| BackgroundGastric cancer is one of the most common malignant tumors,and about 50% of the new cases occur in east Asia,mainly in China.China has about 400,000 new cases of gastric cancer per year,causing great pain to the patients themselves,as well as great burden to their families and society.Surgery is the main treatment of gastric cancer,and various processing operation and perioperative inevitably brings to the patient trauma,pain,and all kinds of complications,the bad factors will bring adverse effect on postoperative rehabilitation patients that lead to more health resources utilization,the increase of medical expenses,the case fatality rate increases,and affect patients with postoperative quality of life and long-term survival.Objective:1 To explore the difference of postoperative complications in patients undergoing radical gastrectomy by laparoscopic and open gastrectomy(LG and OG),and evaluate the safety of laparoscopy in patients undergoing radical gastrectomy.2 This systematic review and meta-analysis is aimed to compare the application of epidural analgesia(EA)with intravenous analgesia(IA)in radical gastrectomy for gastric cancer.Methods:1 Retrospectively collected 2966 patients with gastric cancer who underwent laparoscopy or open gastrectomy between February 2009 and March 2016 were enrolled in this study.Complications were categorized according to the Clavien-Dindo classification system.The complications and severity following laparoscopic and open gastrectomy were compared using one-to-one propensity score matching(PSM)analysis.Logistic regression analyses were performed to identify risk factors related to complications.2 A systematic review and meta-analysis of randomized controlled trials of EA and IA in radical gastrectomy was conducted.Primary outcome was pain scores at 24 h after surgery,while the secondary outcomes included incidence of postoperative complications,first flatus time and length of stay in hospital(LOS).Results:1 A total of 2966 patients were included in the study,including 687(23.2%)in LG group and 2279(76.8%)in OG group.After PSM,a well-balanced cohort of 1354 patients(677 cases in each group)was further analyzed.The result showed that the incidence of overall complications of LG group were significantly less than that of OG group(17.0%vs.24.2%,P=0.001),however,the severe complications(Clavien-Dindo classification ≥Ⅲa)of LG group showed no significant difference towards OG group(5.8% vs.6.1%,P =0.818).Subgroup analysis was conducted according to gender,age,ASA classification,TNM stage,BMI,histologic type,extent of gastric resection,tumor size,operation time and number of retrieved lymph nodes showed the same pattern in most stratification.Multivariate analysis revealed that laparoscopic surgery is a protective factor for the reduction of postoperative complications,age≥60 years,ASA classification Ⅲ and estimated blood loss≥200ml were confirmed as independent predictors of overall complications.Age≥60,stage T2–T4a,estimated blood loss≥200ml were confirmed as independent risk factors for severe complications.2 A total of 6 randomized controlled studies was identified and 393 patients were enrolled in this review,4 published in English and 2 in Chinese.Meta-analysis revealed that,the EA group had lower pain score at 24 h either pain at rest(WMD=﹣0.74,95%CI :[-1.35,-0.13],P =0.02)or pain on movement or coughing(WMD=﹣1.5,95%CI :[-1.95,-1.05],P<0.00001)than that of the IA group.In terms of complications,postoperative nausea and vomiting(RR=0.32,95% CI: [0.18,0.58],P=0.0001)and respiratory complications(RR=0.50,95%CI: [0.29,0.85],P =0.01)in EA group were obviously lower than those of the IA group.No difference was observed in postoperative urinary complications between the two groups(RR=0.87,95%CI:[0.38,1.96],P =0.73),However,the incidence of hypotension was obviously higher than that of IA group(RR=3.27,95%CI:[1.28,8.32],P =0.01).Time of first exhaust time after operation(WMD = 14.01,95% CI: [22.85,5.17],P = 0.002),postoperative length of hospital stay(WMD = 0.69,95%CI: [0.90,0.49],P<0.00001)were shorter than IA group.Conclusions:1 Compared with traditional open gastrectomy,laparoscopic radical gastrectomy is safe and feasible with better minimally invasive effect for the treatment of gastric cancer in terms of the lower incidence of overall complications,mainly for those Clavien-Dindo classification Ⅱ or less and less intraoperative estimated blood loss.2 For patients who underwent radical gastrectomy for gastric cancer,epidural analgesia could provide better pain control either pain at rest or on movement,although a rising incidence of hypotension was leaded,reduced pulmonary complications,nausea and vomiting were found,and promote the bowel function and shorten the duration of hospital stay. |
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