Esophagogastrostomy using a circular stapler in laparoscopy-assisted proximal gastrectomy with an incision in the left abdomen

Laparoscopic Proximal Gastrectomy with Novel Valvuloplastic Esophagogastrostomy vs. Laparoscopic Total Gastrectomy for Stage I Gastric Cancer: a Propensity Score Matching Analysis

BACKGROUND

Laparoscopic total gastrectomy for early proximal gastric cancer is widely performed. Recently, the number of laparoscopic proximal gastrectomies performed, a surgery limited to early proximal gastric cancer, has gradually increased. However, evidence for the long-term outcomes of laparoscopic total gastrectomy and laparoscopic proximal gastrectomy is insufficient. Therefore, this study aimed to clarify and compare the long-term outcomes of laparoscopic total gastrectomy and laparoscopic proximal gastrectomy with novel valvuloplastic esophagogastrostomy for treatment of clinical stage I proximal gastric cancer.

METHODS

This study included 111 patients who underwent laparoscopic total gastrectomy or laparoscopic proximal gastrectomy for the treatment of upper third clinical stage I gastric cancer between April 2004 and December 2017. After adjusting for propensity score matching analysis, we compared the postoperative complications, nutritional status, and long-term outcomes between the two groups.

RESULTS

After matching the inclusion criteria, 56 patients (28 in each group) were enrolled. No significant differences were noted in the postoperative complications between the two groups. While laparoscopic proximal gastrectomy was associated with lower albumin levels, lower body weight loss was seen by 1 year after surgery and higher hemoglobin levels by 1, 2, and 3 years after surgery. No significant differences were observed in the 3-year overall survival and 3-year recurrence-free survival between the laparoscopic total gastrectomy and laparoscopic proximal gastrectomy groups (P = 0.74 and 0.72, respectively).

CONCLUSION

Laparoscopic proximal gastrectomy and laparoscopic total gastrectomy for patients with upper third clinical stage I gastric cancer are feasible as regards its safety and outcomes.

Simple modifications of conventional esophagogastrostomy after proximal gastrectomy adequately reduces the postoperative reflux esophagitis: a retrospective analysis of posterolateral fundoplication

PURPOSE

While proximal gastrectomy is being performed increasingly frequently for the treatment of gastric cancer, a standard reconstruction method to obtain optimal postoperative quality of life (QOL) still remains to be established. We modified the original esophagogastrostomy technique by introducing an additional posterolateral fundoplication (PLF) technique to minimize the risk of reflux esophagitis in patients undergoing proximal gastrectomy. The aim of this study was to clarify the clinical benefit of PLF.

METHODS

A retrospective analysis of the database was conducted to evaluate the effects of PLF. The data were compared between 44 patients in whom PLF was performed (PLF group) and 17 patients in whom conventional esophagogastrostomy without PLF was performed (C group). A number of incidence of postoperative reflux esophagitis and symptoms were assessed by findings of endoscopic examination and the PGSAS-45 questionnaire, respectively.

RESULTS

The incidence of grade B or worse esophagitis after surgery was significantly lower in the PLF group than in the C group (0% vs. 58.8%, P < 0.01). The score for the esophageal reflux subscale, as the main outcome measure of PGSAS-45, was significantly better in the PLF group (PLF: 1.5 vs C: 2.4, P < 0.01). Cohen's d value was 1.75, which suggested a rather large effect size. Postoperative benign anastomotic stricture was encountered in 10 cases (22.7%) of the PLF group and 4 cases (23.5%) of the C group, all of whom were successfully treated by brief endoscopic mechanical dilatation.

CONCLUSION

PLF is an expedient procedure for reconstruction 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.

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.

Current status of proximal gastrectomy for gastric and esophagogastric junctional cancer: A review

Proximal gastrectomy (PG) is one of the function-preserving surgical methods for the treatment of upper gastric cancer. Favorable postoperative results have been reported in comparison with total gastrectomy. However, because there are challenges, such as postoperative reflux esophagitis, anastomotic stenosis, and residual food, appropriate selection of a reconstruction method is crucial. Some methods include esophagogastric anastomosis, including simple esophagogastrostomy, tube-like stomach esophagogastrostomy, side overlap with fundoplication by Yamashita, and double-flap technique, and reconstruction using the small intestine, including double-tract methods, jejunal interposition, and jejunal pouch interposition. However, standard reconstruction methods are yet to be established. PG has also been employed in early gastric cancer of the upper third of the stomach, and indications have also been extended to esophagogastric junction cancer, which has shown an increase in recent years. Although many retrospective studies have revealed the functional benefits or oncological safety of PG, the characteristics of each surgical procedure should be understood so that an appropriate reconstruction method, with a reflux prevention mechanism and minimal postoperative injury, can be selected.

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.

Non-flap hand-sewn esophagogastrostomy as a simple anti-reflux procedure in laparoscopic proximal gastrectomy for gastric cancer

AIMS

No ideal and generally accepted method of reconstruction for laparoscopic proximal gastrectomy (LPG) has been established because of a high incidence of postoperative reflux and anastomotic stenosis. The aim of this study was to evaluate the short-term outcomes of LPG with a non-flap hand-sewn technique as a simple anti-reflux procedure for the upper part of clinical Stage I gastric cancer.

METHODS

Between November 2016 and June 2019, 23 consecutive gastric cancer patients, who underwent curative LPG with lymphadenectomy, were enrolled in the study. In this study, we devised a simple hand-sewn technique for esophagogastrostomy, which comprises a 5-cm pseudo-fornix as a fundoplication, the posterior pressure mechanism by the remnant stomach and bilateral crus, and a flat-shaped anastomotic hole as a valvuloplasty.

RESULTS

The median operation time and hospital stay was 325 min and 10 days, respectively. There was no patient with anastomotic leakage and delayed gastric empting. No patient had symptoms of gastroesophageal reflux, but two patients (8.6% (2/23): Grade M and Grade A) had endoscopic findings during a follow-up period of more than 6 months. There was no patient with Grade B or more severe reflux esophagitis. One patient (4.3%, 1/23) developed anastomotic stenosis, which was resolved with endoscopic dilatation. The mean body weight loss at 6 months after surgery was 7.5% in comparison with the preoperative body weight.

CONCLUSION

Our non-flap hand-sewn technique for esophagogastrostomy had favorable outcomes and might be one of reliable techniques as an anti-reflux procedure in LPG for gastric cancer.

Short-Term Surgical Outcomes of Laparoscopic Proximal Gastrectomy With Double-Tract Reconstruction Versus Laparoscopic Total Gastrectomy for Adenocarcinoma of Esophagogastric Junction: A Matched-Cohort Study

BACKGROUND

Laparoscopic proximal gastrectomy (LPG) with double-tract reconstruction (DTR) is performed as a function-preserving surgery for patients with adenocarcinoma of esophagogastric junction. However, whether LPG with DTR has postoperative advantages over laparoscopic total gastrectomy (LTG) is debatable. To evaluate benefits of LPG with DTR, we compared short-term surgical outcomes between LPG with DTR and LTG for adenocarcinoma of esophagogastric junction (AEG).

METHODS

Twelve patients who underwent LPG with DTR for AEG between February 2016 and August 2017 were included. Twenty-four patients who underwent LTG in the same period were matched to LPG with DTR cases for demographics, comorbidities, tumor characteristics, and tumor node metastasis stage. Short-term surgical outcomes were compared between the two groups.

RESULTS

Demographics of the LPG with DTR group and LTG group were comparable. The number of harvested lymph nodes in the LPG with DTR group was less than that in the LTG group, and the amount of estimated blood loss, the operative time, the days of gas-passing, start of diet, postoperative hospital stay were not significantly different between the groups. Furthermore, the postoperative reflux symptom in the LPG with DTR group was not significantly different with that in the LTG group. However, the increasing percentages of the serum albumin, total protein, and hemoglobin levels in the LPG with DTR group were significantly higher than those in the LTG group.

CONCLUSIONS

This study reveals that LPG with DTR may be a valuable procedure for the treatment of AEG because it has the advantages over LTG in terms of postoperative serum albumin, total protein, and hemoglobin.

Robot-Assisted Versus Laparoscopy-Assisted Proximal Gastrectomy for Early Gastric Cancer in the Upper Location: Comparison of Oncological Outcomes, Surgical Stress, and Nutritional Status

Background:

An increasing amount of attention has been paid to minimally invasive function-preserving gastrectomy, with an increase in incidence of early gastric cancer in the upper stomach. This study aimed to compare oncological outcomes, surgical stress, and nutritional status between robot-assisted proximal gastrectomy (RAPG) and laparoscopy-assisted proximal gastrectomy (LAPG).

Methods:

Eighty-nine patients were enrolled in this retrospective study between November 2011 and December 2013. Among them, 27 patients underwent RAPG and 62 underwent LAPG. Perioperative parameters, surgical stress, nutritional status, disease-free survival, and overall survival were compared between the 2 groups.

Results:

Sex, age, and comorbidity were similar in the RAPG and LAPG groups. There were also similar perioperative outcomes regarding operation time, complications, and length of hospital stay between the groups. The reflux esophagitis rates following RAPG and LAPG were 18.5% and 14.5%, respectively (P = .842). However, patients in the RAPG group had less blood loss (P = .024), more harvested lymph nodes (P = .021), and higher costs than those in the LAPG group (P < .001). With regard to surgical stress, no significant differences were observed in C-reactive protein concentrations and white blood cell count on postoperative days 1, 3, and 7 between the groups (Ps > .05). There appeared to be higher hemoglobin levels at 6 months (P = .053) and a higher body mass index at 12 months (P = .056) postoperatively in patients in the RAPG group compared with those in the LAPG group, but this difference was not significant. Similar disease-free survival and overall survival rates were observed between the groups.

Conclusions:

RAPG could be an alternative to LAPG for patients with early gastric cancer in the upper stomach with comparable oncological safety and nutritional status. Further well-designed, prospective, large-scale studies are needed to validate these results.

Comparison of outcomes of laparoscopy-assisted and open proximal gastrectomy with jejunal interposition for early gastric cancer in the upper third of the stomach: A retrospective observational study

INTRODUCTION

Laparoscopy-assisted proximal gastrectomy with jejunal interposition (LAPG-JI) is not yet widely used because the three anastomotic procedures involved in this operation are technically complicated. This study aimed to describe our surgical procedure for LAPG-JI and assess its feasibility and safety.

METHODS

This was a retrospective study of 70 patients who had undergone proximal gastrectomy with jejunal interposition for gastric cancer in the upper third of the stomach between July 2007 and October 2016. Of these patients, 32 underwent LAPG-JI, and 38 underwent open proximal gastrectomy with jejunal interposition. Clinical characteristics and both surgical and postoperative outcomes were compared between LAPG-JI and open proximal gastrectomy with jejunal interposition.

RESULTS

The operation time was longer in the LAPG-JI group (189 vs 154 min, P < 0.001) and estimated blood loss was lower (30 vs 180 mL, P < 0.001). There were no differences in the rates of early (9.4% vs 13.2%) or late postoperative complications (12.5% vs 10.5%). No anastomotic leakage was observed in either group. In the LAPG-JI group, the time to first eating was shorter, and the white blood cell counts on postoperative days 1 and 7 and body temperature on postoperative day 3 were lower. The number of additional doses of postoperative analgesia was lower in the LAPG-JI group. Reflux esophagitis graded C according to the Los Angeles classification was observed in only one patient (3.1%) in the LAPG-JI group.

CONCLUSION

Although the operation time was longer in the LAPG-JI group, the procedure seemed to be feasible and safe. Also, it offered the advantages of laparoscopic surgery, including less invasiveness and quicker recovery.

Function-preserving surgery for gastric cancer: current status and future perspectives

The number of early gastric cancer (EGC) cases has been increasing because of improved diagnostic procedures including endoscopy and screening systems. Therefore, function-preserving gastrectomy (FPG) for EGC with the expectation of better quality of life (QOL) after surgery may be increasingly utilized, due to its association with low rate of lymph node metastasis and excellent survival and the possibility of employing less invasive procedures such as laparoscopic gastrectomy in combination. Pylorus-preserving gastrectomy (PPG) with curative intent lymph node dissection is a representative FPG that has been used in EGC, and its superiorities, indications, limitations, and survival benefits have already been reported in several retrospective studies. Laparoscopic proximal gastrectomy (LAPG) has also been employed in EGC of the upper third of the stomach; however, LAPG was found to be associated with major issues in achieving a balance between swallowing and reflux prevention. In patients with EGC in the upper third of the stomach, laparoscopy-assisted subtotal gastrectomy with a preserved, albeit very small, stomach may provide a better QOL and fewer postoperative complications. FPG is recommended as a surgical treatment for EGC if the indication is accurately diagnosed and strictly confirmed; however, these techniques in laparoscopic surgery present technical difficulties to surgeons without a certain degree of skills. Although many retrospective studies revealed the functional benefits or oncological safety with FPG, further prospective studies using large case series are necessary to reveal the value of FPG compared with the conventional procedures.

Modified esophagogastrostomy in laparoscopy-assisted proximal gastrectomy: A reverse-Tornado anastomosis

INTRODUCTION

The aim of this study was to introduce and examine a modified mechanical end-to-side esophagogastrostomy method ("reverse-Tornado" anastomosis) in laparoscopy-assisted proximal gastrectomy.

METHODS

Five patients with gastric cancer who underwent laparoscopy-assisted proximal gastrectomy were analyzed retrospectively. Esophagogastrostomy in the anterior wall was performed in three patients, and esophagogastrostomy in the posterior wall was performed in two patients. Clinicopathological features, operative outcomes (operative time, operative blood loss), and postoperative outcomes (complications, postoperative hospital stay, reflux esophagitis) were evaluated.

RESULTS

Operative time was normal (278 min). There was no marked operative blood loss, postoperative complications, prolonged hospital stay, or reflux esophagitis.

CONCLUSION

Esophagogastrostomy was completed in a normal time with reverse-Tornado anastomosis. This method can be safe and can enable good postoperative quality of life.

Laparoscopic and endoscopic co-operative surgery for non-ampullary duodenal tumors

AIM

To assess the safety and feasibility of laparoscopic and endoscopic co-operative surgery (LECS) for early non-ampullary duodenal tumors.

METHODS

Twelve patients with a non-ampullary duodenal tumor underwent LECS at our hospital. One patient had two mucosal lesions in the duodenum. The indication for this procedure was the presence of duodenal tumors with a low risk for lymph node metastasis. In particular, the tumors included small (less than 10 mm) submucosal tumors (SMT) and epithelial mucosal tumors, such as mucosal cancers or large mucosal adenomas with malignant suspicion. The LECS procedures, such as full-thickness dissection for SMT and laparoscopic reinforcement after endoscopic submucosal dissection (ESD) for epithelial tumors, were performed for the 13 early duodenal lesions in 12 patients. Here we present the short-term outcomes and evaluate the safety and feasibility of this new technique.

RESULTS

Two SMT-like lesions and eleven superficial epithelial tumor-like lesions were observed. Seven and Six lesions were located in the second and third parts of the duodenum, respectively. All lesions were successfully resected en bloc. The defect in the duodenal wall was manually sutured after resection of the duodenal SMT. For epithelial duodenal tumors, the ulcer bed was laparoscopically reinforced via manual suturing after ESD. Intraoperative perforation occurred in two out of eleven epithelial tumor-like lesions during ESD; however, they were successfully laparoscopically repaired. The median operative time and intraoperative estimated blood loss were 322 min and 0 mL, respectively. Histological examination of the tumors revealed one adenoma with moderate atypia, ten adenocarcinomas, and two neuroendocrine tumors. No severe postoperative complications (Clavien-Dindo classification grade III or higher) were reported in this series, but minor leakage secondary to pancreatic fistula occurred in one patient.

CONCLUSION

LECS can be a safe and minimally invasive treatment option for non-ampullary early duodenal tumors.

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.

Clinical and surgical factors associated with organ/space surgical site infection after laparoscopic gastrectomy for gastric cancer

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.

A newly modified esophagogastrostomy with a reliable angle of His by placing a gastric tube in the lower mediastinum in laparoscopy-assisted proximal gastrectomy

BACKGROUND

An optimal reconstruction method for proximal gastrectomy (PG) remains elusive. Esophagogastrostomy (EG) is technically simple but suffers from the disadvantage of gastroesophageal reflux. Jejunal interposition (JI) has a low rate of gastroesophageal reflux, but the procedure is more complicated, and delayed gastric emptying is a problem.

METHODS

We created a modified EG and have used the modified technique for PG since 2006. The procedure involves shaping the remnant stomach into a gastric conduit. The EG is performed high on the anterior wall, and the conduit is kept straight by applying a circular stapler inserted from the anterior wall of the antrum. The tip of the gastric conduit is then inserted into the lower mediastinum, creating a sharp angle of His. In this retrospective cohort study, the clinical and physiological outcomes were compared between 25 patients who underwent this procedure and 21 patients who underwent JI from 2001 to 2005.

RESULTS

Laparoscopic procedures were performed more frequently, and residual food and bile reflux were less common in the EG group than in the JI group. No significant differences in remnant gastritis or reflux esophagitis were observed between the two groups. However, the late complication of intestinal obstruction occurred only in the JI group.

CONCLUSIONS

The modified EG technique has advantages over the JI technique because of its simplicity and low incidence of residual food and bile reflux. The next step would be to explore this technique further by a prospective multi-institutional study to confirm the reproducibility of its benefits. Miniabstract: The modified EG technique has advantages over the JI technique because of its simplicity, high rate of laparoscopy use, and low incidence of gastroesophageal reflux.

Proximal Gastrectomy for Gastric Cancer

Laparoscopic proximal gastrectomy (LPG) is theoretically a superior choice of minimally-invasive surgery and function-preserving surgery for the treatment of proximal early gastric cancer (EGC) over procedures such as laparoscopic total gastrectomy (LTG), open total gastrectomy (OTG) and open proximal gastrectomy (OPG). However, LPG and OPG are not popular surgical options due to three main concerns: the first, oncological safety; the second, functional benefits; and the third, anastomosis-related late complications (reflux symptoms and anastomotic stricture). Numerous recent studies have concluded that OPG and LPG present similar oncological safety profiles and improved functional benefits when compared with OTG and LTG. While OPG with modified esophagogastrostomy does not provide satisfactory results, OPG with modified esophagojejunostomy showed similar rates of anastomosis-related late complications when compared to OTG. At this stage, no standard reconstruction method post-LPG exists in the clinical setting. We recently showed that LPG with double tract reconstruction (DTR) is a superior choice over LTG for proximal EGC in terms of maintaining body weight and preventing anemia. However, as there is no definitive evidence in favor of LPG with DTR, a randomized clinical trial comparing LPG with DTR to LTG was recommended. This trial, the Korean Laparoscopic Gastrointestinal Surgery Study-05 (NCT01433861), is expected to assist surgeons in choice of surgical approach and strategy for patients with proximal EGC.

Reconstruction after proximal gastrectomy for gastric cancer in the upper third of the stomach: a review of the literature published from 2000 to 2014

Proximal gastrectomy (PG) is occasionally performed to preserve the physiological function of the remnant stomach with the aim of maintaining a gastric reservoir for patients with early gastric cancer in the upper third of the stomach. Many reconstructive procedures after PG have been reported, including esophagogastrostomy (EG), jejunal interposition, jejunal pouch interposition, and double tract. However, no general agreement exists regarding the optimal reconstructive procedure. This article reviews the current reconstructive procedures available for PG. We examined the surgical outcomes, postoperative complications, endoscopic findings, and quality of life (QOL) according to the reconstructive procedures. We found no significant difference in anastomotic leakage and anastomotic stricture among the procedures. The frequency of reflux esophagitis was higher with simple EG compared with the other reconstructive procedures. Some additional procedures, such as fundoplication, the use of a narrow gastric conduit, and placement of a gastric tube in the lower mediastinum on EG, could decrease the frequency of reflux esophagitis and reflux symptoms. These additional procedures may improve the QOL; however, the previous studies were small and could not adequately compare the reconstructive procedures. Prospective randomized controlled trials that involve a longer trial period and more institutions are needed to clarify the optimal reconstructive procedures after PG.

Feasibility and Nutritional Benefits of Laparoscopic Proximal Gastrectomy for Early Gastric Cancer in the Upper Stomach

BACKGROUND

Laparoscopic proximal gastrectomy (LPG) has recently been applied for early gastric cancer (EGC) in the upper stomach as a minimally invasive and function-preserving surgery. This study aimed to clarify the feasibility and nutritional benefits of LPG over laparoscopic total gastrectomy (LTG).

METHODS

This was a retrospective study of 77 patients with clinical stage I gastric cancer in the upper stomach. Of these patients, 25 underwent LPG, while 52 underwent LTG. Surgical outcomes and postoperative nutritional status such as changes in body weight and blood chemistries were compared between LPG and LTG.

RESULTS

Intraoperative blood loss and C-reactive protein levels at 3 and 7 days after surgery were significantly lower in LPG than in LTG (p = 0.018, 0.036, and 0.042, respectively). No significant differences were observed in postoperative early or late complication rates between LPG and LTG. The incidence of Los Angeles Grade B or more severe reflux esophagitis after LPG was 9.1 %, which was similar to that after LTG (9.3 %). Postoperative changes in body weight at 6 months and 1 and 2 years after surgery were consistently less in LPG than in LTG (p = 0.001, 0.022, and 0.001, respectively). Moreover, postoperative levels of hemoglobin and serum albumin and total lymphocyte count were also higher in LPG than in LTG.

CONCLUSION

LPG may be a better choice for EGC in the upper stomach than LTG because it has distinct advantages in terms of surgical invasiveness and postoperative nutritional status.

Long-term outcomes of patients who underwent limited proximal gastrectomy

BACKGROUND

Because the incidence of early gastric cancers has been increasing in Asian countries, postoperative quality of life has received considerable attention in addition to oncological outcomes.

METHODS

Eighty-four patients with clinically early gastric cancers were enrolled in this retrospective study. Among them, 35 patients underwent total gastrectomy (TG) and 49 patients underwent limited proximal gastrectomy (PG). Blood chemistry, changes in body weight, and oncological outcomes were compared between the two groups.

RESULTS

Postoperative hemoglobin levels and body weights were significantly lower in the TG group than in the PG group, and there were no significant differences in the levels of other nutritional indicators such as serum total protein and total cholesterol. However, the overall survival rates of patients in the PG group were similar to those of patients in the TG group (5-year survival rates, 95 versus 97 %, respectively; p = 0.86).

CONCLUSIONS

Limited proximal gastrectomy with regional lymph node dissection has possible positive effects on maintaining body weight and preventing postgastrectomy anemia with similar oncological outcomes to total gastrectomy in patients with early gastric cancers.

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.

Evaluation of symptoms related to reflux esophagitis in patients with esophagogastrostomy after proximal gastrectomy

PURPOSE

We investigated postoperative symptoms related to reflux esophagitis in patients who underwent esophagogastrostomy reconstruction after proximal gastrectomy (PG) by conducting a questionnaire survey.

METHOD

Quality of life was assessed using two different questionnaires, the gastrointestinal symptom rating scale (GSRS) for postoperative abdominal symptoms and F-scale for reflux esophagitis. The survey was conducted among 39 patients who underwent esophagogastrostomy after proximal gastrectomy for gastric cancer in the upper third of the stomach, and findings were compared with those in patients who underwent total gastrectomy (TG).

RESULTS

The questionnaire was returned by 32 of 39 patients (82%) in the PG group and 40 of 45 patients (89%) in the TG group. On GSRS, the score for indigestion syndrome tended to be higher in the TG group than in the PG group (p < 0.10), and the score for constipation was significantly higher in the PG group than in the TG group (p < 0.05). The score for reflux syndrome, however, was almost the same in both groups. Similarly, there was no significant difference in the frequency of GERD symptoms between the PG and TG groups on F-scale questionnaire (47% vs. 63%, p = 0.18).

CONCLUSIONS

Esophagogastrostomy after PG in an end-to-side manner with creation of acute angle at the anastomosis is not associated with an increased risk of reflux esophagitis compared with TG.