Advantage of completely laparoscopic gastrectomy with linear stapled reconstruction: a long-term follow-up study

Totally laparoscopic total gastrectomy for locally advanced middle-upper-third gastric cancer

BACKGROUND

Totally laparoscopic total gastrectomy (TLTG) for locally advanced middle-upper-third gastric cancer is becoming increasingly popular. The difficulty of TLTG for locally advanced middle-upper-third gastric cancer is laparoscopic spleen-preserving splenic hilar lymphadenectomy and the intracorporeal digestive tract reconstruction. We summed up a set of unique experience through clinical practice to simplify operation procedures.

METHODS

We performed TLTG with Huang's three-step maneuver in laparoscopic spleen-preserving splenic hilar lymphadenectomy and a later-cut overlap Roux-en-Y anastomosis in the intracorporeal digestive tract reconstruction for patients with locally advanced middle-upper-third gastric cancer. The Huang's three-step maneuver divided the complicated procedure of laparoscopic spleen-preserving splenic hilar lymphadenectomy into three steps, including the dissection of the lymph nodes (LNs) in the inferior pole region of the spleen (1^st step), the region of the splenic artery trunk (2^nd step), and the superior pole region of the spleen (3^rd step). The later-cut overlap Roux-en-Y anastomosis used only endoscopic linear staplers intracorporeally and the small intestine was cut off after the esophagojejunostomy was completed, so that we could grasp the small intestine more easily and determine the direction of anastomosis more conveniently.

RESULTS

One patient experienced later anastomotic leakage and was successfully treated by conservative in 16 consecutive patients. No patient experienced any operation-related complications. At a median follow-up of 15 months, no patients had died or experienced recurrent or metastatic disease.

CONCLUSIONS

TLTG with Huang's three-step maneuver in laparoscopic spleen-preserving splenic hilar lymphadenectomy and a later-cut overlap Roux-en-Y anastomosis in the intracorporeal digestive tract reconstruction for locally advanced middle-upper-third gastric cancer was technically safe and feasible, with acceptable short-term outcomes.

Laparoscopic subtotal gastrectomy for advanced gastric cancer: technical aspects and surgical, nutritional and oncological outcomes

BACKGROUND

Higher morbidity in total gastrectomy than in distal gastrectomy has been reported, but laparoscopic subtotal gastrectomy (LsTG) has been reported to be safe and feasible in early gastric cancer (GC). We determined the surgical, nutritional and oncological outcomes of LsTG for advanced gastric cancer (AGC).

METHODS

Of the 816 consecutive patients with GC who underwent radical gastrectomy at our institution between 2008 and 2012, 253 who underwent curative laparoscopic gastrectomy (LG) for AGC were enrolled. LsTG was indicated for patients with upper stomach third tumors, who hoped to avoid total gastrectomy, <4 cm to the esophagogastric junction and a 2-cm proximal margin with cut end negative in frozen section, whereas laparoscopic conventional distal gastrectomy (LcDG) and laparoscopic total gastrectomy (LTG) were performed otherwise. Surgical outcomes and postoperative nutritional status were primarily assessed.

RESULTS

Of 253 patients, the morbidity (Clavien-Dindo classification grade ≥ III) was 17.0% (43 patients). The 3-year overall survival and 3-year recurrence-free survival rates were 80.2 and 73.5%, respectively. LcDG, LsTG and LTG were performed in 121, 27 and 105 patients, individually. Morbidity was strongly associated with LTG (P = 0.001). Postoperative loss of body weight was significantly greater after LTG in comparison with LcDG or LsTG (P < 0.001). No difference in morbidity and postoperative loss of body weight were observed between LcDG and LsTG group.

CONCLUSIONS

LG for AGC was feasible and safe surgically and oncologically. LsTG for AGC may be safer than LTG from surgical and postoperative nutritional point of view.

Superiority of laparoscopic proximal gastrectomy with hand-sewn esophagogastrostomy over total gastrectomy in improving postoperative body weight loss and quality of life

BACKGROUND

Proximal gastrectomy is not widely performed because the procedure is complicated, particularly under laparoscopy. We developed a simple laparoscopic technique of hand-sewn esophagogastrostomy with an anti-reflux mechanism. This study aimed to evaluate and compare the postoperative body weight loss (BWL) and quality of life (QOL) following laparoscopic proximal gastrectomy (LPG) and laparoscopic total gastrectomy (LTG) in patients with upper gastric cancer.

METHODS

We retrospectively analyzed patients with stage I upper gastric cancer undergoing LPG or LTG at Kyoto University Hospital between March 2006 and June 2014. The main outcome measures were the % BWL 1 year after gastrectomy, postoperative anastomotic stricture, and reflux esophagitis. Additionally, patient-reported outcomes were evaluated using the Post-Gastrectomy Syndrome Assessment Scale (PGSAS)-45 in patients presenting at the outpatient clinic and exhibiting no recurrence.

RESULTS

A total of 62 patients were included in this study (LTG, n = 42 vs. LPG, n = 20). The % BWL at 12 months in the LPG group was less than that in the LTG group (-16.3 vs. -10.7%). Multivariate analysis revealed that LPG was associated with less BWL (P = 0.003). Anastomotic stricture occurred more frequently in the LPG group than in the LTG group (0 vs. 25%). One patient in each group exhibited grade B severity of reflux esophagitis (based on the Los Angeles classification). In the questionnaire survey, LPG was better than LTG in terms of diarrhea and dissatisfaction with symptoms. In terms of reflux symptoms, patients in the LPG group experienced less acid and bile regurgitation symptoms compared with those in the LTG group.

CONCLUSIONS

LPG with hand-sewn esophagogastrostomy results in less postoperative BWL and better QOL than LTG despite higher rates of anastomotic stricture.

Feasibility of Laparoscopic Radical Gastrectomy for Gastric Cancer of Clinical Stage II or Higher: Early Outcomes in a Phase II Study (KUGC04)

PURPOSE

A phase II study was performed to evaluate the safety and efficacy of laparoscopic gastrectomy (LG) for gastric cancer of clinical stage II or higher.

METHODS

The eligibility criteria were gastric cancer of clinical stage II or higher that was amenable to potentially curative resection. Patients with prior chemotherapy, tumors requiring total gastrectomy (TG), tumors that invaded adjacent organs, and patients with bulky lymph node metastasis were included. The primary endpoint was incidence of postoperative complications of grade II or higher in the Clavien-Dindo classification. The sample size was determined to be 73, based on an expected rate of complications of 19 % and a threshold of 30 %. Gastrectomy was performed by expert surgeons who were certified by the Japan Society for Endoscopic Surgery.

RESULTS

A total of 73 patients were enrolled; 54 patients (74 %) had clinical T stage T4a/T4b, and 47 patients (64 %) were administered preoperative chemotherapy. The type of surgery was distal gastrectomy in 41 patients and TG in 31 patients. Dissection of D2 or more was performed in 62 patients (85 %). Of the 25 patients who underwent D2/D2+ TG, 15 underwent splenectomy or pancreaticosplenectomy. R0 resection was performed in 64 patients (88 %). The median number of resected lymph nodes was 56, and postoperative complications occurred in 15 patients (20.5 %), which was significantly lower than the threshold value (p = 0.039). One in-hospital death occurred (1.4 %).

CONCLUSION

LG for gastric cancer of clinical stage II or higher can be safely performed by experienced surgeons.

Laparoscopic and robot-assisted gastrectomy for gastric cancer: Current considerations

Radical gastrectomy with an adequate lymphadenectomy is the main procedure which makes it possible to cure patients with resectable gastric cancer (GC). A number of randomized controlled trials and meta-analysis provide phase III evidence that laparoscopic gastrectomy is technically safe and that it yields better short-term outcomes than conventional open gastrectomy for early-stage GC. While laparoscopic gastrectomy has become standard therapy for early-stage GC, especially in Asian countries such as Japan and South Korea, the use of minimally invasive techniques is still controversial for the treatment of more advanced tumours, principally due to existing concerns about its oncological adequacy and capacity to carry out an adequately extended lymphadenectomy. Some intrinsic drawbacks of the conventional laparoscopic technique have prevented the worldwide spread of laparoscopic gastrectomy for cancer and, despite technological advances in recent year, it remains a technically challenging procedure. The introduction of robotic surgery over the last ten years has implied a notable mutation of certain minimally invasive procedures, making it possible to overcome some limitations of the traditional laparoscopic technique. Robot-assisted gastric resection with D2 lymph node dissection has been shown to be safe and feasible in prospective and retrospective studies. However, to date there are no high quality comparative studies investigating the advantages of a robotic approach to GC over traditional laparoscopic and open gastrectomy. On the basis of the literature review here presented, robot-assisted surgery seems to fulfill oncologic criteria for D2 dissection and has a comparable oncologic outcome to traditional laparoscopic and open procedure. Robot-assisted gastrectomy was associated with the trend toward a shorter hospital stay with a comparable morbidity of conventional laparoscopic and open gastrectomy, but randomized clinical trials and longer follow-ups are needed to evaluate the possible influence of robot gastrectomy on GC patient survival.

Impact of Sarcopenic Obesity on Surgical Site Infection after Laparoscopic Total Gastrectomy

BACKGROUND

The critical risk factors for surgical site infection (SSI) after laparoscopic total gastrectomy (LTG) remain unclear. We analyzed the association between body composition and SSI after LTG.

METHODS

We performed a retrospective study of patients with gastric cancer who underwent LTG between March 2006 and October 2014 at Kyoto University Hospital, Japan. Visceral fat area and skeletal muscle mass were assessed from preoperative computed tomography scans to define sarcopenia and obesity. Patients were classified into one of four body composition categories according to the presence or absence of sarcopenia or obesity. The incidence of SSI was compared between the four body composition categories.

RESULTS

Of the 157 eligible patients, 45 (24 %) fulfilled the criteria for sarcopenic obesity, 28 (18 %) for nonsarcopenic obesity, 52 (33 %) for sarcopenic nonobesity, and 32 (20 %) for nonsarcopenic nonobesity. Thirty-two patients developed SSI (overall incidence rate, 20 %). The incidence of SSI in each body composition category was 33, 25, 13, and 9 %, respectively (P = 0.03). Multivariate logistic regression analysis showed that only sarcopenic obesity was associated with an increased incidence of SSI (odds ratio 4.59, 95 % confidence interval 1.18-17.78, P = 0.028).

CONCLUSIONS

Sarcopenic obesity is an independent risk factor for the development of SSI after LTG.

Feasibility of laparoscopic and endoscopic cooperative surgery for gastric submucosal tumors (with video)

BACKGROUND AND AIMS

Laparoscopic gastric resection is widely used for gastric submucosal tumors (SMTs). However, determining an appropriate resection line using only the laparoscopic approach is difficult. We developed a laparoscopic and endoscopic cooperative surgery (LECS) technique by combining laparoscopic gastric resection with endoscopic submucosal dissection, and we have used this procedure to resect gastric SMTs. In this study, the procedure is presented and its safety and feasibility for resecting gastric SMTs are evaluated.

METHODS

This retrospective study included 100 patients who underwent LECS for SMTs at the Department of Gastroenterological Surgery, Cancer Institute, between June 2006 and November 2014. The demographics, tumor histopathologic characteristics, and operative and follow-up data were reviewed.

RESULTS

Complete resection with negative surgical margins was achieved in all patients, and LECS was performed regardless of tumor location. The mean operation time was 174.3 minutes, with an estimated blood loss of 16.3 mL. In addition, the mean time until the initiation of oral intake was 1.4 days, and the mean postoperative hospital stay was 8.4 days. Moreover, no local or distant tumor recurrence was observed. The only severe adverse event was leakage, which was observed in 1 patient.

CONCLUSIONS

LECS was performed with a reasonable operation time, low blood loss, and minimal adverse events. Therefore LECS is safe and feasible for resecting gastric SMTs.

Single incision gastrectomy for gastric cancer

Based on rapid development of laparoscopic techniques and instruments, single-incision laparoscopic surgery (SILS) is expected to be the next step of "more" minimally invasive surgery. A few institutions gradually started to report their experience of single incision gastrectomy (SIG) for gastric cancer, but it is still difficult to accept that SIG can be performed as a popular procedure because of its technical difficulty. For wide adoption of SIG, the simplicity, safety and reproducibility of not only lymph node dissection but also reconstruction should be evaluated compared to a conventional procedure. With a thorough understanding of unique characteristics of SILS, single incision distal gastrectomy (SIDG) for early gastric cancer performed by laparoscopic surgeons with advanced technique is expected to have promising potential about excellent cosmesis, comparable morbidity and mortality in carefully selected patients. For appropriate adoption and steady progress of this state-of-the art surgery, scientific evaluation with healthy critics is necessary with new generation of SILS instrument platform.

Laparoscopic splenic hilar lymphadenectomy for advanced gastric cancer

Laparoscopic distal gastrectomy has recently become accepted as a surgical option for early gastric cancer in the distal stomach, but laparoscopic total gastrectomy (LTG) has not become widespread because of technical difficulties of esophagojejunal anastomosis and splenic hilar lymphadenectomy. Splenic hilar lymphadenectomy should be employed in the treatment of advanced proximal gastric cancer to complete D2 dissection, but laparoscopically it is technically difficult even for skilled surgeons. Based on the evidence that prophylactic combined resection of spleen in total gastrectomy increased the risk of postoperative morbidity with no survival impact, surgeons have preferred laparoscopic spleen-preserving splenic hilar lymphadenectomy (LSPL) for advanced tumors without metastasis to splenic hilar nodes or invasion to the greater curvature of the stomach, and reports with LSPL have been increasing rather than LTG with splenectomy. In this paper, recent reports with laparoscopic splenic hilar lymphadenectomy were reviewed.

Totally laparoscopic versus laparoscopy-assisted Billroth-I anastomosis for gastric cancer: a case-control and case-matched study

OBJECTIVE

To evaluate the safety, feasibility and clinical results of the modified delta-shaped gastroduodenostomy (MDSG) in totally laparoscopic distal gastrectomy (TLDG) for gastric cancer (GC).

METHODS

We performed a case-control and case-matched study enrolling 642 patients with GC undergoing laparoscopic distal gastrectomy with Billroth-I anastomosis from January 2011 to December 2014. TLDG with MDSG was performed in 158 patients (Group TL), and laparoscopy-assisted distal gastrectomy with circular anastomosis was performed in 484 patients (Group LA). One-to-one propensity score matching (PSM) was performed to compare the clinicopathological characteristics between the two groups.

RESULTS

Patients with smaller tumors or stage I cancer were more likely to receive TLDG (P < 0.05). In the propensity-matched analysis of 143 pairs, there were no differences in demographic and pathologic characteristics between groups (all P < 0.05). All patients successfully underwent laparoscopic radical distal gastrectomy. Before PSM, Group TL had more dissected lymph nodes (LNs), a longer time to first fluid diet and a longer postoperative length of stay than Group LA (all P < 0.05). After PSM, except for the fact that more dissected LNs were obtained in Group LA (P < 0.05), no difference was found in the intraoperative and postoperative outcomes between the groups (all P > 0.05). The postoperative complications were similar in both groups (all P > 0.05). Stratification analysis performed after PSM showed that in early GC, no difference was observed in intraoperative and postoperative outcomes between the groups (all P > 0.05). However, in locally advanced GC, Group TL had more dissected LNs and a higher rate of postoperative complications (both P < 0.05). Univariate analysis carried out in locally advanced cases after PSM showed that the body mass index (BMI), the method of digestive tract reconstruction and Charlson's score were significant factors that affected postoperative morbidity (all P < 0.05). Multivariate analysis indicated that BMI was an independent risk factor for postoperative morbidity (P < 0.05).

CONCLUSIONS

The MDSG in TLDG is safe and feasible for early GC; however, it should be chosen with caution in advanced GC, particularly in patients with a high BMI.

Linear-shaped gastroduodenostomy (LSGD): safe and feasible technique of intracorporeal Billroth I anastomosis

BACKGROUND

Although delta-shaped gastroduodenostomy (DSGD) is used increasingly as an intracorporeal Billroth I anastomosis after distal gastrectomy, worries about anatomical distortion always exist in twisting stomach and making an oblique incision on duodenum. We developed a new method of intracorporeal gastroduodenostomy, the linear-shaped gastroduodenostomy (LSGD), in which anastomosis is done using endoscopic linear staplers only without any complicated rotation. In this report, we introduced LSGD and compared its short-term and long-term outcomes with DSGD.

METHODS

We analyzed 261 consecutive gastric cancer patients who underwent the intracorporeal gastroduodenostomy between January 2009 and May 2014 (LSGD: 190, DSGD: 71), retrospectively. All of them underwent a laparoscopic or robotic distal gastrectomy with regional lymph node dissection. Early surgical outcomes such as operation time, postoperative complications, days until soft diet began, length of hospital stay, and endoscopic findings in postoperative 6 and 12 months were evaluated.

RESULTS

Although the proportion of robotic approach and D2 lymphadenectomy were significantly higher in LSGD group, the rates for overall complications (13.2 % [LSGD] vs. 9.9 % [DSGD], p = 0.470) and major complications (5.8 vs. 5.6 %, p = 1.0) were similar between two groups. There were no differences in anastomotic bleeding (1.1 vs. 1.4 %, p = 1.0), stenosis (3.2 vs. 2.8 %, p = 1.0), and leakage (0.5 vs. 0.0 %, p = 1.0). Endoscopy performed 6 months postoperatively showed that residual food (p = 0.022), gastritis (p = 0.018), and bile reflux (42.0 vs. 63.2 %, p = 0.003) were significantly decreased in LSGD and there were no significant differences in postoperative 12 months.

CONCLUSION

LSGD is an innovative reconstruction technique with comparable short-term outcomes to DSGD. In addition, reduced residual food, gastritis, and bile reflux were seen in LSGD.

Current status of surgical treatment of gastric cancer in the era of minimally invasive surgery in China: Opportunity and challenge

Gastric cancer is one of the most common cancers in China. In the past decade, with the developments in surgical instruments and technologies, minimally invasive surgery has rapidly become an accepted treatment for gastric cancer in China. Many Chinese surgeons and researchers have contributed to the rapid evolution of minimally invasive surgery for gastric cancer. Their efforts have transformed into unique laparoscopic technique, workshops, academic communications, education and international communications in China. Meanwhile, many retrospective comparative trials and randomized controlled trials have revealed the advantages in minimally invasive surgery for gastric cancer. However, multicenter randomized controlled trials are still needed to delineate significantly quantifiable differences between laparoscopic and open gastrectomy. With more and more experience has accumulated, laparoscopic gastrectomy has been performed on older and overweight patients. Moreover, advanced minimally invasive techniques, such as modified laparoscopic spleen-preserving splenic hilum lymphadenectomy, various laparoscopic gastric reconstruction methods and robotic gastrectomy have been developed. It seems that China owns the potential to keep up with her neighbor, Japan and Korea, to become one of leading countries utilizing minimally invasive surgery for gastric cancer.

Laparoscopic gastrointestinal anastomoses using knotless barbed absorbable sutures are safe and reproducible: a single-center experience with 242 patients

OBJECTIVE

Intracorporeal reconstruction of the digestive tract is technically challenging. The V-Loc 180 wound closure device (Covidien) is a self-anchoring unidirectional barbed suture that obviates the need for knot tying. The aim of this prospective cohort study was to investigate the use of the novel suture in gastrointestinal enterotomy closure.

METHODS

The subjects comprised patients with malignant disease who were scheduled to undergo laparoscopic gastrectomy with curative intent. The barbed suture was used to close the entry hole for the linear stapler during intracorporeal reconstruction following laparoscopic gastric resection. The primary endpoint was the proportion of patients who developed anastomotic leakage at the site where the barbed suture was applied.

RESULTS

Between July 2012 and March 2015, 242 patients were enrolled. Of 362 anastomoses, the enterotomy hole at 256 sites was closed using the barbed suture. These 256 sites consisted of 95 gastroduodenostomies, 25 gastrogastrostomies, 13 gastrojejunostomies, 90 jejunojejunostomies, 17 esophagojejunostomies and 16 primary closures of the stomach following local gastric resection. There were no anastomosis-related complications, conversion to usual sutures, mechanical closure of the entry hole and reoperation due to adhesive obstructions or mortality over a median follow-up period of 17.8 months.

CONCLUSIONS

The use of the unidirectional barbed absorbable suture for gastrointestinal closure is safe and effective in laparoscopic gastrectomy.

Laparoscopic gastrectomy for remnant gastric cancer: a comprehensive review and case series

BACKGROUND

Remnant gastric cancer is increasing with the earlier detection of gastric cancer and improved medical care. Laparoscopic gastrectomy for remnant gastric cancer has been reported sporadically in association with the increased use of minimally invasive techniques. However, because of the rarity of remnant gastric cancer, the number of cases reported per study has been small. We therefore reviewed all published English-language reports, including our experience, to better characterize the technical aspects of currently used procedures.

METHODS

Ten patients who underwent laparoscopic gastrectomy for remnant cancer between August 2005 and March 2014 were retrospectively studied. A comprehensive literature search was performed using the PubMed database to identify English-language studies on laparoscopic gastrectomy for remnant gastric cancer that were published before May 2014.

RESULTS

There was no conversion to open surgery. The mean operating time was 325 min, and mean intraoperative blood loss was 55 g. The mean number of retrieved lymph nodes was 22, and mean postoperative hospital stay was 13 days. There was only one minor wound infection (overall morbidity rate, 10%). From the literature review, all comparative studies revealed that laparoscopic gastrectomy for remnant gastric cancer required a longer operating time, and most studies reported less intraoperative blood loss, an equivalent number of harvested lymph nodes, and a shorter postoperative stay as compared with open surgery.

CONCLUSION

Proficiency in advanced laparoscopic surgical techniques, such as proper adhesiolysis and stable laparoscopic anastomosis, will allow laparoscopic gastrectomy for remnant gastric cancer to be performed with satisfactory short-term results. This minimally invasive approach can be one treatment option for remnant gastric cancer.

Internal hernia after laparoscopic gastrectomy with Roux-en-Y reconstruction for gastric cancer

BACKGROUND/OBJECTIVE

Laparoscopic gastrectomy (LG) is increasingly used to treat gastric cancer. Simultaneously, internal hernia (IH) has been reported after LG with Roux-en-Y reconstruction (RY). The aim of this study was to investigate IH after LG with RY for gastric cancer.

METHODS

This study included 15 patients with IH from a database of 355 consecutive patients who underwent LG with RY for gastric cancers. We retrospectively analyzed IH incidence and clinical characteristics by operative procedures.

RESULTS

The total incidence of IH was 4.2%. The incidence of IH at Petersen's defect tended to decrease with modifications to the reconstruction methods, but not significantly so. The incidence of IH at jejunojejunostomy mesenteric defect significantly decreased with closure of this defect (p = 0.01). The incidence of IH at transverse mesocolic defect was 1.3% in patients who underwent retrocolic RY; emergent small-bowel resection was only required in two cases of herniation through this defect after laparoscopic total gastrectomy.

CONCLUSION

Retrocolic RY with appropriate closure of defects can reduce IH incidence at Petersen's defect and at jejunojejunostomy mesenteric defect. Although the IH incidence at the transverse mesocolic defect is not particularly high, the possibility of herniation through this defect should be kept in mind.

Comparison of outcomes after laparoscopy-assisted and open total gastrectomy for early gastric cancer

BACKGROUND

The aim of this study was to compare the results of laparoscopy-assisted total gastrectomy with those of open total gastrectomy for early gastric cancer.

METHODS

Patients with gastric cancer who underwent total gastrectomy with curative intent in three Korean tertiary hospitals between January 2003 and December 2010 were included in this multicentre, retrospective, propensity score-matched cohort study. Cox proportional hazards regression models were used to evaluate the association between operation method and survival.

RESULTS

A total of 753 patients with early gastric cancer were included in the study. There were no significant differences in the matched cohort for overall survival (hazard ratio (HR) for laparoscopy-assisted versus open total gastrectomy 0.96, 95 per cent c.i. 0.57 to 1.65) or recurrence-free survival (HR 2.20, 0.51 to 9.52). The patterns of recurrence were no different between the two groups. The severity of complications, according to the Clavien-Dindo classification, was similar in both groups. The most common complications were anastomosis-related in the laparoscopy-assisted group (8.0 per cent versus 4.2 per cent in the open group; P = 0.015) and wound-related in the open group (1.6 versus 5.6 per cent respectively; P = 0.003). Postoperative death was more common in the laparoscopy-assisted group (1.6 versus 0.2 per cent; P = 0.045).

CONCLUSION

Laparoscopy-assisted total gastrectomy for early gastric cancer is feasible in terms of long-term results, including survival and recurrence. However, a higher postoperative mortality rate and an increased risk of anastomotic leakage after laparoscopic-assisted total gastrectomy are of concern.

Clinical Significance of C-reactive Protein Level After Laparoscopic Gastrectomy: From a Viewpoint of Intra-Abdominal Complications

In this retrospective study, we investigated whether postoperative intra-abdominal infectious complications (IIC) after laparoscopic gastrectomy (LG) is predictable in an early postoperative period using C-reactive protein (CRP). Intra-abdominal infectious complication after gastrectomy is caused mainly by anastomotic leakage or pancreatic injury associated with peripancreatic lymph node (LN) dissection, which may sometimes result in serious outcomes. C-reactive protein is widely used to evaluate the inflammatory status. However, the relationship between the CRP level and postoperative IIC following LG remains unclear. White blood cell count (WBC), CRP counts, and clinical data were available for 229 consecutive patients undergoing LG with lymphadenectomy. We compared CRP and WBC between patients with (Group A) and without (Group B) IIC to check whether these could be used to predict IIC in an early postoperative period. Using the receiver-operating characteristic (ROC) curve, the diagnostic accuracy was evaluated. On postoperative day 1 (POD1), increased CRP levels were associated with IIC (Group A: 9.6 mg/dL, Group B: 6.0 mg/dL; P = 0.000048), while WBC did not differ significantly. On POD3, the difference in CRP between both groups increased (A: 20.2 mg/dL, B: 10.7 mg/dL; P = 1.6 × 10−8). The optimal cutoff value was 14.9 mg/dL on POD3 (sensitivity: 0.79, specificity: 0.78), and the area under the ROC curve was 0.86. Measurements of CRP on POD1 and 3 are helpful for detecting possible IIC after LG, compared with WBC. It is necessary to pay attention to CRP levels for earlier detection of IIC.

Short-term outcomes of totally laparoscopic total gastrectomy: experience with the first consecutive 112 cases

INTRODUCTION

Although laparoscopic distal gastrectomy has become a viable treatment option for gastric cancer, laparoscopic total gastrectomy remains in limited use.

PURPOSE

The present study was designed to evaluate the short-term outcomes of totally laparoscopic total gastrectomy (TLTG).

METHODS

The records of 112 consecutive patients who underwent TLTG for gastric cancer between September 2006 and November 2012 were reviewed, and surgical outcomes were retrospectively investigated.

RESULTS

Neoadjuvant chemotherapy was given to 21 patients (18.8 %). The degree of lymphadenectomy was D1+ in 83 patients (74.1 %) and D2 in 29 (25.9 %). The operation time was 359 min, median intraoperative blood loss was 85 ml, and median total number of harvested lymph nodes was 64. Grade II or higher postoperative complications developed in 25 patients (22.3 %). On univariate analysis, pathologic stages IB to IV (versus stage IA) overlapped esophagojejunostomy (versus functional end-to-end esophagojejunostomy) and operation time >360 min (versus ≤360 min) were related to postoperative morbidity. In the multivariate analysis, operative time and pathologic stage were independent risk factors for postoperative complications.

CONCLUSIONS

TLTG is feasible and can be performed with acceptable postoperative morbidity. A longer operating time and more advanced pathologic stage were significantly associated with higher postoperative morbidity.

Unaided Stapling Technique for Pure Single-Incision Distal Gastrectomy in Early Gastric Cancer: Unaided Delta-Shaped Anastomosis and Uncut Roux-en-Y Anastomosis

Purpose

Intracorporeal anastomosis is the most difficult procedure during pure single-incision distal gastrectomy (SIDG) that affects its generalization. We introduced unaided delta-shaped anastomosis (uDelta), a novel anastomosis technique, for gastroduodenostomy after pure SIDG, and compared the results with those of previously reported Roux-en-Y anastomosis (RY).

Materials and Methods

Between March 2014 and March 2015, SIDG with D1+ lymph node dissection was performed for early gastric cancer through a 2.5-cm transumbilical incision without any additional port. uDelta was performed by the operator alone, without any intracorporeal assistance.

Results

uDelta was performed on 11 patents, and uncut RY was performed on 5-patients without open or multiport conversion. R0 resection was performed in all cases. No significant differences were observed in mean age and body mass index between patients who underwent uDelta or RY. Mean operation times were 214.5±36.2 minutes for uDelta and 240.8±65.9 minutes for RY, which was not significantly different. Reconstruction time for uDelta was shorter than that for RY, with marginal statistical significance (26.1±8.3 minutes vs. 38.0±9.1 minutes, P=0.05). There were no intraoperative transfusions, 30-day mortality, or anastomosis-related complications in either group. Average length of hospital stay was 8.2±1.9 days in the uDelta group and 7.2±0.8 days in the RY group (P=0.320).

Conclusions

After carefully considering indications, uDelta can be a feasible and can be a reproducible reconstruction method after SIDG in early gastric cancer.

Laparoscopic assisted total gastrectomy for gastric cancer - operative technique

For many years, open gastrectomy with lymphadenectomy was the gold standard treatment for gastric cancer. In recent years, however, laparoscopic assisted total gastrectomy with associated D2 lymphadenectomy has gained in popularity. It has a similar oncological outcome to open resection, but has all of the added advantages of a laparoscopic procedure, such as early mobilisation, less postoperative pain and shorter hospital stay. This article describes the operative techniques, including key procedure steps, as well as a guide for using the new OrVil device for the laparoscopic creation of the oesophago-jejunal anastomosis. A video of a laparoscopic assisted total gastrectomy is presented.

A systematic review of laparoscopic total gastrectomy for gastric cancer

BACKGROUND

Laparoscopic total gastrectomy (LTG) has been performed since 1999. Although surgical outcomes have been reported from Japan, Korea, China, and many Western countries, the effectiveness of this technique has not been conclusively established. This study therefore aimed to review the literature systematically.

METHODS

Our search of the research literature identified 150 studies, which were mostly retrospective and from single institutions.

RESULTS

There has recently been a remarkable increase in the number of studies from Korea, and the number of patients included in studies has increased since 2009. In most studies, the surgical procedures were longer, blood loss was reduced, and the number of retrieved lymph nodes was the same in the LTG group as in the open total gastrectomy group. The incidence of postoperative complications and that of inflammation during postoperative recovery were the same in these two groups.

CONCLUSIONS

During LTG, the method used for esophagojejunostomy is important for surgical reliability and to reduce postoperative complications. There has been rapid development of new techniques from the level of esophagojejunostomy through a small skin incision to the high level of intracorporeal esophagojejunostomy using various techniques. A nationwide prospective phase II study is urgently needed to establish the value of LTG.

Totally laparoscopic total gastrectomy for gastric cancer: literature review and comparison of the procedure of esophagojejunostomy

There has been a recent increase in the use of totally laparoscopic total gastrectomy (TLTG) for gastric cancer. However, there is no scientific evidence to determine which esophagojejunostomy (EJS) technique is the best. In addition, both short- and long-term oncological results of TLTG are inconsistent. We reviewed 25 articles about TLTG for gastric cancer in which at least 10 cases were included. We analyzed the short-term results, relationships between EJS techniques and complications, long-term oncological results, and comparative study results of TLTG. TLTG was performed in a total of 1170 patients. The mortality rate was 0.7%, and the short-term results were satisfactory. Regarding EJS techniques and complications, circular staplers (CSs) methods were significantly associated with leakage (4.7% vs. 1.1%, p < 0.001) and stenosis (8.3% vs. 1.8%, p < 0.001) of the EJS as compared with the linear stapler method. The long-term oncological prognosis was acceptable in patients with early gastric cancers and without metastases to lymph nodes. Although TLTG tended to increase surgical time compared with open total gastrectomy and laparoscopy-assisted total gastrectomy, it reduced intraoperative blood loss and was expected to shorten postoperative hospital stay. TLTG is found to be safer and more feasible than open total gastrectomy and laparoscopy-assisted total gastrectomy. At present, there is no evidence to encourage performing TLTG for patients with advanced gastric cancer from the viewpoint of long-term oncological prognosis. Although the current major EJS techniques are CS and linear stapler methods, in this review, CS methods are significantly associated with leakage and stenosis of the EJS.

Surgical outcomes in the newly introduced phase of intracorporeal anastomosis following laparoscopic distal gastrectomy is safe and feasible compared with established procedures of extracorporeal anastomosis

BACKGROUND

Totally laparoscopic distal gastrectomy (TLDG) with intracorporeal anastomosis has been introduced to achieve safer anastomosis with good vision, and a small wound. However, little is known about the surgical outcomes of newly introduced TLDG compared with established procedures of laparoscopy-assisted gastrectomy (LADG) with extracorporeal anastomosis.

METHODS

This retrospective study included 114 patients who underwent laparoscopic distal gastrectomy (LDG) between January 2010 and September 2012. The patients were classified into two groups according to the approach of reconstruction (LADG group: n = 74; TLDG group: n = 40). The parameters analyzed included patients, operation details, and operative outcomes.

RESULTS

No complication was observed in the TLDG group. Surgical outcomes of the TLDG group, such as mean operation time, estimated blood loss, and rate of conversion to laparotomy were not inferior to the LADG group. Furthermore, postoperative hospital stay of the TLDG group was significantly shorter than the LADG group (p < 0.05).

CONCLUSION

Surgical outcomes in the newly introduced phase of TLDG were safe as well as feasible compared with established LADG. TLDG has several advantages over LADG, such as shorter post-hospital stay, no incidence of operative complication, adequate working space, and small wound size. Although prospective, randomized control studies are warranted, we submit that TLDG can be used as a standard procedure for LDG.

A new intracorporeal Billroth II stapled anastomosis technique in totally laparoscopic distal gastrectomy

BACKGROUND

We introduced a new, safe and simple intracorporeal Billroth II (B-II) gastrojejunostomy technique using laparoscopic linear staplers with totally laparoscopic distal gastrectomy (TLDG) for gastric cancer. We further compared the short-term operative outcomes between intracorporeal B-II gastrojejunostomy with TLDG and extracorporeal B-II gastrojejunostomy with laparoscopy-assisted distal gastrectomy (LADG).

METHODS

From January 01, 2012 to January 31, 2013, a total of 36 patients with gastric cancer underwent TLDG and LADG. Overall, 11 patients underwent intracorporeal B-II gastrojejunostomy with TLDG, and 25 patients underwent a mini-laparotomy incision for extracorporeal B-II anastomosis with LADG. Perioperative parameters, including patient and tumor characteristics, short-term postoperative outcomes, and anastomosis-related complications, were analyzed to compare the two operations.

RESULTS

The time to first flatus, the time on a liquid diet, and the mean postoperative length of hospital stay were significantly different between the groups (P < 0.05). In the TLDG group, the postoperative time to first flatus and the mean postoperative length of hospital stay were significantly shorter than in the LADG group (2.6 ± 0.20 vs. 3.8 ± 0.1 days; 10 ± 1.84 vs. 12.7 ± 3.35 days). However, the operation-related costs were significantly greater for totally laparoscopic distal gastrectomy (P < 0.001). The mean number of staples used in TLDG was six compared with four in LADG.

CONCLUSION

Our new intracorporeal B-II anastomosis method using laparoscopic linear staplers with TLDG was safe, feasible, and minimally invasive compared with extracorporeal B-II gastrojejunostomy with LADG. At the same time, one of its characteristics of our technique is to avoid stricturing of the efferent loop or afferent loop of the jejunum when the entry hole is closed with a stapler.

Comparision of modified and conventional delta-shaped gastroduodenostomy in totally laparoscopic surgery

AIM: To evaluate the safety and feasibility of a modified delta-shaped gastroduodenostomy (DSG) in totally laparoscopic distal gastrectomy (TLDG).

METHODS: We performed a case-control study enrolling 63 patients with distal gastric cancer (GC) undergoing TLDG with a DSG from January 2013 to June 2013. Twenty-two patients underwent a conventional DSG (Con-Group), whereas the other 41 patients underwent a modified version of the DSG (Mod-Group). The modified procedure required only the instruments of the surgeon and assistant to complete the involution of the common stab incision and to completely resect the duodenal cutting edge, resulting in an anastomosis with an inverted T-shaped appearance. The clinicopathological characteristics, surgical outcomes, anastomosis time and complications of the two groups were retrospectively analyzed using a prospectively maintained comprehensive database.

RESULTS: DSG procedures were successfully completed in all of the patients with histologically complete (R0) resections, and none of these patients required conversion to open surgery. The clinicopathological characteristics of the two groups were similar. There were no significant differences between the groups in the operative time, intraoperative blood loss, extension of the lymph node (LN) dissection and number of dissected LNs (150.8 ± 21.6 min vs 143.4 ± 23.4 min, P = 0.225 for the operative time; 26.8 ± 11.3 min vs 30.6 ± 14.8 mL, P = 0.157 for the intraoperative blood loss; 4/18 vs 3/38, P = 0.375 for the extension of the LN dissection; and 43.9 ± 13.4 vs 39.5 ± 11.5 per case, P = 0.151 for the number of dissected LNs). The anastomosis time, however, was significantly shorter in the Mod-Group than in the Con-Group (13.9 ± 2.8 min vs 23.9 ± 5.6 min, P = 0.000). The postoperative outcomes, including the times to out-of-bed activities, first flatus, resumption of soft diet and postoperative hospital stay, as well as the anastomosis size, did not differ significantly (1.9 ± 0.6 d vs 2.3 ± 1.5 d, P = 0.228 for the time to out-of-bed activities; 3.2 ± 0.9 d vs 3.5 ± 1.3 d, P = 0.295 for the first flatus time; 7.5 ± 0.8 d vs 8.1 ± 4.3 d, P = 0.489 for the resumption of a soft diet time; 14.3 ± 10.6 d vs 11.5 ± 4.9 d, P = 0.148 for the postoperative hospital stay; and 30.5 ± 3.6 mm vs 30.1 ± 4.0 mm, P = 0.730 for the anastomosis size). One patient with minor anastomotic leakage in the Con-Group was managed conservatively; no other patients experienced any complications around the anastomosis. The operative complication rates were similar in the Con- and Mod-Groups (9.1% vs 7.3%, P = 1.000).

CONCLUSION: The modified DSG, an alternative reconstruction in TLDG for GC, is technically safe and feasible, with a simpler process that reduces the anastomosis time.

A modified delta-shaped gastroduodenostomy in totally laparoscopic distal gastrectomy for gastric cancer: a safe and feasible technique

Background

The present study introduced a modified delta-shaped gastroduodenostomy (DSG) technique and assessed the safety, feasibility and clinical results of this procedure in patients undergoing totally laparoscopic distal gastrectomy (TLDG) for gastric cancer (GC).

Materials and Methods

A total of 102 patients with distal GC undergoing TLDG with modified DSG between January 2013 and December 2013 were enrolled. A retrospective study was performed using a prospectively maintained comprehensive database to evaluate the results of the procedure. Univariate and multivariate analyses were performed to estimate the predictive factors for postoperative morbidity.

Results

The mean operation time was 150.6±30.2 min, the mean anastomosis time was 12.2±4.2 min, the mean blood loss was 48.2±33.2 ml, and the mean times to first flatus, fluid diet, soft diet and postoperative hospital stay were 3.8±1.3 days, 5.0±1.0 days, 7.4±2.1 days and 12.0±6.5 days, respectively. Two patients with minor anastomotic leakage after surgery were managed conservatively; no patient experienced any complications around the anastomosis, such as anastomotic stricture or anastomotic hemorrhage. Univariate analysis showed that age, gastric cancer with hemorrhage and cardiovascular disease combined were significant factors that affected postoperative morbidity (P<0.05). Multivariate analysis found that gastric cancer with hemorrhage was the independent risk factor for the postoperative morbidity (P = 0.042). At a median follow-up of 7 months, no patients had died or experienced recurrent or metastatic disease.

Conclusions

The modified DSG was technically safe and feasible, with acceptable surgical outcomes, in patients undergoing TLDG for GC, and this procedure may be promising in these patients.

Enhanced recovery (ERAS) protocol in patients undergoing laparoscopic total gastrectomy

INTRODUCTION

Laparoscopic technique combined with the ERAS (Enhanced Recovery after Surgery) protocol enables a shorter hospital stay and a lower complication rate. Although it has been widely used in many patients undergoing elective abdominal surgery, especially in patients with colorectal cancer, there are only a few papers describing laparoscopic total gastrectomy and the enhanced recovery protocol in patients with gastric cancer. Minimally invasive gastrectomy is still an uncommon procedure, mostly because of its difficulty.

AIM

To present the preliminary results of treatment of patients with gastric neoplasms who underwent laparoscopic gastrectomy D2 with perioperative care according to ERAS principles.

MATERIAL AND METHODS

Eleven patients (5 male and 6 female, age 52-77 years) underwent laparoscopic D2 gastrectomy with intracorporeal esophagojejunal anastomosis. In all patients the ERAS protocol was implemented. We analyzed operation time, complications and hospital stay. Additionally we focused on operative technique as well as the perioperative care protocol.

RESULTS

The mean duration of the procedure was 245 min. There was 1 conversion due to unclear tumor infiltration. Mean hospital stay was 4.6 days. One postoperative complication (central venous catheter sepsis) was reported. Histological analysis confirmed the tentative diagnosis (R0 resection) in 10/11 patients. There were no readmissions.

CONCLUSIONS

Laparoscopic gastrectomy is a valuable alternative to the classical approach and combined with the ERAS protocol can result in reduced hospital stay. However, due to the small group of patients it is difficult to adequately assess the incidence of early and late complications of the laparoscopic procedures; therefore further research is needed.

Is laparoscopic total gastrectomy a safe operation? A review of various anastomotic techniques and their outcomes

Laparoscopic distal gastrectomy is an accepted option for gastric cancer surgery; however, laparoscopic total gastrectomy (LTG) is not widely performed. There is concern about the safety of the operation due to the difficulty of extracorporeal reconstruction through a mini-laparotomy. Efforts have been made to establish an intracorporeal anastomotic technique for esophagojejunostomy. This article reviews the current techniques available for laparoscopic esophagojejunostomy and their surgical outcomes. Several different techniques using either circular or linear staplers have been reported; however, the apparent superiority of any particular method has not been confirmed. The incidence of anastomosis-related complications varied among studies, but different techniques all successfully achieved excellent outcomes. The overall complication rate of LTG was similar to that of open total gastrectomy, suggesting that LTG is a safe and feasible option. However, the feasibility of LTG with D2 lymph node dissection for advanced upper gastric cancer needs to be confirmed in further studies, because most of the patients included in the LTG studies were diagnosed with early stages of disease.

Robotic spleen-preserving total gastrectomy for gastric cancer: comparison with conventional laparoscopic procedure

BACKGROUND

Robotic systems recently have been introduced to overcome technical limitations of conventional laparoscopic surgery, especially for complex procedures. Laparoscopic spleen-preserving total gastrectomy with D2 lymph node (LN) dissection (LTGD2) is one of the most complicated procedures. We hypothesized that robotic LN dissection would be more thorough and accurate. We compared robotic spleen-preserving total gastrectomy with D2 LN dissection (RTGD2) with LTGD2 to investigate the impact of robotics.

METHODS

Clinicopathologic characteristics and short-term and long-term outcomes of RTGD2 (n = 51) versus LTGD2 (n = 58) in gastric adenocarcinoma patients were extracted from a prospectively designed database and analyzed retrospectively.

RESULTS

There was no difference of patients' characteristics between groups. Mean operation time of RTGD2 was longer than LTGD2 (p < 0.001), and no differences in tumor histology, size, location, and TNM stage were seen. Total retrieved LNs from RTGD2 was similar to LTGD2 (mean 47.2 vs. 42.8, respectively), as were retrieved LNs at splenic hilum (1.3 vs. 0.8). However, mean numbers of retrieved LNs along the splenic artery from RTGD2 was higher than LTGD2 (2.3 vs. 1.0, respectively; p = 0.013), as was also the case at the splenic hilum and artery (3.6 vs. 1.9, p = 0.014). Postoperative complication (16 vs. 22 %, p = 0.374) and overall and disease-free survival between the two groups were not significantly different (p = 0.767 and p = 0.666, respectively).

CONCLUSIONS

Robotic spleen-preserving total gastrectomy with D2 LN dissection is feasible. Operation time and retrieved total LNs and splenic hilar LNs in the robotic procedure are acceptable.

Systematic review and meta-analysis of laparoscopy-assisted and open total gastrectomy for gastric cancer

AIM: To evaluate the safety and efficacy of laparoscopy-assisted total gastrectomy (LATG) and open total gastrectomy (OTG) for gastric cancer.

METHODS: A comprehensive search of PubMed, Cochrane Library, Web of Science and BIOSIS Previews was performed to identify studies that compared LATG and OTG. The following factors were checked: operating time, blood loss, harvested lymph nodes, flatus time, hospital stay, mortality and morbidity. Data synthesis and statistical analysis were carried out using RevMan 5.1 software.

RESULTS: Nine studies with 1221 participants were included (436 LATG and 785 OTG). Compared to OTG, LATG involved a longer operating time [weighted mean difference (WMD) = 57.68 min, 95%CI: 30.48-84.88; P < 0.001]; less blood loss [standard mean difference (SMD) = -1.71; 95%CI: -2.48 - -0.49; P < 0.001]; earlier time to flatus (WMD= -0.76 d; 95%CI: -1.22 - -0.30; P < 0.001); shorter hospital stay (WMD = -2.67 d; 95%CI: -3.96 - -1.38, P < 0.001); and a decrease in medical complications (RR = 0.41, 95%CI: 0.19-0.90, P = 0.03). The number of harvested lymph nodes, mortality, surgical complications, cancer recurrence rate and long-term survival rate of patients undergoing LATG were similar to those in patients undergoing OTG.

CONCLUSION: Despite a longer operation, LATG can be performed safely in experienced surgical centers with a shorter hospital stay and fewer complications than open surgery.