Short-term outcomes of totally laparoscopic total gastrectomy: experience with the first consecutive 112 cases. World J Surg. 2014;38:2662-2667. [PMID: 24838484 DOI: 10.1007/s00268-014-2611-2]

Total gastrectomy as a risk factor for postoperative loss of skeletal muscle in minimally invasive surgery for patients with gastric cancer

PURPOSE

Loss of skeletal muscle mass after gastrectomy for gastric cancer leads to decreased quality of life and poor postoperative survival. However, few studies have examined the postoperative loss of skeletal muscle mass following minimally invasive gastrectomy. This study investigated the impact of minimally invasive total gastrectomy (MI-TG) on changes in skeletal muscle mass during the early postoperative period.

METHODS

Patients who underwent MI-TG or minimally invasive distal or proximal gastrectomy (MI-nonTG) for cStage I-III gastric cancer were retrospectively analyzed (n = 58 vs. 182). Their body composition was measured before surgery and 2 months after surgery. Multivariable linear regression analysis was performed to clarify the impact of the surgical procedure on skeletal muscle index changes using clinically relevant covariates.

RESULTS

Skeletal muscle mass decreased more in the MI-TG group than in the MI-nonTG group (median [interquartile range]; -5.9% [-10.6, -3.7] vs -4.5% [-7.3, -1.9], P = 0.004). In multivariable linear regression analysis using clinically relevant covariates, MI-TG was an independent risk factor for postoperative loss of skeletal muscle mass (coefficient - 2.6%, 95% CI -4.5 to -0.68, P = 0.008).

CONCLUSIONS

Total gastrectomy was a risk factor for loss of skeletal muscle mass during the early postoperative period. If oncologically feasible, proximal or distal gastrectomy with a small remnant stomach should be considered.

Comparison of Minimally Invasive Surgery with Open Surgery for Remnant Gastric Cancer: A Multi-institutional Cohort Study

BACKGROUND

Despite growing evidence of the effectiveness of minimally invasive surgery (MIS) for primary gastric cancer, MIS for remnant gastric cancer (RGC) remains controversial due to the rarity of the disease. This study aimed to evaluate the surgical and oncological outcomes of MIS for radical resection of RGC.

PATIENTS AND METHODS

Patients with RGC who underwent surgery between 2005 and 2020 at 17 institutions were included, and a propensity score matching analysis was performed to compare the short- and long-term outcomes of MIS with open surgery.

RESULTS

A total of 327 patients were included in this study and 186 patients were analyzed after matching. The risk ratios for overall and severe complications were 0.76 [95% confidence interval (CI): 0.45, 1.27] and 0.65 (95% CI: 0.32, 1.29), respectively. The MIS group had significantly less blood loss [mean difference (MD), -409 mL; 95% CI: -538, -281] and a shorter hospital stay (MD, -6.5 days; 95% CI: -13.1, 0.1) than the open surgery group. The median follow-up duration of this cohort was 4.6 years, and the 3-year overall survival were 77.9% and 76.2% in the MIS and open surgery groups, respectively [hazard ratio (HR), 0.78; 95% CI: 0.45, 1.36]. The 3-year relapse-free survival were 71.9% and 62.2% in the MIS and open surgery groups, respectively (HR, 0.71; 95% CI: 0.44, 1.16).

CONCLUSIONS

MIS for RGC showed favorable short- and long-term outcomes compared to open surgery. MIS is a promising option for radical surgery for RGC.

Required esophageal resection length beyond the tumor boundary to ensure a negative proximal margin for gastric cancer with gross esophageal invasion or esophagogastric junction cancer

BACKGROUND

To obtain a pathologically negative proximal margin (PM) for gastric cancer with gross esophageal invasion (EI) or esophagogastric junction (EGJ) cancer, we should transect the esophagus beyond the proximal boundary of gross EI with a safety margin because of a discrepancy between the gross and pathological boundaries of cancer. However, recommendations regarding the esophageal resection length for these cancers have not been established.

METHODS

Patients who underwent proximal or total gastrectomy for gastric cancer with gross EI or EGJ cancer were enrolled. A parameter ΔPM, which corresponded to the length of a discrepancy between the gross and pathological proximal boundary of the tumor, was evaluated. The maximum ΔPM, which corresponded to the minimum length ensuring a pathologically negative PM, was first determined in all patients. Then subgroup analyses according to factors associated with ΔPM ≥ 10 mm were performed to identify alternative maximum ΔPMs.

RESULTS

A total of 289 patients with gastric cancer with gross EI or EGJ cancer were eligible and analyzed in this study. The maximum ΔPM was 25 mm. Clinical tumor (cTumor) size and growth and pathological types were independently associated with ΔPM ≥ 10 mm. In subgroup analyses, the maximum ΔPM was 15 mm for cTumor size ≤ 40 mm and superficial growth type. Furthermore, the maximum ΔPM was 20 mm in the expansive growth type.

CONCLUSIONS

Required esophageal resection lengths to ensure a pathologically negative PM for gastric cancer with gross EI or EGJ cancer are proposed.

Minimum Esophageal Resection Length to Ensure Negative Proximal Margin in Total Gastrectomy for Gastric Cancer: A Retrospective Study

Objective

To identify the minimum length of esophageal resection to ensure a pathologically negative proximal margin (PM) in total gastrectomy for gastric cancer.

Background

In total gastrectomy, a certain esophageal length is resected to obtain a pathologically negative PM because of the possibility of unexpected pathological esophageal invasion. However, a recommendation regarding the esophageal transection site in total gastrectomy has not been established.

Methods

The data of patients who underwent total gastrectomy for gastric cancer from 2005 to 2018 were collected. We evaluated the length of unexpected pathological esophageal invasion (esophageal ΔPM) in each type of disease and each location of the gross proximal tumor boundary (PB) using the length between the PB and the esophagogastric junction (PB-EGJ length).

Results

Of the 1005 patients eligible for this study, 277, 196, and 532 had cT1, cT2-4 expansive (Exp), and cT2-4 infiltrative (Inf) growth patterns, respectively. In cT1 and Exp, no unexpected pathological esophageal invasion occurred when the PB-EGJ length was >1 cm, whereas pathological esophageal invasion occurred in 20.0% of cT1 and 32.7% of Exp when the PB-EGJ length was ≤1 cm. The esophageal ΔPM was <1 cm. In Inf, no unexpected pathological esophageal invasion occurred when the PB-EGJ length was >3 cm, whereas pathological esophageal invasion occurred in 17.4% of patients when the PB-EGJ length was ≤3 cm. The esophageal ΔPM was <2 cm.

Conclusions

New recommendations regarding the esophageal resection length required to ensure a pathologically negative PM in total gastrectomy are herein proposed.

Outcomes of laparoscopic total gastrectomy in elderly patients: a propensity score matching analysis

PURPOSE

This study evaluated the short-term outcomes and prognosis after laparoscopic total gastrectomy (LTG) in elderly patients aged ≥ 80 years in a multicenter retrospective cohort study using propensity score matching.

METHODS

We retrospectively enrolled 440 patients who underwent curative LTG for gastric cancer at six institutions between January 2004 and December 2018. Patients were categorized into an elderly patient group (EG; age ≥ 80 years) and non-elderly patient group (non-EG; age < 80 years). Patients were matched using the following propensity score covariates: sex, body mass index, American Society of Anesthesiologists physical status, extent of lymph node dissection, and Japanese Classification of Gastric Carcinoma stage. Short-term outcomes and prognoses were compared.

RESULTS

We identified 37 propensity score-matched pairs. The median operative time was significantly shorter, and postoperative stay was longer in the EG. In terms of postoperative outcomes, the rates of all complications were comparable. The median follow-up period of the EG and non-EG was 11.5 (1-106.4) months and 35.7 (1-110.0) months, respectively; there were significant differences in 5-year overall survival between the two groups (EG, 58.5% vs. non-EG, 91.5%; P = 0.031). However, there were no significant differences in 5-year disease-specific survival (EG, 62.1% vs. non-EG, 91.5%; P = 0.068) or 5-year disease-free survival (EG, 52.9% vs. non-EG, 60.8%; P = 0.132).

CONCLUSIONS

LTG seems to be safe and feasible in elderly patients. LTG had a limited effect on morbidity, disease recurrence, and survival in elderly patients. Therefore, age should not prevent elderly patients from benefitting from LTG.

Reverse rolling-mat type lymph node dissection is the key step to solve the operative difficulties in hand-assisted laparoscopic D2 radical gastrectomy

Background

We have improved and named a new reverse rolling-mat type lymph node dissection, which effectively solves the dilemma faced by the traditional lymph node dissection in hand-assisted laparoscopic D2 radical gastrectomy through the optimization of the surgical procedure. However, the relevant clinical data are still scarce. The study aims to compare the clinical effects of two surgical procedure and explore the safety and feasibility of “reverse procedure”.

Study design

The clinicopathological data of 195 patients who underwent hand-assisted D2 radical total gastrectomy (HALTG) in our hospital from January 2011 to September 2017 were collected. A retrospective case–control study was used to compare the clinical outcomes of the two patterns of lymph node dissection. Among them, 89 patients underwent “cabbage type” lymph node dissection and 106 patients underwent the “reverse procedure” lymph node dissection.

Results

There were no significant differences between the two groups of patients in terms of gender, age, tumor location, incision length, postoperative hospitalization duration, pathological classification, recent complications, long-term recurrence and metastasis. The operation time of “cabbage type” group was shorter than that of “reverse procedure” group (178.35 ± 31.52 min vs 191.25 ± 32.77 min; P = 0.006). While, in the “reverse procedure” group, intraoperative blood loss was less (249.4 ± 143.12 vs 213.58 ± 101.43; P = 0.049), and there were more numbers of lymph nodes dissected (18.04 ± 7.00 vs 32.25 ± 14.23; P < 0.001).

Conclusion

The pattern of reverse rolling-mat type lymph node dissection in HALTG perform well in terms of safety and feasibility.

Comparison of reverse puncture device and overlap in laparoscopic total gastrectomy for gastric cancer

BACKGROUND

Intracorporeal oesophagojejunostomy is one of the key steps in laparoscopic total gastrectomy (LTG). At present, there is no widely accepted anastomosis technique in oesophagojejunostomy.

MATERIALS AND METHODS

We retrospectively studied 63 patients with gastric cancer who underwent LTG. Two types of anastomosis techniques have been applied during LTG: the reverse puncture device (RPD) (28 patients) and overlap (35 patients).

RESULTS

A total of 63 patients (51 males and 12 females: mean age = 58 years and mean body mass index [BMI] = 26.3 kg/m2) were enrolled in this study. There were no significant difference in age, BMI, duration of surgery, duration of anastomosis, blood loss, post-operative hospital stay, tumour location, tumour size, degree of tumour differentiation, Borrmann type, total number of lymph nodes, number of positive lymph nodes, hospital stay, hospitalisation costs, intra-operative complications, post-operative complications and prognosis between the RPD group and the overlap group. RPD group showed a significant advantage in terms of the distance between the top border of tumours and the top resection margin (P < 0.001). We further found that the oesophageal lateral negative surgical margin distance of the upper gastric cancer in the RPD group was significantly longer than that in the overlap group (P < 0.001).

CONCLUSIONS

Both the RPD and overlap techniques are safe and applicable in LTG. However, RPD has the advantage of obtaining an adequate safe margin compared with that of overlap technique, especially in patients with gastro-oesophageal junction carcinoma.

Feasibility of totally laparoscopic total gastrectomy in obese patients with gastric cancer

PURPOSE

This study aimed to evaluate the short- and long-term outcomes in obese patients with gastric cancer undergoing totally laparoscopic total gastrectomy (TLTG) to clarify its feasibility in this population.

METHODS

We examined 136 consecutive patients who underwent TLTG for gastric cancer (GC) between 2013 and 2018. A total of 45 patients with a body mass index (BMI) ≥ 25 kg/m² were defined as the obese group (obese and overweight patients by the WHO classification), and 91 patients with a BMI < 25 kg/m² were defined as the non-obese group. Short- and long-term outcomes were compared, and the correlation between obesity and postoperative complications was examined in patients who underwent TLTG.

RESULTS

Although the operation time (min) was significantly longer in the obese group than in the non-obese group (329 vs 307, p = 0.002), there were no significant differences in the total volume of blood loss (mL) (118 vs 60, p = 0.059) or the rate of conversion to laparotomy between the two groups (2 vs 2, p = 0.466). Moreover, there was no significant difference in the incidence of postoperative complications between the two groups (16% vs 19%, p = 0.653). In the multivariate analysis, obesity was not identified as a risk factor for postoperative complications among patients who underwent TLTG. The rate of overall survival was not significantly different between the groups (p = 0.512).

CONCLUSION

TLTG is feasible for obese Japanese patients with GC. To validate the results of the present study, it is necessary to conduct a prospective study of a large population of patients with GC.

Long-Term Outcomes of Laparoscopic Radical Gastrectomy for Highly Advanced Gastric Cancer: Final Report of a Prospective Phase II Trial (KUGC04)

BACKGROUND

This is the final report evaluating the long-term outcomes of a single-arm phase II clinical trial that demonstrated the short-term efficacy of laparoscopic gastrectomy (LG) for highly advanced gastric cancer (AGC) [KUGC04].

PATIENTS AND METHODS

Seventy-three patients with histologically confirmed gastric adenocarcinoma and diagnosed with clinical stage II or higher, who potentially underwent curative resection between August 2009 and November 2014, were prospectively enrolled. Long-term outcomes with 5-year progression-free survival (PFS) and 5-year overall survival (OS) were evaluated according to clinical or pathological stages. Recurrence and progression patterns were also investigated. These outcomes were compared with those of previous reports to assess the applicability of LG for highly advanced gastric cancer (HAGC).

RESULTS

The median observation period of all surviving patients was 75.1 months. The 5-year PFS and 5-year OS of all patients was 47.4% and 54.4%, respectively. Clinical stage-specific 5-year PFS and 5-year OS was 75.0, 69.1, 53.9, 39.4, 40.0 and 9.1, and 75.0, 68.8, 61.5, 45.0, 60.0 and 27.3, respectively, in stages IIA, IIB, IIIA, IIIB, IIIC, and IV, respectively. Pathological stage-specific 5-year PFS and 5-year OS, including ypStage with preoperative chemotherapy, was 100, 80.0, 100, 62.5, 80.0, 51.3, 16.7, 22.2 and 12.5, and 100, 80.0, 100, 75.0, 80.0, 64.2, 25.0, 33.3 and 12.5, respectively, in stage X (no residual tumor with preoperative chemotherapy), IA, IB, IIA, IIB, IIIA, IIIB, IIIC, and IV, respectively. Recurrence or progression was observed in 30 patients (41.1%).

CONCLUSION

LG for HAGC performed by experienced surgeons is safe and oncologically acceptable.

Comparative Outcomes of Laparoscopic Gastrectomy and Open Gastrectomy for Scirrhous Gastric Cancer: A Multicenter Retrospective Cohort Study

Objective

A multicenter retrospective cohort study was performed to compare the outcomes of laparoscopic gastrectomy (LG) versus open gastrectomy (OG) for scirrhous gastric cancer (GC) as a unique subtype also known as type 4 gastric cancer or linitis plastica.

Background

Although data on the efficacy and safety of LG as an alternative to OG are emerging, the applicability of LG to scirrhous GC remains unclear.

Methods

Patients with clinical type 4 GC undergoing gastrectomy at 13 hospitals from 2005 to 2015 were retrospectively reviewed. As the primary endpoint, we compared overall survival (OS) between the LG and OG groups. To adjust for confounding factors, we used multivariate Cox regression analysis for the main analyses and propensity-score matching for sensitivity analysis. Short-term outcomes and recurrence-free survival were also compared.

Results

A total of 288 patients (LG, 62; OG, 226) were included in the main analysis. Postoperative complications occurred in 25.8% and 30.1%, respectively (P = 0.44). No significant difference in recurrence-free survival was observed (P = 0.72). The 5-year OS rates were 32.4% and 31.6% in the LG and OG groups, respectively (P = 0.60). The hazard ratio (LG/OG) for OS was 0.98 (95% confidence interval [CI], 0.65-1.43) in the multivariate regression analysis. In the sensitivity analyses after propensity-score matching, the hazard ratio for OS was 0.92 (95% CI, 0.58-1.45).

Conclusions

Considering the hazard ratios and 95% CIs for OS, LG for scirrhous GC was not associated with worse survival than that for OG.

Comparison of short-term outcomes between robotic and laparoscopic gastrectomy for gastric cancer: a propensity score-matching analysis

Robotic gastrectomy (RG) is increasingly performed based on expected benefits in short-term outcomes. However, it is still unclear if RG has any advantages over laparoscopic gastrectomy (LG). A retrospective cohort study was performed in patients who underwent minimally invasive gastrectomy between January 2012 and January 2020. A total of 366 patients were enrolled and short-term outcomes were compared between RG and LG. Propensity score matching was conducted to reduce selection bias based on age, sex, body mass index, performance status, physical status, clinical T, clinical N, clinical M, tumor location, neoadjuvant chemotherapy, type of gastrectomy, and extent of lymphadenectomy. A propensity score-matching algorithm was used to select 93 patients for each group. Estimated blood loss was smaller (0 vs. 37 mL, P = 0.001), length of hospital stay was shorter (10 vs. 12 days, P = 0.012), and the time until starting a soft diet was shorter (3 vs. 4 days, P = 0.001) in RG compared to LG. The overall complication rate was also lower in RG (9.7% vs 14.0%), but the difference was not significant. There was no mortality in either group. Total gastrectomy was an independent risk factor for postoperative complications. RG can be safely performed with a similar complication rate to that in LG and may permit faster postoperative recovery and a shorter hospital stay.

Comparison of surgical outcomes among different methods of esophagojejunostomy in laparoscopic total gastrectomy for clinical stage I proximal gastric cancer: results of a single-arm multicenter phase II clinical trial in Korea, KLASS 03

BACKGROUND

Laparoscopic distal gastrectomy for early gastric cancer has been widely accepted, but laparoscopic total gastrectomy has still not gained popularity because of technical difficulty and unsolved safety issue. We conducted a single-arm multicenter phase II clinical trial to evaluate the safety and the feasibility of laparoscopic total gastrectomy for clinical stage I proximal gastric cancer in terms of postoperative morbidity and mortality in Korea. The secondary endpoint of this trial was comparison of surgical outcomes among the groups that received different methods of esophagojejunostomy (EJ).

METHODS

The 160 patients of the full analysis set group were divided into three groups according to the method of EJ, the extracorporeal circular stapling group (EC; n = 45), the intracorporeal circular stapling group (IC; n = 64), and the intracorporeal linear stapling group (IL; n = 51). The clinicopathologic characteristics and the surgical outcomes were compared among these three groups.

RESULTS

There were no significant differences in the early complication rates among the three groups (26.7% vs. 18.8% vs. 17.6%, EC vs. IC vs. IL; p = 0.516). The length of mini-laparotomy incision was significantly longer in the EC group than in the IC or IL group. The anastomosis time was significantly shorter in the EC group than in the IL group. The time to first flatus was significantly shorter in the IL group than in the EC group. The long-term complication rate was not significantly different among the three groups (4.4% vs. 12.7% vs. 7.8%; EC vs. IC vs. IL; p = 0.359), however, the long-term incidence of EJ stenosis in IC group (10.9%) was significantly higher than in EC (0%) and IL (2.0%) groups (p = 0.020).

CONCLUSIONS

The extracorporeal circular stapling and the intracorporeal linear stapling were safe and feasible in laparoscopic total gastrectomy, however, intracorporeal circular stapling increased EJ stenosis.

Comparison of the short-term outcomes between totally laparoscopic total gastrectomy and laparoscopic-assisted total gastrectomy for gastric cancer: a meta-analysis

BACKGROUND

Totally laparoscopic total gastrectomy (TLTG) and laparoscopic-assisted total gastrectomy (LATG) are two common surgical approaches for upper and middle gastric cancer. Which surgical approach offers more advantages is still controversial due to a lack of evidence from randomized controlled trials (RCTs). This meta-analysis was conducted to compare the short-term outcomes between the two surgical approaches.

METHODS

A systematic literature search was performed to evaluate short-term outcomes between TLTG and LATG, including overall postoperative complications, anastomosis-related complications, time for anastomosis, operation time, intraoperative blood loss, harvested lymph nodes, proximal margin, distal margin, time to first flatus, time to first diet, and postoperative hospital stay. Short-term outcomes were pooled and compared by meta-analysis using RevMan 5.3. Mean differences (MDs) or risk ratios (RRs) were calculated with 95% confidence intervals (CIs). P < .05 was considered statistically significant.

RESULTS

A total of 9 cohort studies fulfilled the selection criteria. The total sample included 1671 cases. The meta-analysis showed no significant difference between the two surgical approaches in overall postoperative complications (RR = 1.02, 95% CI = 0.82 to 1.26, P = .87),anastomosis-related complications (RR = 0.64, 95%CI = 0.39 to 1.03, P = .06),time for anastomosis (MD = -5.13, 95% CI = -10.54 to 0.27, P = .06),operation time (MD = -10.68, 95% CI = -23.62 to 2.26, P = .11), intraoperative blood loss (MD = -25.58, 95% CI = -61.71 to 10.54, P = .17), harvested lymph nodes (MD = 1.61, 95% CI = -2.09 to 5.31, P = .39), proximal margin (MD = -0.37, 95% CI = -0.78 to 0.05, P = .09), distal margin (MD = 0.79, 95% CI = -0.57 to 2.14, P = .25), time to first flatus (MD = 0.01, 95% CI = -0.13 to 0.15, P = .87), time to first diet (MD = -0.22, 95% CI = -0.45 to 0.02, P = .07), and postoperative hospital stay (MD = -0.51, 95% CI = -1.10 to 0.07, P = .09).

CONCLUSIONS

TLTG is a safe and feasible surgical approach for upper and middle gastric cancer, with short-term outcomes that are similar to LATG. Nevertheless, high-quality, large-sample and multicenter RCTs are still required to further verify our conclusions.

Laparoscopic gastrectomy using intracorporeally hand-sewn anastomosis of esophagojejunostomy, gastroduodenostomy, or gastrojejunostomy for gastric cancer

Laparoscopic gastrectomy (LG) using intracorporeal anastomosis has recently become more prevalent due to the advancements of laparoscopic surgical instruments. However, intracorporeally hand-sewn anastomosis (IHSA) is still uncommon because of technical difficulties. In this study, we evaluated various types of IHSA following LG with respect to the technical aspects and postoperative outcomes.Seventy-six patients who underwent LG using IHSA for treatment of gastric cancer between September 2014 and June 2018 were enrolled in this study. We described the details of IHSA in step-by-step manner, evaluated the clinicopathological data and surgical outcomes, and summarized the clinical experiences.Four types of IHSA have been described: one for total gastrectomy (Roux-en-Y) and 3 for distal gastrectomy (Roux-en-Y, Billroth I, and Billroth II). The mean operation time and anastomotic time was 288.7 minutes and 54.3 minutes, respectively. Postoperative complications were observed in 13 patients. All of the patients recovered well with conservative surgical management. There was no case of conversion to open surgery, anastomotic leakage, or mortality.LG using IHSA was safe and feasible and had several advantages compared to mechanical anastomosis. The technique lengthened operating time, but this could be mitigated by increased surgical training and experience.

The Incidence of Postoperative Complications after Gastrectomy Increases in Proportion to the Amount of Preoperative Visceral Fat

Background

Visceral obesity is a risk factor for complications after gastrectomy in patients with gastric cancer. However, it is unclear whether postoperative complications decrease with preoperative reduction of visceral fat without the achievement of a nonobese state. This is because previous studies have performed categorical comparisons of obesity and nonobesity. The current study was performed to estimate the impact of the preoperative visceral fat area (VFA) as a continuous variable on postoperative complications after gastrectomy.

Methods

Consecutive patients with gastric cancer who underwent curative gastrectomy between June 2006 and August 2017 at the Kyoto University Hospital were included in this retrospective study. The VFA at the level of the umbilicus was measured using preoperative computed tomography. The relationship between postoperative complications and VFA was investigated with univariate and multivariate analyses.

Results

total of 566 patients were included in the study. Their mean VFA was 110 ± 58 cm², and postoperative complications occurred in 121 patients (21.4%). The larger the VFA (<50, 50–99, 100–149, and ≥150 cm²), the higher the incidence of postoperative complications (11%, 14%, 21%, and 38%, respectively, P < 0.001). Multivariate logistic regression analyses showed that the VFA was associated with postoperative complications (odds ratio: 1.009, 95% confidence interval (CI): 1.004–1.013, P < 0.001), with an incidence of postoperative complications that was 9% (95% CI: 4%–12%) higher for every 10 cm² increase in the VFA.

Conclusion

The incidence of postoperative complications after gastrectomy increases in proportion to an increase in the preoperative VFA.

Linear or circular stapler? A propensity score-matched, multicenter analysis of intracorporeal esophagojejunostomy following totally laparoscopic total gastrectomy

BACKGROUND

Presently, there is no consensus as to what procedure of intracorporeal esophagojejunostomy (EJS) in totally laparoscopic total gastrectomy (TLTG) is best to reduce postoperative complications. The aim of this study was to demonstrate the superiority of linear stapled reconstruction in terms of anastomotic-related complications for EJS in TLTG.

METHODS

We collected data on 829 consecutive gastric cancer patients who underwent TLTG reconstructed by the Roux-en-Y method with radical lymphadenectomy between January 2010 and December 2016 in 13 hospitals. The patients were divided into two groups according to reconstruction method and matched by propensity score. Postoperative EJS-related complications were compared between the linear stapler (LS) and the circular stapler (CS) groups.

RESULTS

After matching, data from 196 patients in each group were analyzed. The overall incidence of EJS-related complications was significantly lower in the LS group than in the CS group (4.1% vs. 11.7%, p = 0.008). The incidence of EJS anastomotic stenosis during the first year after surgery was significantly lower in the LS group than in the CS group (1.5% vs. 7.1%, p = 0.011). The incidence of EJS bleeding did not differ significantly between the groups, although no bleeding was observed in the LS group (0% vs. 2.0%, p = 0.123). The incidence of EJS leakage did not differ significantly between the groups (2.6% vs. 3.6%, p = 0.771).

CONCLUSION

The use of linear stapled reconstruction is safer than the use of circular stapled reconstruction for intracorporeal EJS in TLTG because of its lower risks of stenosis.

Three-dimensional Stereoscopic Visualization Shortens Operative Time in Laparoscopic Gastrectomy for Gastric Cancer

Laparoscopic gastrectomy for gastric cancer is now widely accepted and has become a standard surgery. This study investigated the advantages of three-dimensional (3D) stereoscopic visualization for laparoscopic gastrectomy over a conventional two-dimensional (2D) planar screen. The primary outcome of this study was operative time. Ninety-four consecutive cases of gastric cancer patients who underwent laparoscopic total gastrectomy (LTG) (25 cases) or laparoscopic distal gastrectomy (LDG) (69 cases) were enrolled in this study before and after the introduction of the 3D system. Operative time was significantly shorter in the 3D groups for both LTG (351 vs. 406 min, P = 0.026) and LDG (269 vs. 344 min, P < 0.01). During intracorporeal procedures, dissection time was significantly shorter in the 3D groups for both LTG (183 vs. 232 min, P = 0.011) and LDG (161 vs. 213 min, P < 0.01), although the time needed for anastomosis was similar between the groups. However, operators preferred intracorporeal knot-tying as a ligature for anastomosis under 3D (LTG, P = 0.012; LDG, P < 0.01). These data suggest that 3D stereoscopic visualization shortens the operative time of laparoscopic gastrectomy by reducing the intracorporeal dissection time.

Optimal Cutoff Values of Skeletal Muscle Index to Define Sarcopenia for Prediction of Survival in Patients with Advanced Gastric Cancer

BACKGROUND

Sarcopenia, characterized by loss of skeletal muscle mass, is recognized as a prognostic factor in patients with gastric cancer. However, wide variability exists in the cutoff values of muscle mass for defining sarcopenia across previous studies, and the best cutoff values to predict survival remain unknown. This study aimed to determine the optimal cutoff values for sarcopenia to predict survival in patients with advanced gastric cancer.

PATIENTS AND METHODS

Patients with clinical stage II/III gastric cancer who underwent gastrectomy at Kyoto University Hospital were included in the study. The cross-sectional area of skeletal muscle at the third lumbar vertebra level was measured using preoperative computed tomography scan. The skeletal muscle index (SMI) was calculated by dividing the area by height in meters squared. Five sex-specific cutoffs of SMI, which were significantly associated with prognosis in patients with gastric and nongastric cancers, were examined as a threshold to define sarcopenia.

RESULTS

In the 177 eligible patients, the five cutoffs of SMI resulted in an incidence of sarcopenia between 6 (3%) and 114 (64%). The 5-year overall survival was 48% in patients with sarcopenia based on the cutoffs reported by Martin et al., compared with 68% in those without sarcopenia (p = 0.013). A multivariate regression model demonstrated that sarcopenia based on the cutoffs was significantly associated with overall survival (hazard ratio 2.00, 95% confidence interval 1.24-3.24, p = 0.005).

CONCLUSIONS

The cutoff values reported by Martin et al. were optimal to predict survival in patients with advanced gastric cancer.

Esophagojejunostomy With Linear Staplers in Laparoscopic Total Gastrectomy: Experience With 168 Cases in 5 Consecutive Years

PURPOSE

We evaluate surgical outcomes of intracorporeal esophagojejunostomy in laparoscopic total gastrectomy using 2 linear stapler methods.

MATERIALS AND METHODS

The functional end-to-end anastomosis (FEEA) method was chosen as a first choice. The overlap method was chosen in cases with esophageal invasion. We retrospectively analyzed the early and late surgical outcomes of consecutive 168 laparoscopic total gastrectomy cases from April 2011 to December 2016.

RESULTS AND CONCLUSIONS

The FEEA method was selected in 120 cases, and the overlap method was selected in 48 cases. The mean time of esophagojejunostomy for the FEEA and overlap method was 13.2 and 36.5 minutes, respectively. Two cases with FEEA method and 3 cases with overlap method experienced complications due to esophagojejunostomy leakage. These cases were treated without performing a reoperation. One case with FEEA method was complicated due to esophagojejunostomy stenosis. This case was endoscopically treated. Our procedures are safe and feasible.

Esophagojejunostomy Using the Purse-String Suturing Device After Laparoscopic Total or Proximal Gastrectomy for Gastric Cancer

BACKGROUND

Performing a safe esophagojejunostomy is important for the standardization of laparoscopic total gastrectomy. We have performed intracorporeal esophagojejunostomy by a circular stapler using the purse-string suturing device that we co-developed. The advantage of this device is that it makes use of the same surgical procedure as open surgery, but it does not depend on the surgeon's technical skills since this device does not require the laparoscopic hand-sewn technique. Furthermore, we have also adapted this device for double-tract reconstruction after laparoscopic proximal gastrectomy. In this study, we present the surgical procedures and postoperative short-term outcomes that were obtained using this novel technique.

METHODS

We enrolled 94 patients that underwent intracorporeal esophagojejunostomy by circular stapler using our device after laparoscopic total or proximal gastrectomy for gastric cancer between November 2009 and October 2016.

RESULTS

Postoperative complications related to esophagojejunostomy were due to anastomotic stenosis in two cases (2.1%) and leakage of the jejunum stump in one case (1.1%).

CONCLUSIONS

Intracorporeal esophagojejunostomy by circular stapler using the purse-string suturing device is safe and feasible. This method can be one of the standard procedures for performing intracorporeal esophagojejunostomy.

Completion Gastrectomy with Esophagojejunostomy for Management of Complications of Benign Foregut Surgery

BACKGROUND

With the worldwide epidemic of obesity, an increasing number of bariatric operations and antireflux fundoplications are being performed. Despite low morbidity of the primary foregut surgery, completion gastrectomy may be necessary as a definitive procedure for complications of prior foregut surgery; however, the literature evaluating outcomes after completion gastrectomy with esophagojejunostomy (EJ) for benign diseases is limited. We present our experience of completion gastrectomy with Roux-en-Y EJ in the setting of benign disease at a single tertiary center.

METHODS AND PROCEDURES

All patients who underwent total, proximal, or completion gastrectomy with EJ for complications of benign foregut surgery from January 2006 to December 2015 were retrospectively identified. All cancer operations were excluded.

RESULTS

There were 23 patients who underwent gastrectomy with EJ (13 laparoscopic EJ [LEJ] and 10 open EJ). The index operations included 12 antireflux, 9 bariatric, and 2 peptic ulcer disease surgeries. Seventy-eight percent of patients had surgical or endoscopic interventions before EJ, with a median of one prior intervention and a median interval from the index operation to EJ of 25 months (interquartile range 9-87). The 30-day perioperative complication rate was 30% with 17% classified being major (Clavien-Dindo ≥ III) and no 30-day perioperative mortality. Comparing laparoscopic and open approaches showed similar operative times, estimated blood loss, and overall complication rate. LEJ was associated with a shorter length of stay (LOS) (P < .001), fewer postoperative ICU days (P = .002), fewer 6-month complication rates (P < .007), and decreased readmission rate (P = .024).

CONCLUSION

Our series demonstrates that EJ is a reasonable option for reoperative foregut surgery. The laparoscopic approach appears to be associated with decreased LOS and readmissions.

Intra-corporeal hand-sewn esophagojejunostomy is a safe and feasible procedure for totally laparoscopic total gastrectomy: short-term outcomes in 100 consecutive patients

BACKGROUND

An optimal method for intracorporeal esophagojejunostomy has not yet been standardized. This study sought to introduce intracorporeal hand-sewn end-to-side esophagojejunostomy after totally laparoscopic total gastrectomy.

METHODS

The author conducted a consecutive series of 100 intracorporeal hand-sewn esophagojejunostomies after totally laparoscopic total gastrectomy for upper third gastric cancer from September 2012 to December 2016.

RESULTS

All patients were successfully operated on without conversion to open- or laparoscope-assisted surgery. The mean reconstruction time was 45 min, and the time until first flatus was 4 days. The time to start a soft diet was 7 days. The length of postoperative hospital stay was 8 days. The overall postoperative morbidity was 8%, including one anastomotic leak, and the mortality was zero. The median follow-up duration was 13 months; no anastomotic strictures were encountered.

CONCLUSIONS

Intracorporeal hand-sewn end-to-side esophagojejunostomy after totally laparoscopic total gastrectomy is a safe and feasible procedure. This method can identify negative margins with intraoperative frozen sections before reconstruction and could be a good option for performing intracorporeal esophagojejunostomy with an advanced endoscopic suture technique.

Short-term outcomes of laparoscopic total gastrectomy for gastric cancer: a comparative study with laparoscopic distal gastrectomy at a high-volume center

BACKGROUND

Laparoscopic distal gastrectomy (LDG) for gastric cancer has gradually gained popularity. However, laparoscopic total gastrectomy (LTG) has been reported rarely when compared with LDG. This study was designed to evaluate the surgical outcomes as well as the morbidity and mortality of LTG compared with LDG to confirm the feasibility and safety of LTG.

MATERIAL AND METHODS

We reviewed the data of patients at our institution undergoing LTG (n = 448) or LDG (n = 956) for gastric cancer between January 2008 and July 2016. Then the clinical characteristics and perioperative clinical outcomes of the two groups were compared.

RESULTS

Except for tumor size and stage, there were no statistically significant differences in the clinicopathological parameters between the groups. LTG was associated with significantly longer operation time, late time to postoperative diet, and longer hospital stay compared with the LDG group. Overall complications developed in 60 patients (13.4%) and surgical complications in 48 patients (10.7%) after LTG. Postoperative complications were less frequent in the LDG group than in the LTG group (8.4% versus 13.4%, p < .01), and fewer surgical complications were observed with LDG than with LTG (7.5% versus 10.7%, p = .05).

CONCLUSIONS

The results of LTG were favorable even though are not inferior to those of LDG. LTG for gastric cancer is technically feasible and safe. However, because of the limits of this study, other high-quality studies are needed for further evaluation.

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.

Linear-Stapled Side-to-Side Esophagojejunostomy with Hand-Sewn Closure of the Common Enterotomy After Prophylactic and Therapeutic Total Gastrectomy

After total gastrectomy, anastomosis-related complications such as leak or stricture can be highly morbid. Between July 2005 and December 2015, a linear-stapled side-to-side esophagojejunostomy with hand-sewn closure of the common enterotomy (modified Orringer technique) was used for Roux-en-Y reconstruction after prophylactic total gastrectomy in 22 germline CDH1 mutation carriers and after therapeutic total gastrectomy in 18 patients diagnosed with gastric adenocarcinoma. All operations were performed by the same surgeon. No patient in either cohort developed a clinically evident anastomotic leak, one patient (2.5%) developed a contained radiographic leak that healed without intervention, and one patient (2.5%) developed an anastomotic stricture treated by endoscopic dilatation 7 months after operation. These rates were lower than radiographic leak and stricture rates in a comparison group of 32 patients who received a completely hand-sewn esophagojejunostomy (6.3 and 3.1%, respectively). Here, we describe how to perform the linear-stapled esophagojejunostomy anastomosis.

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.

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.

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.

Systematic review of anastomotic complications of esophagojejunostomy after laparoscopic total gastrectomy

AIM: To investigate the anastomotic complications of esophagojejunostomy (EJS) after laparoscopic total gastrectomy (LTG), we reviewed retrospective studies.

METHODS: A literature search was conducted in PubMed for studies published from January 1, 1994 through January 31, 2015. The search terms included “laparoscopic,”“total gastrectomy,” and “gastric cancer.” First, we selected 16 non-randomized controlled trials (RCTs) comparing LTG with open total gastrectomy (OTG) and conducted an updated meta-analysis of anastomotic complications after total gastrectomy. The Newcastle-Ottawa scoring system (NOS) was used to assess the quality of the non-RCTs included in this study. Next, we reviewed anastomotic complications in 46 case studies of LTG to compare the various procedures for EJS.

RESULTS: The overall incidence of anastomotic leakage associated with EJS was 3.0% (30 of 984 patients) among LTG procedures and 2.1% (31 of 1500 patients) among OTG procedures in the 16 non-RCTs. The incidence of anastomotic leakage did not differ significantly between LTG and OTG (odds OR = 1.42, 95%CI: 0.86-2.33, P = 0.17, I² = 0%). Anastomotic stenosis related to EJS was reported in 72 (2.9%) of 2484 patients, and the incidence was 3.2% among LTG procedures and 2.7% among OTG procedures. The incidence of anastomotic stenosis related to EJS was slightly, but not significantly, higher in LTG than in OTG (OR = 1.55, 95%CI: 0.94-2.54, P = 0.08, I² = 0%). The various procedures for LTG were classified into six categories in the review of case studies of LTG. The incidence of EJS leakage was similar (1.1% to 3.2%), although the incidence of EJS stenosis was relatively high when the OrVil^TM device was used (8.8%) compared with other procedures (1.0% to 3.6%).

CONCLUSION: The incidence of anastomotic complications associated with EJS was not different between LTG and OTG. Anastomotic stenosis was relatively common when the OrVil^TM device was used.

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.