OBJECTIVETo systematically evaluate the efficacy and safety of surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of advanced gastric cancer (AGC).

METHODSClinical control trials about the efficacy and safety of surgery combined with HIPEC in the treatment of advanced gastric cancer published before June 2014 were searched in Embase, PubMed, Cochrane Library, Wanfang database and CNKI database. Quality of enrolled articles was evaluated with the guidelines from Cochrane collaborative network. All the retrieved data were analyzed by RevMan 5.3 software for meta-analysis. Sensitivity analysis was performed by exclusion of non-randomly clinical control trials. Publication bias was evaluated by failure safe number (Nfs0.05).

RESULTSOf the 1489 AGC cases included from 16 literature, 698 underwent surgery with HIPEC (HIPEC group) while 791 underwent surgery alone (control group). According to whether or not the patient presented macroscopic peritoneal metastasis before the surgery, the HIPEC group was further divided into the curative HIPEC (n=102) and prophylactic HIPEC groups (n=421). The results of meta-analysis showed that, compared with control group, the 1-year (OR=2.26, 95%CI:1.71 ~ 3.00, P=0.000), 3-year (OR=2.27, 95%CI:1.80 - 2.87, P=0.000) and 5-year (OR=1.58, 95%CI:1.20 - 2.07, P=0.001) survival rates of HIPEC group were significantly improved with significantly decreased overall recurrence rate of liver, lung, bone or peritoneal metastasis (OR=0.43, 95%CI:0.26 - 0.71, P=0.001) and lower peritoneal metastasis recurrence rate (OR=0.30, 95%CI:0.17 - 0.52, P=0.000). However, there was higher incidence of procedure-related morbidity in the HIPEC group (OR=1.67, 95%CI:1.13 - 2.45, P=0.009), whereby the incidences of myelotoxicity (OR=4.90, 95%CI:1.05 - 22.83, P=0.040) and renal insufficiency were higher (OR=3.59, 95%CI:1.67 - 7.74, P=0.001). While the other complications, such as anastomotic leakage, intestinal obstruction and respiratory diseases were not significantly different between the two groups(all P>0.05). Subgroup analysis showed that compared with control group, the rates of peritoneal recurrence and metastasis in the prophylactic HIPEC group were significantly lower (OR=0.34, 95%CI:0.24 - 0.48, P=0.000), while such rates were not significantly different in curative HIPEC group (OR=0.07, 95%CI:0.00 - 1.88, P=0.110).

CONCLUSIONSSurgery combined with HIPEC can improve survival of AGC patients and reduce the recurrence rate after surgery. However its safety should be improved in the future.

Objective:To explore the diagnostic value of laparoscopy in the postoperative recurrence of peritoneal metastasis in gastric cancer, and to investigate the efficacy of bidirectional intraperitoneal and systemic (BIPS) chemotherapy for the recurrence.Methods:The descriptive case series study was conducted. Case inclusion criteria: (1) gastric cancer patients without synchronous distant metastasis received D2 radical gastrectomy; (2) postoperative adjuvant chemotherapy was administered; (3) no other distant metastasis except recurrence of peritoneal metastasis; (4) age of 18-75 years; (5) Eastern Cooperative Oncology Group (ECOG) performance-status score≤2; (6) pretreatment evaluation suggested that surgery and chemotherapy could be tolerated. Eight consecutive gastric cancer patients with postoperative recurrence of peritoneal metastasis who met the above criteria at Department of Gastrointestinal Surgery of Ruijin Hospital from September 2015 to September 2016 were enrolled into the study. There were 6 males and 2 females with the median age of 52 (38-68) years. They received laparoscopy or laparotomy first, and then were evaluated with reference to the Sugarbaker peritoneal cancer index (PCI) and the peritoneal metastasis classification of gastric cancer developed by the Japanese Gastric Cancer Research Association. A peritoneal access port was implanted in the subcutaneous space of the lower abdomen and the patients received chemotherapy for 21 days as a course of treatment. All the patients received intraperitoneal 20 mg/m 2 of paclitaxel (PTX) via implanted subcutaneous peritoneal access ports and intravenous 50 mg/m 2 of PTX at day 1 and day 8, meanwhile 80 mg/m 2 of Tigio was orally administered per day for 14 consecutive days, followed by 7 days of interval. Follow-up ended on December 15, 2019. Results:Of these 8 patients with recurrence of peritoneal metastasis after gastric cancer surgery, 1 case underwent laparotomy and loop stoma of terminal ileum because of complete colonic obstruction, and the remaining 7 cases underwent laparoscopy successfully and the recurrence of peritoneal metastasis was clearly diagnosed. Two patients with ovarian metastasis underwent laparoscopic bilateral adnexectomy. The median follow-up time was 17.5 (1.5 to 39.0) months, the median number of BIPS chemotherapy course was 11 (1 to 30), and the median survival time (MST) after BIPS chemotherapy was 17.0 months. The major adverse reaction in BIPS treatment was mainly myelosuppression, of which grade 3/4 leukopenia and neutropenia developed in 1 and 2 cases respectively. No BIPS-related death occurred. The MST of gastric cancer after radical gastrectomy was 40.0 months.Conclusions:Laparoscopy is a safe and feasible method for diagnosing the recurrence of peritoneal metastasis of gastric cancer. BIPS chemotherapy is effective and safe for its treatment and deserves further study.

Objective:To explore the diagnostic value of laparoscopy in the postoperative recurrence of peritoneal metastasis in gastric cancer, and to investigate the efficacy of bidirectional intraperitoneal and systemic (BIPS) chemotherapy for the recurrence.Methods:The descriptive case series study was conducted. Case inclusion criteria: (1) gastric cancer patients without synchronous distant metastasis received D2 radical gastrectomy; (2) postoperative adjuvant chemotherapy was administered; (3) no other distant metastasis except recurrence of peritoneal metastasis; (4) age of 18-75 years; (5) Eastern Cooperative Oncology Group (ECOG) performance-status score≤2; (6) pretreatment evaluation suggested that surgery and chemotherapy could be tolerated. Eight consecutive gastric cancer patients with postoperative recurrence of peritoneal metastasis who met the above criteria at Department of Gastrointestinal Surgery of Ruijin Hospital from September 2015 to September 2016 were enrolled into the study. There were 6 males and 2 females with the median age of 52 (38-68) years. They received laparoscopy or laparotomy first, and then were evaluated with reference to the Sugarbaker peritoneal cancer index (PCI) and the peritoneal metastasis classification of gastric cancer developed by the Japanese Gastric Cancer Research Association. A peritoneal access port was implanted in the subcutaneous space of the lower abdomen and the patients received chemotherapy for 21 days as a course of treatment. All the patients received intraperitoneal 20 mg/m 2 of paclitaxel (PTX) via implanted subcutaneous peritoneal access ports and intravenous 50 mg/m 2 of PTX at day 1 and day 8, meanwhile 80 mg/m 2 of Tigio was orally administered per day for 14 consecutive days, followed by 7 days of interval. Follow-up ended on December 15, 2019. Results:Of these 8 patients with recurrence of peritoneal metastasis after gastric cancer surgery, 1 case underwent laparotomy and loop stoma of terminal ileum because of complete colonic obstruction, and the remaining 7 cases underwent laparoscopy successfully and the recurrence of peritoneal metastasis was clearly diagnosed. Two patients with ovarian metastasis underwent laparoscopic bilateral adnexectomy. The median follow-up time was 17.5 (1.5 to 39.0) months, the median number of BIPS chemotherapy course was 11 (1 to 30), and the median survival time (MST) after BIPS chemotherapy was 17.0 months. The major adverse reaction in BIPS treatment was mainly myelosuppression, of which grade 3/4 leukopenia and neutropenia developed in 1 and 2 cases respectively. No BIPS-related death occurred. The MST of gastric cancer after radical gastrectomy was 40.0 months.Conclusions:Laparoscopy is a safe and feasible method for diagnosing the recurrence of peritoneal metastasis of gastric cancer. BIPS chemotherapy is effective and safe for its treatment and deserves further study.