Laparoscopic side-to-side esophagogastrostomy using a linear stapler after proximal gastrectomy

Laparoscopic Esophagogastric Anastomosis With Stapled Pseudo-Fornix for Reflux Esophagitis Prevention After Proximal Gastrectomy

Laparoscopic esophagogastric anastomosis is not commonly performed after proximal gastrectomy (PG) because of its technical complexity and the lack of a gold standard for reconstruction. We describe a simple and convenient technique of laparoscopic esophagogastrostomy with stapled pseudo-fornix for reflux esophagitis (RE) prevention after PG.

Laparoscopic PG (LPG) was performed in four patients with gastric cancer in the upper third of the stomach, and the remnant stomach was prepared for reconstruction. After making a small hole on the anterior wall of the remnant stomach 45 mm distal to the proximal stump and on the dorsal side of the esophageal stump, a 45 mm no-knife linear stapler was applied. To create a "pseudo-fornix," a common lumen was made by cutting the center of the four staple rows at a length of 15 mm. The entry hole was closed using the laparoscopic hand-sewn suturing technique.

The mean operation time was 240 min, with an estimated blood loss of <10 ml. No intraoperative complications or conversion to open surgery were observed. One patient developed stenosis of the esophagogastrostomy successfully treated by endoscopic balloon dilatation. Endoscopic surveillance three months after surgery revealed no incidence of RE in any of the patients.

Laparoscopic esophagogastric anastomosis with stapled pseudo-fornix is convenient and beneficial in preventing RE after PG and should be considered the treatment of choice for reconstruction after LPG in selected patients with proximal gastric cancer.

Proximal gastrectomy with double-tract reconstruction versus total gastrectomy for proximal early gastric cancer: A systematic review and meta-analysis

BACKGROUND

The incidence of proximal gastric cancer in the gastric fundus, cardia, and other parts is increasing rapidly. The purpose of this study was to systematically compare the short-term and long-term clinical effects of proximal gastrectomy with double tract reconstruction (PG-DTR) to total gastrectomy (TG) for proximal early gastric cancer (EGC).

METHODS

A systematic review and meta-analysis was conducted through searching the literature in PubMed, Web of Science, Cochrane Library, EMBASE, CNKI, WAN FANG, and VIP databases. All clinical controlled trials and randomized controlled trials (RCTs) of PG-DTR and PG were included. Simultaneously, the relevant data were extracted, and the software RevMan version 5.1 was used for the meta-analysis.

RESULTS

Eight studies with a total of 753 patients were eligible for the meta-analysis. There were no significant differences in the operation time, intraoperative blood loss, postoperative hospital stay, early complications (anastomotic fistula and anastomotic bleeding), late complications (reflux symptoms and anastomotic stenosis), and 5-year survival rate between PG-DTR and TG. However, the levels of partial nutritional indicators (vitamin B12 supplements and vitamin B12 deficiency) were significantly higher in the PG-DTR group than in the TG group.

CONCLUSION

This study showed ample evidence to suggest that PG-DTR improved the postoperative nutritional status without compromising patient safety while providing the same surgical characteristics and postoperative morbidity as TG.

Linear stapler anastomosis for esophagogastrostomy in laparoscopic proximal gastrectomy reduce reflux esophagitis

PURPOSE

There are various reconstruction methods for Laparoscopic proximal gastrectomy (LPG), such as esophagogastrostomy (EG), double-tract reconstruction, and jejunal interposition. We have performed EG using a circular stapler (OrVil) from 2013 and using a linear stapler from 2017. The aim of this retrospective study was to clarify which stapler is better for EG for LPG.

METHODS

The data of 84 patients who underwent EG for LPG between January 2013 and September 2019 were analyzed. EG with fundoplication was done using a circular stapler (OrVil) in 45 patients (CS group) and a linear stapler in 39 patients (LS group). The patients' medical records were reviewed. Clinical symptoms were obtained by interview at each outpatient consultation. All patients underwent postoperative 1-year follow-up endoscopy. To minimize bias between the two groups, propensity scores were calculated using a logistic regression model. After propensity-score matching, 60 patients (30 in the CS group and 30 in the LS group) were studied.

RESULTS

Patient characteristics, operative outcomes were similar in two groups. Anastomotic leakage occurred in one patient (3.3%) in both groups. Anastomotic stenosis occurred in five patients (16.7%) in the CS group and two patients (6.7%) in the LS group. The rate of patients with severe reflux esophagitis (grade C or D) was significantly lower in the LS group (3.4%) than in the CS group (26.7%) (p = 0.026).

CONCLUSIONS

EG with a linear stapler could reduce the risk of severe reflux esophagitis, and it could be a safe and feasible anastomosis for patients after LPG.

Effects of reconstruction techniques after proximal gastrectomy: a systematic review and meta-analysis

BACKGROUND

Additional studies comparing several reconstruction methods after proximal gastrectomy have been published; of note, it is necessary to update systematic reviews and meta-analysis from the current evidence-based literature.

AIM

To expand the current knowledge on feasibility and safety, and also to analyze postoperative outcomes of several reconstructive techniques after proximal gastrectomy.

METHODS

PubMed, Google Scholar, and Medline databases were searched for original studies, and relevant literature published between the years 1966 and 2019 concerning various reconstructive techniques on proximal gastrectomy were selected. The postoperative outcomes and complications of the reconstructive techniques were assessed. Meta-analyses were performed using Rev-Man 5.0. A total of 29 studies investigating postoperative outcomes of double tract reconstruction, jejunal pouch interposition, jejunal interposition, esophagogastrostomy, and double flap reconstruction were finally selected in the quantitative analysis.

RESULT

Pooled incidences of reflux esophagitis for double tract reconstruction, jejunal pouch interposition, jejunal interposition esophagogastrostomy, and double flap reconstruction were 8.6%, 13.8%, 13.8%, 19.3%, and 8.9% respectively. Meta-analysis showed a decreased length of hospital in the JI group as compared to the JPI group (heterogeneity: Chi2 = 1.34, df = 1 (P = 0.25); I2 = 26%, test for overall effect: Z = 2.22 (P = 0.03). There was also a significant difference between JI and EG in length of hospital stay with heterogeneity: Chi2 = 1.40, df = 3 (P = 0.71); I2 = 0%, test for overall effect: Z = 5.04 (P < 0.00001). Operative time was less in the EG group as compared to the JI group (heterogeneity: Chi2 = 31.09, df = 5 (P < 0.00001); I2 = 84%, test for overall effect: Z = 32.35 (P < 0.00001).

CONCLUSION

Although current reconstructive techniques present excellent anti-reflux efficacy, the optimal reconstructive method remains to be determined. The double flap reconstruction proved to lower the rate of complication, but the DTR, JI, JPI, and EG groups showed higher incidence of complications in anastomotic leakage, anastomotic stricture, and residual food. In the meta-analysis result, the complications between the JI, JPI, and EG were comparable but the EG group showed to have better postoperative outcomes concerning the operative time, blood loss, and length of hospital stay.

Surgical outcomes and risk assessment for anastomotic complications after laparoscopic proximal gastrectomy with double-flap technique for upper-third gastric cancer

BACKGROUND

Double-flap technique (DFT) has received increased attention as an anastomotic procedure preventing reflux esophagitis after laparoscopic proximal gastrectomy (LPG) for upper-third gastric cancer. However, incidence of anastomotic stricture still remains high. This study was a retrospective review aimed to demonstrate details of surgical outcomes and to assess risk factors for anastomotic complications using pre-operative CT image after LPG with DFT (LPG-DFT).

METHODS

Patient background data, surgical outcomes, post-operative courses, and complications for patients who underwent LPG-DFT from January 2013 to June 2017 were collected. In addition to the details of short-term outcomes, risk factors for anastomotic stricture and gastroesophageal reflux were analyzed.

RESULTS

The study sample was 147 patients, including 139 patients with upper-third gastric cancer and 8 patients with submucosal tumor of the upper-third stomach. The overall morbidity rate was 12.2% (18/147), and 97.3% (143/147) of the patients achieved R0 resection. Twelve (8.3%) patients required endoscopic balloon dilatation for anastomotic stenosis, and six (4.2%) suffered regurgitation grade ≥ B in the Los Angeles classification. Multivariate analysis revealed that diameter of the esophagus < 18 mm on pre-operative CT image and the presence of short-term complications were found to be independent risk factors for post-operative anastomotic stenosis. No specific risk for gastroesophageal reflux was identified.

CONCLUSIONS

The incidence rate of anastomotic complications after LPG-DFT was far lower than that reported after conventional esophagogastrostomy. Alternative anastomotic method may be considered for patients with diameter of the esophagus < 18 mm on pre-operative CT image. Prevention of short-term complications may lessen post-operative stricture.

Laparoscopic esophagogastrostomy using a knifeless linear stapler after proximal gastrectomy

Proximal gastrectomy should improve the late postoperative function in patients with gastric cancer located in the upper third of the stomach or esophagogastric junction. However, a standard method of esophagogastrostomy has not been established for improving the postoperative function. To prevent reflux and stenosis following proximal gastrectomy, we introduced a novel esophagogastrostomy method using a knifeless linear stapler. The stapler was inserted into holes created in both the esophagus and remnant stomach and fired proximally. A 1.5-cm incision was made from the edge of the entry hole between the staples. The entry hole was then closed with continuous sutures, and fundoplication was performed by wrapping the remnant stomach. We performed this technique in 12 consecutive patients without observing any anastomosis-related complications. The proportion of weight lost 1 year after surgery was 8.8%. Our surgical procedure might be feasible for treating gastric cancer located in the upper third of the stomach or esophagogastric junction.

Side overlap esophagogastrostomy to prevent reflux after proximal gastrectomy

BACKGROUND

No optimal method of reconstruction for proximal gastrectomy has been established because of problems associated with postoperative reflux and anastomotic stenosis. It is also important that the reconstruction is easily performed laparoscopically because laparoscopic gastrectomy has become widely accepted in recent years.

METHODS

We have developed a new method of esophagogastrostomy, side overlap with fundoplication by Yamashita (SOFY). The remnant stomach is fixated to the diaphragmatic crus on the dorsal side of the esophagus. The esophagus and the remnant stomach are overlapped by a length of 5 cm. A linear stapler is inserted in two holes on the left side of the esophageal stump and the anterior gastric wall. The stapler is rotated counterclockwise on its axis and fired. The entry hole is closed, and the right side of the esophagus is fixated to the stomach so that the esophagus sticks flat to the gastric wall. The surgical outcomes of the SOFY method were compared with those of esophagogastrectomy different from SOFY.

RESULTS

Thirteen of the 14 patients in the SOFY group were asymptomatic without a proton pump inhibitor, but reflux esophagitis was observed in 5 of the 16 patients in the non-SOFY group and anastomotic stenosis was observed in 3 patients. Contrast enhancement findings in the SOFY group showed inflow of Gastrografin to the remnant stomach was extremely good, and no reflux into the esophagus was observed even with patients in the head-down tilt position.

CONCLUSIONS

SOFY can be easily performed laparoscopically and may overcome the problems of postoperative reflux and stenosis.

Feasibility and safety of modified inverted T-shaped method using linear stapler with movable cartridge fork for esophagojejunostomy following laparoscopic total gastrectomy

BACKGROUND

We previously reported the use of an inverted T-shaped method to obtain a suitable view for hand sewing to close the common entry hole when the linear stapler was fired for esophagojejunostomy after laparoscopic total gastrectomy (LTG). This conventional method involved insertion of the fixed cartridge fork to the Roux limb and the fine movable anvil fork to the esophagus to avoid perforation of the jejunum. However, insertion of the movable anvil fork to the esophagus during this procedure often requires us to strongly push down the main body of the stapler with the fixed cartridge fork to bring the direction of the anvil fork in line with the direction of the long axis of the esophagus while controlling the opening of the movable anvil fork. We therefore modified this complicated inverted T-shaped method using a linear stapler with a movable cartridge fork. This modified method involved insertion of the movable cartridge fork into the Roux limb followed by natural, easy insertion of the fixed anvil fork into the esophagus without controlling the opening of the movable cartridge fork.

METHODS

We performed LTG in a total of 155 consecutive patients with gastric cancer from November 2007 to December 2015 in Kyushu University Hospital. After LTG, we performed the conventional inverted T-shaped method using a linear stapler with a fixed cartridge fork in 61 patients from November 2007 to July 2011 (fixed cartridge group). From August 2011, we used a linear stapler with a movable cartridge fork and performed the modified inverted T-shaped method in 94 patients (movable cartridge group). We herein compare the short-term outcomes in 94 cases of LTG using the modified method (movable cartridge fork) with those in 61 cases using the conventional method (fixed cartridge fork).

RESULTS

We found no significant differences in the perioperative or postoperative events between the movable and fixed cartridge groups. One case of anastomotic leakage occurred in the fixed cartridge group, but no anastomotic leakage occurred in the movable cartridge group.

CONCLUSIONS

Although there were no remarkable differences in the short-term outcomes between the movable and fixed cartridge groups, we believe that the modified inverted T-shaped method is technically more feasible and reliable than the conventional method and will contribute to the improved safety of LTG.

Laparoscopic proximal gastrectomy for early gastric cancer

The incidence of proximal early gastric cancer (EGC) is increasing, and while laparoscopic proximal gastrectomy (LPG) has been performed as a surgical option, it is not yet the standard treatment, because there is no established common reconstruction method following proximal gastrectomy (PG). We reviewed the English-language literature to clarify the current status and problems associated with LPG in treating proximal EGC. This procedure is considered indicated for EGC located in the upper third of the stomach with clinical T1N0, but not when it can be treated endoscopically. No operative mortality or conversion to open surgery was reported in our review, suggesting that this procedure is technically feasible. The most frequent postoperative complication involved problems with anastomoses, possibly caused by the technical complexity of the reconstruction. Although various reconstruction methods following open PG (OPG) and LPG have been reported, there is no standard reconstruction method. Well-designed multicenter, randomized, controlled, prospective trials to evaluate the various reconstruction methods are necessary.

Short-Term Outcomes of Laparoscopic Distal Gastrectomy for Advanced Gastric Cancer

The purpose of this study was to investigate the oncologic outcomes of laparoscopic distal gastrectomy (LDG) for advanced gastric cancer (AGC). Between April 2003 and March 2014, LDG was performed for 392 patients, 91 patients (23.2%) had histopathologically diagnosed AGC beyond T2 depth. The clinicopathological features, postoperative outcomes, mortality, morbidity, recurrence rate, and survivals of those patients were reviewed. The TNM stages of the tumor were IB in 26 patients (28.5%), IIA in 20 (21.9%), IIB in 18 (19.7%), IIIA in 13 (14.2%), IIIB in 6 (6.5%), IIIC in 6 (6.5%), and IV in 2 (2.1%). Major morbidity occurred in 14 patients (15.3%), with no postoperative mortality. Median follow-up was 24.5 months; 10 patients developed recurrence during the follow-up period, and 10 patients died, including 6 cancer deaths. The 5-year overall and disease-free survival rates were 76.8% and 72.6%, respectively. By stage, OS/DFS was 92.3%/91.8% in stage IB, 85.4%/85.4% in stage II, and 49.3%/26.9% in stage III. Oncologic outcomes were good in patients with AGC, especially with stage IB-IIB, who underwent LDG. LDG appears to be an effective approach for treating stage IB and II gastric cancer.

Assessment of the Double-Staple Technique for Esophagoenteric Anastomosis in Gastric Cancer

INTRODUCTION

Reports on outcomes after double-staple technique (DST) for total and proximal gastrectomy are limited, originating mostly from Asian centers. Our objective was to examine anastomotic leak and stricture with DST for esophagoenteric anastomosis in gastric cancer patients.

METHODS

A single institution review was performed for patients who underwent total/proximal gastrectomy with DST between 2006 and 2015. DST was performed using transoral anvil delivery (OrVil) with end-to-end anastomosis. Clinical characteristics and outcomes, including anastomotic leak and stricture, were recorded.

RESULTS

Overall, DST was performed in 60 patients [total gastrectomy (81.7%, n = 49/60), proximal gastrectomy (10.0%, n = 6/60), and completion gastrectomy (8.3%, n = 5/60)]. Neoadjuvant chemotherapy was administered to 21 patients (35.0%), and 6 patients (10.0%) received external beam radiation therapy prior to completion gastrectomy. Operative approach was open (51.7%, n = 31/60), laparoscopic (43.3%, n = 26/60), or robotic (5.0%, n = 3/60). Anastomotic leak occurred in 6.7% (n = 4/60), while stricture independent of leak was identified in 19.0% (n = 11/58) of patients. Complications occurred in 38.3% (n = 23/60) of patients, of which 52% were classified as Clavien-Dindo grades III-V complications.

CONCLUSION

In the largest Western series of DST for esophagoenteric anastomoses in gastric cancer surgery, our experience demonstrates that DST is safe and effective with low rates of leak and stricture.

In vivo evaluation of a modified linear stapling device designed to facilitate accurate pathologic examination of the surgical margin

BACKGROUND

Microscopic involvement of the resection margin could influence the long-term outcome of patients undergoing curative surgery for gastric cancer. Linear staplers, commonly used for gastrectomies, are often equipped with three lines of staples on either side of the resection line. Although multiple lines of staples reinforce closure of the gastric or intestinal stump, they could hinder accurate histopathologic evaluation of the surgical margin of the resected specimen.

METHODS

We modified a linear stapling device by removing one line (stapler E2) or two lines (stapler E1) of staples on the specimen side, and attempted to dissect a silicon film and then the stomach from a porcine model using the stapling device and examined the distances between the cutting edge and the nearest staple line.

RESULTS

The distance between the cutting edge and the staple line for stapler E1 was significantly greater than the distance between the cutting edge and the nearest staple line for stapler E2 or the control device. Consequently, specimens of exemplary quality were available for pathologic examination of the surgical margin. Moreover, the lack of multiple layers of staples did not result in contamination of the abdominal cavity with gastric juice during laparoscopic procedures in the porcine model.

CONCLUSIONS

Stapler E1 is safe and could be useful for the pathologic evaluation of the true surgical margin.

Laparoscopy-assisted total gastrectomy: a simplified approach

Laparoscopy-assisted total gastrectomy (LATG), esophagojejunostomy is an effective but difficult procedure to perform. We describe a simple modification that substantially facilitates insertion of the anvil into the esophagus and avoids oral injuries and complications. After mobilization of the stomach and esophagus, a semicircumferential esophagotomy is made at the anterior esophageal wall. An OrVil anvil (Orvil, Covidien, Norwalk, CT, USA) is delivered laparoscopically and secured with a POLYSORB (Covidien) suture to the esophagus. The suture is advanced anteriorly so that the center rod penetrates the esophageal wall. The esophagus is transected with the stapler at this point. A circular-stapled esophagojejunostomy is then performed using the hemidouble stapling technique. Laparoscopy-assisted total gastrectomies were performed for 40 patients with gastric cancers (T1N0M0). All procedures were completed laparoscopically without any complications. The time required to place the anvil averaged 5 min compared with 9 min reported by others. There were no major complications or mortality in this series. The major advantage of this technique is that circular stapling is much easier than linear stapling, allowing surgeons without advanced surgical skills in LATG to perform the procedure effectively and safely.

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.

Esophagogastric tube reconstruction with stapled pseudo-fornix in laparoscopic proximal gastrectomy: a novel technique proposed for Siewert type II tumors

PURPOSE

The incidence of adenocarcinoma of the esophagogastric junction is increasing, but laparoscopic proximal gastrectomy is not widely accepted due to the absence of a standardized technique of reconstruction. This report describes a novel technique of esophagogastric tube reconstruction in laparoscopic proximal gastrectomy for Siewert type II tumors.

METHODS

Laparoscopic proximal gastrectomy, sometimes with transhiatal distal esophagectomy, was performed. After a perigastric, suprapancreatic, and lower thoracic paraesophageal lymphadenectomy, a gastric tube of 35-mm width was prepared. An esophagogastric tube anastomosis with pseudo-fornix was made with a no-knife linear stapler to prevent postoperative reflux esophagitis.

RESULTS

Fifteen patients with Siewert type II tumors underwent this operation. They included six patients with early-stage cancer, six at high risk for transhiatal total gastrectomy due to several comorbidities, and three who needed palliative tumor resection. The mean operation time was 315 min. One postoperative anastomotic leak was treated conservatively, and three anastomotic stenoses were resolved with endoscopic balloon dilatation. Postoperative 1-year follow-up endoscopy revealed four cases of reflux esophagitis that were well controlled by medication.

CONCLUSIONS

This new technique of reconstruction was feasible. With the advantage of a gastric tube, a tension-free anastomosis was possible even for bulky tumors that needed lower esophagectomy. Although long-term follow-up and a larger number of patients are required to evaluate long-term functional outcomes and oncological adequacy, our procedure has the potential of becoming a treatment of choice for early-stage Siewert type II tumors and/or for some selected high-risk patients who need tumor resection.

Single incision laparoscopic total gastrectomy and d2 lymph node dissection for gastric cancer using a four-access single port: the first experience

Single incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) have been developed to reduce the invasiveness of laparoscopic surgery. SILS has been frequently applied in various clinical settings, such as cholecystectomy, colectomy, and sleeve gastrectomy. So far, there have been four reports on single incision laparoscopic distal gastrectomy and one report on single incision laparoscopic total gastrectomy with D1 lymph node dissection for gastric cancer. In this report, we present our single incision laparoscopic total gastrectomy with D2 lymph node dissection technique using a four-hole single port (OctoPort) in a patient with gastric cancer.

Lower esophageal sphincter-preserving laparoscopy-assisted proximal gastrectomy in patients with early gastric cancer: a method for the prevention of reflux esophagitis

Although laparoscopy-assisted proximal gastrectomy (LAPG) with esophagogastrostomy for early gastric cancer (EGC) is technically feasible and oncologically safe, it has not been popularized because of the frequent occurrence of reflux esophagitis associated with loss of the lower esophageal sphincter (LES). Herein, we present surgical outcomes in patients with LES-preserving LAPG (LES-p LAPG), which may contribute to protecting against postoperative gastroesophageal reflux or stricture in the treatment of proximal EGC. From November 2009 to May 2010, LES-p LAPG was performed in nine patients with clinical EGC, located at the proximal one-third of the stomach with the upper margin of the tumor 3-4 cm from the esophagogastric junction. After the resection of the proximal stomach with D1 + β lymph node dissection, gastrogastrostomy was performed using a 25-mm circular stapler through a mini-laparotomy wound at the epigastrium. The median operating time was 137.5 min (range 120-180). The median number of retrieved lymph nodes and length of the proximal resection margin were 27 (range 7-49) and 2.4 cm (range 0.7-5), respectively. The postoperative complications included one gastrogastrostomy stricture and one case of leakage, which were managed by endoscopic balloon dilation and conservative treatment, respectively. None of the patients suffered from symptoms of reflux esophagitis during the follow-up period (median 15 months; range 8-28 months). This technique of LES-p LAPG for the treatment of proximal EGC could be a simple, safe, and useful technique to prevent esophageal reflux or stricture. This technique requires prospective validation.

Laparoscopic proximal gastrectomy with a hand-sewn esophago-gastric anastomosis using a knifeless endoscopic linear stapler

Proximal gastrectomy has been applied for selected patients with early upper gastric cancer, because of its potential advantages over total gastrectomy, such as preserving gastric capacity and entailing fewer hormonal and nutritional deficiencies. Esophago-gastric anastomosis is a simple reconstruction method with an excellent postoperative outcome provided that gastroesophageal reflux is properly prevented. Following open surgery, the esophagus is anastomosed to the anterior stomach wall with partial fundoplication to prevent esophageal reflux. We developed a novel laparoscopic hand-sewn method to reproduce the anti-reflux procedure that is used in open surgery. The esophagus is first fixed to the anterior stomach wall with a knifeless endoscopic linear stapler. This fixation contributes to maintaining a stable field for easier hand-sewn anastomosis, and allows us to complete the left side of the fundoplication at the same time. This novel technique was used to successfully perform complete laparoscopic proximal gastrectomy with a hand-sewn esophago-gastric anastomosis in ten patients, without any postoperative complications. No patient had symptoms of gastroesophageal reflux during a median follow-up period of 19.9 months. One patient developed anastomotic stenosis, and this was resolved with endoscopic dilatation. The mean percent body weight loss at 12 months after surgery, in comparison to the preoperative weight, was 10.4 %. Laparoscopic proximal gastrectomy with an esophago-gastric anastomosis using our novel technique would be a feasible choice would be a feasible choice and would show benefit for selected patients with early upper gastric cancer.

Feasibility and safety of intracorporeal esophagojejunostomy after laparoscopic total gastrectomy: inverted T-shaped anastomosis using linear staplers

BACKGROUND

Although laparoscopic distal gastrectomy has been widely accepted in clinical practice, laparoscopic total gastrectomy (LTG) is not yet familiar because of the difficulty in esophagojejunostomy. The purpose of this study was to evaluate perioperative and short-term outcomes of our procedure of intracorporeal gastrojejunostomy using linear staplers after LTG.

METHODS

Of 98 consecutive patients who underwent LTG for gastric cancer in our department between August 2002 and December 2010, 94 patients underwent esophagojejunostomy with a linear stapling device. After October 2007, we modified the esophagojejunostomy; ie, the most recent 57 patients underwent transection of the esophagus in the ventrodorsal direction and insertion of a linear stapler from the anterior wall of the Roux limb to the posterior wall so as to make an inverted T-shaped anastomosis. We evaluated the results in these 57 patients (recent group) and compared them with the results in the earlier 37 patients (early group).

RESULTS

The mean operative time in the recent group was 368 to 94.6 min, and the mean estimated blood loss was 57 to 33 g; both were comparable with those in the early group. Neither open conversion nor intraoperative complications were encountered. Two patients experienced anastomotic leakage in the earlier group, but anastomotic leakage did not occur in the recent group. No mortality was encountered.

CONCLUSION

We herein report our procedure of intracorporeal gastrojejunostomy using linear staplers after LTG. Our procedure of esophagojejunostomy using linear staplers is safe and feasible and has acceptable morbidity.

Modified techniques and early outcomes of totally laparoscopic total gastrectomy with side-to-side esophagojejunostomy

BACKGROUND

Construction of an esophagojejunostomy is a major concern in totally laparoscopic total gastrectomy (TLTG). Use of a circular stapler can be technically challenging in laparoscopic procedures. We aimed to introduce our modified techniques and to assess the early outcomes following TLTG with side-to-side esophagojejunostomy using a linear stapler in patients with gastric cancer.

SUBJECTS AND METHODS

From December 2010 to June 2011, 27 patients who underwent TLTG for gastric cancer were retrospectively reviewed. Their clinicopathologic characteristics, surgical time, hospital stay, morbidity, and mortality were analyzed.

RESULTS

The mean age of patients was 59.1 years, and the average body mass index was 24.6 kg/m(2). The mean operating time was 126.2 minutes, and the hospital stay averaged 8.1 days. No conversion to open laparotomy was required. There were 2 luminal bleeding cases and 1 intra-abdominal bleeding case, but all were successfully managed with conservative treatment only. No patient experienced reoperation, anastomosis leakage, stricture, duodenal stump leakage, or wound problems.

CONCLUSIONS

Our TLTG with side-to-side esophagojejunostomy method can be a feasible and safe option for patients with gastric cancer.

Intracorporeal anastomosis in laparoscopic gastric cancer surgery

Laparoscopic gastrectomy has become widely used as a minimally invasive technique for the treatment of gastric cancer. When it was first introduced, most surgeons preferred a laparoscopic-assisted approach with a minilaparotomy rather than a totally laparoscopic procedure because of the technical challenges of achieving an intracorporeal anastomosis. Recently, with improved skills and instruments, several surgeons have reported the safety and feasibility of a totally laparoscopic gastrectomy with intracorporeal anastomosis. This review describes the recent technical advances in intracorporeal anastomoses using circular and linear staplers that allow for totally laparoscopic distal, total, and proximal gastrectomies. Data that demonstrate advantages in early surgical outcomes of a total laparoscopic method compared to laparoscopic-assisted operations are also discussed.

Laparoscopic gastrectomy after incomplete endoscopic resection for early gastric cancer

Endoscopic submucosal dissection (ESD) utilizes electrical coagulation, which can cause burns, fibrosis and adhesion of the stomach and surrounding tissue; these complications might increase the surgical difficulties for subsequent laparoscopy-assisted gastrectomy (LAG) and the risk of complications. However, scarce data are available on the influence of previous ESD on LAG. The purpose of this study was to evaluate the feasibility and safety of LAG following incomplete ESD in patients with early gastric cancer. Ninety-seven patients who underwent LAG were analyzed retrospectively; 17 patients had undergone ESD previously and the remaining 80 patients had no history of ESD. Clinicopathological data and surgical outcomes were compared between the two groups. No differences were observed in surgical outcomes of LAG after ESD in terms of operation time, intraoperative blood loss, total number of harvested lymph nodes, time until start of flatus, and postoperative hospital stay. These results were not influenced by tumor location and operative procedures. In conclusion, in terms of surgical outcomes, LAG is a safe and feasible procedure for the treatment of early gastric cancer regardless of previous endoscopic treatment. LAG may be the first-choice radical treatment after incomplete ESD for early gastric cancer.

Laparoscopic proximal gastrectomy with jejunal interposition for gastric cancer in the proximal third of the stomach: a retrospective comparison with open surgery

BACKGROUND

The incidence of cancer in the proximal third of the stomach is increasing. Laparoscopic proximal gastrectomy (LPG) seems an attractive option for the treatment of early-stage proximal gastric cancer but has not gained wide acceptance because of technical difficulties, including the prevention of severe reflux. In this study, we describe our technique for LPG with jejunal interposition (LPG-IP) and evaluate its safety and feasibility.

METHODS

In this retrospective analysis, we reviewed the data of patients with proximal gastric cancer who underwent LPG-IP (n = 22) or the same procedure with open surgery (OPG-IP; n = 68) between January 2008 and September 2011. Short-term surgical variables and outcomes were compared between the groups. The reconstruction method was the same in both groups, with creation of a 15 cm, single-loop, jejunal interposition for anastomosis.

RESULTS

There were no differences in patient or tumor characteristics between the groups. Operation time was longer in the LGP-IP group (233 vs. 201 min, p = 0.0002) and estimated blood loss was significantly less (20 vs. 242 g, p < 0.0001). The average number of harvested lymph nodes did not differ between the two groups (17 vs. 20). There also were no differences in the incidence of leakage at the esophagojejunostomy anastomosis (9.1 vs. 7.4%) or other postoperative complications (27 vs. 32%). The number of times additional postoperative analgesia was required was significantly less in the LPG-IP group compared with the OPG-IP group (2 vs. 4, p < 0.0001).

CONCLUSIONS

LPG-IP has equivalent safety and curability compared with OPG-IP. Our results imply that LPG-IP may lead to faster recovery, better cosmesis, and improved quality of life in the short-term compared with OPG-IP. Because of the limitations of retrospective analysis, a further study should be conducted to obtain definitive conclusions.

Laparoscopy-assisted proximal gastrectomy with sentinel node mapping for early gastric cancer

BACKGROUND

Laparoscopy-assisted proximal gastrectomy (LAPG) remains a relatively uncommon procedure because of certain technical issues, such as curability, safety, and retention of postoperative patients' quality of life. The aim of the present study was to evaluate the feasibility of a newly developed LAPG procedure for early-stage proximal gastric cancer.

METHODS

We enrolled 37 consecutive patients who were preoperatively diagnosed with cT1N0M0 primary gastric cancer in the upper third of the stomach with the primary tumor diameter less than 4 cm. Laparoscopy-assisted proximal gastrectomy with sentinel node (SN) mapping and esophagogastric anastomosis with a circular stapler and transoral placement of the anvil was attempted.

RESULTS

The LAPG procedure was completed in 36 patients. It was converted to laparoscopy-assisted total gastrectomy in one patient because one SN detected intraoperatively was positive for metastasis by intraoperative pathological diagnosis. There were no severe postoperative complications in any patient. Only one patient (3%) complained of mild reflux symptoms immediately after operation, which were graded endoscopically as B by the Los Angeles Classification of gastroesophageal reflux disease; however, the symptoms were controlled well by a proton-pump inhibitor. Sentinel nodes were detected successfully in 37 (100%) of our patients. The mean number of dissected lymph nodes and identified SNs per case was 29.7 and 5.8, respectively. The sensitivity of prediction of nodal metastasis (including isolated tumor cells) and diagnostic accuracy based on SN status were 100% (3/3) and 100% (37/37), respectively. All patients have been free from recurrence for a median follow-up period of 26 months.

CONCLUSIONS

This study reveals that our novel LAPG approach is curative and represents a feasible minimally invasive surgical procedure with minimal morbidity and postoperative reflux esophagitis in patients with upper-third early-stage gastric cancer.

Long-term outcomes and feasibility with laparoscopy-assisted gastrectomy for gastric cancer

Purpose

Recently, laparoscopy-assisted gastrectomy (LAG) has been widely accepted modality for early gastric cancer in Korea. The indication of LAG may be extended in an experienced institution. In our institution, the first case of laparoscopy-assisted gastrectomy (LAG) for gastric cancer was performed in May 1998. We retrospectively reviewed the long-term oncologic outcomes over 12 years to clarify the feasibility of LAG for gastric cancer.

Materials and Methods

The authors retrospectively analyzed 753 patients who underwent LAG for gastric cancer, from May 1998 to August 2010. We reviewed clinicopathological features, postoperative outcomes, mortality and morbidity, recurrence, and survival of LAG for gastric cancer.

Results

During the time period, 3,039 operations for gastric cancer were performed. Among them, 753 cases were done by LAG (24.8%). There were 69 cases of total gastrectomy, 682 subtotal gastrectomies, and 2 proximal gastrectomies. According to TNM stage, 8 patients were in stage 0, 619 in stage I, 88 in stage II, and 38 in stage III. The operation-related complications occurred in 77 cases (10.2%). Median follow-up period was 56.2 months (range 0.7~165.6 months). Twenty-five patients (3.3%) developed recurrence, during the follow-up period. The overall 5-year and disease free survival rates were 97.1% and 96.3%, respectively.

Conclusions

The number of postoperative complications and survival rates of our series were comparable to the results from that of other reports. The authors consider LAG to be a feasible alternative for the treatment of early gastric cancer. However, rationale for laparoscopic surgery in advanced gastric cancer has yet to be determined.

Impact of anastomotic complications on outcome after laparoscopic gastrectomy for early gastric cancer

BACKGROUND

The effects of anastomotic complications after laparoscopically assisted gastrectomy (LAG) have not been studied widely. The aims of this observational study were to identify potential factors that predict anastomotic complications and investigate the impact of anastomotic complications in patients undergoing gastrectomy for early gastric cancer.

METHODS

The study included consecutive patients with histologically proven T1 gastric adenocarcinoma treated by LAG with regional lymphadenectomy between August 1997 and March 2008, who had not received neoadjuvant chemotherapy. Anastomotic complications included anastomotic leakage, stricture and remnant gastric stasis of grade II or higher (modified Clavien classification) and were identified by clinical assessment and confirmatory investigation. Predictive factors for the development of anastomotic complications were identified by univariable and multivariable analyses. Long-term survival with or without anastomotic complications was examined.

RESULTS

Anastomotic complications occurred in 37 (9·3 per cent) of 400 patients. Multivariable analysis indicated surgeon experience as the only independent predictor of anastomotic complications (hazard ratio 4·40, 95 per cent confidence interval 2·04 to 9·53; P < 0·001). Patients with anastomotic complications had a significantly worse overall 5-year survival rate than those without (81 versus 94·2 per cent; P = 0·009).

CONCLUSION

Anastomotic complications after LAG lead to worse long-term survival.

Comparison of long-term prognosis of laparoscopy-assisted gastrectomy and conventional open gastrectomy with special reference to D2 lymph node dissection

BACKGROUND

Laparoscopy-assisted gastrectomy (LAG) is becoming widely used for early gastric cancer. However, how the curability and long-term prognosis of LAG and open gastrectomy (OG) for early and advanced gastric cancer compare remains unclear. This study assessed short- and long-term outcomes after LAG with lymph node dissection in early and advanced gastric cancer.

METHODS

A total of 332 patients who underwent LAG or OG for early and advanced gastric cancer from January 2001 through December 2010 were reviewed retrospectively. The mean operating time, estimated mean blood loss, number of dissected lymph nodes, and survival rates were compared between LAG and OG for early and advanced gastric cancer.

RESULTS

Overall, 47.6% (158/332) of patients underwent LAG; D1, D1+ lymph node dissection was carried out in 77.2%, with D2 dissection in 22.8%. Only one patient required conversion to OG. Comparing LAG and OG with D1, D1+ lymph node dissection for early gastric cancer (EGC), mean operating time was significantly longer, estimated mean blood loss was significantly smaller, and the average number of retrieved lymph nodes was significantly greater with LAG. The rate of specific postoperative morbidity was 17.2% for LAG patients and 25.0% for OG patients, with no postoperative mortality. Survival and recurrence rates were not significantly different. Comparing LAG and OG with D2 lymph node dissection for advanced gastric cancer (AGC), mean operating time was significantly longer and estimated mean blood loss was significantly smaller with LAG, while the average number of retrieved lymph nodes, specific postoperative morbidity and mortality, and survival and recurrence rates were not significantly different.

CONCLUSIONS

LAG with D1, D1+ lymph node dissection for EGC is safe and equivalent to open gastrectomy in curability. Moreover, LAG with D2 lymph node dissection for AGC is comparable to OG with D2 lymph node dissection with regard to short- and long-term results.

Disk suspension method: a novel and safe technique for the retraction of the liver during laparoscopic surgery (with video)

BACKGROUND

A good operative field is important for safe operations, but it is sometimes difficult to obtain a satisfactory operative field in laparoscopic upper abdominal surgery. We developed a novel and safe technique for the retraction of the liver and falciform ligament during laparoscopic surgery, and evaluated its technical feasibility and safety.

METHODS

Forty-three patients with gastric cancer were divided into two groups: disk suspension group (DS group; snake retractor and elastic band fixation with a silicon disk), and fixed retractor group (FR group; snake retractor and nonelastic band fixation without a silicon disk). To evaluate liver damage during retraction, we measured the aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels preoperatively and on postoperative day (POD) 1.

RESULTS

In the DS group, all liver lobes were adequately retracted and the hepatoduodenal and gastrohepatic ligaments were fully exposed. This procedure took less than 3 min. On the other hand, 5 of 18 patients of the FR group had insufficient surgical fields for laparoscopic gastrectomy because of soft and/or large livers. Although the preoperative AST and ALT levels were not different between the two groups, the DS group did not display increases in both AST and ALT levels, whereas the FR group showed increases in both on POD 1 (AST: 50.2 ± 8.4 IU/l vs. 124.2 ± 37.7 IU/l, P = 0.07; and ALT: 35.6 ± 6.4 IU/l vs. 106.1 ± 36.2 IU/l, P = 0.07). No complications related to the liver retraction were observed in the DS group. However, liver congestion was evident in six patients and minor liver injury in two patients of the FR group during the esophagojejunostomy.

CONCLUSIONS

The DS method is a simple and safe and provides a better surgical field during laparoscopic surgery of the upper abdomen without damaging the liver.

Trans-vaginal specimen extraction following totally laparoscopic subtotal gastrectomy in early gastric cancer

BACKGROUND

Although natural orifice extraction is now widely performed, there have been no reports of this procedure following subtotal gastrectomy for gastric cancer. This report describes trans-vaginal specimen extraction in four patients with early gastric cancer.

METHODS

The clinical data of four patients with early gastric cancer were reviewed. Totally laparoscopic subtotal gastrectomy and D1 + β lymph node dissection was performed using five trocars and a conventional procedure. Posterior colpotomy was performed by an experienced gynecologist, who retrieved the specimens in a retrieval bag via the trans-vaginal route. The colpotomy site was repaired immediately following specimen removal. Reconstruction was performed using the intracorporeal Billroth II method and an endo-GIA 60.

RESULTS

Totally laparoscopic subtotal gastrectomy and trans-vaginal specimen extraction was successfully accomplished in all patients without intraoperative complications.

CONCLUSIONS

The present technique may be a safe and feasible operative procedure for some limited groups of elderly female patients with early gastric cancer.

Risk of recurrence after laparoscopy-assisted radical gastrectomy for gastric cancer performed by a single surgeon

BACKGROUND

The risk of recurrence after laparoscopy-assisted radical gastrectomy (LAG) was investigated.

MATERIALS AND METHODS

Clinical data of 398 consecutive patients who underwent radical gastrectomy with R0 resection for gastric cancer at Gyeongsang National University Hospital between January 2005 and December 2007 were reviewed retrospectively.

RESULTS

Of the patients, 65.4% (n = 261) and 34.6% (n = 138) underwent LAG and open radical gastrectomy (OG), respectively. Of the LAG cases, 73.2% (n = 192), 10.7% (n = 28), 12.6% (n = 33), and 3.1% (n = 8) had stage I, II, III, and IV gastric cancer, respectively. All patients were followed up for a mean of 36.8 ± 13.7 months, and 14.6% (n = 58) had recurrence during the follow-up period. Univariate analysis revealed that tumor size, tumor-node-metastasis (TNM) stage, method of approach (LAG versus OG), and operation type were associated significantly with recurrence. Multivariate analysis revealed that only high TNM stage was significantly associated with recurrence (P = 0.00). While patients who underwent OG had higher incidence of recurrence than patients who underwent LAG, OG was not significantly associated with recurrence on multivariate analysis (P = 0.06).

CONCLUSIONS

LAG and OG did not differ significantly in terms of recurrence, even when used in advanced gastric cancer cases. Multivariate analysis revealed that high TNM stage was significantly associated with recurrence. Thus, LAG appears to be a safe and feasible procedure that has the potential to be an alternative to open surgery, even for advanced gastric cancer.

Application of the transorally inserted anvil (OrVil) after laparoscopy-assisted total gastrectomy

BACKGROUND

Laparoscopy-assisted total gastrectomy (LATG) is not a commonly performed procedure due to the surgical difficulty associated with reconstruction. Although various reconstruction methods have been reported, a standard technique has not yet been established. In this study, we compared the short-term outcomes of LATG reconstructed by mini-laparotomy and by the newly developed transorally inserted anvil (OrVil).

METHODS

From April 2006, a series of 45 patients underwent LATG. Of these, 15 were reconstructed by mini-laparotomy and 30 by OrVil. Short-term outcomes were compared between the two groups.

RESULTS

Operation time was significantly shortened and intraoperative blood loss significantly reduced by the use of OrVil. The postoperative course, including morbidity, did not differ between the two groups.

CONCLUSIONS

LATG using OrVil for the treatment of early gastric cancer is a technically feasible surgical procedure with sufficient lymph node dissection, satisfactory early recovery, and acceptable morbidity. It will be necessary to perform this novel technique in a large number of patients to confirm its feasibility.

Long-term oncologic outcomes from laparoscopic gastrectomy for gastric cancer: a single-center experience of 601 consecutive resections

BACKGROUND

Laparoscopic gastrectomy (LG) is becoming increasingly popular for management of early gastric cancer (EGC). Although short-term efficacy is proven, reports on long-term effectiveness are still infrequent.

STUDY DESIGN

All patients with a diagnosis of gastric cancer undergoing LG from the beginning of our laparoscopic experience were included in the analysis. At our unit, LG is indicated for all cancers up to preoperative stage T2N1.

RESULTS

Six-hundred and one laparoscopic resections were included in the analysis. There were 392 men and 209 women. Mean age was 64.2 +/- 10.9 years. Distal gastrectomy was performed in 305 patients, pylorus-preserving gastrectomy in 148, segmental gastrectomy in 42, proximal gastrectomy in 53, total gastrectomy in 27, and wedge resection in 26. Histological staging revealed that 478 patients had stage IA disease, 47 had stage IB, 44 had stage IIA, 19 had stage IIB, 8 had stage IIIA, 3 had stage IIIB, and 2 had stage IIIC. Morbidity and mortality rates were 17.6% and 0.3%, respectively. Median follow-up was 35.9 months (range 3 to 113 months). Cancer recurrence occurred in 15 patients and metachronous gastric remnant cancer was detected in 6 patients. The 5-year overall and disease-free survival rates were 94.2% and 89.9%, respectively, for stage IA tumors, 87.4% and 82.7% for stage IB, 80.8% and 70.7% for stage IIA, and 69.6% and 63.1% for stage IIB.

CONCLUSIONS

In our experience, long-term oncological outcomes from LG for EGC are acceptable. Wherever expertise permits, LG should be considered as the primary treatment in patients with EGC.

New double-stapling technique for esophagojejunostomy and esophagogastrostomy in gastric cancer surgery, using a peroral intraluminal approach with a digital stapling system

In the abdominal-transhiatal approach for resection of adenocarcinoma of the cardia or subcardia, and in laparoscopy-assisted total gastrectomy (LATG), the use of a circular stapling device has potential problems with the placement of the purse-string suture and insertion of the anvil of the instrument. We describe a new double-stapling technique for esophagojejunostomy and esophagogastrostomy, using a peroral intraluminal approach with a digital stapling system, a flexible shaft remote-control stapler - the Surg-ASSIST and Power Circular Stapler 21 mm (PCS). The overtube of the flexible shaft of the PCS is prepared with a nylon tie and secured to a nasogastric (NG) tube. The flexible shaft is manually advanced down the esophagus with guidance by pulling the NG tube from the abdominal cavity side. The trocar of the flexible shaft is removed from the stump of the abdominal esophagus and connected to the anvil and they are approximated; the stapler device is then fired to form a double-stapled esophagojejunostomy and esophagogastrostomy. Our peroral intraluminal approach does not require a suturing technique, and it can make anastomosis after resection for carcinoma of the esophagogastric junction and after LATG safe and simple.

Clinical factors affecting the length of minilaparotomy incision in laparoscopy-assisted distal gastrectomy

This study investigated the factors affecting the length of the minilaparotomy incision (LOMI) in laparoscopy-assisted distal gastrectomy with Billroth I reconstruction. By using abdominal computed tomography scans, we measured the thickness of the rectus muscle (TRM), the thickness of the abdominal wall (TAW), and the distance from the gastroduodenal artery to the skin (GDAS) in 80 patients with early gastric cancer who had undergone surgery. There were positive correlations between the LOMI and body mass index (BMI), TRM, and TAW, and the LOMI increased significantly in patients with BMI > or =25 kg/m2, TAW > or =2.1 cm, and TRM > or =1.0 cm. These observations suggest that patients with two or more of the following clinical factors, BMI > or =25 kg/m2, TAW > or =2.1 cm, and TRM > or =1.0 cm, may require surgical procedures other than laparoscopy-assisted Billroth I, such as total laparoscopic intracorporeal Billroth I, Billroth II, or uncut Roux-en-Y reconstruction.

Laparoscopy-assisted combined resection for synchronous gastric and colorectal cancer: report of three cases

In gastric cancer patients, the most common form of synchronous cancer is colorectal cancer. To reduce the invasiveness of the resection, a laparoscopy-assisted combined resection was performed in three patients with synchronous gastric and colorectal cancer. Although all gastric lesions were in the early stages, two colorectal lesions were advanced cases. In all cases, the laparoscopic gastric resection and reconstruction was performed first, followed by the colorectal resection. In the case of right-side colon cancer in addition to gastric cancer, it was relatively easy to perform the combined resection with lymph node dissection sharing the same ports used for the gastrectomy, although we needed an additional port. In one case, in which rectal cancer was present in addition to gastric cancer located in the upper portion of the stomach, a totally laparoscopic proximal gastrectomy was combined with a laparoscopy-assisted low anterior resection, leaving only a lower abdominal minilaparotomy wound. All patients quickly returned to normal activity without remarkable complications, with the exception of a wound infection in one patient. With a mean follow-up of 30.7 months, all patients survived without any sign of recurrence. This procedure represents a feasible option for minimally invasive treatment of synchronous gastric and colorectal cancer.

Ancillary N.O.T.E.S. procedures for early stage gastric cancer

The potential for performing truly scarless, safe surgery that at the same time may be less morbid is tempting both patients and physicians alike to seriously consider Natural Orifice Transluminal Endoscopy Surgery (NOTES) for a range of clinical applications. Given the move towards gastric-preservation by minimally invasive techniques for definitive management of early gastric cancer, this radical approach may find a niche within future clinical care paradigms for early stage malignant lesions of the stomach. Indeed already selected T1,N0 adenocarcinoma is being treated and even cured by advanced endoscopic techniques such as Endoscopic Submucosal Dissection. NOTES may initially therefore find a role in furthering the application of such endeavour by ensuring oncological providence in the treatment of those T1 lesions with higher risk of lymphatic metastases that currently are advised to lie outwith the scope of pure endoscopic resection (for reasons of oncological propriety rather than technical capacity). One such means NOTES could supplement ESD is by providing for direct sampling of sentinel nodes from the perigastric lymph basins. Subsequently perhaps a NOTES technique may develop capable of performing localized, full-thickness gastric wedge or sleeve resection for T2,N0 adenocarcinoma (and indeed perhaps other pathologies such as small gastrointestinal stromal tumors). This review examines how advancing technology along with progressive surgical thinking and innovation could lead to NOTES becoming absorbed into clinical care pathways for early gastric malignancy.

Preliminary experience using a computer-mediated flexible circular stapler in laparoscopic esophagogastrostomy

Intracorporeal esophagogastrostomy after laparoscopic proximal gastrectomy is technically challenging. We employed a computer-mediated flexible circular stapler (SurgASSIST) for esophagogastrostomy in 2 cases with gastrointestinal stromal tumor located near the esophagogastric junction. Esophagogastrostomy was successfully constructed intracorporeally using the double-stapling technique. Operation times for the 2 cases were 225 and 170 minutes. No anastomotic leakage was encountered. However, anastomotic stricture requiring balloon dilatation occurred in 1 patient. The SurgASSIST system was feasible for esophageal anastomosis in laparoscopic proximal gastrectomy. However, the digital loading unit (DLU) is too large to introduce transorally, and attempting introduction of the DLU through the narrow lumen may create lesions or perforate the organ. Further improvements in the DLU will facilitate wider use of this system for various procedures in laparoscopic surgery.

Current status of minimal access surgery for gastric cancer

BACKGROUND

The aim was to conduct a systematic review of the literature on the subject of laparoscopic gastrectomy (LG) and determine the relative merits of laparoscopic (LG) and open gastrectomy (OG) for gastric carcinoma.

MATERIAL AND METHODS

A search of the Medline, Embase, Science Citation Index, Current Contents and PubMed databases identified individual retrospective and prospective series on LG (proximal, distal and total). Furthermore, all clinical trials that compared LG and OG published in the English language between January 1990 and the end of December 2006 were also identified. A large number of outcome variables were analysed for individual series and comparative trials between LG and OG and results discussed and tabulated.

RESULTS

The majority of the literature is published from Japan showing both oncological adequacy and safety of LG. The majority of early series and comparative studies have utilized laparoscopic resection for early and distal gastric cancer. However, with increasing advanced laparoscopic experience, advancement in digital technology and improvement in instrumentation, more advanced gastric cancers and more extensive procedures such as laparoscopic-assisted total gastrectomy and laparoscopy-assisted D2 dissection are becoming more common. To date lymph node harvesting, resection margins and complication rates seem to be equivalent to open procedures. Furthermore, the earlier fears of port-site metastases have not been borne out.

CONCLUSIONS

The available data suggests that LG seems to be associated with quicker return of gastrointestinal function, faster ambulation, earlier discharge from hospital, and comparable complications and recurrence rate to OG. However, the operating time for LG remains significantly longer compared to its open counterpart, although with experience it is achieving parity with OG. However, the majority of the comparative trials (if not all) probably do not have the power to detect differences in the outcome. As far as the RCT's (LG vs. OG) are concerned, the numbers of patients in such trials are small and the majority of patients were operated upon for early distal gastric cancer and, therefore, any meaningful conclusions regarding the advantages or disadvantages of LG for both the ECGs and extensive and advanced gastric tumours are difficult to justify.

Hemidouble stapling for esophagogastrostomy during laparoscopically assisted proximal gastrectomy

In esophagogastrostomy during laparoscopically assisted proximal gastrectomy, some problems have occurred; the main ones being reflux esophagitis and the technical difficulty in anastomosis. We have had good results with a hemidouble stapling technique; the center rod of circular stapler is pierced through the left end of the staple line of the stomach. The longest distance from the pylorus to the esophagogastrostomy can be fired in this position. The distance is longer, so alkaline esophagitis is rarer. When the center rod is pierced through the anterior or posterior gastric wall, the operator may be worried about ischemia of the area surrounded by the linear stapler and circular stapler. In hemidouble stapling, an ischemic area is not created at all structurally. Any surgeon can perform a reproducible anastomosis because the place pierced with the center rod is fixed. This technique is easy and safety to operate via minilaparotomy.

A multicenter study on oncologic outcome of laparoscopic gastrectomy for early cancer in Japan

BACKGROUND

Laparoscopic surgery for gastric cancer is technically feasible, but it is not widely accepted because it has not been evaluated from the standpoint of oncologic outcome. We conducted a retrospective, multicenter study of a large series of patients in Japan to evaluate the short- and long-term outcomes of laparoscopic gastrectomy for early gastric cancer (EGC).

METHODS

The study group comprised 1294 patients who underwent laparoscopic gastrectomy during the period April 1994 through December 2003 in 16 participating surgical units (Japanese Laparoscopic Surgery Study Group). The short- and long-term outcomes of these patients were examined.

RESULTS

Distal gastrectomy was performed in 1185 patients (91.5%), proximal gastrectomy in 54 (4.2%), and total gastrectomy in 55 (4.3%); all were performed laparoscopically. The morbidity and mortality rates associated with these operations were 14.8% and 0%, respectively. Histologically, 1212 patients (93.7%) had stage IA disease, 75 (5.8%) had stage IB disease, and 7 (0.5%) had stage II disease (the UICC staging). Cancer recurred in only 6 (0.6%) of 1294 patients treated curatively (median follow-up, 36 months; range, 13-113 months). The 5-year disease-free survival rate was 99.8% for stage IA disease, 98.7% for stage IB disease, and 85.7% for stage II disease.

CONCLUSIONS

Although our findings may be considered preliminary, our data indicate that laparoscopic surgery for EGC yields good short- and long-term oncologic outcomes.

Laparoscopic gastrectomy with lymph node dissection for gastric cancer

Since 1991, laparoscopic surgery has been adopted for the treatment of gastric cancer, and it has been performed worldwide, especially in Japan and Korea. We reviewed the English-language literature to clarify the current status of and problems associated with laparoscopic gastrectomy with lymph node dissection as treatment for gastric cancer. In Japan, early-stage gastric cancer (T1/T2, N0) is considered the only indication for laparoscopic gastrectomy. As yet, there is little high-level evidence based on long-term outcome supporting laparoscopic gastrectomy for cancer, but reports have provided level 3 evidence that the procedure is technically safe, and that it yields better short-term outcomes than open surgery; that is, recovery is faster, hospital stay is shorter, there is less pain, and cosmesis is better. However, investigation into the oncological outcome of laparoscopic gastrectomy as treatment for cancer is lacking. To establish laparoscopic surgery as a standard treatment for gastric cancer, multicenter randomized controlled trials to compare the short- and long-term outcomes of laparoscopic surgery versus open surgery are necessary.

A simple technique for performing laparoscopic purse-string suturing during circular stapling anastomosis

An esophagojejunostomy using a circular stapler requires the fixing of an anvil at the esophageal stump. When this placement procedure is laparoscopically performed, purse-string suturing is difficult, and there is a risk of loosening when a conventional needle driver is used. We herein present a simple but effective technique for performing laparoscopic purse-string suturing of the esophageal stump using a semiautomatic suturing device called the Endostitch. Gastrointestinal anvil placement was laparoscopically performed for 10 patients who underwent an esophagojejunostomy following a total gastrectomy. After the lumen of the esophagus was expanded using bowel forceps, the Endostitch was used to place approximately 12 encircling purse-string sutures. An anvil was positioned with support of the esophageal wall at three points with forceps. The Endostitch was used for the ligation with a sufficient degree of tension applied by extracorporeally pulling the sutures through the abdominal wall. The time for placement of the anvil averaged approximately 8 min. The ring formation following anastomosis was favorable in all patients. As a result, we consider our technique to be simple but very effective.

Comparison of laparoscopy-assisted by conventional open distal gastrectomy and extraperigastric lymph node dissection in early gastric cancer

BACKGROUND AND OBJECTIVES

Laparoscopy-assisted gastrectomy with lymph node dissection for gastric cancer is considered technically more complicated than the open method. Moreover, the safety and efficacy of laparoscopy-assisted distal gastrectomy (LADG) with extraperigastric lymph node dissection in patients with gastric cancer have not been established yet. To evaluate short-term surgical validity, surgical outcome of the laparoscopy-assisted distal gastrectomy (LADG) with extraperigastric lymph node dissection was compared with that of the conventional open distal gastrectomy (CODG) in patients with early gastric cancer.

METHODS

One hundred and forty-seven patients with early gastric cancer received radical distal gastrectomy during 2002 and 2003, where LADG was undergone in 71 patients. The clinicopathologic characteristics, postoperative outcomes and courses, and postoperative morbidities and mortalities were compared between the two groups. Data were retrieved from the stomach cancer database at Dong-A University Medical center.

RESULTS

Baseline characteristics, including sex, age, body mass index (BMI), American Society of Anesthesiology (ASA) class, tumor size, T stage, and lymph node metastasis were similar between the two groups. No significant differences were found between these groups in terms of the number of retrieved lymph nodes with respect to D1 + alpha (D1 + no. 7) and D1 + beta (D1 + no. 7, 8a, and 9) lymphadenectomy. In the LADG group, wound size was smaller (P < 0.0001), but operation time was longer (P = 0.0001) than in the CODG group. Perioperative recovery was faster in the LADG group than in the CODG group, as reflected by a shorter hospital stay (P = 0.0176) and less times of additional analgesics (P = 0.0370). Serum albumin level in LADG was higher (P = 0.0002) on day 7 than that in CODG, and the leukocyte count in LADG lower (P = 0.0445) on day 1 than that in CODG. Postoperative morbidities and mortalities were not significantly different between the two groups.

CONCLUSIONS

Our data confirmed that LADG with extraperigastric (no. 7, 8, and 9) lymph node dissection proved to be feasible and acceptable surgical technique for early gastric cancer. At least taking a surgical point of view, LADG with extraperigastric lymph node dissection is suggested to be a preferred surgical option for patients with early gastric cancer. Its oncologic validity awaits larger and prospective multicenter trials.

Minimally invasive surgery for gastric tumors

Since 1991, laparoscopic surgery has been adopted for the treatment of gastric tumors, including gastric cancer and gastric gastro-intestinal submucosal tumor (GIST). Although laparoscopic gastric resection for gastric tumors has not been accepted worldwide, its use has definitively increased due to its reduced invasiveness. The most common procedures are laparoscopy-assisted distal gastrectomy (LADG) for cancer and laparoscopic gastric resection as a standard of care for gastric tumors, multicenter randomized controlled clinical trials are needed to evaluate its short- and long-term outcomes.