What technique is suitable for laparoscopic suprapancreatic lymph node dissection?

Validation study of a skill assessment tool for education and outcome prediction of laparoscopic distal gastrectomy

BACKGROUND

The Japanese operative-rating scale for laparoscopic distal gastrectomy (JORS-LDG) was developed through cognitive task analysis together with the Delphi method to measure intraoperative performance during laparoscopic distal gastrectomy. This study aimed to investigate the value of this rating scale as an educational tool and a surgical outcome predictor in laparoscopic distal gastrectomy.

METHODS

The surgical performance of laparoscopic distal gastrectomy was assessed by the first assistant, through self-evaluation in the operating room and by video raters blind to the case. We evaluated inter-rater reliability, internal consistency, and correlations between the JORS-LDG scores and the evaluation methods, patient characteristics, and surgical outcomes.

RESULTS

Fifty-four laparoscopic distal gastrectomy procedures performed by 40 surgeons at 16 institutions were evaluated in the operating room and with video recordings using the proposed rating scale. The video inter-rater reliability was > 0.8. Participating surgeons were divided into the low, intermediate, and high groups based on their total scores. The number of laparoscopic surgeries and laparoscopic gastrectomy procedures performed differed significantly among the groups according to laparoscopic distal gastrectomy skill levels. The low, intermediate, and high groups also differed in terms of median operating times (311, 266, and 229 min, respectively, P < 0.001), intraoperative complication rates (27.8, 11.8, and 0%, respectively, P = 0.01), and postoperative complication rates (22.2, 0, and 0%, respectively, P = 0.002).

CONCLUSIONS

The JORS-LDG is a reliable and valid measure for laparoscopic distal gastrectomy training and could be useful in predicting surgical outcomes.

A Multi-institutional, Prospective, Phase II Feasibility Study of Laparoscopy-Assisted Distal Gastrectomy with D2 Lymph Node Dissection for Locally Advanced Gastric Cancer (JLSSG0901)

BACKGROUND

The efficacy and safety outcomes of laparoscopy-assisted distal gastrectomy (LADG) with D2 lymph node dissection for locally advanced gastric cancer remain unclear. Therefore, we conducted a randomized, controlled phase II trial to confirm the feasibility of LADG in terms of technical safety, and short-term surgical outcomes were investigated.

METHODS

Eligibility criteria included pre-operatively diagnosed advanced gastric cancer that could be treated by distal gastrectomy with D2 lymph node dissection; MP, SS, and SE without involvement of other organs; and N0-2 and M0. Patients aged 20-80 years were pre-operatively randomized.

RESULTS

In total, 180 patients were registered and randomized to the open (89 patients) and laparoscopic arms (91 patients). Among 91 patients in the laparoscopic arm, 86 underwent laparoscopic gastrectomy according to the study protocol. Regarding the primary endpoint of the phase II trial, the proportion of patients with either anastomotic leakage or pancreatic fistula was 4.7 % (4/86). The grade 3 or higher morbidity rate, including systemic and local complications, was 5.8 %. Conversion to open surgery was required for 1 patient (1.2 %), without any intra-operative complication. The post-operative mortality rate was 0, and no patient required readmission for surgical complications within 6 months after initial discharge.

CONCLUSIONS

The technical safety of LADG with D2 lymph node dissection for locally advanced gastric cancer was demonstrated. A phase III trial to confirm the non-inferiority of this procedure to open gastrectomy in terms of long-term outcomes is ongoing. Registered Number: UMIN 000003420 ( www.umin.ac.jp/ctr/).

The anatomical location of the pancreas is associated with the incidence of pancreatic fistula after laparoscopic gastrectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) is one of the major complications after laparoscopic gastrectomy (LG). We investigated the impact of the anatomical location of the pancreas, especially in relation to the suprapancreatic lymph nodes, on the incidence of POPF after LG.

METHODS

We retrospectively reviewed the preoperative computed tomography (CT) images of 246 patients who underwent LG with the suprapancreatic lymph node dissection between November 2008 and November 2015. The length between the levels of the pancreatic body surface and the root of the common hepatic artery (LPC) was measured on a CT image with an axial view. A receiver operating characteristics (ROC) curve analysis was performed to determine the cutoff LPC value. A multivariate analysis was performed to determine the predictive factors for POPF.

RESULTS

POPF occurred in 11 patients (4.5 %). The median LPC was significantly longer in the patients with POPF than in those without (26 mm vs. 21 mm, p = 0.026). The ROC curve analysis revealed that the optimal cutoff LPC value for predicting POPF was 25 mm. The POPF rate was significantly higher in the long LPC group than in the short LPC group (10 vs. 1.3 %, p = 0.002). A multivariate analysis demonstrated that a long LPC (p = 0.018) and dissection of the lymph nodes along the distal splenic artery (p = 0.042) were independent predictors of POPF. The amylase level in the drainage fluid on postoperative day 1 was significantly higher in the long LPC group than in the short LPC group.

CONCLUSIONS

The LPC is a simple and reliable predictor of POPF after LG. Surgeons should take the anatomical location of the pancreas into consideration when performing LG with suprapancreatic lymph node dissection.

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.

Application Value of a 6-Type Classification System for Common Hepatic Artery Absence During Laparoscopic Radical Resections for Gastric Cancer: A Large-Scale Single-Center Study

The common hepatic artery (CHA) is an important blood vessel that must be vascularized during D2 lymphadenectomies for gastric cancer. When the CHA is absent, the risk of vascular injury increases.To explore the anatomic classification of CHA absence and its application value in laparoscopic radical resections for gastric cancer.Clinical data were collected prospectively from 2170 gastric cancer patients from June 2007 to December 2013, and the data were analyzed retrospectively. The anatomy of CHA absence was assessed synthetically by combining preoperative CT scans and intraoperative images, which were classified according to the anatomy of replaced hepatic arteries (RHAs) and were grouped into the early-year group (2007-2011) and the later-year group (2012-2013) based on the year in which the operation was performed.CHA absence was noted in 38 cases (1.8%) and was classified into 6 types: type I (replaced CHA [RCHA] from the superior mesenteric artery [SMA] with retropancreatic course, 28), type II (RCHA from the SMA with circumambulated course, 1), type III (RCHA from the aortic artery, 1), type IV (replaced left hepatic artery [RLHA] from the left gastric artery [LGA] and replaced right hepatic artery [RRHA] from the SMA, 5), type V (RLHA from the LGA and RRHA from the celiac artery, 2), and type VI (RLHA from the aberrant gastroduodenal artery and RRHA from the SMA, 1). Of the 38 cases, 17 cases (44.7%) belong to the early-year group, and 21 cases (55.3%) belong to the later-year group. The vascular injury rate was significantly lower in the later-year group than in the early-year group (4.8% [1/21] vs 41.2% [7/17], P = 0.005]. Additionally, the alanine aminotransferase (ALT), aspartate aminotransferase (AST), and total bilirubin (TBIL) values were significantly lower in the later-year group than in the early-year group on postoperative day 3 (all P < 0.05).A 6-type anatomic classification system can be used to demonstrate variations in features resulting from CHA absence in detail. Knowledge regarding a patient's classification is helpful for surgeons, and vascular injury and liver function damage may be reduced in patients who are properly classified prior to surgery.

Why the Proximal Splenic Artery Approach is the Ideal Approach for Laparoscopic Suprapancreatic Lymph Node Dissection in Advanced Gastric Cancer? A Large-Scale Vascular-Anatomical-Based Study

Laparoscopic gastrectomy with D2 lymph node (LN) dissection has not yet been widely adopted for advanced gastric cancer because it is technically complicated. Due to the high suprapancreatic lymph nodes metastasis rate (LMR) and the various vascular anatomies, the suprapancreatic LN dissection is a crucial and demanding procedure for radical resection of gastric cancer.To explore the anatomical basis of the proximal splenic artery (SA) approach for laparoscopic suprapancreatic LN dissection and its application in advanced gastric cancer.Laparoscopic suprapancreatic LN dissections were performed in 1551 consecutive advanced gastric cancer patients between June 2007 and November 2013. A total of 994 consecutive patients since January 2011 were selected to compare the clinicopathological characteristics and surgical outcomes between the conventional approach group (330) and the proximal SA approach group (664). In the proximal SA approach, the No. 11p LNs are dissected first, followed by the Nos. 9, 7, and 8a LNs; dissection of the Nos. 5 and 12a LNs is performed last.In the suprapancreatic arteries, the proximal SA had the lowest anatomic variation rate (P < 0.05, each) and maximum diameter (P < 0.05, each) compared with the common hepatic artery (CHA), left gastric artery (LGA), right gastric artery (RGA), and gastroduodenal artery (GDA). In addition, the proximal SA was located closer to the suprapancreatic border than the CHA (P = 0.000). The No. 11p LMR was lower than the Nos. 9, 7, 8a, 5, and 12a LMR (P < 0.01, each). Compared with the conventional approach, the proximal SA approach was associated with less blood loss (P < 0.05), significantly more retrieved total LNs and suprapancreatic LNs (P < 0.01, each).The proximal SA exhibits the most constant and maximum diameter, is located closer to the suprapancreatic border, and exhibits the lowest LMR; therefore, the proximal SA approach is the ideal approach for laparoscopic suprapancreatic LN dissection in advanced gastric cancer.

[OPTIMIZATION OF THE METHOD OF SUPRAPANCREATIC LYMPH NODE DISSECTION IN LAPAROSCOPY-ASSISTED GASTRECTOMY (IN THE FINAL ANALYSIS OF INTERNATIONAL CONFERENCES <<SCHOOL OF STOMACH SURGERY>>)]

The article analyzed the methods of suprapancretic lymph node dissection in laparoscopic gastrectomy which were devel- oped and applied in Japan. The authors described the details of operation technique. There were noted the advantages of medial approach for suprapancreatic lymph node dissection.

Clinical experience of 528 laparoscopic gastrectomies on gastric cancer in a single institution

BACKGROUND

Laparoscopic gastrectomy (LG) for locally advanced gastric cancer (AGC) as well as early gastric cancer (EGC) has gradually gained popularity. However, long-term experiences of LG for AGC as well as EGC rarely have been reported.

METHODS

A total of 528 patients with gastric cancer were enrolled in the study, and clinical experiences of LG were evaluated.

RESULTS

The study included 332 men and 196 women. The mean age was 61.3 ± 11.8 years. Of the 528 patients, 432 underwent distal gastrectomy, 87 had a total gastrectomy, and 9 had a proximal gastrectomy. There were 198 T1a, 139 T1b, 63 T2, 83 T3, and 45 T4a lesions. In 127 patients, lymph node metastasis was observed, and the rate of it was 1.5% in T1a, 12.2% in T1b, 34.9% in T2, 59.0% in T3, and 80.0% in T4a. The median follow-up period was 24 months (range, 1-83 months). The 5-year survival and disease-free survival rates according to the stage of tumor were 99.3% and 97.8% in stage I, 95.4% and 89.7% in stage II, and 44.4% and 31.3% in stage III, respectively. Operation related morbidities occurred in 45 patients, and there were 2 mortalities. Tumors recurred in 36 patients consisting of 2 in T1a, 2 T1b, 2 T2, 12 T3, and 18 T4a. Carcinomatosis peritonei was observed most commonly.

CONCLUSION

In our experience, oncologic results and the safety of LG for EGC and serosa-negative AGC were acceptable. This treatment may be considered as an alternative operative approach.

Minimally invasive approaches for gastric cancer-Japanese experiences

Since development of laparoscopy-assisted distal gastrectomy with lymph node dissection in 1991 in Japan, laparoscopic gastrectomy (LAG) is improving and evolving. Recently, advanced LAG techniques including D2 lymph node dissection or anastomosis after total gastrectomy have been developed. Retrospective and prospective multicenter studies have been conducted for early and non-early gastric cancers to establish high-quality evidence. This review summarizes the current trends of minimally invasive approaches for gastric cancer based on current Japanese experiences.