Technical aspects and short- and long-term outcomes of totally laparoscopic total gastrectomy for advanced gastric cancer: a single-institution retrospective study

Standardized procedure for preventing late intestinal complications following minimally invasive total gastrectomy for gastric cancer: a single-center retrospective cohort study

BACKGROUND

Although minimally invasive total gastrectomy for gastric cancer is commonly performed, reports regarding late complications are limited. We have made several improvements each time we experienced severe late complications since 2009. This study aimed to evaluate the clinical efficacy of these improved procedures in preventing late complications.

METHODS

Between January 2009 and December 2019, 302 patients who underwent laparoscopic or robotic total gastrectomy for gastric cancer were enrolled. The patients were divided into two groups: Period-I (2009-2013, before established standardization of procedure, 166 patients) and Period-II (2014-2019, after established standardization of procedure, 136 patients). The standardized procedure comprised four major steps, including closure of the mesentery defects and diaphragm crus, circumferential fixation of the anastomotic site into the diaphragm, and linearization around the anastomotic site of esophagojejunostomy. The incidence of late complications was retrospectively compared between the two groups.

RESULTS

Late overall complications that occurred over 30 days after surgery were observed in 19 (6.3%) patients. In all, 14 of 24 (58.3%) patients admitted due to late intestinal complications eventually required reoperation for treatment. The most frequent complication was nonstenotic outlet obstruction of the distal jejunal limb. The incidence of late overall complications was significantly lower in Period-II than in Period-I (2.9 vs 9.0%, p = 0.030). Intestinal complications were reduced considerably in Period-II. The 3-year cumulative incidence rate of late overall complications was significantly lower in Period-II than in Period-I (0.03 vs 0.10, p = 0.035). Period-I as the only independent risk factor for the development of late intestinal complications.

CONCLUSION

Late complications after laparoscopic total gastrectomy sometimes occurred, and more than half of the patients with intestinal complications required reoperation. Our standardized procedure was associated with a lower risk of late intestinal complications after minimally invasive total gastrectomy followed by intracorporeal esophagojejunostomy using linear staplers in a cohort of patients with gastric cancer.

Minimally Invasive Conversion Surgery for Unresectable Gastric Cancer with Splenic Metastasis and Splenic Vein Tumor Thrombus: A Case Report

While the importance of conversion surgery has increased with the development of systemic chemotherapy for gastric cancer (GC), reports of conversion surgery for patients with GC with distant metastasis and tumor thrombus are extremely scarce, and a definitive surgical strategy has yet to be established. Herein, we report a 67-year-old man with left abdominal pain referred to our hospital following a diagnosis of unresectable GC. Esophagogastroduodenoscopy and contrast-enhanced abdominal computed tomography (CT) revealed advanced GC with splenic metastasis. A splenic vein tumor thrombus (SVTT) and a continuous thrombus to the main trunk of the portal vein were detected. The patient was treated with anticoagulation therapy and systemic chemotherapy comprising S-1 and oxaliplatin. One year following chemotherapy initiation, a CT scan revealed progressive disease (PD); therefore, the chemotherapy regimen was switched to ramucirumab with paclitaxel. After 10 courses of chemotherapy resulting in primary tumor and SVTT shrinkage, the patient underwent laparoscopic total gastrectomy (LTG) and distal pancreaticosplenectomy (DPS). He was discharged without complications and remained alive 6 months postoperatively without recurrence. In summary, the wait-and-see approach was effective in a patient with GC with splenic metastasis and SVTT, ultimately leading to an R0 resection performed via LTG and DPS.

Surgical Approach to the Upper Side of the Gastrosplenic Ligament During Laparoscopic Total Gastrectomy for Proximal Gastric Cancer: Operative Techniques and Initial Results

Background: Laparoscopic gastrectomy for gastric cancer has become widespread as minimally invasive surgical treatment, but use of laparoscopic total gastrectomy (LTG) remains limited because of the technical difficulty and complexity of lymphadenectomy at the splenic hilum. Surgical techniques and initial experiences with the surgical approach to the upper side of the gastrosplenic ligament during LTG are introduced. Materials and Methods: Between January 2019 and December 2022, 57 patients with proximal gastric cancer underwent LTG using this approach. Results: Regarding the extent of lymphadenectomy, D1+, D2, spleen-preserving D2 + 10, and D2 + 10 with splenectomy were performed in 31, 18, 4, and 4 patients, respectively. Operative time was 341 (192-724) minutes, and estimated blood loss was 30 (0-515) g. There were no conversions to laparotomy and no postoperative complications of Clavien-Dindo grade ≥III. Conclusions: The present procedure is safe and feasible and provides an excellent operative view at the splenic hilum, making it easier to determine exactly the extent of lymphadenectomy in accordance with cancer progression.

Laparoscopic gastrectomy for remnant gastric cancer: A single-center retrospective study

BACKGROUND

Laparoscopic gastrectomy (LG) for remnant gastric cancer (RGC) remains controversial because of its rarity and heterogeneity of clinical characteristics. Based on our experience, we posited that our established methodology in LG could be applied to the laparoscopic procedure for RGC surgery and introduced LG for RGC at our institution in 2004.

METHODS

This study enrolled 46 patients who underwent LG for RGC between January 2004 and December 2017. Data were obtained through a review of our prospectively maintained database. Laparoscopic total gastrectomy (LTG) was the standard surgical procedure for RGC. Laparoscopic subtotal gastrectomy (LsTG) was performed as an alternative procedure for patients with RGC located near the anastomotic site after primary gastrectomy. The technical and oncological feasibility and safety of LG for RGC were evaluated.

RESULTS

LTG for RGC was performed on 36 patients. LsTG for RGC was performed on 10 patients. All patients completed LG procedure and succeeded R0 resection. Complications of Clavien-Dindo classification grade ≥ IIIa occurred in 4 (8.7%) patients. The retrospective video reviews showed that the time for adhesiotomy around the suprapancreatic area and the lesser curvature of the remnant stomach was significantly shorter in the primary-benign group than in the primary-malignant group. With the median follow-up period of 40 months, the 3-year recurrence-free survival and 3-year overall survival rates were 72.3% and 80.2%, respectively.

CONCLUSION

LG for RGC represents a safe and feasible surgical option with favorable short-term and long-term outcomes in patients with RGC.

Risk factors for postoperative pancreatic fistula (POPF) in gastric cancer patients: A systematic review and meta-analysis

BACKGROUND

Postoperative pancreatic fistula (POPF) is a common and serious consequence of gastrectomy. The prevalence of POPF among patients with gastric cancer varies greatly, and the risk factors and outcomes of POPF are also controversial. The meta-analysis aims to comprehensively assess the risk factors for POPF in gastric cancer patients.

METHODS

PubMed, Web of Science, the Cochrane Library, Embase, and Chinese databases (SinoMed, CNKI, WanFang, and VIP Databases) were searched to identify relevant studies (from inception to May 2023). Two researchers evaluated the literature quality and extracted data individually. The Review Manager 5.4 program was used to analyze all of the data.

RESULTS

In our meta-analysis, 22 studies totaling 11,647 patients were analyzed. Male sex (OR = 3.06), older age (OR = 3.22), body mass index (BMI) ≥ 25 kg/m2 (OR = 2.58), visceral fat area (VFA) ≥ 100 cm2 (OR = 3.65), pTNM Ⅲ-Ⅳ (OR = 2.47), the number of lymphlode dissections (OR = 1.04), neoadjuvant chemotherapy (NAC) (OR = 2.91), the application of LigaSure (OR = 3.30), open surgery (OR = 3.23), intraoperative combined organ resection (OR = 4.11), drainage amylase concentration on the first postoperative day (OR = 5.73) and C-reactive protein on the 3rd postoperative day ≥20 mg/dL (OR = 7.29) were the risk factors for POPF in gastric cancer patients. On the other hand, the operation time (OR = 1.34) was not a risk factor for POPF.

CONCLUSION

The frequency of POPF in people undergoing gastrectomy was determined by a variety of risk factors. Medical professionals should identify risk factors early and impose interventions to prevent them to lower the incidence of POPF in gastric cancer patients.

Incidence and clinical relevance of postoperative diarrhea after minimally invasive gastrectomy for gastric cancer: a single institution retrospective study of 1476 patients

PURPOSE

Postoperative diarrhea (PD) remains one of the significant complications. Only a few studies focused on PD after minimally invasive surgery. We aimed to investigate PD after minimally invasive gastrectomy for gastric cancer.

METHODS

A total of 1476 consecutive patients with gastric cancer undergoing laparoscopic or robotic gastrectomy between 2009 and 2019 at our institution were retrospectively reviewed. PD was defined as continuous diarrhea for ≥ 2 days, positive stool culture, or positive clostridial antigen test. The incidence, causes, and related clinical factors were analyzed.

RESULTS

Of the 1476 patients, the median age was 69 years. Laparoscopic and robotic approaches were performed in 1072 (72.6%) and 404 (27.4%), respectively. Postoperative complications with Clavien-Dindo classification grade of ≥ IIIa occurred in 108 (7.4%) patients. PD occurred in 89 (6.0%) patients. Of the 89 patients with PD, Clostridium difficile, enteropathogenic Escherichia coli, and methicillin-resistant Staphylococcus aureus were detected in 24 (27.0%), 16 (33.3%), and 7 (14.6%) patients, respectively. Multivariate analysis revealed that age ≥ 75 years (OR 1.62, 95% CI [1.02-2.60], p = 0.042) and postoperative complications (OR 6.04, 95% CI [3.54-10.32], p < 0.001) were independent risk factors for PD. In patients without complications, TG (OR 1.88) and age of ≥ 75 years(OR 1.71) were determined as independent risk factors.

CONCLUSION

The incidence of PD following minimally invasive gastrectomy for gastric cancer was 6.0%. Older age and TG were obvious risk factors in such a surgery, with the latter being a significant risk even in the absence of complications.

Muscle mass ratio in male gastric cancer patients as an independent predictor of postoperative complications after minimally invasive distal gastrectomy

BACKGROUND

The current study aimed to investigate the relationship between muscle mass proportion and the incidence of total complications in male gastric cancer (GC) patients after minimally invasive distal gastrectomy (MIDG).

METHODS

Between March 2017 and March 2020, 152 male GC patients with clinical stage III or lower GC who underwent MIDG were enrolled in this study. The muscle mass ratio (MMR) was calculated by dividing the total muscle weight obtained from bioelectrical impedance analysis by the whole-body weight. Thereafter, the association between MMR and surgical outcomes was determined.

RESULTS

Based on the optimal MMR cutoff value of 0.712 obtained using the receiver operating characteristic (ROC) curve, patients were divided into two groups (69 and 83 patients in the MMR-L and MMR-H groups). The MMR-L group had a significantly higher total complication rate compared to the MMR-H group (MMR-L, 24.6% vs. MMR-H, 7.2%; P = 0.005). Multivariate analysis also identified MMR-L as a significant independent risk factor for total complications and intra-abdominal infectious complications after MIDG.

CONCLUSIONS

The MMR calculated using bioelectrical impedance analysis can be a useful predictor for postoperative complications after MIDG in male GC patients.

Efficacy of minimally invasive proximal gastrectomy followed by valvuloplastic esophagogastrostomy using the double flap technique in preventing reflux oesophagitis

BACKGROUND

Valvuloplastic esophagogastrostomy (VEG) using the double flap technique (DFT) after proximal gastrectomy (PG) represents a promising procedure for the prevention of reflux oesophagitis. We aimed to retrospectively investigate the efficacy of minimally invasive PG followed by VEG-DFT in preventing reflux oesophagitis among patients who require intra-mediastinal anastomosis.

METHODS

A total of 80 patients who underwent reconstruction with DFT after LPG from November 2013 to January 2021 were enrolled in the present study. Data were obtained through a review of our prospectively maintained database. At 1 year after surgery, multivariate analyses were performed to identify risk factors for gastroesophageal reflux disease of Los Angeles (LA) classification grade B or higher.

RESULTS

The incidence of LA grade B or higher reflux oesophagitis 1 year after surgery was 10%. Multivariate analyses revealed that the longitudinal length of the resected oesophagus of > 20 mm was the only significant risk factor for reflux oesophagitis. Patients with a longitudinal length of the resected oesophagus > 20 mm (group-L, n = 35) had a significantly longer total operative time and a higher rate of complications within 30 days of surgery than those with a length of ≤ 20 mm (group-S, n = 45). LA grade B or higher reflux oesophagitis was significantly higher in group-L than in group-S (20% vs. 2.2%; P = 0.011).

CONCLUSIONS

There is a need for surgical procedures with improved efficacy for the prevention of reflux oesophagitis in patients requiring oesophageal resection of > 20-mm.

Clinical advantage of standardized robotic total gastrectomy for gastric cancer: a single-center retrospective cohort study using propensity-score matching analysis

BACKGROUND

Although recent studies have shown that robotic gastrectomy offers clinical advantages over laparoscopic gastrectomy in decreasing gastric cancer (GC) morbidity, studies focusing on robotic total gastrectomy (RTG) remain limited. The current study aimed to clarify whether the use of a robotic system could clinically improve short-term outcomes.

METHODS

Between January 2009 and June 2021, 371 patients diagnosed with both clinical and pathological Stage III or lower GC and underwent RTG or laparoscopic total gastrectomy (LTG) were enrolled in this study. The primary outcome was the incidence of intra-abdominal infectious complications over Clavien-Dindo classification grade IIIa. Demographic characteristics of those who underwent the RTG and LTG were matched using propensity-score matching (PSM), after which short-term outcomes were compared retrospectively.

RESULTS

After PSM, 100 patients were included in each group. The RTG group had a significantly shorter duration of hospitalization following surgery [RTG 13 (11-16) days vs. LTG 14 (11-19) days; p = 0.032] and a greater number of dissected LNs [RTG 48 (39-59) vs. LTG 43 (35-54) mL; p = 0.025], despite having a greater total operative time [RTG 511 (450-646) min vs. LTG 448 (387-549) min; p < 0.001]. In addition, the RTG group had significantly fewer total complications (3% vs. 13%, p = 0.019) and intra-abdominal infectious complications (1% vs. 9%; p = 0.023).

CONCLUSIONS

The current study showed that robotic surgery might improve short-term outcomes following minimally invasive radical total gastrectomy by reducing intra-abdominal infectious complications.

Effect of different oesophagojejunostomy methods on the quality of life of gastric cancer patients after totally laparoscopic total gastrectomy with self-pulling and latter transected technique: study protocol for a randomised trial

INTRODUCTION

Gastric cancer is the fifth most common cancer worldwide and the detection rate of proximal gastric cancer has been increasing. Currently, surgical resection using gastrectomy and proper perigastric lymphadenectomy is the only treatment option to enhance the survival rate of patients with gastric cancer. Laparoscopic total gastrectomy (LTG) is increasingly performed for adenocarcinoma of the oesophagogastric junction. However, totally LTG (TLTG) is only performed by a few surgeons due to difficulty associated with oesophagojejunostomy (OJ), in which there is no consensus on a standardised anastomosis technique. We propose a randomised trial to compare functional end-to-end anastomosis (FETE) and side-to-side anastomosis (Overlap) for OJ.

METHODS AND ANALYSIS

A prospective, randomised, open-label, single-centre, interventional trial has been designed to evaluate the quality of life (QoL) outcomes and safety of FETE and Overlap, with a 1-year follow-up as the primary endpoint. The trial began in 2020 and is scheduled to enrol 96 patients according to a previous sample size calculation. Patients were randomly allocated to the FETE or Overlap groups with a follow-up of 1 year to assess QoL after the procedure. All relevant clinical data including biological markers were collected. The primary indicator is the D-value between the postoperative and preoperative QoL. Student's t-tests will be used to compare continuous variables, while χ² tests or Fisher's exact tests will be used to compare categorical variables. Statistical analysis will be performed with SPSS V.23.0 statistical software. A p<0.05 will be considered statistically significant.

ETHICS AND DISSEMINATION

This study has been approved by the Hospital Institutional Review Board of Huashan Hospital, Fudan University (2020-1055). The results will be submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ChiCTR2000035583.

Recovery procedure for linear stapler mis-insertion in the esophageal submucosal layer during intracorporeal esophagojejunostomy

INTRODUCTION

Intracorporeal esophagojejunostomy is a technically demanding procedure, with many challenges. This study presents the anastomotic and technical complications associated with the mis-insertion of a linear stapler into the esophageal submucosal layer and the recovery procedure for this complication.

MATERIALS AND SURGICAL TECHNIQUES

Of 100 intracorporeal esophagojejunostomy cases from 2017 to 2020, this complication occurred in three cases-one during functional end-to-end anastomosis and two during the overlap method. To recover, the residual esophageal mucosa was incised from the entry point to the top of the incomplete staple line, which was then reinforced by suturing in full thickness, including the incised mucosa. After reinforcement, the common stab incision was closed by the linear stapler or handsewn. As a result, none of the patients developed anastomotic leakage or stenosis.

DISCUSSION

Mucosal dissection and suturing for recovery for the anastomotic site may be an option to address cases of mis-insertion of a linear stapler into the submucosal layer.

Impact of routine preoperative sonographic screening with early intervention for deep venous thrombosis in lower extremities on preventing postoperative venous thromboembolism in patients with gastric cancer scheduled for minimally invasive surgery

PURPOSE

This study aimed to investigate the clinical efficacy of lower-extremity ultrasonography screening with early intervention for deep venous thrombosis (DVT) on the incidence of venous thromboembolism (VTE) after minimally invasive surgery (MIS) for gastric cancer (GC).

METHODS

Between January 2012 and December 2019, 1070 patients were diagnosed with both clinical and pathological stage I-III GC and underwent MIS at our institution. Routine ultrasonographic screening for DVT in lower extremities is performed before MIS. Patients diagnosed with DVT were preoperatively administered anticoagulant therapy. Enoxaparin was routinely administrated after surgery irrespective of the presence of DVT. The incidence of postoperative symptomatic VTE was examined retrospectively.

RESULTS

A total of 74 (6.9%) patients were preoperatively diagnosed with DVT. Multivariate analyses revealed that age > 70 years (p = 0.015), female sex (p < 0.001), and positive serum D-dimer test (p < 0.001) were significant and independent risk factors for preoperative DVT. The incidence of symptomatic postoperative VTE was 1 (0.09%); symptomatic VTE developed in one patient among patients without DVT, whereas no patient with DVT developed VTE.

CONCLUSIONS

Preoperative DVT screening using lower-extremity ultrasonography followed by preoperative anticoagulant therapy should be considered as a useful strategy to safely perform MIS for GC without increasing the incidence of VTE.

Feasibility of laparoscopic total gastrectomy with splenectomy for proximal advanced gastric cancer: A comparative study with open surgery

INTRODUCTION

Total gastrectomy with splenectomy (TGS) is sometimes performed for treatment of locally advanced gastric cancer invading the greater curvature because metastasis to splenic hilar nodes is expected. Despite the widespread use of laparoscopic procedures, the feasibility of laparoscopic TGS (LTGS) has been scarcely reported because of its technical difficulties.

METHODS

This retrospective single-institutional study included 93 consecutive patients with proximal advanced gastric cancer who underwent either LTGS or open TGS (OTGS) from 2010 to 2018. The patients who underwent LTGS (n = 12) were compared with a 1:2 ratio propensity score-matched cohort of patients who underwent OTGS (n = 20). Clinical outcomes were retrospectively reviewed and compared between the two groups.

RESULTS

The patients' baseline characteristics were well balanced between the two groups. The operating time was longer (332.5 vs 222.5 minutes, P < .01) but the blood loss volume was smaller (34.5 vs 426 mL, P < .01) in the LTGS than OTGS group. The incidence of postoperative morbidity (≥ Clavien-Dindo grade III) was much lower (0.0% vs 36.8%, P = .02) and the median postoperative hospital stay was shorter (9 vs 11 days, P < .01) in the LTGS than OTGS group. The median number of harvested No. 10 or 11 days lymph nodes was equivalent between the two groups.

CONCLUSIONS

Although TGS is not a common procedure, LTGS may be safely performed in selected patients when carried out by an experienced surgical team. The oncological safety remains unclear and needs to be further examined in future trials.

Comparison of Outcomes of Totally Laparoscopic Total Gastrectomy (Overlap Reconstruction) versus Laparoscopic-Assisted Total Gastrectomy for Advanced Siewert III Esophagogastric Junction Cancer and Gastric Cancer of Upper and Middle Third of Stomach: Study Protocol for a Single-Center Randomized Controlled Trial

Background

Totally laparoscopic total gastrectomy (TLTG) using the overlap reconstruction method is associated with fewer postoperative complications and fast recovery than laparoscopic-assisted radical total gastrectomy (LATG). However, evidence on the safety and feasibility of TLTG (overlap reconstruction) in patients with advanced Siewert III esophagogastric junction cancer and gastric cancer of the upper and middle third of the stomach is scarce.

Methods

This study is a prospective, single-center, single-blind, two-arm randomized controlled trial designed to include 292 patients with advanced Siewert III esophagogastric junction cancer and gastric cancer of the upper and middle third of the stomach who will be randomly assigned to two groups: a TLTG overlap group (n=146) and an LATG group (n=146). The patients’ demographics, pathological characteristics, intraoperative variables, postoperative complications, postoperative recovery variables, 3-year disease-free survival and 3-year overall survival will be collected and analyzed. The primary outcome is the postoperative complications within 30 days after surgery including intra-abdominal hemorrhage, anastomotic leakage, duodenal stump fistula, pancreatic fistula, chyle leakage, abdominal infection, intestinal obstruction, wound complications, pulmonary infection, pleural effusion, pulmonary embolism, cardiovascular and cerebrovascular complications, and deep vein thrombosis. The secondary outcomes are the 3-year disease-free survival and 3-year overall survival.

Discussion

This trial will provide high-level evidence for the safety and feasibility of TLTG (overlap reconstruction) compared with LATG in advanced Siewert III esophagogastric junction cancer and the upper and middle third of gastric cancer.

Trial Registration

This trial has been registered at the Chinese Clinical Trial Registry: ChiCTR1900025667 (registration date: September 4, 2019).

Postoperative pancreatic fistula after gastrectomy for gastric cancer

Postoperative pancreatic fistula is one of the most severe complications after gastric cancer surgery, and can cause critical patient conditions leading to surgery-related death. Fortunately, the incidence of postoperative pancreatic fistula after gastrectomy seems to be decreasing with changes in operative procedures. The rate was reported at about 30% after open gastrectomy with Appleby's method in 1997, but lately has improved below 1% for robotic gastrectomy in 2019. For the diagnosis of postoperative pancreatic fistula, drain amylase concentration has been demonstrated to be beneficial and some reports have proposed the optimal cut-off values of drain amylase to predict major postoperative pancreatic fistula. There have been many reports identifying risk factors for postoperative pancreatic fistula, including overweight patients, pancreatic anatomy, blunt trauma from compression of the pancreas, and thermal injuries caused by the continuous use of energy devices. And importantly, laparoscopic gastrectomy has been shown to be more often associated with postoperative pancreatic fistula than open gastrectomy in the prospective national clinical database in Japan. Hence, further sophistication of surgical techniques to reduce pancreas compression would have great promise in reducing postoperative pancreatic fistula after laparoscopic gastrectomy.

Impact of the Endoscopic Surgical Skill Qualification System on the safety of laparoscopic gastrectomy for gastric cancer

BACKGROUND

We hypothesized that the Endoscopic Surgical Skill Qualification System (ESSQS) can shorten operative time, resulting in a decrease in postoperative morbidity. Here, we aimed to clarify whether ESSQS-qualified surgeons could decrease the incidence of complications.

METHODS

Between January 2009 and June 2019, 1042 patients diagnosed with both clinical and pathological Stage ≤ III gastric cancer and undergoing LG were enrolled. In all LG procedures involving ESSQS-qualified surgeons, these served as the operator or the instructive assistant. The short-term outcomes were retrospectively compared between the ESSQS-qualified and the non-ESSQS-qualified surgeons using a propensity-score matched analysis.

RESULTS

After propensity-score matching, 321 patients were included in each group. No significant differences were observed in morbidity rate, and length of hospitalization following surgery, although the non-ESSQS-qualified surgeon group had a significantly longer total operative time (Non-ESSQS-qualified group, 368 [170-779] min vs. ESSQS-qualified group, 316 [147-772] min; p < 0.001), and larger estimated blood loss (Non-ESSQS-qualified group, 28 [0-702] mL vs. ESSQS-qualified group 25, [0-1069] mL; p = 0.042). Multivariate analysis revealed that operative time ≥ 360 min (OR 1.818 [1.069-3.094], p = 0.027) was identified as the only significant independent risk factor determining morbidity.

CONCLUSIONS

The incidence of postoperative morbidity did not differ between patients operated by the qualified and nonqualified surgeons, as long as ESSQS-qualified surgeons provide intraoperative instructions.

Laparoscopic gastrectomy for elderly gastric-cancer patients: comparisons with laparoscopic gastrectomy in non-elderly patients and open gastrectomy in the elderly

Background

The benefits of laparoscopic gastrectomy (LG) in elderly gastric-cancer patients still remain unclear. The purpose of this study was to evaluate the feasibility and safety of LG in elderly gastric-cancer patients.

Methods

We retrospectively evaluated patients who underwent LG or open gastrectomy (OG) between June 2009 and July 2015 in a single high-volume center. We compared surgical, short-term, and long-term survival outcomes among an elderly (≥70 years old) LG (ELG) group (n = 114), a non-elderly (<70 years old) LG (NLG) group (n = 740), and an elderly OG (EOG) group (n = 383).

Results

Except for extended time to first flatus, the surgical and short-term outcomes of the ELG group were similar to those of the NLG group. The ELG group revealed comparable disease-specific survival (DSS) rates to the NLG group (64.9% vs 66.2%, P = 0.476), although the overall survival (OS) rate was lower (57.0% vs 65.5%, P < 0.001) in the ELG group than in the NLG group. The ELG group showed longer operation time than the EOG group (236.4 ± 77.3 vs 179 ± 52.2 min, P < 0.001). The ELG group had less estimated blood loss (174.0 ± 88.4 vs 209.3 ± 133.8, P = 0.008) and shorter post-operative hospital stay (8.3 ± 2.5 vs 9.2 ± 4.5, P = 0.048) than the EOG group. The severity of complications was similar between the ELG and NLG groups. Multivariate analysis confirmed that LG was not a risk factor for post-operative complications.

Conclusions

LG is a feasible and safe procedure for elderly patients with acceptable short- and long-term survival outcomes.

Comparative outcomes between totally laparoscopic total gastrectomy with the modified overlap method for early gastric cancer and advanced gastric cancer: review of 149 consecutive cases

Introduction

Totally laparoscopic total gastrectomy (TLTG) for advanced gastric cancer (AGC) has not been conclusively substantiated.

Aim

To evaluate TLTG treatment of AGC by comparing its effectiveness and surgical outcomes to those of TLTG treatment of early gastric cancer (EGC).

Material and methods

We performed TLTG with the (modified) overlap method for 149 gastric cancer cases between March 2012 and December 2018. We evaluated clinicopathologic characteristics, complications (including esophagojejunostomy site complications), and surgical outcomes. We also evaluated these variables in terms of their associations with EGC and AGC.

Results

Ninety-two males and 57 females, with a mean age of 60.7 years, were included. The mean operation time was 147.7 min. The mean number of harvested lymph nodes was 39.6. Thirteen (8.7%) patients experienced early complications, and 6 (4.0%) experienced late complications (Clavien-Dindo classification ≥ III). Eight (5.4%) patients underwent reoperation, and 8 (5.4%) were readmitted due to complications. There were no statistically significant differences in operation time, hospital stay, or surgical mortality between EGC and AGC. However, there were significant differences in early complications, late complications, rate of reoperation, and rate of readmission between EGC and AGC.

Conclusions

Although it has some limitations, TLTG with the (modified) overlap method for AGC treatment is feasible, safe, and associated with favorable outcomes.

Non-robotic minimally invasive gastrectomy as an independent risk factor for postoperative intra-abdominal infectious complications: A single-center, retrospective and propensity score-matched analysis

BACKGROUND

Minimally invasive surgery for gastric cancer (GC) has gained widespread use as a safe curative procedure especially for early GC.

AIM

To determine risk factors for postoperative complications after minimally invasive gastrectomy for GC.

METHODS

Between January 2009 and June 2019, 1716 consecutive patients were referred to our division for primary GC. Among them, 1401 patients who were diagnosed with both clinical and pathological Stage III or lower GC and underwent robotic gastrectomy (RG) or laparoscopic gastrectomy (LG) were enrolled. Retrospective chart review and multivariate analysis were performed for identifying risk factors for postoperative morbidity.

RESULTS

Morbidity following minimally invasive gastrectomy was observed in 7.5% of the patients. Multivariate analyses demonstrated that non-robotic minimally invasive surgery, male gender, and an operative time of ≥ 360 min were significant independent risk factors for morbidity. Therefore, morbidity was compared between RG and LG. Accordingly, propensity-matched cohort analysis revealed that the RG group had significantly fewer intra-abdominal infectious complications than the LG group (2.5% vs 5.9%, respectively; P = 0.038), while no significant differences were noted for other local or systemic complications. Multivariate analyses of the propensity-matched cohort revealed that non-robotic minimally invasive surgery [odds ratio = 2.463 (1.070–5.682); P = 0.034] was a significant independent risk factor for intra-abdominal infectious complications.

CONCLUSION

The findings showed that robotic surgery might improve short-term outcomes following minimally invasive radical gastrectomy by reducing intra-abdominal infectious complications.

Short-Term Clinical Outcomes After Laparoscopic and Robotic Gastrectomy for Gastric Cancer: a Propensity Score Matching Analysis

BACKGROUND

The different advantages of laparoscopic gastrectomy (LG) and robotic gastrectomy (RG), two new minimally invasive surgical techniques for gastric cancer, remain controversial.

PURPOSE

To compare the short-term clinical outcomes of LG and RG.

METHODS

A retrospective, single-center comparative study of 1044 patients (LG = 750, RG = 294) was conducted. Patients undergoing LG and RG were matched (2:1 ratio) according to sex, age, BMI, extent of gastric resection, and pathologic stage. The primary outcomes were morbidity and mortality and perioperative recovery parameters; major types of complications were also analyzed.

RESULTS

After matching, 798 patients (LG = 532, RG = 266) were included. Both the LG and RG groups showed similar overall complication rates (LG = 12.8% vs RG = 12.4%) and operative mortality (LG = 0.4% vs RG = 0.4%). Compared to those who underwent LG, patients undergoing RG had significantly longer operative times (236.92 ± 57.28 vs 217.77 ± 65.00 min, p < 0.001), higher total costs (US$16,241.42 vs US$12,497, p < 0.001), less operative blood loss (77.07 ± 64.37 vs 103.68 ± 86.92 ml, p < 0.001), higher numbers of retrieved lymph nodes (32.0 vs 29.9, p < 0.001), and higher rates of retrieving more than 16 lymph nodes (94.0 vs 85.5%; p < 0.001). No significant differences between groups were noted in terms of the rate of reoperation, time until a soft diet was consumed, or length of hospital stay. The major complication and readmission rates were similar in both groups.

CONCLUSION

RG and LG produced similar short-term clinical outcomes, indicating that RG is a safe and beneficial surgical procedure.

Technical details of and prognosis for the "China stitch", a novel technique for totally laparoscopic hand-sewn esophagojejunostomy

The current study describes the technical details of and the clinical prognosis for the "China stitch", a novel technique for hand-sewn esophagojejunostomy in totally laparoscopic total gastrectomy. This study also explores the feasibility and safety of the technique. Clinical data of 20 patients with esophagogastric junction cancer in Beijing Shijitan Hospital, Capital Medical University from January 2017 to April 2018 were retrospectively analyzed. All 20 patients underwent esophagojejunostomy via a novel hand-sewn technique that uses traction to turn the left or right wall of the esophagus into an anterior wall. This avoids the difficulty of suturing the posterior wall. All patients were followed until June 2019. All 20 patients successfully underwent the procedure. The mean operating time was 216.5 ± 24.9 (176-254) min, the mean hand-sewn reconstruction time was 44.4 ± 9.4 (26-61) min, intraoperative bleeding was 141.2 ± 24.9 (130-160) mL, and the number of resected lymph nodes was 23 ± 8 (14-33). After surgery, there was one case of anastomotic leakage and one case of anastomotic stenosis, but both were alleviated with conservative treatment. The mean duration of follow-up was 15 (4-33) months. There was no significant difference in postoperative complications of and short-term oncologic prognosis for the 20 patients who underwent hand-sewn esophagojejunostomy and the 21 patients who underwent mechanical esophagojejunostomy during the same period. In conclusion, the "China stitch", a novel hand-sewn technique, is a cost-effective, safe, and reliable method for esophagojejunostomy in totally laparoscopic total gastrectomy.

Reverse puncture device technique: an innovation of esophagojejunostomy in radical laparoscopic total gastrectomy

Aim: To evaluate the feasibility, safety, short- and long-term efficacy of a reverse puncture device (RPD) technique for esophagojejunostomy in laparoscopic-assisted total gastrectomy. Patients & methods: This retrospective study analyzed outcome data of 104 patients in propensity score matching whom were divided into the RPD and the purse-string suture technique group. Results: The RPD group had a shorter anvil placement time, shorter operative time, longer resected esophageal length, shorter incision length, shorter postoperative drainage time, shorter postoperative hospital stay and anastomotic complications than the purse-string suture technique group (p < 0.05). Multivariate analysis showed that BMI (odds ratio: 6.285, 1.446-27.322) and anvil placement time (odds ratio: 5.645, 1.089-29.321) were independent risk factors for anastomotic complications (p < 0.05). Conclusion: Laparoscopic-assisted total gastrectomy using an RPD technique is feasible, safe and effective.

Impact of high amylase level in drainage fluid after gastric cancer surgery: Is it a complication or suspicious biochemical measurement?

Purpose: Pancreatic fistula is a potential postoperative complication with variable definitions, incidences and risk factors. We intended to evaluate its impact after gastric surgery. Materials and Methods: A total of 28 consecutive patients who underwent curative open gastrectomy with lymphadenectomy for gastric adenocarcinoma were retrospectively analyzed. Patients’ demographics, peri-operative and pathological data were collected. Pancreatic fistula that was diagnosed and graded according to International Study Group of Pancreatic Fistula’s system was identified as main variable.Results: Mean age of patients was 58.8±10.1 years with a female to male ratio of 9/19. Grade A pancreatic fistula was diagnosed in six patients (21.4%). There was no grade B and C pancreatic fistula. Drain amylase level was significantly higher in patients with pancreatic fistula (p=0.0001). There was no significant difference with regard to amount of drainage, length of hospital stay and duration of drains in patients with and without fistula. No significant association was shown between development of fistula and patients’ demographics, peri-operative and pathological data. Conclusion: The development of grade A pancreatic fistula after gastric surgery does not appear to be a major complication with clinical consequences. High amylase level in the drainage fluid can be considered as a biochemical measure only.  

Intra-corporeal delta-shaped anastomosis in laparoscopic right hemicolectomy for right colon cancer: a safe and effective technique

Background and objective

Intra-corporeal delta-shaped anastomosis (IDA) is an important development in laparoscopic digestive-tract reconstruction. We applied it in laparoscopic right hemicolectomy for right colon cancer and compared the short-term outcomes between the patients treated with IDA and conventional extracorporeal anastomosis (EA).

Methods

Between 1 January 2016 and 1 October 2017, 36 and 50 patients who underwent IDA and EA, respectively, were included. Data on clinicopathological characteristics, surgical outcomes, post-operative recovery and complications were collected and compared between the two groups.

Results

Surgical outcomes and clinicopathological characteristics were similar between the two groups except the length of incision, which was significantly shorter in the IDA group than in the EA group (4.6 ± 0.6 vs 5.6 ± 0.7 cm, P < 0.001). The time to ground activities, fluid diet intake and post-operative hospitalization did not differ between the groups; however, the time to first flatus was significantly shorter in the IDA group than in the EA group (2.8 ± 0.5 vs 3.2 ± 0.8 days, P = 0.004). The post-operative visual analogue scale for pain was lower in the IDA group than in the EA group on post-operative Day 1 (4.0 ± 0.7 vs 4.5 ± 1.0, P = 0.002) and post-operative Day 3 (2.7 ± 0.6 vs 3.4 ± 0.6, P < 0.001). The surgical complication rates were 8.3 and 16.0% in the IDA and EA groups (P = 0.470), respectively. No complications such as anastomotic bleeding, stenosis and leakage occurred in any patient.

Conclusions

IDA is safe and feasible and shows more satisfactory short-term outcomes than EA.

Intracorporeal Isosceles Right Triangle-shaped Anastomosis in Totally Laparoscopic Distal Gastrectomy

PURPOSE

This study aimed to evaluate the feasibility and safety of intracorporeal anastomosis with Billroth I, Billroth II, or Roux-en-Y reconstructions in totally laparoscopic distal gastrectomy.

MATERIALS AND METHODS

A single-institution, retrospective, cohort study including 553 patients was conducted. Intracorporeal isosceles right triangle-shaped anastomosis without slack and torsion was created using linear staplers. Billroth I was primarily used. Surgical outcomes and perioperative nutritional status were assessed.

RESULTS

Morbidity was 11.5%. Postoperative early complications related to anastomosis occurred in 13 patients (2.4%). Operative time and reconstruction type (Billroth I vs. others) were the only significant independent risk factors determining postoperative early and late complications, respectively. No difference was observed in postoperative changes in nutritional status across the groups, although Billroth II increased reflux esophagitis requiring medication.

CONCLUSIONS

Intracorporeal isosceles right triangle-shaped anastomosis using linear staplers in totally laparoscopic distal gastrectomy, in combination with our selection algorithm for type of reconstruction, is feasible and safe.

Unplanned reoperation after radical gastrectomy for gastric cancer: causes, risk factors, and long-term prognostic influence

Purpose

Unplanned reoperation (URO) after radical gastrectomy for gastric cancer (GC) mostly results from serious postoperative complications. At present, there is still controversy over the predictive factors for URO. Our goal was to identify the risk factors for URO and to investigate its potential impact on long-term survival.

Patients and methods

We included 2,852 GC patients who underwent a gastrectomy. Multivariate logistic regression analyses were performed to determine the risk factors for URO. Patients were randomly selected from the non-URO group by 1:4 propensity score matching with multiple parameters with patients from the URO group. The survival disparity of 34 URO patients and 136 non-URO patients was examined using the Kaplan-Meier method and the multivariate Cox proportional hazard model.

Results

The incidence of URO was 1.4% (39/2, 852). The primary cause of URO was intra-abdominal bleeding (53.9%, 21/39). Multivariate logistic regression analyses revealed that male gender (OR = 4.630, 95% CI = 1.412-15.152, P = 0.011), diabetes (OR = 4.189, 95% CI = 1.705-10.290, P = 0.002), and preoperative hypoproteinemia (OR = 2.305, 95% CI = 1.079-4.923, P = 0.031) were independent risk factors for URO. With regard to early surgical outcomes, patients undergoing URO had a longer hospital stay (P < 0.001), higher incidence of postoperative complications (P < 0.001), and greater mortality (P < 0.001) compared with the non-URO group. No significant correlation was found between URO and cancer-specific survival in univariate (P = 0.275) and multivariate (P = 0.090) survival analyses.

Conclusion

Male gender, diabetes, and preoperative hypoproteinemia were suggested as independent risk factors for URO. URO was associated with longer hospital stay and increased perioperative mortality, but might not be correlated with long-term mortality.

Severity of complications and long-term survival after laparoscopic total gastrectomy with D2 lymph node dissection for advanced gastric cancer: A propensity score-matched, case-control study

BACKGROUND

Increasing numbers of studies have shown that postoperative complication is a negative predictor of long-term survival outcomes in various malignancies. However, the impact of severity of complications on long-term survival for patients with gastric cancer still remains unclear. This study aimed to explore the relationship between the severity of complications and long-term survival outcomes after laparoscopic total gastrectomy (LTG) for advanced gastric cancer (AGC).

METHODS

The study analyzed 571 patients with AGC who underwent LTG in a single institution between April 2008 and June 2015. Patients were divided into two groups based on the occurrence or absence of postoperative complications which were recorded using the Clavien-Dindo (C-D) classification. Long-term survival outcomes were compared between groups in the propensity score-matched cohort.

RESULTS

The groups were well balanced after the propensity score matched. The complication (C) group was associated with decreased 5-year cancer-specific survival (CSS) (65.1% vs. 76.2%, P=0.049). Subgroup analysis showed that the severe complication (C-D grade > II) group was associated with decreased 5-year overall survival (OS) (46.3% vs. 65.9%, P = 0.042) and cancer-specific survival (CSS) (53.7% vs. 74.4%, P = 0.030). However, a comparative analysis of 5-year OS and CCS showed no significant differences between the minor complication (C-D grade II) group and matched NC group (68.9% vs. 72.2%, P = 0.578; 75.6% vs. 77.8%, P = 0.649; respectively). Multivariate analysis confirmed severe complication was an independent risk factor for decreased OS. Further analysis showed that older age, lower body mass index (BMI), and combined resection were independent risk factor for the occurrence of severe complications.

CONCLUSIONS

Severe complications adversely affected long-term survival outcomes after LTG with D2 lymph node dissection for AGC. More attention should be paid to patients at high risk for severe complications in preoperative assessment and postoperative management.

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

BACKGROUND

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

METHODS AND PROCEDURES

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

RESULTS

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

CONCLUSION

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

Use of endoscopy to determine the resection margin during laparoscopic gastrectomy for cancer

Background

It can be difficult to determine the transection line during totally laparoscopic surgery for early gastric cancer owing to lack of tactile feedback. This retrospective cohort study aimed to assess the role of intraoperative endoscopy in determining the resection margin in totally laparoscopic gastrectomy.

Methods

Consecutive patients with histologically confirmed gastric cancer who underwent laparoscopic gastrectomy between March 2012 and July 2015 were eligible. Preoperative placement of marking clips and intraoperative endoscopy were performed to determine the resection margin. Frozen-section analyses were also performed to confirm the absence of cancer cells at the surgical margin. Success was defined as the proportion of specimens with all clips present and by the proportion of resections with a negative surgical margin following initial transection.

Results

Total laparoscopic gastrectomy with intraoperative endoscopy was performed in 522 patients; a total of 662 surgical margins were analysed. The overall success rate was 99·8 per cent (661 of 662 margins). The success rate of achieving a negative surgical margin during the initial transection was 98·9 per cent (550 of 556 margins).

Conclusion

Preoperative placement of marking clips and intraoperative endoscopy is helpful in the determination of a safe surgical margin in patients with gastric cancer who undergo laparoscopic gastrectomy.

Laparoscopic subtotal gastrectomy for advanced gastric cancer: technical aspects and surgical, nutritional and oncological outcomes

BACKGROUND

Higher morbidity in total gastrectomy than in distal gastrectomy has been reported, but laparoscopic subtotal gastrectomy (LsTG) has been reported to be safe and feasible in early gastric cancer (GC). We determined the surgical, nutritional and oncological outcomes of LsTG for advanced gastric cancer (AGC).

METHODS

Of the 816 consecutive patients with GC who underwent radical gastrectomy at our institution between 2008 and 2012, 253 who underwent curative laparoscopic gastrectomy (LG) for AGC were enrolled. LsTG was indicated for patients with upper stomach third tumors, who hoped to avoid total gastrectomy, <4 cm to the esophagogastric junction and a 2-cm proximal margin with cut end negative in frozen section, whereas laparoscopic conventional distal gastrectomy (LcDG) and laparoscopic total gastrectomy (LTG) were performed otherwise. Surgical outcomes and postoperative nutritional status were primarily assessed.

RESULTS

Of 253 patients, the morbidity (Clavien-Dindo classification grade ≥ III) was 17.0% (43 patients). The 3-year overall survival and 3-year recurrence-free survival rates were 80.2 and 73.5%, respectively. LcDG, LsTG and LTG were performed in 121, 27 and 105 patients, individually. Morbidity was strongly associated with LTG (P = 0.001). Postoperative loss of body weight was significantly greater after LTG in comparison with LcDG or LsTG (P < 0.001). No difference in morbidity and postoperative loss of body weight were observed between LcDG and LsTG group.

CONCLUSIONS

LG for AGC was feasible and safe surgically and oncologically. LsTG for AGC may be safer than LTG from surgical and postoperative nutritional point of view.

Robotic valvuloplastic esophagogastrostomy using double flap technique following proximal gastrectomy: technical aspects and short-term outcomes

BACKGROUND

Valvuloplastic esophagogastrostomy by double flap technique (VEG-DFT) is a promising procedure to prevent reflux after proximal gastrectomy (PG), and is achieved by the burial of the abdominal esophagus into the gastric submucosa; however, laparoscopic VEG-DFT is technically demanding due to complicated suturing and ligation maneuvers. The present study was designed to determine the feasibility and safety of robotic VEG-DFT.

METHODS

After robotic PG, seromuscular flaps were extracorporeally created at the anterior wall of the remnant stomach through a small umbilical incision. Then, using a robot, the posterior wall of the esophagus was fixed to the cranial end of the mucosal window, and layer-to-layer sutures were placed between the anterior aspects of esophagus and the remnant stomach. Finally, the anastomosis was covered by seromuscular flaps. Short-term outcomes of 12 consecutive patients who underwent VEG-DFT between January 2014 and December 2015 were assessed.

RESULTS

Operations were successfully completed using robotic assistance in all patients. Median operative, surgeon console, and anastomosis times were 406 (324-613 min), 267 (214-483), and 104 (76-186) min, respectively, and median estimated blood loss was 31 (5-130) ml. The first six cases were required to reach a learning plateau. Both mortality and morbidity rates within 30 days after surgery were 0%. Postoperative hospital stay was 10 (9-30) days. No postoperative reflux esophagitis was observed, whereas anastomotic stenosis, which required endoscopic balloon dilation, developed in three patients (25%) in postoperative month 2. There was a significant association between the total number of stitches used for VEG-DFT and anastomotic stenosis (p < 0.001).

CONCLUSIONS

Robotic assistance may be useful for VEG-DFT with a short learning curve. Attention is required to prevent postoperative anastomotic stenosis possibly caused by an excessive number of stitches for esophagogastrostomy.

Evaluation of the recurrence pattern of gastric cancer after laparoscopic gastrectomy with D2 lymphadenectomy

Background

The aim of this study was to analyze the oncological aspects of gastric cancer following laparoscopic gastrectomy with D2 lymphadenectomy (LG-D2).

Methods

We retrospectively evaluated the long-term outcomes of 354 patients who underwent LG-D2 for primary gastric cancer. Recurrence patterns and predictors of peritoneal metastasis were analyzed.

Results

Median follow-up time was 43.8 months. Five-year overall survival rates for yp/pStages I, II, and III gastric cancer were 93.7, 78.5, and 42.2 %, respectively. Recurrence was observed in 86 patients. Peritoneal metastasis was the most frequent recurrence pattern (n = 51), followed by hepatic metastasis (n = 17). Lymphatic recurrence at distant sites was observed in 10 patients. No locoregional lymph node metastasis or local recurrence was seen. Nine of 51 cases of peritoneal recurrence were detected by probe laparoscopy. Peritoneal recurrence rates were significantly higher in yp/pT4 and yp/pN3 diseases compared with yp/pT ≤ 3 and yp/pN ≤ 2 diseases. Multivariate analyses demonstrated that yp/pT4, yp/pN3, tumor size ≥70 mm, vascular invasion, and undifferentiated tumors were predictors of peritoneal recurrence following LG-D2.

Conclusion

Long-term outcomes of gastric cancer following LG-D2, including recurrence patterns and predictors of peritoneal metastasis, were comparable to those following open D2 gastrectomy. LG-D2 showed good local control. Probe laparoscopy after LG may be effective in detecting peritoneal recurrence, which is not determined with less invasive examinations, including a CT scan. Future large-scale prospective studies are desirable to evaluate not only surgical but also oncological benefits and safety of LG-D2 for advanced gastric cancer.

Effectiveness of laparoscopic stomach-partitioning gastrojejunostomy for patients with gastric outlet obstruction caused by advanced gastric cancer

BACKGROUND

Distal advanced gastric cancer (AGC) occasionally causes gastric outlet obstruction (GOO). We developed a laparoscopic stomach-partitioning gastrojejunostomy (LSPGJ) to restore the ability of food intake.

METHODS

This was a retrospective study performed at a single institution. Of consecutive 78 patients with GOO caused by AGC between 2006 and 2012, 43 patients who underwent LSPGJ were enrolled. The procedure was performed in an antiperistaltic Billroth II fashion, and the afferent loop was elevated and fixed along the staple line of the proximal partitioned stomach. Then, patients for whom R0 resection was planned received chemotherapy prior to laparoscopic gastrectomy. The primary end point was food intake at the time of discharge, which was evaluated using the GOO scoring system (GOOSS). Short- and long-term outcomes were assessed as secondary end points. Overall survival was estimated and compared between the groups who received neoadjuvant chemotherapy followed by surgery (NAC group), definitive chemotherapy followed by curative resection (Conversion group), and best supportive care (BSC group).

RESULTS

The median operative time was 92 min, blood loss did not exceed 30 g in any patient, and postoperative complications (Clavien-Dindo grade ≥2) were only seen in four patients (9.3 %). The median time to food intake was 3 days, and GOOSS scores were significantly improved in 41 patients (95.3 %). Chemotherapy was administered to 38 patients (88.4 %), of whom 11 later underwent radical resection, and 4 of 11 patients underwent conversion surgery following definitive chemotherapy. Median survival times were significantly superior in the NAC (n = 7; 46.8 months) and Conversion (n = 4; 35.9 months) groups than in the BSC group (n = 26; 12.2 months); however, the difference was not significant between the Conversion and NAC groups.

CONCLUSIONS

LSPGJ is a feasible and safe minimally invasive induction surgery for patients with GOO from surgical and oncological perspectives.

Minimally invasive surgery for upper gastrointestinal cancer: Our experience and review of the literature

Minimally invasive surgery (MIS) for upper gastrointestinal (GI) cancer, characterized by minimal access, has been increasingly performed worldwide. It not only results in better cosmetic outcomes, but also reduces intraoperative blood loss and postoperative pain, leading to faster recovery; however, endoscopically enhanced anatomy and improved hemostasis via positive intracorporeal pressure generated by CO2 insufflation have not contributed to reduction in early postoperative complications or improvement in long-term outcomes. Since 1995, we have been actively using MIS for operable patients with resectable upper GI cancer and have developed stable and robust methodology in conducting totally laparoscopic gastrectomy for advanced gastric cancer and prone thoracoscopic esophagectomy for esophageal cancer using novel technology including da Vinci Surgical System (DVSS). We have recently demonstrated that use of DVSS might reduce postoperative local complications including pancreatic fistula after gastrectomy and recurrent laryngeal nerve palsy after esophagectomy. In this article, we present the current status and future perspectives on MIS for gastric and esophageal cancer based on our experience and a review of the literature.

Comparison of the long-term outcomes of robotic radical gastrectomy for gastric cancer and conventional laparoscopic approach: a single institutional retrospective cohort study

BACKGROUND

Robotic gastrectomy (RG) for gastric cancer (GC) has been increasingly performed over the last decade. The technical feasibility and safety of RG for GC, predominantly early GC, have previously been reported; however, few studies have evaluated the oncological outcomes. This study aimed to determine the long-term outcomes of RG for GC compared with those of conventional laparoscopic gastrectomy (LG).

METHODS

Of the 521 consecutive patients with GC who underwent radical gastrectomy at our institution between 2009 and 2012, 84 consecutive patients who underwent RG and 437 patients who received LG were enrolled in this study. Long-term outcomes including the 3-year overall survival (3yOS) and 3-year recurrence-free survival rates (3yRFS) were examined retrospectively.

RESULTS

In the RG group, the 3yOS rates stratified by pathological stage according to the Japanese classification of gastric carcinoma (IA, IB, II, and III) were 94.7, 90.9, 89.5, and 62.5 %, respectively. No differences in 3yOS (RG, 86.9 % vs. LG, 88.8 %; p = 0.636) or 3yRFS (RG, 86.9 % vs. LG, 86.3 %; p = 0.905) were observed between the groups. 3yOS was strongly associated with cancer recurrence within 3 years (p < 0.001), while 3yRFS was associated with tumor size ≥ 30 mm (p < 0.001), clinical stage ≥ IB (p < 0.001), estimated blood loss ≥ 50 mL (p = 0.033), and postoperative pancreatic fistula CD grade ≥ III) (p = 0.035).

CONCLUSIONS

RG for GC was feasible and safe from the oncological point of view in a cohort including a considerable number of patients with advanced GC.

Ongoing clinical studies of minimally invasive surgery for gastric cancer in Japan

Since the development of laparoscopy-assisted distal gastrectomy (LADG) with lymph node dissection for gastric cancer in Japan, this type of surgery is improving and evolving. To establish high-quality evidence of laparoscopic gastrectomy (LAG) in the field of gastric cancer treatments, two large-scale, prospective randomized controlled trials have been performed in Japan; the Japan Clinical Oncology Study Group (JCOG) 0912 for early disease and the Japanese Laparoscopic Surgery Study Group (JLSSG) 0901 for advanced disease. Analyses using mega-data from the National Clinical Database (NCD) have also been carried out as a clinical study to clarify the safety of LAG. Furthermore, as advanced laparoscopic techniques have been developed, prospective clinical studies are being performed with regard to laparoscopy-assisted total gastrectomy (LATG), robotic gastrectomy, and minimally invasive surgery with sentinel node (SN) navigation. This review summarizes the current status of minimally invasive surgeries for gastric cancer based on the latest ongoing clinical trials in Japan.