Open versus minimally invasive total gastrectomy after neoadjuvant chemotherapy: results of a European randomized trial

Abstract

Background Surgical resection with adequate lymphadenectomy is regarded the only curative option for gastric cancer. Regarding minimally invasive techniques, mainly Asian studies showed comparable oncological and short-term postoperative outcomes. The incidence of gastric cancer is lower in the Western population and patients often present with more advanced stages of disease. Therefore, the reproducibility of these Asian results in the Western population remains to be investigated. Methods A randomized trial was performed in thirteen hospitals in Europe. Patients with an indication for total gastrectomy who received neoadjuvant chemotherapy were eligible for inclusion and randomized between open total gastrectomy (OTG) or minimally invasive total gastrectomy (MITG). Primary outcome was oncological safety, measured as the number of resected lymph nodes and radicality. Secondary outcomes were postoperative complications, recovery and 1-year survival. Results Between January 2015 and June 2018, 96 patients were included in this trial. Forty-nine patients were randomized to OTG and 47 to MITG. The mean number of resected lymph nodes was 43.4 ± 17.3 in OTG and 41.7 ± 16.1 in MITG (p = 0.612). Forty-eight patients in the OTG group had a R0 resection and 44 patients in the MITG group (p = 0.617). One-year survival was 90.4% in OTG and 85.5% in MITG (p = 0.701). No significant differences were found regarding postoperative complications and recovery. Conclusion These findings provide evidence that MITG after neoadjuvant therapy is not inferior regarding oncological quality of resection in comparison to OTG in Western patients with resectable gastric cancer. In addition, no differences in postoperative complications and recovery were seen.

Safety and Efficacy of Laparoscopic Versus Open Gastrectomy in Patients With Advanced Gastric Cancer Following Neoadjuvant Chemotherapy: A Meta-Analysis

“…Three studies reported R0 resection, which was defined as a microscopic margin-negative resection with tumor-free margin greater than 1 mm (27,30,31). Results obtained from the pooled analysis showed that 107 (95.5%) out of the 112 AGC patients who underwent LG received R0 resection, while 123 (96.1%) out of 128 AGC patients who received OG received R0 resection, with OR = 0.88, 95%CI: 0.26-2.91, p = 0.83, and a moderate heterogeneity (I 2 = 37%).…”

“…Results obtained from the pooled analysis showed that 107 (95.5%) out of the 112 AGC patients who underwent LG received R0 resection, while 123 (96.1%) out of 128 AGC patients who received OG received R0 resection, with OR = 0.88, 95%CI: 0.26-2.91, p = 0.83, and a moderate heterogeneity (I 2 = 37%). Blood transfusion was recorded in three studies (27,31,32), with the pooled results indicating that 17 (12.2%) out of 139 AGC patients who were assigned to LG required blood transfusion, and 22 (15.5%) out of 142 AGC patients who underwent OG received blood transfusion (OR = 0.72, 95%CI 0.35-1.49, p = 0.64, and I 2 = 0%). All six studies described intraoperative blood loss and the number of dissected lymph nodes (27)(28)(29)(30)(31)(32), with the weighted mean differences for intraoperative blood loss and the number of dissected lymph nodes of LG versus OG being -8.76 ml (CI: -28.17-10.65, p = 0.38, and I 2 = 36%) and -0.33 (CI: -2.76-2.01, p = 0.78, and I 2 = 36%), respectively.…”

“…Moreover, it is not clear whether smaller trauma in AGC patients who receive NAC is equivalent to better surgical effectiveness and postoperative safety, and survival benefit is still a pivotal issue in the clinic. Strikingly, although a review of literature provides direct evidence of the issues listed above (27)(28)(29)(30)(31)(32), including two RCTs, one prospective study, and four retrospective studies, all the studies have reported inconsistent findings. Therefore, further meta-analysis is urgently required to test the safety and efficacy of using laparoscopic surgery as an alternative to open surgery for AGC patients who have completed NAC.…”

The Comparison of the Short and Long-Term Outcomes Between Laparoscopic Total Gastrectomy and Open Total Gastrectomy for Locally Advanced Gastric Cancer After Neoadjuvant Chemotherapy

“…The application to NACT for AGC rapidly increased because of its potential oncological bene t [15] . At present, Surgeons focus mainly on the impact of NACT on gastrectomy [11,16] . In this study, we reported mono-institutional retrospective outcomes aiming to evaluate surgical safety and oncological e cacy between LTG and OTG after NACT in China, which could present Chinese perspective and provide reference to reasonable utilization of minimally invasive surgery for AGC patients who accepted NACT.…”

“…Currently, surgical safety and oncological outcomes after NACT have gradually attracted surgeons to pay attention. Based on standardization of NACT for AGC in western countries which was advised by European Guideline, van der Wielen N et al conducted STOMACH trial as the rst multi-institutional RCT study which demonstrated the comparable complications and non-inferiority of 1-year OS and DFS between LTG and OTG after NACT in western countries [11] .However, it's not clear whether LTG had superior short and long-term outcomes compared with OTG or not for advancer gastric cancer patients who accepted NACT in China. Under the background of popularization of minimally invasive surgery and attaching importance of NACT in China, indispensable study should be conducted to direct application of LTG after NACT appropriately.…”