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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. Surg Endosc 2020; 35:1156-1163. [PMID: 32144557 DOI: 10.1007/s00464-020-07480-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 02/26/2020] [Indexed: 02/07/2023]
Abstract
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.
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Kawaguchi Y, Shiraishi K, Akaike H, Ichikawa D. Current status of laparoscopic total gastrectomy. Ann Gastroenterol Surg 2019; 3:14-23. [PMID: 30697606 PMCID: PMC6345655 DOI: 10.1002/ags3.12208] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 08/12/2018] [Accepted: 08/14/2018] [Indexed: 12/13/2022] Open
Abstract
In this article, the current state of laparoscopic total gastrectomy (LTG) was reviewed, focusing on lymph node dissection and reconstruction. Lymph node dissection in LTG is technically similar to that in laparoscopic distal gastrectomy for early gastric cancer; however, LTG for advanced gastric cancer requires extended lymph node dissections including splenic hilar lymph nodes. Although a recent randomized controlled trial clearly indicated no survival benefit in prophylactic splenectomy for lymph node dissection at the splenic hilum, some patients may receive prognostic benefit from adequate splenic hilar lymph node dissection. Considering reconstruction, there are two major esophagojejunostomy (EJS) techniques, using a circular stapler (CS) or using a linear stapler (LS). A few studies have shown that the LS method has fewer complications; however, almost all studies have reported that morbidity (such as anastomotic leakage and stricture) is not significantly different for the two methods. As for CS, we grouped various studies addressing complications in LTG into categories according to the insertion procedure of the anvil and the insertion site in the abdominal wall for the CS. We compared the rate of complications, particularly for leakage and stricture. The rate of anastomotic leakage and stricture was the lowest when inserting the CS from the upper left abdomen and was significantly the highest when inserting the CS from the midline umbilical. Scrupulous attention to EJS techniques is required by surgeons with a clear understanding of the advantages and disadvantages of each anastomotic device and approach.
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Affiliation(s)
- Yoshihiko Kawaguchi
- First Department of SurgeryFaculty of MedicineUniversity of YamanashiChuoYamanashiJapan
| | - Kensuke Shiraishi
- First Department of SurgeryFaculty of MedicineUniversity of YamanashiChuoYamanashiJapan
| | - Hidenori Akaike
- First Department of SurgeryFaculty of MedicineUniversity of YamanashiChuoYamanashiJapan
| | - Daisuke Ichikawa
- First Department of SurgeryFaculty of MedicineUniversity of YamanashiChuoYamanashiJapan
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Stenosis after esophagojejunostomy with the hemi-double-stapling technique using the transorally inserted anvil (OrVil™) in Roux-en-Y reconstruction with its efferent loop located on the patient's left side following laparoscopic total gastrectomy. Surg Endosc 2018; 33:2128-2134. [PMID: 30341648 DOI: 10.1007/s00464-018-6484-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 10/11/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND The drawback of intracorporeal esophagojejunostomy with the double-stapling technique (DST) using a transorally inserted anvil (OrVil™, Covidien, Mansfield, MA, USA) following laparoscopic total gastrectomy (LTG) is not only the high incidence of stenosis but also the presence of intractable stenosis that is refractory to endoscopic treatments. METHODS From November 2013 to December 2016, 24 patients with gastric cancer underwent intracorporeal circular-stapled esophagojejunostomy with the hemi-double-stapling technique (hemi-DST) using the OrVil™ in antecolic Roux-en-Y reconstruction with its efferent loop located on the left side of the patient following LTG to prevent twisting of the esophagojejunostomy and lifted jejunum, which might cause intractable stenosis of the esophagojejunostomy. RESULTS In this patient series, no twisting of the esophagojejunostomy and lifted jejunum was encountered intraoperatively or postoperatively. Two stenoses of the esophagojejunostomy occurred. Because neither was involved with twisting and both were localized at the anastomotic plane, endoscopic treatments including balloon dilation and electrocautery incisional therapy were successful in both cases. There were no patients with intractable stenosis in this series. CONCLUSIONS Intracorporeal esophagojejunostomy with the hemi-DST using the OrVil™ in antecolic Roux-en-Y reconstruction with its efferent loop located on the left side of the patient can be one option for a circular stapling technique in LTG due to its prevention of intractable stenosis of the esophagojejunostomy that is refractory to endoscopic treatments.
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Linear-Stapled Side-to-Side Esophagojejunostomy with Hand-Sewn Closure of the Common Enterotomy After Prophylactic and Therapeutic Total Gastrectomy. J Gastrointest Surg 2017; 21:712-722. [PMID: 27882512 PMCID: PMC5360481 DOI: 10.1007/s11605-016-3326-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 11/14/2016] [Indexed: 01/31/2023]
Abstract
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.
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Özer İ, Bostancı EB, Ulaş M, Özoğul Y, Akoğlu M. Changing Trends in Gastric Cancer Surgery. Balkan Med J 2017; 34:10-20. [PMID: 28251018 PMCID: PMC5322507 DOI: 10.4274/balkanmedj.2015.1461] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 09/21/2016] [Indexed: 02/07/2023] Open
Abstract
Gastric cancer is one of the most common causes of cancer-related death. It requires multimodal treatment and surgery is the most effective treatment modality. Radical surgery includes total or subtotal gastrectomy with lymph node dissection. The extent of lymphadenectomy still remains controversial. Eastern surgeons have performed D2 or more extended lymphadenectomy while their Western colleagues have performed more limited lymph node dissection. However, the trend has been changing in favour of D2 lymph node dissection in both hemispheres. Currently, D2 is the recommended type of lymphadenectomy in experienced centres in the west. In Japan, D2 lymph node dissection is the standard surgical approach. More extensive lymphadenectomy than D2 has not been found to be associated with improved survival and generally is not performed. Bursectomy and splenectomy are additional controversial issues in surgical performance, and trends regarding them will be discussed. The performance of bursectomy is controversial and there is no clear evidence of its clinical benefit. However, a trend toward better survival in patients with serosal invasion has been reported. Routine splenectomy as a part of lymph node dissection has largely been abandoned, although splenectomy is recommended in selected cases. Minimally invasive surgery has gained wide popularity and indications for minimally invasive procedures have been expanding due to increasing experience and improving technology. Neoadjuvant therapy has been shown to have beneficial effects and seems necessary to provide a survival benefit. Diagnostic laparoscopy should be kept in mind prior to treatment.
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Affiliation(s)
- İlter Özer
- Department of Gastroenterological Surgery, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey
| | - Erdal Birol Bostancı
- Department of Gastroenterological Surgery, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey
| | - Murat Ulaş
- Department of Gastroenterological Surgery, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey
| | - Yusuf Özoğul
- Department of Gastroenterological Surgery, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey
| | - Musa Akoğlu
- Department of Gastroenterological Surgery, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey
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Clinical and surgical factors associated with organ/space surgical site infection after laparoscopic gastrectomy for gastric cancer. Surg Endosc 2016; 31:1667-1674. [PMID: 27506433 DOI: 10.1007/s00464-016-5156-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 07/25/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND Surgical site infection (SSI), particularly organ/space SSI, remains a clinically important issue even after laparoscopic gastrectomy (LG) for gastric cancer (GC). This study aimed to identify specific clinical and surgical factors associated with organ/space SSI after LG. METHODS This was a retrospective study of 407 patients who underwent LG for clinical stage I GC. SSI was defined according to the National Nosocomial Infection Surveillance System. The incidence and treatment outcomes of either incisional or organ/space SSI after LG were examined, and the risk factors for each type of SSI were identified using univariate and multivariate analyses. RESULTS Organ/space SSI was observed in 21 patients (5.2 %), while incisional SSI was detected in 18 patients (4.4 %). Although no mortality was observed, the occurrence of either incisional or organ/space SSI significantly prolonged postoperative hospital stays (p = 0.000 and 0.000, respectively); however, organ/space SSI required more re-operations and re-admissions, and eventually longer total hospital stays than incisional SSI (p = 0.036). Intra-abdominal abscess around the pancreas was the main cause of organ/space SSI, while no anastomotic leakage was observed. Multivariate analyses identified male gender (odds ratio (OR) 3.385; 95 % confidence interval (CI) 1.073-15.07, p = 0.037), chronic liver disease (OR 8.897; 95 % CI 2.502-28.99, p = 0.001), and total gastrectomy (TG) (OR 3.817; 95 % CI 1.380-10.24, p = 0.011) as independent risk factors for organ/space SSI, while TG (OR 3.130; 95 % CI 1.102-8.768, p = 0.033) and operation time ≥320 min (OR 3.732; 95 % CI 1.109-16.98, p = 0.033) were independently associated with incisional SSI. CONCLUSIONS Male gender, chronic liver disease, and TG are independent risk factors for organ/space SSI after LG for GC; thus, meticulous surgical procedures need to be performed among patients with these specific risk factors.
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Nakauchi M, Suda K, Kadoya S, Inaba K, Ishida Y, Uyama I. Technical aspects and short- and long-term outcomes of totally laparoscopic total gastrectomy for advanced gastric cancer: a single-institution retrospective study. Surg Endosc 2015; 30:4632-9. [PMID: 26703126 DOI: 10.1007/s00464-015-4726-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 12/15/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND D2 total gastrectomy combined with splenectomy or pancreaticosplenectomy reportedly increases morbidity and mortality. Totally laparoscopic total gastrectomy (TLTG) for advanced gastric cancer (AGC) remains controversial because of its technical difficulties and lack of long-term results. We determined the feasibility and safety of TLTG for AGC. METHODS A single-institution retrospective study was conducted. Ninety-two consecutive AGC patients who underwent radical TLTG were enrolled. The primary end point was morbidity. The patients were observed for 3 years following TLTG. We assessed short-term surgical and long-term outcomes, including 3-year overall survival rates (3yOS) and 3-year recurrence-free survival rates (3yRFS). RESULTS Early and late morbidities (Clavien-Dindo grade ≥3) were 26.1 and 6.5 %, respectively. Operative time, estimated blood loss, number of dissected lymph nodes, and postoperative hospital stay were 444 (278-694) min, 100 (0-2267) g, 48 (16-89), and 23 (9-136) days, respectively, and 3yOS and 3yRFS rates were 70.7 and 60.9 %, respectively. Factors associated with postoperative complications and 3yOS were operative time [OR 1.011 (1.006-1.017), p < 0.01] and cancer recurrence within 3 years [HR 312.191 (1.126-86573.245], p = 0.045], respectively. 3yRFS was associated with tumor size (≥50 mm) [HR 10.325 (1.328-80.289), p = 0.026], pathological N factor ≥2 [HR 3.188 (1.196-8.495), p = 0.02], and postoperative pancreatic fistula combined with intra-abdominal abscesses Clavien-Dindo grade ≥2; [HR 3.670 (1.440-9.351), p = 0.006]. CONCLUSIONS TLTG for AGC is sufficiently feasible and safe from both surgical and oncological point of view.
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Affiliation(s)
- Masaya Nakauchi
- Division of Upper GI, Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan
| | - Koichi Suda
- Division of Upper GI, Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan.
| | - Shinichi Kadoya
- Division of Upper GI, Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan
| | - Kazuki Inaba
- Division of Upper GI, Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan
| | - Yoshinori Ishida
- Division of Upper GI, Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan
| | - Ichiro Uyama
- Division of Upper GI, Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan
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Kitagami H, Morimoto M, Nakamura K, Watanabe T, Kurashima Y, Nonoyama K, Watanabe K, Fujihata S, Yasuda A, Yamamoto M, Shimizu Y, Tanaka M. Technique of Roux-en-Y reconstruction using overlap method after laparoscopic total gastrectomy for gastric cancer: 100 consecutively successful cases. Surg Endosc 2015; 30:4086-91. [PMID: 26701704 DOI: 10.1007/s00464-015-4724-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 12/15/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND We have established a standard procedure for Roux-en-Y (RY) reconstruction in laparoscopic total gastrectomy (LTG) using esophagojejunostomy by the overlap method (OL). We report on our RY reconstruction technique and special approaches, and evaluate the usefulness of our reconstruction method based on the surgical results of 100 patients we have experienced to date. METHODS We performed LTG in 100 patients with gastric cancer. After total gastrectomy using five ports, the resected stomach was extracted through a small laparotomy. Through that, we performed sacrifice of the jejunum, Y limb anastomosis, creation of the lifted jejunum. As the OL, a side-to-side anastomosis of the lifted jejunum to the esophageal stump was laparoscopically performed using a linear stapler in an isoperistaltic direction, and the entry hole was closed with full-thickness suturing. The lifted jejunum was fixed with suture to the duodenal stump at a location where the esophagojejunostomy site was made linear, and the duodenal stump was buried. The mesenteric gap was laparoscopically closed with suture. RESULTS The median operative time in 100 patients undergoing LTG was 385 min, the median blood loss was 65 mL, and the median time required for the OL was 32 min. The mean hospitalization period was 10 days, and postoperative complications included bleeding requiring reoperation in one patient; other complications such as pancreatic fistula in five patients (5 %) were treated conservatively. No complication associated with anastomosis occurred. CONCLUSION In RY reconstruction using the OL, there were no complications associated with the anastomosis site in 100 consecutive patients, such as anastomotic leak or stenosis, indicating that it is a very useful and safe reconstruction method.
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Affiliation(s)
- Hidehiko Kitagami
- Department of Surgery, KARIYA TOYOTA General Hospital, 5-15 Sumiyoshi-cho, Kariya City, Aichi Prefecture, 448-8505, Japan.
| | - Mamoru Morimoto
- Department of Surgery, KARIYA TOYOTA General Hospital, 5-15 Sumiyoshi-cho, Kariya City, Aichi Prefecture, 448-8505, Japan
| | - Kenichi Nakamura
- Department of Surgery, KARIYA TOYOTA General Hospital, 5-15 Sumiyoshi-cho, Kariya City, Aichi Prefecture, 448-8505, Japan
| | - Takahiro Watanabe
- Department of Surgery, KARIYA TOYOTA General Hospital, 5-15 Sumiyoshi-cho, Kariya City, Aichi Prefecture, 448-8505, Japan
| | - Yo Kurashima
- Department of Surgery, KARIYA TOYOTA General Hospital, 5-15 Sumiyoshi-cho, Kariya City, Aichi Prefecture, 448-8505, Japan
| | - Keisuke Nonoyama
- Department of Surgery, KARIYA TOYOTA General Hospital, 5-15 Sumiyoshi-cho, Kariya City, Aichi Prefecture, 448-8505, Japan
| | - Kaori Watanabe
- Department of Surgery, KARIYA TOYOTA General Hospital, 5-15 Sumiyoshi-cho, Kariya City, Aichi Prefecture, 448-8505, Japan
| | - Shiro Fujihata
- Department of Surgery, KARIYA TOYOTA General Hospital, 5-15 Sumiyoshi-cho, Kariya City, Aichi Prefecture, 448-8505, Japan
| | - Akira Yasuda
- Department of Surgery, KARIYA TOYOTA General Hospital, 5-15 Sumiyoshi-cho, Kariya City, Aichi Prefecture, 448-8505, Japan
| | - Minoru Yamamoto
- Department of Surgery, KARIYA TOYOTA General Hospital, 5-15 Sumiyoshi-cho, Kariya City, Aichi Prefecture, 448-8505, Japan
| | - Yasunobu Shimizu
- Department of Surgery, KARIYA TOYOTA General Hospital, 5-15 Sumiyoshi-cho, Kariya City, Aichi Prefecture, 448-8505, Japan
| | - Moritsugu Tanaka
- Department of Surgery, KARIYA TOYOTA General Hospital, 5-15 Sumiyoshi-cho, Kariya City, Aichi Prefecture, 448-8505, Japan
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