Abstract: Objective: To investigate the clinical efficacy of laparoscopyassisted total gastrectomy (LATG) and laparoscopyassisted proximal gastrectomy (LAPG) in treatment of adenocarcinoma of esophagogastric junction (AEG).
Methods:The retrospective cohort study was conducted. The clinicopathological data of 130 patients with AEG who underwent laparoscopyassisted radical gastrectomy at the Peking University Cancer Hospital between May 2009 and February 2016 were collected. Among 130 patients, 91 undergoing LATG were allocated into the LATG group and 39 undergoing LAPG were allocated into the LAPG group. D2 lymph node dissection was applied to patients in the 2 groups according to the Japanese gastric cancer treatment guidelines. Patients received digestive tract reconstruction though a small midline incision in the epigastric region after laparoscopyassisted lymph node dissection: patients in the LATG group and LAPG group received respectively RouxenY esophagojejunostomy and residual stomachesophagus anastomosis. Observation indicators included: (1) intra and postoperative situations: overall surgical situation, number of patients with conversion to open surgery, operation time, volume of intraoperative blood loss, number of patients with intraoperative blood transfusion, number of lymph node dissected, time to anal exsufflation and duration of postoperative hospital stay. (2) Occurrence of complications: overall complications, surgeryrelated complications (slight and severe complications), reoperation, medical complications and death from surgeryrelated complication within 30 days postoperatively. Severity of complications was evaluated according to ClavienDindo classification. (3) Followup situations. Patients were followed up by outpatient examination, telephone interview and correspondence up to August 31, 2016. Followup included the tumor recurrence and metastasis. Overall survival time was counted from operation date to end of followup or time of death. Because followup time of 48 patients who underwent surgery from September 2014 to February 2016 was less than 2 years, survival analysis of the other 82 patients who underwent surgery from May 2009 to August 2014 was done. Measurement data with normal distribution were represented as ±s and comparison between groups was analyzed using the independentsample t test. Measurement data with skewed distribution were represented as M (range) and comparison between groups was analyzed using the nonparametric test. Comparison of count data was analyzed using the chisquare test, and ranked data was analyzed using the nonparametric test. Survival curve was drawn by the KaplanMeier method, and survival analysis was done using the Logrank test.
Results:(1) Intra and postoperative situations: all the 130 patients underwent successful radical gastrectomy, and 7 patients converted to open surgery due to local tumor progression invading adjacent organs, abdominal adhesions and obesity. Operation time and number of lymph node dissected were (280±46)minutes, 28 (range, 14-80) in the LATG group and (258±57)minutes, 23 (range, 14-46) in the LAPG group, respectively, with statistically significant differences between the 2 groups (t= -2.305, Z=-4.168, P<0.05). (2) Postoperative complications situations: 18 patients in the LATG group and 7 patients in the LAPG group had overall complications. Delayed gastric emptying, intestinal obstruction, endolymphatic leakage and wound infection of slight complications were respectively detected in 0, 1, 0, 2 patients in the LATG group and 1, 0, 1, 0 patients in the LAPG group. Anastomotic leakage, duodenal stump leakage, anastomotic bleeding, intraabdominal bleeding and intraabdominal infection of severe complications were respectively detected in 5, 2, 2, 2, 0 patients in the LATG group and 3, 0, 0, 0, 1 patients in the LAPG group. Reoperation, medical complications and death from surgeryrelated complication within 30 days postoperatively were respectively detected in 5, 7, 2 patients in the LATG group and 1, 1, 0 patients in the LAPG group, with no statistically significant differences in above indicators between the 2 groups (χ²=0.059, 0.111, 0.000, 0.000, 0.514, 0.024, P>0.05). The same patients may have multiple complications. Patients with complications received reoperation or corresponding treatment, 1 with anastomotic bleeding and 1 with intraabdominal bleeding died and other patients had a smooth recovery. (3) Followup situations: 128 of 130 patients were followed up for 1-82 months with a median time of 39 months. During the followup, 28 patients died, including 25 dying of tumor recurrence and 3 dying of nontumor causes. Of 82 patients in survival analysis, 3year overall survival rate was 77.9% in 45 patients of LATG group and 72.2% in 37 patients of LAPG group, showing no statistically significant difference between the 2 groups (χ²=1.432, P>0.05).
Conclusion:Safety of LATG in treatment of AEG is equal to that of LAPG, and LATG can dissect more lymph nodes.