Background
The relation between gastric cancer characteristics and lymph node (LN) metastatic patterns is not fully clear, especially following neoadjuvant chemotherapy (NAC). This study analyzed ...nodal metastatic patterns.
Methods
Individual LN stations were analyzed for all patients from the LOGICA-trial, a Dutch multicenter randomized trial comparing laparoscopic versus open D2-gastrectomy for gastric cancer. The pattern of metastases per LN station was related to tumor location, cT-stage, Lauren classification and NAC.
Results
Between 2015–2018, 212 patients underwent D2-gastrectomy, of whom 158 (75%) received NAC. LN metastases were present in 120 patients (57%). Proximal tumors metastasized predominantly to proximal LN stations (no. 1, 2, 7 and 9;
p
< 0.05), and distal tumors to distal LN stations (no. 5, 6 and 8; OR > 1,
p
> 0.05). However, distal tumors also metastasized to proximal LN stations, and vice versa. Despite NAC, each LN station (no. 1–9, 11 and 12a) showed metastases, regardless of tumor location, cT-stage, histological subtype and NAC treatment, including station 12a for cT1N0-tumors. LN metastases were present more frequently in diffuse versus intestinal tumors (66% versus 52%;
p
= 0,048), but not for cT3–4- versus cT1–2-stage (59% versus 51%;
p
= 0.259). However, the pattern of LN metastases was similar for these subgroups.
Conclusions
The extent of lymphadenectomy cannot be reduced after NAC for gastric cancer. Although the pattern of LN metastases is related to tumor location, all LN stations contained metastases regardless of tumor location, cT-stage (including cT1N0-tumors), histological subtype, or NAC treatment. Therefore, D2-lymphadenectomy should be routinely performed during gastrectomy in Western patients.
Complications can be classified using the most-severe Clavien-Dindo-Classification (CDC) per patient or the total complication burden per patient expressed in the Comprehensive Complication Index ...(CCI). This study determined the additional value of CCI to CDC in examining the impact of complications after gastric cancer surgery.
The CCI and CDC were determined in the multicenter randomized LOGICA-trial comparing laparoscopic versus open D2-gastrectomy for cancer (cT1-4aN0-3M0). Differences in median CCI between laparoscopic and open gastrectomy were compared for overall postoperative complications and cardiovascular, gastrointestinal, infectious, pulmonary, and other complications. CCI and CDC were correlated to hospitalization, ICU-stay and reoperations using Spearman's rho-test and compared with standard Fisher's z-transformation.
Between 2015 and 2018, 211 patients underwent laparoscopic (n = 106) or open (n = 105) D2-gastrectomy, and 157 (74%) received neoadjuvant chemotherapy. Median CCI was comparable between laparoscopic versus open gastrectomy regarding overall complications (CCI 0 IQR 0-23.5 versus 0 IQR 0-22.6; p = 0.755) and subgroups of complications (p > 0.05). Both CCI and CDC showed moderate positive correlations for hospitalization (r
= 0.646 versus r
= 0.628; p = 0.001, difference clinically irrelevant), and reoperations (r
= 0.590 versus r
= 0.599; p = 0.070), and weak correlations for ICU-stay (r
= 0.446 versus r
= 0.440; p = 0.189).
The CCI is a composite scoring system based on the CDC and reflects a subjective interpretation of complication burden from the perspectives of both physicians and patients, following abdominal surgery other than gastrectomy. Implementing CCI showed no clinically relevant benefit and caused additional workload compared to CDC for assessing complication burden. Therefore, using the CCI alongside the CDC after gastric cancer surgery is not recommended.
Abstract Introduction Low rectal surgery remains challenging. New surgical stapler devices have been developed to counteract problems of impaired visibility and inability to get low into the pelvis. ...One of them is the Radial Reload (RR) with Tri-staple™ Technology (Covidien, New Haven, CT, USA). The aim of this study was to assess the first impressions and experiences regarding handling of this new stapler device in low anterior resection procedures in living humans. Methods A questionnaire, consisting of 27 statements concerning accessibility, maneuverability and visibility, was sent to 35 surgeons worldwide. Results A total of 85 rectal surgical procedures, both open and laparoscopic, were assessed by 31 surgeons. In 97% of the procedures the surgeons agreed that the RR stapler device facilitated access in the low pelvis. The first stapler device firing achieved complete transection in 54% of the procedures. According to the surgeons' assessments, in 91% percent of the procedures the RR stapler device enabled creation of adequate margins. Visualization of the pelvic floor was reported in 93% of the procedures. In the surgeons' opinion, the RR stapler device was considered clinically acceptable in 93% of the procedures. In 79% of the procedures the surgeon preferred the RR stapler device over the stapler device they normally used. Conclusion This study showed that the first experiences with the RR stapler device of 33 surgeons in 85 low rectal procedures are positive. It facilitates low stapling in both open and laparoscopic procedures. Good visibility, maneuverability and the possibility to create adequate distal margins were reported.
In gastric cancer patients chronological and biological age might vary greatly between patients. Age as well as American Society of Anaesthesiologists-physical status classifications are very ...non-specific and do not adequately predict adverse outcome. Improvements have been made such as the introduction of Charlson Comorbidity Index. Geriatric frailty is probably a better measure for patients resistance to stressors and physiological reserves. An increasing amount of evidence shows that geriatric frailty is a better predictor for adverse outcome after surgery, including gastric cancer surgery. Geriatric frailty can be assessed in a number of ways. Questionnaires such as the Groningen Frailty Indicator provide an ease and low cost method for gauging the presence of frailty in gastric cancer patients. This can then be used to provide a better preoperative risk assessment in these patients and improve decision making.
Quality of gastric cancer surgery is crucial for favorable prognosis. Generally, prospective trials lack quality control measures. This study assessed surgical quality and a novel D2-lymphadenectomy ...photo-scoring in the LOGICA-trial.
The multicenter LOGICA-trial randomized laparoscopic versus open total/distal D2-gastrectomy for resectable gastric cancer (cT1-4aN0-3M0) in 10 Dutch hospitals. During the trial, two reviewers prospectively analyzed intraoperative photographs of dissected nodal stations for quality control, and provided centers weekly feedback on their D2-lymphadenectomy, as continuous quality-enhancing incentive. After the trial, these photographs were reanalyzed to develop a photo-scoring for future trials, rating the D2-lymphadenectomy dissection quality (optimal-good-suboptimal-unevaluable). Interobserver variability was calculated (weighted kappa). Regression analyses related the photo-scoring to nodal yield, recurrence and 5-years survival.
Between 2015 and 2018, 212 patients underwent total/distal D2-gastrectomy (n = 122/n = 90), and 158 (75%) received neoadjuvant chemotherapy. R0-resection rate was 95%. Rate of ≥15 retrieved lymph nodes was 95%. Moderate agreement was obtained in stations 8 + 9 (κ = 0.522), 11p/11d (κ = 0.446) and 12a (κ = 0.441). Consensus was reached for discordant cases (30%). Stations 8 + 9, 11p/11d and 12a were rated ‘optimal’ in 76%, 63% and 68%. Laparoscopic photographs could be rated better than open (2% versus 12% ‘unevaluable’; 73% versus 50% ‘optimal’; p = 0.042). The photo-scoring did not show associations with nodal yield (p = 0.214), recurrence (p = 0.406) and survival (p = 0.988).
High radicality and nodal yield demonstrated good quality of D2-gastrectomy. The prospective quality control probably contributed to this. The photo-scoring did not show good performance, but can be refined. Laparoscopic D2-gastrectomy was better suited for standardized surgical photo-evaluation than open surgery.
AIM To evaluate the costs of the introduction of a laparoscopic surgery program for gastric cancer in a Western community training hospital and tertiary referral centre for gastric cancer surgery. ...METHODS All patients who underwent surgery for gastric cancer with curative intent in 2013 and 2014 were prospectively included. Primary outcomes were costs regarding surgery and hospital stay. RESULTS Laparoscopic gastrectomy was used in 52 patients mean age 68 years(± 9, range 50 to 87) years and open gastrectomy was used in 25 patients (mean age 70 years(± 10, range 46 to 85))Mean costs(in euro’s) of surgical instrumentation were significantly higher for laparo-scopic surgery: 2270 ± 670 vs 1181 ± 680 in the open approach(P < 0.001). Costs of theatre use were higher in the laparoscopic group: mean 3818 ± 865 vs 2545± 1268 in the open surgery(P < 0.001). Total costs of hospitalization(i.e., costs of surgery and admission)were not different between laparoscopic and open surgery, 8187 ± 4864 and 6152 ± 2680 respectively(P= 0.729). Mean length of hospital stay was 9 ± 12 d in the laparoscopic group vs 14 ± 14 d in the open group(P= 0.044). CONCLUSION The introduction of laparoscopic gastrectomy for gastric cancer coincided with higher costs for theatre use and surgical instrumentation compared to the open technique. Total costs were not significantly different due to shorter length of stay and less intensive care unit(ICU) admissions and shorter ICU stay in the laparoscopic group.
Background
Distal gastrectomy (DG) for gastric cancer can cause less morbidity than total gastrectomy (TG), but may compromise radicality. No prospective studies administered neoadjuvant ...chemotherapy, and few assessed quality of life (QoL).
Methods
The multicenter LOGICA-trial randomized laparoscopic versus open D2-gastrectomy for resectable gastric adenocarcinoma (cT1–4aN0–3bM0) in 10 Dutch hospitals. This secondary LOGICA-analysis compared surgical and oncological outcomes after DG versus TG. DG was performed for non-proximal tumors if R0-resection was deemed achievable, TG for other tumors. Postoperative complications, mortality, hospitalization, radicality, nodal yield, 1-year survival, and EORTC-QoL-questionnaires were analyzed using
Χ
2
-/Fisher’s exact tests and regression analyses.
Results
Between 2015 and 2018, 211 patients underwent DG (
n
= 122) or TG (
n
= 89), and 75% of patients underwent neoadjuvant chemotherapy. DG-patients were older, had more comorbidities, less diffuse type tumors, and lower cT-stage than TG-patients (
p
< 0.05). DG-patients experienced fewer overall complications (34% versus 57%;
p
< 0.001), also after correcting for baseline differences, lower anastomotic leakage (3% versus 19%), pneumonia (4% versus 22%), atrial fibrillation (3% versus 14%), and Clavien-Dindo grading compared to TG-patients (
p
< 0.05), and demonstrated shorter median hospital stay (6 versus 8 days;
p
< 0.001). QoL was better after DG (statistically significant and clinically relevant) in most 1-year postoperative time points. DG-patients showed 98% R0-resections, and similar 30-/90-day mortality, nodal yield (28 versus 30 nodes;
p
= 0.490), and 1-year survival after correcting for baseline differences (
p
= 0.084) compared to TG-patients.
Conclusions
If oncologically feasible, DG should be preferred over TG due to less complications, faster postoperative recovery, and better QoL while achieving equivalent oncological effectiveness.
Mini-abstract
Distal D2-gastrectomy for gastric cancer resulted in less complications, shorter hospitalization, quicker recovery and better quality of life compared to total D2-gastrectomy, whereas radicality, nodal yield and survival were similar.
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