survival.The follow-up period ended in December 2023.Normally distributed data are expressed as the mean±SD,and normally distributed data are expressed as M(Q1,Q3)or M(range).Statistical data are expressed as absolute numbers or percentages;theχ^(2) test was used for comparisons between groups,and the Mann-Whitney U nonparametric test was used for comparisons of rank data.The life table method was used to calculate the survival rate,the Kaplan-Meier method was used to construct survival curves,the log rank test was used for survival analysis,and the Cox risk regression model was used for univariate and multifactor analysis.RESULTS The median overall survival(OS)time for the 652 patients was 81 months,with a 10-year OS rate of 46.1%.Patients with TNM stages II and III had 10-year OS rates of 59.6%and 37.5%,respectively,which were significantly different(P<0.05).Univariate analysis indicated that factors such as age,maximum tumor diameter,tumor diffe-rentiation grade(low to undifferentiated),pathological TNM stage,pathological T stage,pathological N stage(N2,N3),and postoperative chemotherapy significantly influenced the 10-year OS rate for patients with locally advanced GC following laparoscopic D2 radical resection for distal stomach cancer[hazard ratio(HR):1.45,1.64,1.45,1.64,1.37,2.05,1.30,1.68,3.08,and 0.56 with confidence intervals(CIs)of 1.15-1.84,1.32-2.03,1.05-1.77,1.62-2.59,1.05-1.61,1.17-2.42,2.15-4.41,and 0.44-0.70,respectively;P<0.05].Multifactor analysis revealed that a tumor diameter greater than 4 cm,low tumor differentiation,and pathological TNM stage III were independent risk factors for the 10-year OS rate in these patients(HR:1.48,1.44,1.81 with a 95%CI:1.19-1.84).Additionally,postoperative chemotherapy emerged as an independent protective factor for the 10-year OS rate(HR:0.57,95%CI:0.45-0.73;P<0.05).CONCLUSION A maximum tumor diameter exceeding 4 cm,low tumor differentiation,and pathological TNM stage III were identified as independent risk factors for the 10-year OS rate in patients with locally advanced GC following laparoscopic D2 radical resection for distal GC.Conversely,postoperative chemotherapy was found to be an independent protective factor for the 10-year OS rate in these patients.

Totally Laparoscopic Total Gastrectomy with D2 Lymphadenectomy for Advanced Gastric Cancer

Introductions: Gastrectomy, which is the standard surgical procedure for gastric cancer, has gradually come to be performed laparoscopically. Laparoscopic distal gastrectomy (LDG) has been adopted gradually and performed for advanced gastric cancer. However, laparoscopic total gastrectomy (LTG) has not been as widely accepted as LDG due to technical difficulties, especially with reconstruction and proper D2 lymphadenectomy. The purpose of the current study was to determine the utility of TLTG with concomitant splenectomy and D2 lymphadenectomy (TLTGS) for advanced gastric cancer (AGC). Materials and Methods: Between January 2006 and May 2014, 10 consecutive patients who underwent TLTGS for AGC and 76 patients who underwent TLTG with D1 lymphadenectomy were included in this study. These two groups were compared in terms of perioperative results, with assessment of intraoperative and postoperative outcomes. Results: There were no significant differences in patients’ characteristics between the two groups. Operative time was longer in the TLTGS group than in the TLTG group. However, the rate of patients with postoperative complications including major complications was not different between the groups, and no patient in the TLTGS group had anastomotic leakage or pancreatic fistula. Conclusions: In the short-term, TLTGS had good postoperative outcomes and was useful and acceptable for AGC.

Gastric cancer: Current status of lymph node dissection

D2 procedure has been accepted in Far East as the standard treatment for both early(EGC) and advanced gastric cancer(AGC) for many decades. Recently EGC has been successfully treated with endoscopy by endoscopic mucosal resection or endoscopic submucosal dissection, when restricted or extended Gotoda's criteria can be applied and D1+ surgery is offered only to patients not fitted for less invasive treatment. Furthermore, two randomised controlled trials(RCTs) have been demonstrating the non inferiority of minimally invasive technique as compared to standard open surgery for the treatment of early cases and recently the feasibility of adequate D1+ dissection has been demonstrated also for the robot assisted technique. In case of AGC the debate on the extent of nodal dissection has been open for many decades. While D2 gastrectomy was performed as the standard procedure in eastern countries, mostly based on observational and retrospective studies, in the west the Medical Research Council(MRC), Dutch and Italian RCTs have been conducted to show a survival benefit of D2 over D1 with evidence based medicine. Unfortunately both the MRC and the Dutch trials failed to show a survival benefit after the D2 procedure, mostly due to the significant increase of postoperative morbidity and mortality, which was referred to splenopancreatectomy. Only 15 years after the conclusion of its accrual, the Dutch trial could report a significant decrease of recur-rence after D2 procedure. Recently the long term survival analysis of the Italian RCT could demonstrate a benefit for patients with positive nodes treated with D2 gastrectomy without splenopancreatectomy. As nowadays also in western countries D2 procedure can be done safely with pancreas preserving technique and without preventive splenectomy, it has been suggested in several national guidelines as the recommended procedure for patients with AGC.

A decade in gastric cancer curative surgery:Evidence of progress(1999-2009)

To investigate the progress in evidence-based surgical treatment of non-metastatic gastric cancer,we re- viewed the last ten years'literature.The data used in this review were identified by searches made on MED-LINE,Current Contents,PubMed,and other references taken from relevant original articles(on prospective and retrospective studies)concerning gastric cancer surgery.Only papers published in English between January 1999 and December 2009 were selected.Data from ongoing studies were obtained in December 2009, from the trials registry of the United States National Institutes of Health(http://www.clinicaltrial.gov).The citations list was presented according to evidence based relevance(i.e.,randomized controlled trials,pro- spective studies,retrospective series).In the last ten years,many challenges have been faced relating to the extension of gastric resection and nodal dissection as well as surgical timing,but we found only limited evidence,regardless of latitude of study.The ongoing phase-Ⅲ trials may provide answers that will be valid for the coming decades,and which may bring definitive answers for the currently unresolved questions.

腹腔镜与开腹进展期远端胃癌D2根治术疗效对比

目的 比较腹腔镜与开腹D2根治术在进展期远端胃癌治疗中的疗效.方法 选取66例腹腔镜和52例开腹进展期远端胃癌D2根治术患者（分别为腹腔镜组和开腹组）,比较其手术相关指标、术后恢复指标、肿瘤根治性指标、住院费用、术后并发症及随访结果.结果 腹腔镜组患者术后肛门排气、留置导尿及术后住院时间均明显短于开腹组（P＜0.05）,手术时间略长于开腹组（P＜0.05）,而术中出血量、肿瘤大小、清扫淋巴结数目、上切缘距肿瘤距离及下切缘距肿瘤距离与开腹组无明显差异（P ＞0.05）;腹腔镜组患者手术费及住院总费用均高于开腹组（P＜0.01）;腹腔镜组患者术后并发症明显少于开腹组（P＜0.05）,复发及无瘤生存率与开腹组无明显差异（P ＞0.05）.结论 腹腔镜下进展期远端胃癌D2根治术安全、有效、可行性好,且创伤小、恢复快、并发症少.

开腹与腹腔镜辅助下远端胃癌D2根治术治疗进展期胃癌的疗效及对循环肿瘤细胞的影响

目的探讨开腹与腹腔镜辅助下远端胃癌D2根治术治疗进展期胃癌的疗效及对循环肿瘤细胞(CTC)的影响。方法采用随机数字表法将88例进展期胃癌患者分为对照组和观察组,每组44例。对照组患者接受开腹远端胃癌D2根治术治疗,观察组患者接受腹腔镜辅助下远端胃癌D2根治术治疗。比较两组患者的手术相关指标、术后不良反应发生情况及术后CTC水平。结果观察组患者的手术时间、术后肛门排气时间、术后下床活动时间、术后进食流质饮食时间、术后平均住院时间均短于对照组,手术切口长度小于对照组,术中出血量少于对照组,不良反应发生率及术后CTC水平均低于对照组,差异均有统计学意义(P﹤0.05)。结论与开腹手术比较,腹腔镜辅助下远端胃癌D2根治术治疗进展期胃癌的疗效更佳,并且可以有效降低患者的CTC水平。

A matched cohort study of laparoscopy-assisted and open total gastrectomy for advanced proximal gastric cancer without serosa invasion

Background Little is known about the feasibility and safety of laparoscopy-assisted total gastrectomy （LATG） with extended lymphadenectomy in patients with advanced gastric cancer （AGC）.This study compared the technical feasibility,safety,and oncologic efficacy of LATG with open total gastrectomy （OTG） for AGC without serosa invasion.Methods From January 2009 to December 2011,235 patients underwent LATG and 153 patients underwent OTG for AGC without serosa invasion.Age,gender,and depth of invasion （pT2 and pT3） were matched by propensity scoring,and 116 patients （58 LATG and 58 OTG） were selected for analysis.Their clinicopathologic characteristics,postoperative outcomes,and survival were compared.Results There was no significant difference in clinicopathologic characteristics between the two propensity-matched groups.Median number of lymph nodes per patient was 29,and the mean number of retrieved lymph nodes was similar in the LATG and OTG groups （30.8±10.2 vs.29.0±8.3）.Peri-operative characteristics,operation time,number of transfused units per patient,and time to resumption of activities were similar in the two groups; while blood loss,times to first flatus and resumption of soft diet,and post-operative stay were significantly lower in the LATG group （P ＜0.05,respectively）.Rates of post-operative complications （12.1％ vs.15.5％） and postoperative mortality （0％ vs.1.7％）,as well as cumulative survival rates,were similar.Conclusions LATG with D2 lymphadenectomy is a safe and feasible procedure for AGC patients without serosa invasion.ProsPective.multicenter,randomized trials are needed to confirm the efficacy of LATG in this patient population.

腹腔镜手术与开腹手术对进展期远端胃癌患者肿瘤根治效果和术后生存质量影响的对比研究

目的对比分析腹腔镜手术与开腹手术对进展期远端胃癌患者肿瘤根治效果和生存质量的影响。方法将本院2013年3月至2015年3月收治的146例进展期远端胃癌患者采用区组随机化方法分为腹腔镜组和开腹组,每组各73例。腹腔镜组患者行腹腔镜胃癌根治术,开腹组患者行开腹胃癌根治术。比较两组患者的手术相关指标(包括手术时间、术中失血量、镇痛时间、术后肛门排气时间、开始进食时间、开始下床活动时间及术后住院天数)、术后病理指标(包括上切缘与肿瘤间的距离、下切缘与肿瘤间的距离及术中淋巴结清扫数目)、术后并发症发生情况以及术后生存质量。结果两组患者术中失血量比较无显著差异(P>0.05),腹腔镜组患者手术时间明显长于开腹组(P<0.01),但镇痛时间、术后肛门排气时间、开始进食时间、开始下床活动时间及术后住院天数均短于开腹组(P<0.01)。两组患者上切缘与肿瘤间的距离、下切缘与肿瘤间的距离、淋巴结清扫数目、第一站和第二站淋巴结清扫数目比较均无显著差异(P>0.05);腹腔镜组患者术后并发症发生率明显低于开腹组(P<0.01)。术后1周,腹腔镜组患者的主观症状、生理功能状态、心理情绪状态评分以及消化病生存质量指数(gastrointestinal quality of life index,GLQI)总分均高于开腹组(P<0.05)。术后3个月,腹腔镜组患者的主观症状评分和GLQI总分均高于开腹组(P<0.05)。结论腹腔镜胃癌根治术治疗进展期远端胃癌,可达到与开腹胃癌根治术相近的肿瘤切除及淋巴结清扫效果,同时其微创特点有助于加快患者术后恢复、减少术后并发症,提高患者术后生存质量。

腹腔镜辅助远端胃癌D_(2)根治术治疗无浆膜层侵犯的进展期胃癌的效果及对炎症指标的影响

目的分析腹腔镜辅助远端胃癌D_(2)根治术治疗无浆膜层侵犯的进展期胃癌的效果。方法选取2016年1月2日至2020年1月2日收治的60例无浆膜层侵犯的进展期胃癌患者为研究对象,采取抽签法将其分为观察组(30例,腹腔镜辅助远端胃癌D_(2)根治术治疗)和对照组(30例,常规手术治疗)。比较两组的术后并发症发生情况、手术指标、术中并发症发生情况、临床疗效及炎症指标。结果观察组的术后并发症总发生率低于对照组,差异具有统计学意义(P<0.05)。观察组的排气时间、切口长度、住院时间短于对照组,术中出血量少于对照组,差异具有统计学意义(P<0.05);两组的手术时间、淋巴结清扫数比较,差异无统计学意义(P>0.05)。两组的术中并发症总发生率比较,差异无统计学意义(P>0.05)。观察组的治疗总有效率高于对照组,差异具有统计学意义(P<0.05)。手术前,两组的肿瘤坏死因子-α(TNF-α)、白细胞介素-6(IL-6)、干扰素-γ(IFN-γ)、转化生长因子-β(TGF-β)水平比较,差异无统计学意义(P>0.05);手术后,两组的TNF-α、IL-6水平高于手术前,IFN-γ、TGF-β水平低于手术前,差异具有统计学意义(P<0.05);手术后,观察组的TNF-α、IL-6水平低于对照组,差异具有统计学意义(P<0.05);手术后,两组的IFN-γ、TGF-β水平比较,差异无统计学意义(P>0.05)。结论腹腔镜辅助远端胃癌D_(2)根治术治疗无浆膜层侵犯的进展期胃癌的效果显著,可降低术后并发症发生率,且炎症应激反应较小,值得临床应用。

新辅助化疗联合完全腹腔镜下远端胃癌D2根治术的临床疗效

目的探讨新辅助化疗联合完全腹腔镜下远端胃癌D2根治术的临床疗效及对复发率和死亡率的影响。方法观察2015年1月至2017年6月预行根治性远端胃切除的72例患者,其中观察组为SOX方案新辅助化疗后行完全腹腔镜根治性远端胃切除的33例患者,对照组为仅行完全腹腔镜根治性远端胃切除的39例患者。分析两组手术时间、术中出血量、中转开腹率、淋巴结清扫数目、术后手术相关并发症、非手术并发症、术后分期、复发及远处转移等临床资料。结果观察组新辅助化疗有效率54.55%(18/33);观察组患者术后TNM分期与对照组相比较术前下降,差异有统计学意义(P<0.05)。观察组手术时间[(248.0±37.0)minvs(224.9±29.6)min]、术中出血量[(139.4±51.7)mlvs(109.6±48.7)ml]较对照组略有增加,差异具有统计学意义(P<0.05);两组在淋巴结清扫数目和术后并发症等方面对比差异无统计学意义(P>0.05)。随访时间截至2017年10月,与对照组相比,观察组肿瘤复发转移(12.1%vs41.0%)及死亡率(6.0%vs76.9%)降低,差异有统计学意义(P<0.05)。结论新辅助化疗联合完全腹腔镜下远端胃癌D2根治术是安全、可行的,手术创伤更小,恢复快,且短期疗效具有优势。

腹腔镜远端胃癌D_(2)根治术治疗局部进展期胃癌10年预后及影响因素分析:基于CLASS队列的全国多中心研究

目的探讨腹腔镜远端胃癌D2根治术治疗局部进展期胃癌10年预后及影响因素。方法采用回顾性队列研究方法。收集2004年2月至2010年12月中国腹腔镜胃肠外科研究组(CLASS研究组)腹腔镜胃癌外科多中心临床数据库中16家医院收治的652例(陆军军医大学第一附属医院214例、福建医科大学附属协和医院191例、南方医科大学南方医院52例、四川大学华西医院49例、空军军医大学附属西京医院43例、江苏省中医院25例、解放军总医院第一医学中心14例、解放军联勤保障部队第九八九医院12例、中山大学附属第三医院12例、南昌大学第一附属医院10例、佛山市第一人民医院9例、南方医科大学珠江医院7例、福建医科大学附属肿瘤医院7例、复旦大学附属中山医院3例、华中科技大学同济医学院附属协和医院2例、北京大学肿瘤医院2例)局部进展期胃癌患者的临床病理资料;男442例,女210例;年龄为(57±12)岁。患者均行腹腔镜远端胃癌D_(2)根治术。观察指标:(1)手术情况。(2)术后病理学检查情况。(3)术后恢复及并发症情况。(4)随访情况。(5)预后影响因素分析。采用门诊和电话方式进行随访,了解患者术后肿瘤复发转移及生存情况。随访时间截至2020年3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(Q_(1),Q_(3))或M(范围)表示。计数资料以绝对数或百分比表示,组间比较采用χ^(2)检验,等级资料比较采用Mann-Whitney U非参数检验。采用寿命表法计算生存率,Kaplan-Meier法绘制生存曲线,Log-Rank检验进行生存分析。采用COX风险回归模型进行单因素和多因素分析。结果(1)手术情况:652例患者中,617例行D2淋巴结清扫术,35例行D2+淋巴结清扫术;348例消化道重建方式为Billroth Ⅱ吻合,218例为Billroth Ⅰ吻合,25例为Roux-en-Y吻合,61例为其他;12例行联合脏器切除;569例术中输血,83例术中未输血。652例患者手术时间为187(155,240)min,术中出血量为100(50,150)mL。(2)术后病理学检查情况:652例患者肿瘤最大径为(4.5±2.0)cm;淋巴结清扫数目为26(19,35)枚,其中>15枚570例,≤15枚82例;淋巴结转移数目为4(1,9)枚;肿瘤近端切缘为(4.8±1.6)cm,肿瘤远端切缘为(4.5±1.5)cm。652例患者中,肿瘤Borrmann分型为Ⅰ~Ⅱ型255例,Ⅲ~Ⅳ型334例,缺失Borrmann分型资料63例;肿瘤分化程度为高-中分化171例,低-未分化430例,缺失肿瘤分化程度资料51例;肿瘤病理学T分期T2期、T3期、T4a期分别为123、253、276例,病理学N分期N0期、N1期、N2期、N3期分别为116、131、214、191例,病理学TNM分期Ⅱ期、Ⅲ期分别为260、392例。(3)术后恢复及并发症情况:652例患者术后首次下床活动间为3(2,4)d,首次肛门排气时间为4(3,5)d,首次进食全流质食物时间为5(4,6)d,术后住院时间为10(9,13)d。652例患者中,69例发生术后并发症,Clavien-Dindo Ⅰ~Ⅱ级、Ⅲa级、Ⅲb级、Ⅳa级并发症患者分别为60、3、5、1例。同1例患者可合并多种并发症。手术并发症和系统并发症中,发生率最高的分别为十二指肠残端瘘(3.07%,20/652)和呼吸系统并发症(2.91%,19/652)。69例患者经治疗后均顺利转归并出院。(4)随访情况:652例患者均获得随访,随访时间为110~193个月,中位随访时间为124个月。298例术后复发转移患者中,255例术后≤5年复发转移,其中远处转移、腹膜转移、局部复发、多处复发转移、其他部位复发转移分别为21、69、37、52、76例;43例术后>5年复发转移,上述指标分别为5、9、10、4、15例;两者复发转移类型比较,差异无统计学意义(χ^(2)=5.52,P>0.05)。术后≤5年和>5年复发转移患者病理学TNM分期Ⅱ期、Ⅲ期分别为62、193例和23、20例,两者病理学TNM分期比较,差异有统计学意义(χ^(2)=15.36,P<0.05);病理学T分期T2期、T3期、T4a期分别为42、95、118例和9、21、13例,两者病理学T分期比较,差异无统计学意义(Z=-1.80,P>0.05),进一步分析,两者病理学T2期、T3期比较,差异均无统计学意义(χ^(2)=0.52,2.08,P>0.05),两者T4a期比较,差异有统计学意义(χ^(2)=3.84,P<0.05);病理学N分期N0期、N1期、N2期、N3期分别为19、44、85、107例和12、5、18、8例,两者病理学N分期比较,差异有统计学意义(Z=-3.34,P<0.05),进一步分析,两者病理学N0期、N3期比较,差异均有统计学意义(χ^(2)=16.52,8.47,P<0.05),两者N1期、N2期比较,差异均无统计学意义(χ^(2)=0.85,1.18,P>0.05)。652例患者术后中位总生存时间为81个月,10年总生存率为46.1%,其中病理学TNM分期Ⅱ期、Ⅲ期患者10年总生存率分别为59.6%、37.5%,两者比较,差异有统计学意义(χ^(2)=35.29,P<0.05)。进一步分析,病理学TNM分期ⅡA期、ⅡB期、ⅢA期、ⅢB期、ⅢC期患者10年总生存率分别为65.6%、55.8%、46.9%、37.1%、24.0%,5者比较,差异有统计学意义(χ^(2)=55.06,P<0.05)。病理学T2期、T3期、T4a期患者10年总生存率分别为55.2%、46.5%、41.5%,3者比较,差异有统计学意义(χ^(2)=8.39,P<0.05)。病理学N0期、N1期、N2期、N3期患者10年总生存率分别为63.7%、56.2%、48.5%、26.4%,4者比较,差异有统计学意义(χ^(2)=54.89,P<0.05)。(5)预后影响因素分析:单因素分析结果显示年龄,肿瘤最大径,肿瘤分化程度(低-未分化),病理学TNM分期,病理学T分期,病理学N分期(N2期、N3期),术后化疗是影响行腹腔镜远端胃癌D2根治术局部进展期胃癌10年总生存率的相关因素(风险比=1.45,1.64,1.37,2.05,1.30,1.68,3.08,0.56,95%可信区间为1.15~1.84,1.32~2.03,1.05~1.77,1.62~2.59,1.05~1.61,1.17~2.42,2.15~4.41,0.44~0.70,P<0.05)。多因素分析结果显示:肿瘤最大径>4 cm,肿瘤分化程度为低-未分化,病理学TNM分期Ⅲ期是影响行腹腔镜远端胃癌D2根治术局部进展期胃癌10年总生存率的独立危险因素(风险比=1.48,1.44,1.81,95%可信区间为1.19~1.84,1.11~1.88,1.42~2.30,P<0.05),术后化疗是影响行腹腔镜远端胃癌D2根治术局部进展期胃癌10年总生存率的独立保护因素(风险比=0.57,95%可信区间为0.45~0.73,P<0.05)。结论腹腔镜辅助远端胃癌D_(2)根治术治疗局部进展期胃癌10年肿瘤学疗效满意。病理学TNM分期Ⅲ期、病理学T4a期、病理学N3期患者术后≤5年复发转移比例高,而病理学TNM分期Ⅱ期、病理学N0期患者术后>5年复发转移比例高。肿瘤最大径>4 cm,肿瘤分化程度为低-未分化,病理学TNM分期Ⅲ期是影响行腹腔镜远端胃癌D2根治术局部进展期胃癌10年总生存率的独立危险因素,术后化疗是影响行腹腔镜远端胃癌D2根治术局部进展期胃癌10年总生存率的独立保护因素。