Laparoscopic Versus Open Subtotal Gastrectomy for Adenocarcinoma: A Case-Control Study

ArticleinAnnals of Surgical Oncology 16(6):1507-13 · April 2009with9 Reads
DOI: 10.1245/s10434-009-0386-8 · Source: PubMed
Abstract
The aim of this study is to compare technical feasibility and oncologic efficacy of totally laparoscopic versus open subtotal gastrectomy for gastric adenocarcinoma. Laparoscopic gastrectomy for adenocarcinoma is emerging in the West as a technique that may offer benefits for patients, although large-scale studies are lacking. This study was designed as a case-controlled study from a prospective gastric cancer database. Thirty consecutive patients undergoing laparoscopic subtotal gastrectomy for adenocarcinoma were compared with 30 patients undergoing open subtotal gastrectomy. Controls were matched for stage, age, and gender via a statistically generated selection of all gastrectomies performed during the same period of time. Patient demographics, tumor-node-metastasis (TNM) stage, histologic features, location of tumor, lymph node retrieval, recurrence, margins, and early and late postoperative complications were compared. Tumor location and histology were similar between the two groups. Median operative time for the laparoscopic approach was 270 min (range 150-485 min) compared with median of 126 min (range 85-205 min) in the open group (p < 0.01). Hospital length of stay after laparoscopic gastrectomy was 5 days (range 2-26 days), compared with 7 days (range 5-30 days) in the open group (p = 0.01). Postoperative pain, as measured by number of days of IV narcotic use, was significantly lower for laparoscopic patients, with a median of 3 days (range 0-11 days) compared with 4 days (range 1-13 days) in the open group (p < 0.01). Postoperative early complications trended towards a decrease for laparoscopic versus open surgery patients (p = 0.07); however, there were significantly more late complications for the open group (p = 0.03). Short-term recurrence-free survival and margin status was similar between the two groups (p = not significant) with adequate lymph node retrieval in both groups. Laparoscopic subtotal gastrectomy for adenocarcinoma is comparable to the open approach with regard to oncologic principles of resection, with equivalent margin status and adequate lymph node retrieval, demonstrating technically feasibility and equivalent short-term recurrence-free survival. Additional benefits of decreased postoperative complications, decreased length of hospital stay, and decreased narcotic use make this a preferable approach for selected patients.
    • "All complications were stratified according to the Clavien-Dindo (CD) classification, which grades complications according to the required treatment [19, 20] . In line with recent literature , we further divided the CD classification into two groups, minor and major complications respectively [21]. Minor complications consist of grade I and grade II complications, which require no treatment or pharmacological treatment. "
    [Show abstract] [Hide abstract] ABSTRACT: BACKGROUND: Early diagnosis and treatment of complications after major abdominal surgery can decrease associated morbidity and mortality. Postoperative CRP levels have shown a strong correlation with complications. Aim of this systematic review and pooled-analysis was to assess postoperative values of CRP as a marker for major complications and construct a prediction model. STUDY DESIGN: A systematic review was performed for CRP levels as a predictor for complications after major abdominal surgery (MAS). Raw data was obtained from seven studies, including 1427 patients. A logit regression model assessed the probability of major complications as a function of CRP levels on the third postoperative day. Two practical cut-offs are proposed: an optimal cut-off for safe discharge in a fast track protocol and another for early identification of patients with increased risk for major complications. RESULTS: A prediction model was calculated for major complications as a function of CRP levels on the third postoperative day. Based on the model several cut-offs for CRP are proposed. For instance, a two cut-off system may be applied, consisting of a safe discharge criterion with CRP levels below 75 mg/L, with a negative predictive value of 97.2%. A second cut-off is set at 215 mg/L (probability 20%) and serves as a predictor of complications, indicating additional CT-scan imaging. CONCLUSIONS: The present study provides insight in the interpretation of CRP levels after major abdominal surgery, proposing a prediction model for major complications as a function of CRP on postoperative day 3. Cut-offs for CRP may be implemented for safe early-discharge in a fast-track protocol and, secondly as a threshold for additional examinations, such as CT-scan imaging, even in absence of clinical signs, to confirm or exclude major complications. The prediction model allows for setting a cut-off at the discretion of individual surgeons or surgical departments.
    Full-text · Article · Jul 2015
    • "Only a few Western studies, one randomized controlled trial and some cohort analyses, have been conducted comparing laparoscopic and open approaches for gastric can- cer1011121314. In the randomized controlled trial by Huscher et al., they found that laparoscopic partial gastrectomy showed similar results to open gastrectomy with regards to quality of oncological resection, as measured by the number of retrieved lymph nodes, and five-year survival rate, whereas patient recovery was faster and admission duration was shorter1011121314. However, these studies are small and underpowered and are exceeded by changes in neo-adjuvant therapies. "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Laparoscopic surgery has been shown to provide important advantages in comparison with open procedures in the treatment of several malignant diseases, such as less perioperative blood loss and faster patient recovery. It also maintains similar results with regard to tumor resection margins and oncological long-term survival. In gastric cancer the role of laparoscopic surgery remains unclear. Current recommended treatment for gastric cancer consists of radical resection of the stomach, with a free margin of 5 to 6 cm from the tumor, combined with a lymphadenectomy. The extent of the lymphadenectomy is considered a marker for radicality of surgery and quality of care. Therefore, it is imperative that a novel surgical technique, such as minimally invasive total gastrectomy, should be non-inferior with regard to radicality of surgery and lymph node yield. Methods/design: The Surgical Techniques, Open versus Minimally invasive gastrectomy After CHemotherapy (STOMACH) study is a randomized, clinical multicenter trial. All adult patients with primary carcinoma of the stomach, in which the tumor is considered surgically resectable (T1-3, N0-1, M0) after neo-adjuvant chemotherapy, are eligible for inclusion and randomization. The primary endpoint is quality of oncological resection, measured by radicality of surgery and number of retrieved lymph nodes. The pathologist is blinded towards patient allocation. Secondary outcomes include patient-reported outcomes measures (PROMs) regarding quality of life, postoperative complications and cost-effectiveness. Based on a non-inferiority model for lymph node yield, with an average lymph node yield of 20, a non-inferiority margin of -4 and a 90% power to detect non-inferiority, a total of 168 patients are to be included. Discussion: The STOMACH trial is a prospective, multicenter, parallel randomized study to define the optimal surgical strategy in patients with proximal or central gastric cancer after neo-adjuvant therapy: the conventional 'open' approach or minimally invasive total gastrectomy. Trial registration: This trial was registered on 28 April 2014 at Clinicaltrials.gov with the identifier NCT02130726 .
    Full-text · Article · Mar 2015
    • "Interventions consisted of relaparotomy , percutaneous drainage or intensive care admission. All postoperative complications were recorded and based on the classification by Clavien-Dindo, which was modified into minor and major complications as seen in other recent articles [24, 25] ; classified as either minor complications , which require medical treatment or opening of the wound at the bedside, consisting of grade I and II of the Clavien-Dindo classification; or major complications, which require invasive treatment such as surgery or percutaneous drainage and intensive monitoring and consist of grades III, IV and V of the Clavien-Dindo classification [26]. "
    [Show abstract] [Hide abstract] ABSTRACT: Background: The aim of this observational study was to analyze whether differences exist in postoperative C-reactive protein (CRP) levels in elderly, obese or for gender after major abdominal surgery, which might affect the diagnostic value of CRP. Methods: Observational cohort study was made between January 2009 and January 2011 of all adult patients who underwent major abdominal surgery. Medical records and radiology were reviewed. Complications were recorded based on the classification by Clavien-Dindo. CRP data were collected up to 14 days postoperatively, or until discharge. Results: Three hundred ninety-nine patients underwent major abdominal surgery. Seventy-four patients underwent upper gastrointestinal (GI) surgery, 91 patients underwent hepato-pancreatico-billiary (HPB) surgery and 234 underwent lower GI surgery. Two hundred thirty-five patients were male. Eighty-three patients presented with a major complication (20.8%). No effect of gender or age on postoperative CRP levels was observed. Although a positive correlation was observed for BMI, this did not hold in further regression analysis. Conclusions: No effect was observed for gender, age and BMI on postoperative CRP levels. It is proposed that the effect of surgical trauma and inflammation surpasses the effect of these related patient factors. The results further support the use of CRP as an independent marker of postoperative inflammation and complications.
    Full-text · Article · Jul 2014
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