Clinical Application Analysis of Laparoscopic-Assisted Total Gastrectomy in the Surgical Treatment of Gastric Cancer

Objective:To investigate the clinical application effect of laparoscopic-assisted total gastrectomy in the surgical treatment of gastric cancer.Methods:The clinical data of 86 COPD patients included in the study were collected and divided into 43 cases each in Groups A and B using the randomization method,with open total gastrectomy in Group A and laparoscopic-assisted total gastrectomy in Group B.The clinical indexes,pain levels,and complications of patients in the two groups were observed in combination with the indexes.Results:The baseline data of the two groups of patients were not statistically significant(all P>0.05);the operation time,incision length,first flatulence time,and hospitalization time of patients in Group B were shorter than those in Group A(all P=0.000);the NRS scores of patients in Group B on the 1st postoperative day and the 2nd postoperative day were significantly lower than those in Group A(t=23.443,t=28.784,all P=0.000);the total complication rate of patients in Group B(1;2.33%)was significantly lower than that of Group A(9;20.94%)(χ^(2)=7.242,P=0.007).Conclusion:In the surgical treatment of gastric cancer,laparoscopic-assisted total gastrectomy can promote patients’recovery,reduce patients’pain,and lower the probability of complications.

Magnetic compression anastomosis for reconstruction of digestive tract after total gastrectomy in beagle model

BACKGROUND Magnetic compression anastomosis(MCA)is a simple procedure contributing to a reliable anastomosis.However,digestive-tract reconstruction after total gastrectomy using MCA has not yet been reported.AIM To investigate the feasibility of MCA for simultaneous esophagojejunostomy and jejunojejunostomy after total gastrectomy using beagle dogs.METHODS Sixteen beagles were randomly divided into an MCA group(study group,n=8)and a manual-suture anastomosis group(control group,n=8).Two different magnetic anastomosis devices were used in the study group for esophagojejunal and jejunojejunal anastomoses.Both devices included a pair of circular daughter and parent magnets each.The time of esophagojejunostomy and jejunojejunostomy,postoperative complications,and survival rate of the two groups were compared.The dogs were sacrificed one month after the operation and their anastomotic specimens were obtained.Healing was observed by the naked eye and a light microscope.RESULTS Digestive-tract reconstruction after total gastrectomy was successfully completed in both groups(survival rate=100%).In the study group,esophagojejunal and jejunojejunal anastomoses took 6.13±0.58 and 4.06±0.42 min,respectively,significantly lower than those in the control group(15.63±1.53 min,P<0.001 and 10.31±1.07 min,P<0.001,respectively).Complications such as bleeding,anastomotic leakage,and anastomotic stenosis were not observed.In the study group,the magnets did not interfere with each other.Discharge time of the jejunojejunal magnetic anastomosis device was 10.75±1.28 d,while that of the esophagojejunal magnetic anastomosis device was 12.25±1.49 d.Residual silk was found in the control group.The study group showed a greater smoothness of the anastomosis than that of the control group.All layers of anastomosis healed well in both groups.CONCLUSION MCA is a safe and feasible procedure for digestive-tract reconstruction after total gastrectomy in this animal model.

Impact of preoperative therapy on surgical outcomes of laparoscopic total gastrectomy for gastric/gastroesophageal junction cancer

Objective: As laparoscopic surgery is widely applied for primarily treated gastric cancer(GC)/gastroesophageal junction cancer(GEJC) and gains many advantages, the feasibility of laparoscopic total gastrectomy(LTG) for GC/GEJC patients who have received preoperative therapy(PT) has come to the fore. This study aims to analyze the safety and feasibility of LTG after PT for GC/GEJC patients.Methods: We retrospectively analyzed the data of 511 patients with GC/GEJC undergoing LTG, of which 405received LTG(LTG group) and 106 received PT+LTG(PT-LTG group) at Nanfang Hospital between June 2018and September 2022. The surgical outcomes were compared between the two groups.Results: The surgical duration was significantly longer in the PT-LTG group(P<0.001), while the incidence of intraoperative complications(P=1.000), postoperative complications(LTG group vs. PT-LTG group: 26.2% vs.23.6%, P=0.587), the classification of complication severity(P=0.271), and postoperative recovery was similar between two groups. Notably, the incidence of anastomotic complications of esophagojejunostomy was also comparable between the two groups(LTG group vs. PT-LTG group: 5.9% vs. 5.7%, P=0.918). The univariate and multivariate analysis confirmed that positive proximal margin [positive vs. negative: odds ratio(OR)=14.094, 95%confidence interval(95% CI): 2.639-75.260, P=0.002], rather than PT, has an impact on anastomotic complications after LTG(OR=0.945, 95% CI: 0.371-2.408, P=0.905).Conclusions: PT did not increase the surgical risk of LTG for GC/GEJC. Therefore, considering the positive effect of PT on long-term survival, the broader application of PT and LTG for GC/GEJC is supported by our findings.

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.

Laparoscopic vs open total gastrectomy for advanced gastric cancer following neoadjuvant therapy:A propensity score matching analysis

BACKGROUND Laparoscopic total gastrectomy(LTG)has drawn increasing attention over the years.Although LTG has shown surgical benefits compared to open TG(OTG)in early stage gastric cancer(GC),little is known about the surgical and oncological outcomes of LTG for advanced GC following neoadjuvant therapy(NAT).AIM To compare the long-and short-term outcomes of advanced GC patients who underwent LTG vs OTG following NAT.METHODS Advanced GC patients who underwent TG following NAT between April 2011 and May 2018 at the Cancer Hospital of the Chinese Academy of Medical Sciences were enrolled and stratified into two groups:LTG and OTG.Propensity score matching analysis was performed at a 1:1 ratio to overcome possible bias.RESULTS In total,185 patients were enrolled(LTG:78;OTG:109).Of these,138 were paired after propensity score matching.After adjustment for propensity score matching,baseline parameters were similar between the two groups.Compared to OTG,LTG was associated with a significantly shorter length of hospital stay(P=0.012).The rates of R0 resection,lymph node harvest,and postoperative morbidity did not significantly differ between the two groups.Overall survival(OS)outcomes were comparable between the two groups.Pathological T and N stages were found to be independent risk factors for OS.CONCLUSION LTG can be a feasible method for advanced GC patients following NAT,as it appears to be associated with better short-and comparable long-term outcomes compared to OTG.

Observation on the Therapeutic Effect and Complication Rate of Totally Laparoscopic Total Gastrectomy and Laparoscopic-Assisted Total Gastrectomy in the Treatment of Gastric Cancer

Objective:To investigate the effect and complication rate of totally laparoscopic and laparoscopic-assisted total gastrectomy in the treatment of gastric cancer.Methods:From March 2019 to July 2021,60 patients with gastric cancer were selected as the subjects in this study;the patients in group A underwent laparoscopic-assisted total gastrectomy,whereas those in group B underwent totally laparoscopic total gastrectomy;the treatment effect and complication rate were compared between the two groups.Results:The postoperative recovery of group B was significantly better than that of group A,and the postoperative complications(10.00%)of group B were significantly lower than that of group A(33.33%)(P<0.05).Conclusion:For patients with gastric cancer,totally laparoscopic total gastrectomy has better therapeutic effect and lower postoperative complications,which is worthy of popularization.

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.

Efficacy of totally laparoscopic compared with laparoscopic-assisted total gastrectomy for gastric cancer: A meta-analysis

BACKGROUND Laparoscopic radical gastrectomy is currently the most common surgical approach for gastric cancer.The main difference between totally laparoscopic total gastrectomy(TLTG)and laparoscopic-assisted total gastrectomy(LATG)is the route of digestive tract reconstruction.However,TLTG is currently not widespread as the safety and feasibility of intracorporeal esophagojejunostomy is uncertain.AIM To compare the short-term efficacy of TLTG and LATG for radical gastrectomy of gastric cancer,and to determine the safety and feasibility of intracorporeal esophagojejunostomy.METHODS PubMed,EMBASE,and Web of Science databases were searched for all relevant articles regarding TLTG vs LATG for gastric cancer published up to October 1,2019.Inclusion and exclusion criteria were established.All the basic conditions of patients and important clinical data related to surgery were extracted,and a meta-analysis was performed with RevMan 5.3 software.RESULTS Eight studies involving a total of 1883 cases(869 cases in the TLTG group and 1014 cases in the LATG group)were included.Compared with the LATG group,reduced intraoperative blood loss(weighted mean difference=-35.37,95%CI:-61.69--9.06,P=0.008)and a larger number of retrieved lymph nodes(weighted mean difference=3.11,95%CI:-2.60-12.00,P=0.01)were found in the TLTG group.There were no significant differences in operating time,anastomotic time,tumor size,proximal resection margin length,postoperative pain score,time to first flatus,time to first oral intake,postoperative hospital stay,postoperative anastomosis-related complication rate and overall complication rate between the two groups(P>0.05).CONCLUSION Intracorporeal esophagojejunostomy is safe and feasible.TLTG has the advantages of being minimally invasive,reduced intraoperative blood loss and easier access to lymph nodes compared with LATG.Totally laparoscopic gastrectomy is likely to be the surgical trend for gastric cancer in the future.

Could neoadjuvant chemotherapy increase postoperative complication risk of laparoscopic total gastrectomy? A monoinstitutional propensity score-matched study in China

The potential survival benefit of neoadjuvant chemotherapy(NC)in patients with advanced gastric cancer has been widely recognized.With the development of minimally invasive surgery,which is represented by laparoscopy,the effect of NC on the safety of laparoscopic gastrectomy remains to be further explored.AIM To compare the short-term outcomes of laparoscopic total gastrectomy(LTG)after NC(NC-LTG)with LTG alone.METHODS A total of 92 patients who underwent NC-LTG and 381 patients who received LTG alone at the Chinese PLA General Hospital between September 2015 and September 2020 were retrospectively included in our study.We used propensityscore matching(PSM)to balance baseline bias.After 1:1 PSM,73 patients were included in each group with no statistically significant difference in baseline characteristics.RESULTS The NC-LTG group exhibited a longer operation time(244.10±48.13 min vs 225.74±45.33 min,P=0.019)and increased intraoperative blood loss[150(100-300)mL vs 100(100-200)mL,P=0.011]compared to the LTG group.The 30-d postoperative morbidity of the NC-LTG group was 20.5%(15/73),and that of the LTG group was 13.7%(10/73).There were no significant differences in 30-d severe complication rates or anastomotic leakage rates.Subgroup analysis showed that the patients with pTNM(pathological tumor-node-metastasis classification)T0N0-II in the NC-LTG group underwent a longer operation than the LTG group,while no significant difference was found in any perioperative index for the pTNM III patients.A multivariate analysis showed that an operation time longer than 240 min was an independent risk factor(odds ratio=3.021,95%confidence interval:1.160-7.868,P=0.024),while NC was not an independent risk factor for postoperative complications in LTG.CONCLUSION Despite a longer operation time and more blood loss after NC-LTG,which indicate surgical difficulty,NC-LTG exhibits acceptable short-term outcomes compared to LTG,suggesting the safety and feasibility of NC-LTG.

Postoperative complications and weight loss following jejunostomy tube feeding after total gastrectomy for advanced adenocarcinomas

Objective： Patients undergoing total gastrectomy for cancer are at risk of malnourishment. The aim of this self- controlled study was to examine the effect of jejunostomy tube feeding （JTF） and other factors on postoperative weight and the incidence of jejunostomy-related complications in patients undergoing total gastrectomy for cancer. Methods： All consecutive patients who underwent total gastrectomy for gastric cancer with jejunostomy plaeement were included from a prospective single-center database （2003-2014）. Jejunostomy-related complications and postoperative weight changes were evaluated up to 12 months after surgery. Multivariable linear regression analysis was performed to identify factors associated with weight loss 12 months after gastreetomy. Results： Of 113 patients operated in the study period, 65 received JTF after total gastrectomy for a median duration of 18 d [interquartile range （IQR）, 10-55 d]. Jejunostomy-related complieations occurred in 11 （17%） patients, including skin leakage （n=3） and peritoneal leakage （n=2）, luxation （n=3）, occlusion （n=2）, infection （n=l） and torsion （n=l）. In 2 （3%） patients, a reoperation was needed due to jejtmostomy-related complications. The mean preoperative weight of patients was 71.8 kg （100%）, and remained stable during JTF （73.9 kg, 103%, P=0.331）. After JTF was stopped, the mean weight of patients decreased to 64.9 kg （90%） at 12 months after surgery （P〈0.001）. A high preoperative body mass index （BMI） （〉_25 kg/m2） was associated with high postoperative weight loss compared to patients with a low BMI （〈25 kg/m2） （16.3% vs. 8.6%, P=0.016）. Conclusions： JTF can prevent weight loss in the early postoperative phase. However, this is at the prize of possible complications. As weight loss in the long term is not prevented, routine JTF should be re-evaluated and balanced against the selected use in preoperatively malnourished patients. Special attention should be paid to patients with a high preoperative BMI, who are at risk of more postoperative weight loss.

Pouch Roux-en-Yvs No Pouch Roux-en-Y following total gastrectomy:a meta-analysis based on 12 studies

After a total resection of the stomach, the continuity of the gastrointestinal tract can be restored either by Rouxen-Y esophagojejunostomy with or without a pouch. There is still no consensus on the best reconstruction technique. The aim of this report was to derive a more precise estimation of Roux-en-Y esophagojejunostomy with a pouch compared with Roux-en-Y esophagojejunostomy without a pouch. Studies were identified by PubMed and Embase searches, and the inclusion criteria were randomized controlled trials （RCTs） comparing reconstruction techniques between Roux-en-Y with and without a pouch. A total of 12 studies including 1,018 patients were included. The meta-analysis shows that pouch Roux-en-Y does not significantly increase total postoperative complications, anastomotic leakage or mortality, hnportantly, there is no significant difference in S-year survival rates between the two groups. Patients with Roux-en-Y esophagojejunostomy complained significantly less of reflux symptoms and dumping syndrome, and had significantly less severe reflux esophagitis. Quality of life was significantly improved in patients with Roux-en-Y esophagojejunostomy with a pouch compared with patients who received Roux-en-Y reconstruction without a pouch. The results indicate the need for Roux-en-Y esophagojeju- nostomy with a pouch is a gastric substitute after total gastrectomy by comparison with Roux-en-Y esophagojejunostomy without a pouch.

Post-gastrectomy spleen enlargement and esophageal varices: Distal vs total gastrectomy

AIM: To study the relationship between platelet count-to-spleen diameter ratio and post-gastrectomy esopha-geal varices (EVs) development in patients without liver cirrhosis or hepatitis. METHODS: We retrospectively studied 92 patients who underwent gastrectomy. They were divided into 2 groups on the basis of the surgical treatment: the distal gastrectomy (DG) group and total gastrectomy (TG) group. The incidence of EVs was determined and postoperative platelet counts, spleen diameters, and platelet count-to-spleen diameter ratios were com-pared between the 2 groups. RESULTS: EVs were not detected during the first 6 mo after surgery in either group; however, at 12 mo after surgery, EVs were detected in 2 patients (3%) in the DG group and in 1 patient (3.6%) in the TG group; their mean platelet count-to-spleen diameter ratio was 2628 ± 409, and 2604 ± 360, respectively.CONCLUSION: Endoscopy should be performed to detect EVs when the platelet count-to-spleen diameter ratio is < 2600.

Assessing optimal Roux-en-Y reconstruction technique after total gastrectomy using the Postgastrectomy Syndrome Assessment Scale-45

BACKGROUND Following a total gastrectomy,patients suffer the most severe form of postgastrectomy syndrome.This is a significant clinical problem as it reduces quality of life(QOL).Roux-en-Y reconstruction,which is regarded as the gold standard for post-total gastrectomy reconstruction,can be performed using various techniques.Although the technique used could affect postoperative QOL,there are no previous reports regarding the same.AIM To investigate the effect of different techniques on postoperative QOL.The data was collected from the registry of the postgastrectomy syndrome assessment study(PGSAS).METHODS In the present study,we analyzed 393 total gastrectomy patients from those enrolled in PGSAS.Patients were divided into groups depending on whether antecolic or retrocolic jejunal elevation was performed,whether the Roux limb was“40 cm”,“shorter”(≤39 cm),or“longer”(≥41 cm),and whether the device used for esophageal and jejunal anastomosis was a circular or linear stapler.Subsequently,we comparatively investigated postoperative QOL of the patients.RESULTS Reconstruction route:Esophageal reflux subscale(SS)occurred significantly less frequently in patients who underwent antecolic reconstruction.Roux limb length:“Shorter”Roux limb did not facilitate esophageal reflux SS and somewhat attenuated indigestion SS and abdominal pain SS.Anastomosis technique:In terms of esophagojejunostomy techniques,no differences were observed.CONCLUSION The techniques used for total gastrectomy with Roux-en-Y reconstruction significantly affected postoperative symptoms.Our results suggest that elevating the Roux limb,which is not overly long,through an antecolic route may improve patients’QOL.

Short and long-term outcomes between laparoscopic and open total gastrectomy for advanced gastric cancer after neoadjuvant chemotherapy

BACKGROUND Neoadjuvant chemotherapy(NACT)combined with surgery is regarded as an effective treatment for advanced gastric cancer(AGC).Laparoscopic surgery represents the mainstream of minimally invasive surgery.Currently,surgeons focus more on surgical safety and oncological outcomes of laparoscopic gastrectomy after NACT.Thus,we sought to evaluate short-and long-term outcomes between laparoscopic total gastrectomy(LTG)and open total gastrectomy(OTG)after NACT.AIM To compare the short and long-term outcomes between LTG and OTG for AGC after NACT.METHODS We retrospectively collected the clinicopathological data of 136 patients who accepted gastrectomy after NACT from June 2012 to June 2019,including 61 patients who underwent LTG and 75 who underwent OTG.Clinicopathological characteristics between the LTG and OTG groups showed no significant difference.SPSS 26.0,R software,and GraphPad PRISM 8.0 were used to perform statistical analyses.RESULTS Of the 136 patients included,eight acquired pathological complete response,and the objective response rate was 47.8%(65/136).The LTG group had longer operation time(P=0.015),less blood loss(P=0.003),shorter days to first flatus(P<0.001),and shorter postoperative hospitalization days(P<0.001).LTG spent more surgical cost than OTG(P<0.001),while total hospitalized cost of LTG was less than OTG(P<0.001).21(28.0%)patients in the OTG group and 14(23.0%)in the LTG group had 30-d postoperative complications,but there was no significant difference between the two groups(P=0.503).The 3-year overall survival(OS)rate was 60.6%and 64.6%in the LTG and OTG groups,respectively[hazard ratio(HR)=0.859,95%confidence interval(CI):0.522-1.412,P=0.546],while the 3-year disease-free survival(DFS)rate was 54.5%and 51.8%in the LTG and OTG group,respectively(HR=0.947,95%CI:0.582-1.539,P=0.823).Multivariate cox analysis showed that body mass index and pTNM stage were independent risk factors for OS while vascular invasion and pTNM stage were independent risk factors for DFS(P<0.05).CONCLUSION After NACT,LTG shows comparable 30-d postoperative morbidity as well as 3-year OS and DFS rate to OTG.We recommend that experienced surgeons select LTG other than OTG for proper AGC patients after NACT.

Disturbed passage of jejunal limb near esophageal hiatus after overlapped esophagojejunostomy following laparoscopic total gastrectomy

BACKGROUND Overlapped esophagojejunostomy(OEJ) is a secure purely laparoscopic reconstruction after laparoscopic total gastrectomy(LTG). However, long-term surgical results have not been documented well.AIM In this paper, we report unusual patients who manifested jejunal limb stricture near the esophageal hiatus without anastomotic stenosis during long-term observation after surgery.METHODS From April 2009 until May 2020, we retrospectively reviewed 211 patients underwent LTG following by OEJ for gastric carcinoma and took a standard surveillance program. We aimed to characterize a novel complicated disorder observed in these patients to assist treatment and prevention.RESULTS Five patients(2.4%) had unusual jejunal limb stricture after LTG and OEJ,occurring at a mean of 10 mo after initial radical LTG. All five patients had disturbed oral intake and marked weight loss, and two had aspiration pneumonia.Various diagnostic modalities and intraoperative findings in each patient revealed an intact anastomosis, bent or tortuous jejunal limb resulting from loose fibrous adhesions on the left crus at the esophageal hiatus and no cancer recurrence. All five patients were successfully treated by reoperation for adhesiolysis, division of the left crus and rearrangement of the jejunal limb.CONCLUSION Disturbed passage through the jejunal limb near the hiatus can occur after some types of OEJ following LTG. We speculate that it may result from a short remnant esophagus, excessive mobilization of the jejunal limb that permits bending or tortuosity and adhesions on the left crus at the hiatus. Prevention for this complication is possible during the original LTG procedure.

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.

Perioperative outcomes of transvaginal specimen extraction laparoscopic total gastrectomy and conventional laparoscopicassisted total gastrectomy

BACKGROUND Natural orifice specimen extraction surgery(NOSES)has emerged as a promising alternative compared to conventional laparoscopic-assisted total gastrectomy(LATG)for treating gastric cancer(GC).However,evidence regarding the efficacy and safety of NOSES for GC surgery is limited.This study aimed to compare the safety and feasibility,in addition to postoperative complications of NOSES and LATG.METHODS Dual circular staplers were used in Roux-en-Y digestive tract reconstruction for transvaginal specimen extraction LATG,and its outcomes were compared with LATG in a cohort of 51 GC patients with tumor size≤5 cm.The study was conducted from May 2018 to September 2020,and patients were categorized into the NOSES group(n=22)and LATG group(n=29).Perioperative parameters were compared and analyzed,including patient and tumor characteristics,postoperative outcomes,and anastomosis-related complications,postoperative hospital stay,the length of abdominal incision,difference in tumor type,postoperative complications,and postoperative survival.RESULTS Postoperative exhaust time,operation duration,mean postoperative hospital stay,length of abdominal incision,number of specific staplers used,and Brief Illness Perception Questionnaire score were significant in both groups(P<0.01).In the NOSES group,the postoperative time to first flatus,mean postoperative hospital stay,and length of abdominal incision were significantly shorter than those in the LATG group.Patients in the NOSES group had faster postoperative recovery,and achieved abdominal minimally invasive incision that met aesthetic requirements.There were no significant differences in gender,age,tumor type,postoperative complications,and postoperative survival between the two groups.CONCLUSION The application of dual circular staplers in Roux-en-Y digestive tract reconstruction combined with NOSES gastrectomy is safe and convenient.This approach offers better short-term outcomes compared to LATG,while long-term survival rates are comparable to those of conventional laparoscopic surgery.

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.

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.

Comparison of Intracorporeal and Extracorporeal Esophagojejunostomy after Laparoscopic Total Gastrectomy for Gastric Cancer： A Meta-Analysis Based on Short-Term

Background： Laparoscopic total gastrectomy （LTG） is increasingly performed in patients with gastric cancer. However, the usage of intracorporeal esophagojejunostomy （IEJ） following LTG is limited, as the safety and efficacy remain unclear. The present meta-analysis aimed to evaluate the feasibility and safety of IEJ following LTG. Methods： Studies published from January 1994 to January 2017 comparing the outcomes ofl EJ and extracorporeal esophagojejunostomy （EEJ） following LTG were reviewed and collected from the PubMed, EBSCO, Cochrane Library, Embase, and China National Knowledge lntemet （CNKI）. Operative results, postoperative recovery, and postoperative complications were compared and analyzed. The weighted mean difference （WMD） and odds ratio （OR） with a 95% confidence interval （CI） were calculated using the Review Manager 5.3. Results： Seven nonrandomized studies with 785 patients were included. Compared with EEJ, IEJ has less blood loss （WMD： -13.52 ml; 95% CI： -24.82-2.22; P = 0.02）, earlier time to first oral intake （WMD： -0.49 day; 95% CI： -0.83-0.14; P 〈 0.01 ）, and shorter length of hospitalization （WMD： -0.62 day; 95% CI： - 1.08-0.16; P 〈 0.01 ）. There was no significant difference between IEJ and EEJ regarding the operation time, anastomotic time, number of retrieved lymph nodes, time to first flatus, anastomosis leakage rate, anastomosis stenosis rate, and proximal resections （all P 〉 0.05）. Conclusions： Compared with EEJ, IEJ has better cosmesis, milder surgical trauma, and a faster postoperative recovery. IEJ can be performed as safely as EEJ. IEJ should be encouraged to surgeons with sufficient expertise.