Intracorporeal circular-stapled Billroth I anastomosis in single-incision laparoscopic distal gastrectomy

Three-year follow-up outcomes of postoperative quality of life from a randomized controlled trial comparing multi-port versus single-port laparoscopic distal gastrectomy

BACKGROUND

Laparoscopic surgery for gastric cancer has become widely used; minimally invasive surgery has become the mainstream of treatment. This randomized controlled trial (RCT) aimed to compare long-term quality of life (QoL) and weight loss rates in patients who underwent single-port laparoscopic gastrectomy (SLG) or multi-port laparoscopic gastrectomy (MLG) for gastric cancer.

METHODS

This single-center RCT compared MLG and SLG in patients with clinical stage I gastric cancer, all of which underwent distal gastrectomy between April 2016 and September 2018. A total of 101 patients were evaluated for eligibility; all were randomized into either the SLG group (n = 50) or MLG group (n = 51). Blood tests, weight measurements, and postoperative questionnaires (DAUGS20, EORTC QLQ-C30, PGSAS-45) were performed at 3, 6, 12, and 36 months after surgery to compare the QoL.

RESULTS

At six months postoperatively, there was a higher trend toward lower weight loss in the SLG group compared with the MLG group. At 1, 3, 6, and 36 months postoperatively, the neutrophil-to-lymphocyte ratio was significantly lower in the SLG group than that in the MLG group. The QoL, as measured using the postoperative questionnaires, was generally comparable. However, some favorable results, such as fewer diarrheas, were achieved.

CONCLUSIONS

SLG was partially superior to MLG in terms of long-term QoL, in addition to assurance of esthetics and reduced pain. In addition, systemic inflammatory markers and weight loss rates were lower, suggesting a potential long-term benefit. SLG may be an option for stage I gastric cancer surgery. Further follow-up and multicenter studies should be considered.

Comparing the short-term outcomes and cost between solo single-incision distal gastrectomy and conventional multiport totally laparoscopic distal gastrectomy for early gastric cancer: a propensity score-matched analysis

Purpose

Single-incision laparoscopic distal gastrectomy (SIDG) requires experienced camera operators for a stable image. Since it is difficult for skilled camera operators to participate in all SIDG, we began performing solo surgery using mechanical camera holders. We aimed to compare the short-term outcomes and cost between solo SIDG and conventional multiport laparoscopic distal gastrectomy (MLDG) for early gastric cancer (EGC).

Methods

From January 2014 to December 2016, a total of 938 consecutive patients underwent laparoscopic gastrectomy for EGC. Solo SIDG (n = 99) and MLDG patients (n = 198) were selected and 1:2 propensity score matching was done to compare the quality of operation and cost-effectiveness. All solo SIDG was performed by a surgeon using a camera holder, without any assistant.

Results

Mean operation time (120 ± 35.3 vs. 178 ± 53.4 minutes, P = 0.001) and estimated blood loss (24.6 ± 47.4 vs. 46.7 ± 66.5 mL, P = 0.001) were significantly lower in the solo SIDG group. Hospital stay, use of analgesics, and postoperative inflammatory markers (WBC, CRP) were similar between the 2 groups. The early (<30 days) complication rate in solo SIDG and MLDG groups was 21.2% and 23.7%, respectively (P = 0.240); the late (≥30 days) complication rate was 7.1% and 11.1%, respectively (P = 0.672). The manpower cost of solo SIDG was significantly lower than that of MLDG (P = 0.001).

Conclusion

This study demonstrated that solo SIDG performed by experienced laparoscopic surgeons is safe and feasible for EGC. Solo SIDG is expected to be a promising potential treatment for EGC.

Comparing the surgical outcomes of dual-port laparoscopic distal gastrectomy and three-port laparoscopic distal gastrectomy for gastric cancer

Purpose

Many studies have demonstrated that single-incision or reduced-port laparoscopic distal gastrectomy is a feasible method compared to conventional laparoscopic distal gastrectomy. Using rigid-type laparoscope and right-side approach, we could perform dual-port laparoscopic distal gastrectomy (DPLDG) for gastric cancer. This study aimed to compare the surgical outcomes of DPLDG to those of 3-port laparoscopic distal gastrectomy (TPLDG).

Methods

From March 2017 to December 2019, this retrospective study included 218 patients with gastric cancer who underwent DPLDG (106 patients) or TPLDG (112 patients) at SMG-SNU Boramae Medical Center. Surgical outcomes were compared between 2 operation methods.

Results

Operation time was similar between DPLDG and TPLDG (158.9 ± 33.4 minutes vs. 154.0 ± 31.1 min, P = 0.787). The number of retrieved lymph nodes was similar between the 2 groups (35.3 ± 14.6 vs. 37.0 ± 13.5, P = 0.415). The complication rate in DPLDG and TPLDG groups was 10.4% and 8.9%, respectively (P = 0.894). The time to first flatus, time to first diet, and postoperative hospital stay were similar between the 2 groups. There were no reoperation or mortality cases. The cost of trocars was 359.9 US dollars (USD) in DPLDG and 291–391.4 USD in TPLDG.

Conclusion

The surgical outcomes of DPLDG and TPLDG did not differ. Regarding fewer incisions, DPLDG can be an alternative option for TPLDG.

A randomized controlled trial of single-port versus multi-port laparoscopic distal gastrectomy for gastric cancer

OBJECTIVE

This prospective randomized trial compared the invasiveness of laparoscopic gastrectomy using a single-port approach with that of a conventional multi-port approach in the treatment of gastric cancer. The benefit of single-port laparoscopic gastrectomy (SLG) over multi-port laparoscopic gastrectomy (MLG) has yet to be confirmed in a well-designed study.

METHODS

One hundred and one patients who were scheduled to undergo laparoscopic distal gastrectomy for histologically confirmed clinical stage I gastric cancer between April 2016 and September 2018 were randomly allocated to SLG (n = 50) or MLG (n = 51). The primary endpoints were the postoperative visual analog scale pain scores. Secondary endpoints were frequency of use of analgesia, short-term outcomes, such as operating time, intraoperative blood loss, inflammatory reactions, postoperative morbidity, and 90-day mortality.

RESULTS

The postoperative pain score was significantly lower in the SLG group than in the MLG group (p < 0.001) on the operative day and the postoperative day 1-7. Analgesics were administered significantly less often in the SLG group than in the MLG group (1 vs. 3 days, p = 0.0078) and the duration of use of analgesics was significantly shorter in the SLG group (2 vs. 3 days, p = 0.0171). The operating time was significantly shorter in the SLG group than in the MLG group (169 vs. 182 min, p = 0.0399). Other surgical outcomes were comparable between the study groups.

CONCLUSIONS

SLG was shown to be safe and feasible in the treatment of gastric cancer with better short-term results in terms of less severe pain and may be suitable for treatment of cStage I gastric cancer.

CLINICAL TRIAL REGISTRATION

UMIN000022218.

The Safety and Feasibility of Single-Port Laparoscopic Gastrectomy for Advanced Gastric Cancer

BACKGROUND

Single-port laparoscopic surgery maximizes the advantages of laparoscopic surgery by reducing damage of the abdominal wall. However, no comparative studies have addressed its application to gastrectomy for advanced gastric cancer (AGC). We therefore aimed to demonstrate the safety and feasibility of single-port laparoscopic gastrectomy (SLG) for the treatment of AGC by comparing it with conventional multi-port laparoscopic gastrectomy (MLG).

METHODS

We searched the prospective gastric cancer database of our institute for patients with AGC who underwent SLG or MLG between October 2007 and December 2013. Cases of R2 resection with distant metastasis or concurrent surgery for comorbid malignant lesions were excluded. One-to-one propensity score matching was performed to reduce bias from confounding patient-related variables, and the short- and long-term outcomes were compared between the two groups.

RESULTS

We identified 216 patients who underwent SLG (n = 100) or MLG (n = 116). After propensity score matching, we selected 73 pairs of patients who underwent SLG (distal gastrectomy, 49; total gastrectomy, 24) or MLG (distal gastrectomy, 45; total gastrectomy, 28). While the mean operative times were comparable between the groups, the SLG group had less blood loss, a lower postoperative morbidity, and shorter postoperative hospital stays. The 5-year survival rates were 74.2% in the SLG group and 60.2% in the MLG group (P = 0.081 by log-rank test).

CONCLUSIONS

SLG is shown to be safe and feasible for the treatment of AGC, with better short-term results and acceptable oncologic outcomes and may be applicable for AGC treatment.

A New Robot-assisted Billroth-I Reconstruction: Details of the Technique and Early Results

BACKGROUND

Laparoscopic surgery for gastric tumor is considered a demanding procedure because of lymph node dissection and reconstruction. Billroth-I (B-I) reconstruction after laparoscopic distal gastrectomy is commonly performed extracorporeally because of the complexity of an intracorporeal procedure. Robotic surgery overcomes some limitations of laparoscopy, allowing to reproduce the basic maneuvers of open surgery. We describe a new technique to perform robotic B-I anastomosis.

METHODS

Between January 2012 and February 2015, 5 patients underwent distal gastrectomy with intracorporeal B-I-stapled anastomosis. Patient demographics, tumor characteristics, histopathologic features, and perioperative data were analyzed.

RESULTS

Median operative time was 170 minutes (145 to 180 min). There were no conversions. Contrast swallow was routinely performed on the third postoperative day. Median postoperative hospitalization was 7 days (range: 6 to 8). No major complications or mortality were observed.

CONCLUSIONS

Robotic distal gastrectomy with intracorporeal B-I anastomosis is a safe and promising technique in selected cases of gastric tumors.

Single-incision Laparoscopic Gastrectomy for Gastric Cancer

The implementation of national cancer screening has increased the detection rates of early gastric cancer (EGC) in Korea. Since the successful introduction of laparoscopic gastrectomy for gastric cancer in the early 1990s, this technique has demonstrated improved short-term outcomes without compromising long-term oncologic results. It is associated with reduced pain, shorter hospitalization, reduced morbidity rates, better cosmetic outcomes, and equivalent mortality rates as those for open surgery. Laparoscopic gastrectomy improves patients' quality of life (QOL) and provides favorable prognosis. Single-incision laparoscopic gastrectomy (SILG) is one extremely minimally invasive method, theoretically offering improved cosmetic results, less postoperative pain, and earlier recovery after surgery than conventional multiport laparoscopic gastrectomy. In this context, SILG is thought to be an optimal method to promote and maximize patients' QOL in the acute postoperative phase. However, the technical difficulties of this procedure have limited its use. Since the first report describing single-incision distal gastrectomy in 2011, only 16 studies to date have evaluated SILG. Most of these studies have focused on the technical feasibility and safety of SILG because its long-term outcomes have not been reported. This article reviews the advantages and limitations of SILG.

A modified efficient purse-string stapling technique (mEST) that uses a new metal rod for intracorporeal esophagojejunostomy in laparoscopic total gastrectomy

Intracorporeal esophagojejunostomy after laparoscopic total gastrectomy is technically difficult because this procedure should be performed in a narrow surgical field in the upper abdomen even when completely laparoscopic approaches are used. The placement of the anvil of a circular stapling device into the esophagus and connection the instrument to the anvil are extremely difficult steps in this surgery. Therefore, we developed a simple technique for intracorporeal esophagojejunostomy using hemi-double stapling technique; we named this technique the efficient purse-string stapling technique (EST). More recently, we have developed a modified EST (mEST) that utilizes a new stainless steel anvil rod instead of a plastic rod. Relative to the plastic rod, the steel rod is reusable and shorter; thus, it was easier to perform anvil placement into the esophagus with the steel rod. Anvil preparation for mEST: a stainless steel rod is attached to the shaft of the anvil, and the needle and thread are sutured to the tip of the rod. After complete insertion of the anvil into the esophageal cavity, the needle and thread are used to penetrate the anterior esophageal wall, and the esophagus is then clamped using a linear stapler just distal to the site penetrated by the thread. The linear stapler is fired, and anvil placement in the esophagus is simultaneously accomplished. After the rod is removed from the anvil, the instrument is intracorporeally connected to the anvil and then fired to complete the gastrojejunostomy. This technique is simple and facilitates intracorporeal reconstruction procedures in laparoscopic total gastrectomy.

Single-Port Laparoscopic Proximal Gastrectomy with Double Tract Reconstruction for Early Gastric Cancer: Report of a Case

In Korea, proximal gastrectomy has recently attracted attention as a better choice of function-preserving surgery for proximal early gastric cancer than total gastrectomy. Of the various strategies to overcome reflux symptoms from remnant stomach, double tract reconstruction not only reduces the incidence of anastomosis-related complications, but is also sufficiently reproducible as a laparoscopic procedure. Catching up with the recent rise of single-port laparoscopic surgeries, we performed a pure single-port laparoscopic proximal gastrectomy with DTR. This procedure was designed by merging the function-preserving concept of proximal gastrectomy with single-port laparoscopic total gastrectomy.

Comparison of Single-Incision and Conventional Multi-Port Laparoscopic Distal Gastrectomy with D2 Lymph Node Dissection for Gastric Cancer: A Propensity Score-Matched Analysis

BACKGROUND

Single-incision laparoscopic surgery maximizes the advantages of laparoscopic surgery by reducing abdominal trauma; however, few comparative studies have addressed its role in gastric cancer.

PURPOSE

This study sought to demonstrate the safety and feasibility of single-incision laparoscopic distal gastrectomy (SLDG) with radical D2 lymphadenectomy by comparing its short- and long-term outcomes with those of conventional multi-port laparoscopic surgery (MLDG).

METHODS

From October 2007 to December 2011, we identified 175 patients with clinical stage I-III gastric cancer who underwent SLDG with D2 lymphadenectomy (n = 90) and MLDG (n = 85) according to a review of our prospective gastric cancer database in our institute. One-to-one propensity score matching was performed to compare short-term outcomes and long-term survival between the two groups.

RESULTS

Mean operative time was similar between the two groups, while blood loss was significantly lower in the SLDG group than in the MLDG group. Postoperative recovery was faster in the SLDG group in terms of earlier initiation of oral intake, less use of analgesics, and shorter hospital stay. Serum C-reactive protein levels were significantly lower in the SLDG group than in the MLDG group on postoperative days 1, 3, and 7, and the 5-year overall survival rate was not significantly different between the two groups (93.7 vs. 87.6 %; p = 0.689).

CONCLUSIONS

This study shows that SLDG with D2 lymphadenectomy is safe and feasible for gastric cancer, with better short-term outcomes than MLDG and acceptable oncologic outcomes. Thus, SLDG may be an attractive surgical alternative in minimally invasive surgery.

Single incision gastrectomy for gastric cancer

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

Reduced port laparoscopic gastrectomy for gastric cancer

The use of reduced port laparoscopic surgery (RPS) has become increasingly popular. The concept of RPS includes all procedures derived from various efforts minimizing the invasiveness of surgery, with single-incision laparoscopic surgery (SILS) being the ultimate reduced port technique. Reduced-port laparoscopic gastrectomy (RPLG) for gastric cancer has not yet been fully established and still has issues such as feasibility, oncological validity, training, and education. The short-term results of reported studies are acceptable. However, long-term results that verify positive results or radical cure even in cases of cancer have not yet been published. Patients for whom RPLG is indicated should be selected carefully. Prospective multicenter studies should be conducted to establish RPS as a truly evidence-based practice that addresses not only cosmesis but also the appropriate balance between minimal invasiveness and radical cure.

Minimally invasive surgery for stomach cancer

Laparoscopic surgery for gastric cancer has become extremely widespread in recent years especially in Asian countries due to its low invasiveness. As to evidence of indication for laparoscopic surgery for gastric cancer, laparoscopic surgery for gastric cancer often appears to be indicated for early gastric cancer at many institutions, while evidence was considered to be insufficient to recommend laparoscopic surgery for gastric cancer at Stage II and above. There are also problems with indications for cases other than tumour factors. No meta-analyses and prospective studies have been reported, but outcomes of laparoscopic surgery for gastric cancer in gastric cancer patients with co-morbid and/or existing diseases have been reported in retrospective studies. Indications in the elderly appear to be favourable in terms of post-operative ambulation considering factors such as the degree of dissection in accordance with the status of the patient. Meta-analyses, randomized controlled trials and several retrospective studies have compared the short-term usefulness of laparoscopic surgery for gastric cancer with that of conventional gastrectomy. The superiority of laparoscopic surgery for gastric cancer has been reported in terms of the reduced amount of bleeding, a reduction in the administration frequency and period of analgesic doses, a reduction in the duration of fever, early recovery of intestinal movement and early return to oral intake. A small-scale randomized controlled trial and several retrospective studies have demonstrated no significant differences in survival rate, recurrence rate and type of recurrence between laparoscopic surgery for gastric cancer and conventional gastrectomy. The results of the aforementioned trials in early gastric cancer in Japan and Korea for which enrolment is complete remain to be published.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Single-incision totally extraperitoneal inguinal hernia repair as a teaching procedure: one center's experience of more than 300 procedures

PURPOSE

To evaluate resident doctors' proficiency in performing single-incision laparoscopic surgery for totally extraperitoneal inguinal hernia repair (SILS-TEP), and assess patient outcomes by comparing procedures performed by resident surgeons vs. those performed by staff surgeons.

METHODS

We analyzed retrospectively 301 patients who underwent SILS-TEP between January 2011 and May 2015 at Osaka Police Hospital.

RESULTS

The mean operative times for unilateral and bilateral hernia repairs in the resident-surgeon and the staff-surgeon groups were 99 vs. 88 min, respectively (p < 0.05), and 130 vs. 137 min, respectively. There was no significant difference in the incidence of conversion to a different procedure between the groups. The mean postoperative hospital stay was 2.0 days for patients from the resident-surgeon group vs. 2.8 days for those from the staff-surgeon group (p < 0.05). Seromas and wound infections developed in 8 % (12/148) of patients from the resident-surgeon group vs. 12 % (19/153) of those from the staff-surgeon group. No other major complications or hernia recurrence were noted in either group.

CONCLUSIONS

SILS-TEP was performed safely, with low morbidity and no recurrence, by the resident surgeons under appropriate guidance by staff surgeons.

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

Purpose

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

Materials and Methods

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

Results

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

Conclusions

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

Laparoscopy assisted distal gastrectomy for T1 to T2 stage gastric cancer: a pilot study of three ports technique

Laparoscopy assisted distal gastrectomy (LADG) was first reported in 1994. Since then, it has gradually gained maturity. This procedure is less invasive than conventional open gastrectomy, and the oncologic outcomes are comparable. Recently, single-incision laparoscopic surgery (SILS) has been developed, which seems to be less invasive than conventional laparoscopic surgery. However, SILS technique is characterized by a limited working area, crowding and crossing of instruments which make it difficult to be applied for oncologic gastrectomy. In a trial to overcome SILS difficulties, the authors report their initial clinical experience of LADG with D1 lymphadenectomy using a novel 3-ports technique. Twenty-one patients have been enrolled for 3-ports laparoscopic gastrectomy. The patient's demographic and perioperative data have been collected prospectively. The mean operative time in the first ten cases was 170 min and for the last eleven cases was 140 min (P = 0.01). The mean estimated blood loss was 65 ml. There was no use for additional ports or conversion to open surgery. There were no intra-operative major complications. The mean time for hospital stay was 9 days. One case of pneumonia and one death were the postoperative complications. The mean number of retrieved lymph nodes was 21 and all the cases had free surgical margin. Three-ports LADG with D1 lymphadenectomy could be a safe and oncologically feasible procedure; however, a prospective randomized controlled trial comparing three ports LADG with conventional multi-ports LADG is required. It is a step towards three-port total laparoscopic distal gastrectomy.

Reduced port laparoscopic gastrectomy: a review, techniques, and perspective

Reduced port laparoscopic surgery has been used increasingly. It is a concept that has grown out of the various efforts aimed at minimally invasive surgery, with SILS being the ultimate reduced port technique. Reduced port laparoscopic surgery has been used to perform sleeve gastrectomy in bariatric surgery and excision of benign gastric submucosal tumor, applications that generally do not require lymph node dissection or complicated reconstruction. It can be done safely, result in a permanent cure, and offer good cosmetic outcomes. Reduced port laparoscopic surgery for gastric cancer has a short history, and its usefulness has not yet been fully established. This review describes the present situation and challenges faced as well as standardized procedures and the future prospects of reduced port laparoscopic gastrectomy for gastric cancer, which my team performs almost daily. These aspects of reduced port laparoscopic surgery are presented in light of the literature.

Delta-shaped anastomosis, a good substitute for conventional Billroth I technique with comparable long-term functional outcome in totally laparoscopic distal gastrectomy

BACKGROUND

Delta-shaped anastomosis (DA) is a new Billroth I reconstruction technique using only a laparoscopic linear stapler under a totally laparoscopic approach. The present study compared the outcomes of DA with those of laparoscopic conventional Billroth I anastomosis (cBIA).

METHODS

A total of 138 and 100 patients with gastric cancer who underwent laparoscopic distal gastrectomy with DA and cBIA, respectively, were selected. Clinicopathological data and short- and long-term outcomes were compared between the two groups.

RESULTS

The mean operating time in the DA group was similar to that in the cBIA group. Short-term outcomes, such as bowel function recovery, morbidity, and mortality, did not differ between the DA and cBIA groups. There were no significant differences in the 5-year disease-free and overall survival rates between the two groups. All nutritional indices (body weight change, albumin level, transferrin level, and total lymphocyte count) were similar between the two groups with the exception of a few points in the early follow-up period. Endoscopic evaluation using the Residual food, Gastritis, Bile reflux classification revealed relatively better gastritis findings in the DA group despite worse bile reflux for 5 postoperative years. The food amount was significantly larger in the DA group for 2 postoperative years.

CONCLUSIONS

The outcomes of DA were comparable to those of cBIA. DA is a recommendable reconstruction method, especially in totally laparoscopic distal gastrectomy.

Safety and feasibility during the initial learning process of intracorporeal Billroth I (delta-shaped) anastomosis for laparoscopic distal gastrectomy

BACKGROUND

Intracorporeal Billroth I (ICBI) (delta-shaped) anastomosis is being increasingly used for laparoscopic distal gastrectomy. However, few studies have focused on the safety and feasibility of adopting this new technique. The present study aimed to review the surgical outcomes after the initial experience of performing ICBI anastomosis and to evaluate whether this technique can be safely adopted without increasing operative risk during the early learning process.

METHODS

Forty-two consecutive patients who underwent ICBI anastomosis with laparoscopic distal gastrectomy by a single surgeon were enrolled, and their operative outcomes and hospital course were compared with those of 179 patients who underwent conventional extracorporeal Billroth I (ECBI) anastomosis by the same operator. The learning curve was assessed by evaluating the moving average of anastomosis time.

RESULTS

The operating time in the ICBI group was significantly longer than that in the ECBI group (142 vs. 116 min, p < 0.001). However, there were no significant differences in the postoperative hospital course such as gas passage, diet initiation, postoperative fever, and hospital stay between the two groups. Postoperative morbidity did not significantly differ between the ICBI and ECBI groups (7.1 vs. 12.3 %, p = 0.428). No anastomosis-related complications occurred in the ICBI group. The mean anastomosis time for ICBI anastomosis was 24 ± 5 min, and the anastomosis average time curve showed that it reached a plateau approximately after the 14th case.

CONCLUSIONS

ICBI anastomosis has a steep learning curve without increasing operative risk in the early learning process, when performed by experienced laparoscopic surgeons. The technical feasibility and clinical advantages of intracorporeal anastomosis need to be proven in future clinical trials.

Pure single-port laparoscopic distal gastrectomy for early gastric cancer: comparative study with multi-port laparoscopic distal gastrectomy

BACKGROUND

The purpose of this study was to show the feasibility and safety of pure single-port laparoscopic distal gastrectomy (SDG) by comparing its short-term outcomes with those of conventional multiport totally laparoscopic distal gastrectomy (TLDG).

STUDY DESIGN

Prospectively collected data of 50 gastric cancer patients who underwent pure SDG from November 2011 through October 2013 were compared with the matched data of 50 TLDG patients.

RESULTS

Mean operation time (144.5 vs 140.3 minutes; p = 0.561) and number of harvested lymph nodes (51.7 ± 16.3 vs 52.4 ± 17.9; p = 0.836) were comparable. Estimated blood loss was lower in the SDG patients (50.5 ± 31.5 mL vs 87.5 ± 79.6 mL; p = 0.007). Postoperative recovery was faster in the SDG patients in terms of lower maximum pain score on the operative day (6.1 ± 1.4 vs 6.9 ± 1.5; p = 0.015) and postoperative day 1 (4.6 ± 1.0 vs 5.5 ± 1.4; p < 0.001), less use of parenteral analgesics (0.8 ± 1.0 vs 1.4 ± 1.0; p = 0.020), and less increase in C-reactive protein level on postoperative day 5 (4.57 ± 6.26 mg/L vs 8.51 ± 5.25 mg/L; p = 0.008). Postoperative morbidity occurred in 6 (12%) and 5 (10%) patients in the SDG and TLDG group, respectively.

CONCLUSIONS

This study showed that pure SDG is both safe and feasible for early gastric cancer, with similar operation time and better short-term outcomes than TLDG in terms of postoperative pain, estimated blood loss, inflammatory reaction, and cosmetic result.

Feasibility and safety of single-incision laparoscopic surgery in gastric benign and malignant diseases

We systematically searched Medline and Cochrane Library and the related references occurred in the citations until February 2013 and included all the cases who suffered from gastric benign and malignant diseases where single incision laparoscopic surgery was performed. A total of 69 cases with gastric diseases undergoing SILS surgery were reviewed to evaluate the feasibility, safety, and potential benefits of SILS for the gastric diseases. Demographic data, morphologic characterisation of the lesion, and perioperative parameters were analyzed retrospectively. The initial experience with SILS for benign gastric diseases and early gastric cancer showed that it is feasible and safe when performed by experienced laparoscopic surgeons. Despite the limited number and technical difficulties it can be proposed in selected patients.

Single-incision laparoscopic total gastrectomy with D1+beta lymph node dissection for proximal early gastric cancer

Single-incision laparoscopic distal gastrectomy for early gastric cancer has recently been reported by a few centers in Korea and Japan. In this technical report, we describe the world's first pure single-incision laparoscopic total gastrectomy with D1+beta lymph node dissection for proximal early gastric cancer.

A simple and safe method for Billroth I reconstruction in single-incision laparoscopic gastrectomy using a novel intracorporeal triangular anastomotic technique

The intracorporeal anastomosis is one of the most difficult procedures in single-incision laparoscopic gastrectomy for gastric cancer. We describe a simple technique for intracorporeal triangular Billroth I anastomosis in transumbilical single-port surgery. After adequate lymphadenectomy, the stomach and duodenum were staple-transected. Small incisions were made to the remnant stomach and the duodenum. The anvil of a linear stapler and a staple compartment were inserted through the holes, and then both ends were stitched up together by stapler. This staple line would be the bottom of the triangular anastomosis. The second and third lines were created by closure of the common hole and with simultaneous removal of three staple lines (stumps of the stomach and duodenum and the ventral side of the first anastomosis) using two linear staplers, respectively, completing the triangular anastomosis. We performed this technique in 45 patients between March and December 2011. All procedures were completed in single-port approaches. There were no postoperative anastomotic complications such as anastomotic leak and stricture. The median postoperative hospital stay was 7 days. Our technique for intracorporeal Billroth I reconstruction is safe and feasible. This technique could be a useful surgical option in all laparoscopic reconstructive procedures using linear stapling devices.

Laparoscopic stomach-partitioning gastrojejunostomy with reduced-port techniques for unresectable distal gastric cancer

BACKGROUND

The improvement of quality of life is of great importance in managing patients with far-advanced gastric cancer. We report a new cure and less invasive method of creating a stomach-partitioning gastrojejunostomy in reduced-port laparoscopic surgery for unresectable gastric cancers with gastric outlet obstruction.

MATERIALS AND METHODS

A 2.5-cm vertical intraumbilical incision was made, and EZ Access (Hakko Co., Ltd., Tokyo, Japan) was placed. After pneumoperitoneum was created, an additional 5-mm trocar was inserted in the right upper abdomen. A gastrojejunostomy was performed in the form of an antiperistaltic side-to-side anastomosis, in which the jejunal loop was elevated in the antecolic route and anastomosed to the greater curvature of the stomach using an endoscopic linear stapler. The jejunal loop together with the stomach was dissected with additional linear staplers just proximal to the common entry hole so that a functional end-to-end gastrojejunostomy was completed. At the same time, the stomach was partitioned using a linear stapler to leave a 2-cm-wide lumen in the lesser curvature. Subsequently, jejunojejunostomy was performed 30 cm distal to the gastrojejunostomy, and the stomach-partitioning gastrojejunostomy resembling Roux-en Y anastomosis was completed.

RESULTS

All patients resumed oral intake on the day of operation. Neither anastomotic leakage nor anastomotic stricture was observed.

CONCLUSIONS

Our less invasive palliative operation offers the utmost priority to improve quality of life for patients with unresectable gastric cancer.

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

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

Single port Billroth I gastrectomy

Introduction:

Experience has allowed increasingly complex procedures to be undertaken by single port surgery. We describe a technique for single port Billroth I gastrectomy with a hand-sewn intracorporeal anastomosis in the resection of a benign tumour diagnosed incidentally on a background of cholelithiasis.

Materials and Methods:

Single port Billroth I gastrectomy and cholecystectomy was performed using a transumbilical quadport. Flexible tipped camera and straight conventional instruments were used throughout the procedure. The stomach was mobilised including a limited lymph node dissection and resection margins in the proximal antrum and duodenum were divided with a flexible tipped laparoscopic stapler. The lesser curve was reconstructed and an intracorporal hand sewn two layer end-to-end anastomosis was performed using unidirectional barbed sutures. Intraoperative endoscopy confirmed the anastomosis to be patent without leak.

Results:

Enteral feed was started on the day of surgery, increasing to a full diet by day 6. Analgesic requirements were a patient-controlled analgesia morphine pump for 4 postoperative days and paracetamol for 6 days. There were no postoperative complications and the patient was discharged on the eighth day. Histology confirmed gastric submucosal lipoma.

Discussion:

As technology improves more complex procedures are possible by single port laparoscopic surgery. In this case, flexible tipped cameras and unidirectional barbed sutures have facilitated an intracorporal hand-sewn two layer end-to-end anastomosis. Experience will allow such techniques to become mainstream.

Intracorporeal anastomosis in laparoscopic gastric cancer surgery

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