Comparison of single-port and reduced-port totally laparoscopic distal gastrectomy for patients with early gastric cancer

Is single incision laparoscopic surgery (SILS) for gastric gastrointestinal stromal tumor (GIST) dependent on the location of the tumor?

BACKGROUND

We compared the surgical outcomes of single-incision laparoscopic surgery (SILS) and conventional laparoscopic surgery (CLS) for gastric gastrointestinal stromal tumor (GIST).

METHODS

We performed single-incision gastric wedge resection on prospectively-enrolled 15 consecutive patients with gastric GIST between November 2020 and April 2022 in a single tertiary center. The early perioperative outcomes of these patients were compared to those of patients who underwent CLS. The indications did not differ from those for conventional laparoscopic procedures for gastric GIST.

RESULTS

In total, 30 patients were assigned to the SILS (n = 15) and CLS (n = 15) groups. There were no significant differences in the estimated blood loss and intraoperative blood transfusion between the SILS and CLS groups. There were no intraoperative complications or conversions to multiple-port or open surgery in the SILS group. Proximally located tumors were more commonly treated with CLS than with SILS (P = 0.045). GISTs located in the greater curvature were more commonly treated with SILS than with CLS, although the difference was not statistically significant (P = 0.08). The mean incision length in the SILS group was 4.1 cm shorter than that in the CLS group (3.2 ± 0.7 and 7.3 ± 5.2 cm, respectively, P = 0.01). The postoperative analgesic dose was significantly lower in the SILS than in the CLS group (0.4 ± 1.4 and 2.1 ± 2.3, respectively P = 0.01). Also, the duration of postoperative use of analgesic was shorter in SILS than in CLS (0.4 ± 0.7 and 2.0 ± 1.8, respectively, P = 0.01). There were no significant differences in the early postoperative complications between the groups.

CONCLUSIONS

SILS is as safe, feasible, and effective for the treatment of gastric GIST as CLS with comparable postoperative complications, pain, and cosmesis. Moreover, SILS can be considered without being affected by the type or location of the tumor.

Short- and long-term outcomes of single-port versus multiport laparoscopic radical gastrectomy for gastric cancer: a meta-analysis of propensity score-matched studies and randomized controlled trials

BACKGROUND

At present, there is no convincing evidence-based medical basis for the efficacy of single-port laparoscopic gastrectomy. To make a high-quality comparison of the short- and long-term outcomes of single-port laparoscopic gastrectomy versus multiport laparoscopic gastrectomy, we performed this meta-analysis, which only included propensity score-matched studies and randomized controlled trials comparing single-port laparoscopic gastrectomy with multiport laparoscopic gastrectomy for patients with gastric cancer.

METHODS

Data were retrieved from the electronic databases PubMed, EMBASE, Medline, Cochrane Library, CNKI, Wanfang and VIP up to January 2023, and the data included the outcomes of treatment after single-port laparoscopic gastrectomy and multiport laparoscopic gastrectomy. The primary outcomes were early complications, survival rate after surgery at 1 year, and survival rate after surgery at 5 years. The secondary outcomes were number of pain medications, mean operation time, estimated blood loss, hospital mortality, time to first soft fluid diet, time to first flatus, hospital stay after surgery, and retrieved number of lymph nodes. The Jadad score and Newcastle‒Ottawa scale were used to assess the quality of the included studies.

RESULTS

After screening, 9 studies were finally included, including 988 patients. The meta-analysis results showed that estimated blood loss (MD=-29.35, 95% CI: -42.95-15.75, P < 0.0001), hospital stay (MD=-0.99, 95% CI:-1.82~-0.17, P = 0.02), and number of pain medications(MD=-0.65, 95% CI:-1.07~-0.23, P = 0.002) in the single-port laparoscopic gastrectomy group were better than those in the multiport laparoscopic gastrectomy group. There is no significant difference between the single-port laparoscopic gastrectomy group and the multiport laparoscopic gastrectomy group in mean operation time(MD = 5.23,95% CI:-16.58~27.04,P = 0.64), time to first soft fluid diet(MD=-0.06,95% CI: -0.30~0.18,P = 0.63), time to first flatus(MD=-0.18,95% CI:-0.43~0.07,P = 0.16), early complication(OR = 0.73,95% CI:0.50~1.09,P = 0.12), hospital mortality(OR = 1.00,95% CI:0.09~11.16,P = 1.00), retrieved number of lymph nodes(MD=-1.15, 95% CI:-2.71~0.40, P = 0.15), survival rate after surgery 1 year(OR = 2.14,95% CI:0.50~9.07,P = 0.30), and survival rate after surgery 5 year(93.7 vs. 87.6%; p = 0.689).

CONCLUSION

This meta-analysis showed that single-port laparoscopic gastrectomy is both safe and feasible for laparoscopic radical gastrectomy for gastric cancer, with similar operation times and better short-term outcomes than multiport laparoscopic gastrectomy in terms of hospital stay, postoperative pain, and estimated blood loss. There was no significant difference in long-term outcomes between single-port laparoscopic gastrectomy and multiport laparoscopic gastrectomy.

Postoperative pain and quality of life after single-incision distal gastrectomy versus multiport laparoscopic distal gastrectomy for early gastric cancer - a randomized controlled trial

BACKGROUND

Although it has been more than ten years since its first introduction, single-incision distal gastrectomy (SIDG) still lacks solid evidence and there are also no reports on patient quality of life (QOL). This study evaluates the postoperative outcomes and patient QOL of SIDG compared to multiport laparoscopic distal gastrectomy (MLDG).

METHODS

This study was designed as a prospective phase II randomized controlled study. Patients diagnosed with early gastric cancer in the distal 2/3rd of the stomach were randomized to either multiport or single-port group. Primary endpoint was pain using the visual analogue scale on postoperative day (POD) 1. Other outcomes include operative data, complications, and patient QOL using the EORTC C30 and STO22 modules.

RESULTS

A total of 43 patients in the SIDG group and 40 patients in the MLDG group were enrolled from September 2017 to February 2020. Mean operation time was 154.3 ± 53.3 min in the MLDG group and 148.9 ± 50.1 min in the SIDG group (p = 0.631). There was no difference in POD1 pain scores between the two groups (MLDG = 4.0 ± 1.3, SIDG = 4.3 ± 1.3, p = 0.372). Mean hospital stay was 5.5 (range 4-12) days in the MLDG group and 5 (range 4-17) days in the SIDG group (p = 0.993). There was no statistical significance in postoperative QOL scores.

CONCLUSION

Unlike previous reports, there was no difference in POD1 pain scores between SIDG and MLDG. Nevertheless, SIDG did not increase short-term morbidity compared to MLDG and had similar outcomes in QOL.

Laparoscopic gastric dissociation using a two-port approach in minimally invasive esophagectomy

BACKGROUND

A new approach for laparoscopic gastric dissociation in minimally invasive esophagectomy (MIE) was attempted. This study aimed to evaluate the short-term outcomes, safety, and efficacy of two-port laparoscopy using the McKeown procedure.

METHODS

This retrospective study included 206 consecutive patients with esophageal cancer who underwent a modified two-port laparoscopic or the traditional five-port McKeown procedure at our institution from August 2019 to August 2021. Surgical outcomes of the two methods were compared.

RESULTS

Of the 206 patients, 106 (51.46%) underwent the modified two-port procedure, whereas 100 (48.54%) underwent the traditional five-port procedure. Subsequently, 182 propensity score-matched patients were compared. No significant differences were observed in laparoscopic operative time, blood loss during laparoscopic surgery, number of dissected lymph nodes, and pain score on postoperative day 1 between the two groups. The rate of complication and postoperative length of hospital stay did not differ significantly between the two groups. The total hospitalization cost also did not differ significantly between the two groups (p = 0.325). No postoperative deaths occurred in either group.

CONCLUSIONS

Our findings demonstrate that laparoscopic gastric dissociation using the two-port approach in MIE is a safe and effective procedure, with short-term outcomes comparable to those of the traditional five-port procedure in patients with esophageal cancer. Larger studies with longer follow-up duration are warranted.

The Impact of Overweight and Obesity on Reduced-Port Laparoscopic Distal Gastrectomy for Gastric Cancer Patients: A Propensity Score Matching Analysis of a Single-Institution Data

This study aimed to investigate the short-term postoperative outcomes of reduced-port laparoscopic distal gastrectomy and demonstrate its safety and feasibility in overweight and obese patients with gastric cancer. The medical records of 211 patients who underwent reduced-port laparoscopic distal gastrectomy, between August 2014 and April 2020, were reviewed. After propensity score matching, they were divided into a non-overweight group (n = 68) and overweight group (n = 68). Operative details and short-term surgical outcomes were compared between two groups. Reduced-port laparoscopic distal gastrectomy in overweight group showed statistically longer operation time (200.59 vs. 208.68 min, p = 0.044), higher estimated bleeding volume (40.96 vs. 58.01 mL, p = 0.001), and lesser number of harvested lymph nodes (36.81 vs. 32.13, p = 0.039). However, no significant differences were found in hospital course and other surgical outcomes. There was no mortality in either group, and the postoperative morbidity rate was not significantly different (14.7% vs. 16.2%). In the subgroup analysis, overweight and obesity did not significantly affect postoperative complication rates (16.2% vs. 16.2%, p = 1). We demonstrated comparable short-term surgical outcomes of reduced-port laparoscopic distal gastrectomy between the two groups (p = 0.412~1). Reduced-port laparoscopic distal gastrectomy was safe in overweight and obese patients with gastric cancer.

Reduced-port robotic radical gastrectomy for gastric cancer: a single-institute experience

Background

Reduced-port laparoscopic gastrectomy can potentially reduce postoperative pain and improve recovery time. However, the inherent difficulty caused by the narrow manipulation angle makes this operation difficult, especially during lymph node dissection. The intrinsic advantage of the da Vinci^® robotic system might offset this difficulty, maintaining adequate surgical quality with risks of surgical complications equal to those by the conventional four-port robotic approach. The aim of this study was to compare the reduced-port robotic approach and the conventional four-port approach in terms of postoperative pain and short-term surgical outcomes.

Methods

All patients who underwent radical gastrectomy with D2 lymph node dissection using the da Vinci Xi robotic system, including reduced-port or conventional four-port approach, were analyzed retrospectively. The primary outcome was postoperative pain assessed using the numerical rating scale (NRS). The secondary outcomes were the number of harvested lymph nodes, operation time, length of hospital stay, and postoperative 30-day complications.

Results

Forty-eight patients were enrolled in the study, 10 cases in the reduced-port and 38 in the conventional four-port group. Postoperative NRS revealed no significant difference between the reduced-port and conventional four-port groups [postoperative day (POD) 1: 4.5 vs. 3, p = 0.047, POD 3: 4 vs. 3, p = 0.178]. After propensity score matching, there were no significant differences in the median number of harvested lymph nodes, operation time, and length of hospital stay between the groups. The postoperative 30-day complications were more frequent in the conventional four-port group, but there was no significant difference compared with the reduced-port group after propensity score matching.

Conclusions

Reduced-port robotic gastrectomy with D2 lymph node dissection might be comparable to the conventional four-port robotic operation in terms of postoperative pain, surgical quality, and short-term outcomes. However, further studies are required to confirm our results and clarify the advantages of the robotic reduced-port approach.

Long-Term Outcomes of Single-Incision Distal Gastrectomy Compared with Conventional Laparoscopic Distal Gastrectomy: A Propensity Score-Matched Analysis

BACKGROUND

Single-incision laparoscopic surgery is gaining more attention due to advancements in surgical devices and techniques. Ten years have passed since the first report of single-incision distal gastrectomy. This study aims to analyze the long-term oncological safety of single-incision distal gastrectomy by comparing it with multiport distal gastrectomy.

STUDY DESIGN

Patients diagnosed with gastric cancer who underwent laparoscopic distal gastrectomy from January 2010 to December 2017 were enrolled. Palliative surgery, history of other malignancy, preoperative chemotherapy, and distant metastasis were excluded. The 5-year overall survival and 5-year disease-free survival were set as coprimary endpoints. Operative time, blood loss, postoperative outcome, and risk factors for survival were secondary endpoints. Propensity score matching of 1:1 ratio was performed to adjust for age, sex, body mass index, comorbidities, tumor size, operation history, and clinical stage.

RESULTS

A total of 3,097 patients were enrolled. After propensity score matching, 378 patients were allocated to each group. There was no difference in patient demographics after matching. Operation time was faster (170.8 ± 65.3 minutes vs 147.2 ± 44.1 minutes, p < 0.001), with less blood loss in the single-port group (84.1 ± 87.6 mL vs 34.9 ± 49.9 mL, p < 0.001). Administration of additional intravenous analgesics was less frequent in the single-port group (p = 0.043). There was no difference in long-term survival (5-year overall survival: multiport 94.2%, single-port 95.8%, p = 0.43; 5-year disease-free survival: multiport 94.1%, single-port 95.8%, p = 0.32).

CONCLUSIONS

Single-incision distal gastrectomy is safe and feasible with good long-term outcomes and less use of additional analgesics for patients diagnosed with early gastric cancer.

Comparison of short-term surgical outcomes and post-operative recovery between single-incision and multi-port laparoscopic distal gastrectomy for gastric cancer: A systematic review and meta-analysis

Background:

To summarise data from previous reports and perform a meta-analysis to compare the short-term surgical outcomes and post-operative recovery between single-incision and multi-port laparoscopic distal gastrectomy (MLDG) for gastric cancer.

Methods:

A systematic literature search was performed using PubMed and Embase databases and relevant data were extracted. Short-term surgical outcomes and post-operative recovery of single-incision laparoscopic distal gastrectomy (SLDG) and MLDG for gastric cancer were compared using a fixed or random-effect model.

Results:

In total, we identified five relevant studies involving 983 participants for this systematic review and meta-analysis, and 45.8% (450/983) of patients underwent SLDG. The results demonstrated that mean operation time (weighted mean difference [WMD]:-3.22, 95% confidence interval [CI]: 14.64,8.19, P = 0.580; I² = 75.6%), intra-operative blood loss (WMD:-19.77, 95% CI: 40.20,0.65, P = 0.058; I² = 85.0%) and lymph node yield (WMD:-0.71, 95% CI: 1.47, 0.05, P = 0.068; I² = 0%) of SLDG were comparable to those of MLDG for gastric cancer. In addition, SLDG had a similar incidence of post-operative complications compared with MLDG (odds ratio: 0.82, 95% CI: 0.55-1.22, P = 0.326; I² = 0%). There was no significant difference between the two surgical procedures for the conversion to open surgery (OR: 0.32, 95%CI: 0.03-3.15, P = 0.331; I² = 0%), the length of hospital stay (WMD:-0.05, 95% CI: 0.65, 0.55, P = 0.876; I² = 44.1%), the time to first flatus (WMD:-0.24, 95% CI: 0.58, 0.10, P = 0.169; I² = 85.3%) and the time to oral intake (WMD:-0.05, 95% CI: 0.20, 0.10, P = 0.500; I² = 0%).

Conclusion:

Single-incision laparoscopic gastrectomy may be technically feasible and safe for gastric cancer. However, it did not show a more obvious advantage over MLDG.

Reduced-port laparoscopic distal gastrectomy in obese gastric cancer patients

BACKGROUND

Reduced-port laparoscopic gastrectomy is currently widely performed for patients with gastric cancer. However, its safety in obese patients has not yet been verified. This is the first study on reduced-port laparoscopic distal gastrectomy (RpLDG) in obese patients with gastric cancer. This study aimed to evaluate the short-term surgical outcomes and investigate the feasibility and safety of RpLDG in obese patients with gastric carcinoma.

MATERIAL AND METHODS

A total of 271 gastric cancer patients who underwent RpLDG at our institution were divided into two groups: non-obese [body mass index (BMI) <30 kg/m2, n = 251; NOG] and obese (BMI ≥30 kg/m2, n = 20; OG). The mean age of the enrolled patients was 64.8 ± 11.4 years, with 72.0% being men and 28.0% women. Operative details and short-term surgical outcomes, including hospital course and postoperative complications, were compared by retrospectively reviewing the medical records.

RESULTS

No significant difference in operation time was found between the NOG and OG (205.9 ± 40.0 vs. 211.3 ± 37.3 minutes, P = 0.563). Other operative outcomes in the OG, including estimated blood loss (54.1 ± 86.1 vs. 54.0 ± 39.0 mL, P = 0.995) and retrieved lymph nodes (36.2 ± 16.4 vs. 35.5 ± 18.2, P = 0.875), were not inferior to those in the NOG. There were also no statistical differences in short-term surgical outcomes, including the incidence of surgical complications (13.9% vs. 10.0%, P = 1).

CONCLUSION

RpLDG can be performed safely in obese gastric cancer patients by an experienced surgeon. It should be considered a feasible alternative to conventional port distal gastrectomy.

Intracorporeal Esophagojejunostomy during Reduced-port Totally Robotic Gastrectomy for Proximal Gastric Cancer: a Novel Application of the Single-Site® Plus 2-port System

Purpose

Intracorporeal esophagojejunostomy during reduced-port gastrectomy for proximal gastric cancer is a technically challenging technique. No study has yet reported a robotic technique for anastomosis. Therefore, to address this gap, we describe our reduced-port technique and the short-term outcomes of intracorporeal esophagojejunostomy.

Materials and Methods

We conducted a retrospective review of patients who underwent a totally robotic reduced-port total or proximal gastrectomy between August 2016 and March 2020. We used an infra-umbilical Single-Site^® port with two additional ports on both sides of the abdomen. To transect the esophagus, a 45-mm endolinear stapler was inserted via the right abdominal port. The common channel of the esophagojejunostomy was created between the apertures in the esophagus and proximal jejunum using a 45-mm linear stapler. The entry hole was closed with a 45-mm linear stapler or robot-sewn continuous suture. All anastomoses were performed without the aid of an assistant or placement of stay sutures.

Results

Among the 40 patients, there were no conversions to open, laparoscopic, or conventional 5-port robotic surgery. The median operation time and blood loss were 254 min and 50 mL, respectively. The median number of retrieved lymph nodes was 40.5. The median time to first flatus, soft diet intake, and length of hospital stay were 3, 5, and 7 days, respectively. Three (7.5%) major complications, including two anastomosis-related complications and a case of small bowel obstruction, were treated with an endoscopic procedure and re-operation, respectively. No mortality occurred during the study period.

Conclusions

Intracorporeal esophagojejunostomy during reduced-port gastrectomy can be safely performed and is feasible with acceptable surgical outcomes.

Long-Term Oncological Outcomes of Reduced Three-Port Laparoscopic Gastrectomy for Early-Stage Gastric Carcinoma: a Retrospective Large-Scale Multi-Institutional Study

Purpose

With advances in surgical techniques, reduced-port laparoscopic surgery is increasingly being performed for the treatment of gastric carcinoma. Many studies have reported satisfactory short-term outcomes after reduced 3-port laparoscopic gastrectomy (LG). The aim of this study was to investigate the long-term oncological outcomes of 3-port LG in patients with gastric carcinoma.

Materials and Methods

We reviewed the medical records of 1,117 patients who underwent LG for gastric carcinoma in three major institutions between 2012 and 2015. The data showed that 460 patients underwent 3-port LG without assistance, and 657 underwent conventional 5-port LG. We compared the overall and disease-free survival rates between the 2 groups.

Results

There were 642 male and 475 female patients with a mean age of 56.1 years. Among them, 1,028 (92.0%) underwent distal gastrectomy and 89 (8.0%) underwent total gastrectomy. In the final pathologic examination, 1,027 patients (91.9%) were stage I, 73 (6.5%) were stage II, and 17 (1.5%) were stage III, and there were no significant difference in the pathologic stage between groups. The 3- and 5-port LG groups showed no significant differences in the 5-year overall survival (94.3% vs. 96.7%, P=0.138) or disease-free survival (94.3% vs. 95.9%, P=0.231). Stratified analyses according to pT and pN stages also showed no significant differences in overall or disease-free survival between the two groups.

Conclusions

Long-term survival after 3- and 5-port LG was comparable in patients with early-stage gastric carcinoma. The 3-port technique requiring limited surgical assistance may be an appropriate surgical option for this patient population.

Single/reduced port surgery vs. conventional laparoscopic gastrectomy: systematic review and meta-analysis

INTRODUCTION

The aim is to compare single port surgery (SPS)/reduced port surgery (RPS) versus conventional laparoscopy (CL) for gastrectomy for gastric cancer in terms of intra- and postoperative outcomes.

MATERIAL AND METHODS

After a search in Pubmed and Embase, six articles were included. Pooled analysis was used to evaluate the statistically significance for each variable.

RESULTS

Two hundred and thirty-three and 230 patients underwent SPS/RPS and CL, respectively. One hundred and eighty-eight patients and 45 patients underwent subtotal and total gastrectomy, respectively, using the SPS/RPS approach. One hundred and eighty-five patients and 45 patients underwent subtotal and total gastrectomy, respectively, by CL. In 85 patients, an extra trocar was systematically placed at the end of surgery. Statistically significant differences were not observed about preoperative staging. The pooled analysis regarding operative time, blood loss, postoperative complications, number of harvested lymph nodes and postoperative hospital stay showed that the only statistically significant difference between the two approaches is the shorter hospital stay in case of SPS/RPS.

CONCLUSIONS

SPS/RPS total or subtotal gastrectomy shows a lower postoperative hospital stay, with comparable operative time, blood loss, early postoperative complication rate and number of harvested lymph nodes in comparison to CL, provided extensive experience in minimally invasive gastrectomy is present. Abbreviations: AGC: advanced gastric cancer; BMI: body mass index; CI: confidence interval; CL: conventional laparoscopy; LESS: laparoendoscopic single site; MD: mean difference; NOS: Newcastle-Ottawa Scale; OR: odds ratio; PRISMA: Preferred Reporting Items for Systematic Review and Meta-Analysis; ROBIN-I: Risk Of Bias In Non-randomised Studies - of Interventions; RPS: reduced port surgery; RR: risk ratio; SILS: single incision laparoscopic surgery; SPS: single port surgery; WMD: weighted mean differences.

D2 Lymph Node Dissections during Reduced-port Robotic Distal Subtotal Gastrectomy and Conventional Laparoscopic Surgery Performed by a Single Surgeon in a High-volume Center: a Propensity Score-matched Analysis

Purpose

Various studies have indicated that reduced-port robotic gastrectomies are safe and feasible for treating patients with early gastric cancer. However, there have not been any comparative studies conducted that have evaluated patients with clinically advanced gastric cancer. Therefore, we aimed to compare the perioperative outcomes of D2 lymph node dissections during reduced-port robotic distal subtotal gastrectomies (RRDGs) and conventional 5-port laparoscopic distal subtotal gastrectomies (CLDGs).

Materials and Methods

We retrospectively evaluated 118 patients with clinically advanced gastric cancer who underwent minimally invasive distal subtotal gastrectomies with D2 lymph node dissections between February 2016 and November 2019. To evaluate the patient data, we performed a 1:1 propensity score matching (PSM) according to age, sex, body mass index, American Society of Anesthesiologists physical status classification score, and clinical T status. The short-term surgical outcomes were also compared between the two groups.

Results

The PSM identified 40 pairs of patients who underwent RRDG or CLDG. The RRDG group experienced a significantly longer operation time than the CLDG group (P<0.001), although the RRDG group had significantly less estimated blood loss (P=0.034). The number of retrieved extraperigastric lymph nodes in the RRDG group was significantly higher than that of the CLDG group (P=0.008). The rate of postoperative complications was not significantly different between the two groups (P=0.115).

Conclusions

D2 lymph node dissections can be safely performed during RRDGs and the perioperative outcomes appear to be comparable to those of conventional laparoscopic surgeries. Further studies are needed to compare long-term survival outcomes.

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.

Initial experience of single-incision plus one port left-side approach totally laparoscopic distal gastrectomy with uncut Roux-en-Y reconstruction

BACKGROUND

Single incision plus one port left-side approach (SILS+1/L) totally laparoscopic distal gastrectomy (TLDG) is an emerging technique for the treatment of gastric cancer. Reduced port laparoscopic gastrectomy has a number of potential advantages for patients compared with conventional laparoscopic gastrectomy: relieving postoperative pain, shortening hospital stay and offering a better cosmetic outcome. Nevertheless, there are no previous reports on the use of SILS+1/L TLDG with uncut Roux-en-Y (uncut R-Y) reconstruction.

AIM

To investigate the initial feasibility of SILS+1/L TLDG with uncut Roux-en-Y digestive tract reconstruction (uncut R-Y reconstruction) to treat distal gastric cancer.

METHODS

A total of 21 patients who underwent SILS+1/L TLDG with uncut R-Y reconstruction for gastric cancer were enrolled. All patients were treated at The Second Hospital of Shandong University. Reconstructions were performed intracorporeally with 60 mm endoscopic linear stapler and 45 mm no-knife stapler. The clinicopathological characteristics, surgical details, postoperative short-term outcomes, postoperative follow-up upper gastrointestinal radiography findings and endoscopy results were analyzed retrospectively.

RESULTS

All SILS+1/L operations were performed by SILS+1/L TLDG successfully. The patient population included 13 men and 8 women with a mean age of 48.2 years (ranged from 40 years to 70 years) and median body mass index of 22.8 kg/m². There were no conversions to open laparotomy, and no other port was placed. The mean operation time was 146 min (ranged 130-180 min), and the estimated mean blood loss was 54 mL (ranged 20-110 mL). The mean duration to flatus and discharge was 2.3 (ranged 1-3.5) and 7.3 (ranged 6-9) d, respectively. The mean number of retrieved lymph nodes was 42 (ranged 30-47). Two patients experienced mild postoperative complications, including surgical site infection (wound at the navel incision) and mild postoperative pancreatic fistula (grade A). Follow-up upper gastrointestinal radiography and endoscopy were carried out at 3 mo postoperatively. No patients experienced moderate or severe food stasis, alkaline gastritis or bile reflux during the follow-up period. No recanalization of the biliopancreatic limb was found.

CONCLUSION

SILS+1/L TLDG with uncut R-Y reconstruction could be safely performed as a reduced port surgery.

Initial Experience of Dual-Port Laparoscopic Distal Gastrectomy for Gastric Cancer: A Single-Arm Study

INTRODUCTION

Dual-port laparoscopic gastrectomy (DPLG) has been widely performed in recent years for treating gastric cancers. The present study reports our initial experience of dual-port laparoscopic distal gastrectomy (DPLDG).

METHODS

From November 2016 to August 2018, 38 consecutive patients underwent DPLDG in our center. The observational outcomes included 30-day morbidity and mortality rates, time to first flatus, time to first oral liquid diet, time to first oral semiliquid diet, time to drainage tube removal, visual analogue scale (VAS) score, postoperative 4-day recovery rate, additional analgesic use, hospital stay and cosmetic benefits.

RESULTS

Mean operative time was 191.6 ± 44.4 min, mean intra-operative blood loss was 39.8 ± 48.7 ml, and the mean number of dissected lymph nodes was 38.3 ± 13.7 nodes. One case was converted to five-port laparoscopic surgery, and no intraoperative complications occurred in any of the cases. The mean time to postoperative first flatus was 45.3 ± 18.0 h. The mean time to intake of an oral liquid diet was 56.7 ± 30.4 h. The mean time to drainage tube removal was 97.9 ± 52.3 h. The mean VAS scores for the 3 days after surgery were 2.3 ± 0.7, 2.0 ± 0.6 and 1.6 ± 0.5, respectively. A total of 81.6% of the enrolled patients met the postoperative 4-day recovery standard, and 15.8% of patients received additional analgesics. The mean postoperative hospital stay was 6.0 ± 2.0 days. No deaths were observed, and the 30-day morbidity rate was 13.2%.

CONCLUSION

DPLDG is a feasible and safe procedure for experienced surgeons with acceptable short-term outcomes, reduced invasiveness and good cosmetic effects.

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.

European association for endoscopic surgery (EAES) consensus statement on single-incision endoscopic surgery

BACKGROUND

Laparoscopic surgery changed the management of numerous surgical conditions. It was associated with many advantages over open surgery, such as decreased postoperative pain, faster recovery, shorter hospital stay and excellent cosmesis. Since two decades single-incision endoscopic surgery (SIES) was introduced to the surgical community. SIES could possibly result in even better postoperative outcomes than multi-port laparoscopic surgery, especially concerning cosmetic outcomes and pain. However, the single-incision surgical procedure is associated with quite some challenges.

METHODS

An expert panel of surgeons has been selected and invited to participate in the preparation of the material for a consensus meeting on the topic SIES, which was held during the EAES congress in Frankfurt, June 16, 2017. The material presented during the consensus meeting was based on evidence identified through a systematic search of literature according to a pre-specified protocol. Three main topics with respect to SIES have been identified by the panel: (1) General, (2) Organ specific, (3) New development. Within each of these topics, subcategories have been defined. Evidence was graded according to the Oxford 2011 Levels of Evidence. Recommendations were made according to the GRADE criteria.

RESULTS

In general, there is a lack of high level evidence and a lack of long-term follow-up in the field of single-incision endoscopic surgery. In selected patients, the single-incision approach seems to be safe and effective in terms of perioperative morbidity. Satisfaction with cosmesis has been established to be the main advantage of the single-incision approach. Less pain after single-incision approach compared to conventional laparoscopy seems to be considered an advantage, although it has not been consistently demonstrated across studies.

CONCLUSIONS

Considering the increased direct costs (devices, instruments and operating time) of the SIES procedure and the prolonged learning curve, wider acceptance of the procedure should be supported only after demonstration of clear benefits.

Surgical Outcomes of Reduced-Port Laparoscopic Gastrectomy Versus Conventional Laparoscopic Gastrectomy for Gastric Cancer: A Propensity-Matched Retrospective Cohort Study

BACKGROUND

The technical feasibility and oncologic efficacy of reduced-port laparoscopic gastrectomy (RPG) for gastric cancer remain unclear.

METHODS

A series of 767 patients with gastric cancer who underwent R0 laparoscopic gastrectomy were retrospectively matched for age, gender, American Society of Anesthesiology score, body mass index, surgeon, lymph node dissection, and pathologic stages by propensity scoring. Finally, data from 274 patients (74 conventional laparoscopic distal gastrectomy [CLDG] cases, 74 reduced-port distal gastrectomy [RPDG] cases, 63 conventional laparoscopic total gastrectomy [CLTG] cases, and 63, reduced-port total gastrectomy [RPTG] cases) were selected for analysis.

RESULTS

Compared with the conventional group, the reduced-port group had significantly longer operation times (RPDG 265 min vs CLDG 239 min; p = 0.001 and RPTG 305 min vs CLTG 285 min; p = 0.012) and reduced blood loss (RPDG 48 ml vs CLDG 68 ml; p = 0.001 and RPTG 75 ml vs CLTG 110 ml; p = 0.026). The number of dissected lymph nodes was significantly higher in the CLDG group than in the RPDG group (38 vs 31; p = 0.002). Cosmetic satisfaction showed significant superiority in the reduced-port group compared with the conventional group. No significant difference was observed in overall survival (OS) (5-year OS: RPDG 100% vs CLDG 96.7%; p = 0.207 and RPTG 91.6% vs CLTG 91.8%; p = 0.615) or relapse-free survival (RFS) (5-year RFS: RPTG 92.3% vs CLTG 92.1%; p = 0.587).

CONCLUSIONS

The study results suggest that RPG for gastric cancer by an experienced surgeon is a feasible and safe technique. The RPG procedure can be presented to patients as one of the effective treatment options.

Three-Port Right-Side Approach-Duet Totally Laparoscopic Distal Gastrectomy for Uncut Roux-en-Y Reconstruction

BACKGROUND

This study presents the initial feasibility of three-port right-side approach-duet totally laparoscopic distal gastrectomy (R-duet TLDG) with uncut Roux-en-Y (R-Y) reconstruction for the treatment of lower- or middle-third gastric cancer.

METHODS

A total of 30 patients who underwent R-duet TLDG with uncut R-Y reconstruction for gastric cancer were enrolled. All patients were treated at the Catholic Medical Center. Reconstructions were performed intracorporeally without special instruments. The clinicopathological characteristics, operative details, postoperative short-term outcomes, and postoperative follow-up endoscopy results were analyzed retrospectively.

RESULTS

All operations were performed by three-port R-duet TLDG. There were no conversions to an open approach, and no additional ports were placed. The mean operating time was 170 minutes, and the mean number of retrieved lymph nodes was 44. Three patients experienced mild postoperative complications, including small bowel ileus and pneumonia. Follow-up endoscopy was carried out at 3 months. No patients had experienced moderate-or-severe food stasis, alkaline gastritis, or bile reflux during the follow-up period. Recanalization of the biliopancreatic limb was not observed.

CONCLUSIONS

R-duet TLDG with uncut R-Y reconstruction could be safely performed as a reduced port surgery without special instruments.

Learning Curve of Pure Single-Port Laparoscopic Distal Gastrectomy for Gastric Cancer

Purpose

Despite the fact that there are several reports of single-port laparoscopic distal gastrectomy (SPDG), no analysis of its learning curve has been described in the literature. The aim of this study was to investigate the favorable factors for SPDG and to analyze the learning curve of SPDG.

Materials and Methods

A total of 125 cases of SPDG performed from November 2011 to December 2015 were enrolled. All operations were performed by 2 surgeons (surgeon A and surgeon B). The moving average method was used for defining the learning curve. All cases were divided into 10 cases in a sequence, and the mean operative time and estimated blood loss data were extracted from each group.

Results

Surgeon A performed 68 cases (female-to-male sex ratio, 91.1%:8.82%), and surgeon B performed 57 cases (female-to-male sex ratio, 61.4%:38.5%). The operative time of surgeon B significantly decreased after 30 cases (157.8±38.4 minutes vs. 118.1±34.5 minutes, P=0.003); that of surgeon A did not significantly decrease before and after around 30 cases (160.8±51.6 minutes vs. 173.3±35.2 minutes, P=0.6). The subgroup analysis showed that the operative time significantly decreased in the patients with body mass index (BMI) of <25 kg/m² (<25 kg/m²:≥25 kg/m², 159.3±41.7 minutes: 194.25±81.1 minutes; P=0.001).

Conclusions

Although there was no significant decrease in the operative time for surgeon A, surgeon B reached the learning curve upon conducting 30 cases of SPDG. BMI of <25 kg/m² was found to be a favorable factor for SPDG.

Atraumatic Liver Retraction Using Nelaton Catheters During Totally Laparoscopic Gastrectomy

This study introduces a novel technique for liver retraction during laparoscopic gastrectomy and assesses its impact on postoperative recovery. This study included 139 patients in whom Nelaton catheters (n=57) or Nathanson retractors (n=82) were used for liver retraction. Serum liver enzyme levels were measured preoperatively and on the first, second, third, fifth, and seventh postoperative days. Clinicopathologic features and postoperative recovery variables between the 2 groups were compared. The aspartate aminotransferase, alanine aminotransferase, and C-reactive protein levels were significantly lower (P<0.001, P<0.001, and P=0.007, respectively), and the day of first flatus, the day of initiating a soft diet, and the length of hospital stay were shorter in the Nelaton catheter U-shaped retractor group than those seen in the Nathanson retractor group (P=0.035, P=0.002, and P=0.024, respectively). Atraumatic liver retraction with Nelaton catheters is recommended in laparoscopic gastrectomy.

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.

Three-Port Versus Five-Port Laparoscopic Distal Gastrectomy for Early Gastric Cancer Patients: A Propensity Score Matched Case-Control Study

AIM

The aim of this study was to evaluate the feasibility and safety of three-port laparoscopic distal gastrectomy (TP-LDG) as a reduced port laparoscopic gastrectomy.

MATERIALS AND METHODS

We retrospectively identified 146 patients preoperatively diagnosed with early gastric cancer who underwent five-port laparoscopic distal gastrectomy (FP-LDG) or TP-LDG between May 2013 and July 2016. A propensity score matching analysis was used to create patient groups (48 patients in each group) matched for sex, age, body mass index, previous abdominal surgery history, and American Society of Anesthesiologist score. The short-term surgical outcomes between TP-LDG and FP-LDG were compared.

RESULTS

The TP-LDG group had a statistically shorter umbilical wound length [3.4 (range, 3.0-4.0) cm vs. 3.9 (range, 3.7-4.0) cm, p = .000], shorter operative time [230 (range, 190-310) min vs. 250 (range, 180-320) min, p = .036], and lower estimated blood loss [68 (range, 20-180) mL vs. 80 (range, 40-150) mL, p = .005] compared to that in the FP-LDG group. However, there was no specific superiority regarding inflammatory profiles. Complication rates were also similar (8.4% TP-LDG vs. 12.6% FP-LDG, p = .504).

CONCLUSIONS

TP-LDG is a feasible and safe surgical procedure for the patients with early gastric cancer and provides the benefit of better cosmesis.

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.

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.