Feasibility of laparoscopy-assisted total gastrectomy in patients with clinical stage I gastric cancer

Laparoscopic Gastrectomy for Advanced Gastric Cancer

BACKGROUND

Application of laparoscopic gastrectomy (LG) to advanced gastric cancer is still controversial due to lack of sufficient surgical and oncological outcomes. The purpose of this study was to elucidate the feasibility of LG for advanced gastric cancer by multicenter prospective cohort study.

METHODS

A total of 98 patients with clinical stage II or III gastric cancer from 8 institutes were analyzed in this study. The primary endpoint was incidence of severe postoperative complications of Clavien-Dindo classification grade Ⅲa or higher.

RESULTS

Sixty-six patients underwent laparoscopic distal gastrectomy (LDG), 10 patients laparoscopic proximal gastrectomy (LPG), 21 patients laparoscopic total gastrectomy (LTG), and 1 patient received gastro-jejunostomy. Seven patients had positive lavage cytology (CY1) and R0 rate was 90.8%. Three patients (3.1%) required conversion to open surgery. The incidence of overall postoperative complications and severe postoperative complications were 17.3% and 9.2%, respectively, those were comparable to the data of open surgery for advanced gastric cancer previously published. By surgical procedure, the incidence of severe postoperative complications of LDG, LPG, and LTG were 4.6, 0, and 28.6% and the rate of severe anastomotic leakage of LDG, LPG, and LTG were 0, 0, and 9.5%, respectively. Total gastrectomy was an only independent risk factor of severe postoperative complications in LG for advanced gastric cancer (odds ratio 8.75; 95% confidence interval 1.70-56.69, P = .0092).

DISCUSSION

The incidence of severe postoperative complications after LG performed by qualified surgeons was acceptable even in cases of advanced gastric cancer; however, careful attention is required to adopt LTG. (UMIN000025733).

Surgical invasiveness and lymphadenectomy in robotic and laparoscopic gastrectomy: A retrospective study with propensity-score matching

BACKGROUND

There is no consensus amongst comparative studies about the advantages of robotic over laparoscopic surgeries for gastric cancer (GC). We compared invasiveness and lymph node dissection between robotic and laparoscopic gastrectomies (RG and LG).

METHODS

We retrospectively reviewed the medical records of 215 consecutive patients with GC who underwent RG or LG with lymphadenectomy from January 2011-December 2020. Propensity score matching analysis was performed to control selection bias.

RESULTS

The RG group had less operative blood loss (P = 0.0005) and higher C-reactive protein levels on postoperative day 1 (P = 0.0006) than the LG group. When analyzing the specific sites of dissected lymph nodes, station groups of supra-pancreatic and lesser curvature areas accounted for this difference (P = 0.0073 and 0.0362, respectively).

CONCLUSIONS

RG demonstrated lesser intraoperative bleeding, less of a postoperative inflammatory response, and a higher proportion of lymph node removal than LG, suggesting that it is a better surgical and oncological procedure.

Application of Half-Transected and Self-Pulling Esophagojejunostomy in Total Laparoscopic Gastrectomy for Gastric Cancer: A Safe and Feasible Technique

OBJECTIVE

This study introduces a technique for esophagojejunostomy with half transected and self-pulling (HTSP) and evaluates the safety, feasibility, and clinical results of this technique in totally laparoscopic total gastrectomy (TLTG).

MATERIALS AND METHODS

From May 2019 to March 2021, 42 patients (HTSP group) who underwent HTSP-TLTG surgery in the Department of Abdominal Tumor Surgery of Jiangxi Cancer Hospital were included in this study. The control group consisted of 50 patients undergoing conventional TLTG surgery (conventional anastomosis group) performed by the same surgical team from March 2018 to March 2020. The clinical data of the two groups were retrospectively analyzed and compared.

RESULTS

The mean operation time of the HTSP-TLTG surgery was 166.7 ± 13.1 minutes and the anastomosis time was 20.8 ± 2.0 minutes, which were significantly shorter than those of traditional TLTG (P < 0.05). There were no significant differences between the two groups in blood loss, time to first exhaust, postoperative hospital stay, and incidence of surgery-related complications.

CONCLUSION

HTSP is a safe and feasible way of endoscopic esophagojejunal anastomosis, which requires a relatively low suture technique under endoscopy, and is suitable for promotion.

Minimum Esophageal Resection Length to Ensure Negative Proximal Margin in Total Gastrectomy for Gastric Cancer: A Retrospective Study

Objective

To identify the minimum length of esophageal resection to ensure a pathologically negative proximal margin (PM) in total gastrectomy for gastric cancer.

Background

In total gastrectomy, a certain esophageal length is resected to obtain a pathologically negative PM because of the possibility of unexpected pathological esophageal invasion. However, a recommendation regarding the esophageal transection site in total gastrectomy has not been established.

Methods

The data of patients who underwent total gastrectomy for gastric cancer from 2005 to 2018 were collected. We evaluated the length of unexpected pathological esophageal invasion (esophageal ΔPM) in each type of disease and each location of the gross proximal tumor boundary (PB) using the length between the PB and the esophagogastric junction (PB-EGJ length).

Results

Of the 1005 patients eligible for this study, 277, 196, and 532 had cT1, cT2-4 expansive (Exp), and cT2-4 infiltrative (Inf) growth patterns, respectively. In cT1 and Exp, no unexpected pathological esophageal invasion occurred when the PB-EGJ length was >1 cm, whereas pathological esophageal invasion occurred in 20.0% of cT1 and 32.7% of Exp when the PB-EGJ length was ≤1 cm. The esophageal ΔPM was <1 cm. In Inf, no unexpected pathological esophageal invasion occurred when the PB-EGJ length was >3 cm, whereas pathological esophageal invasion occurred in 17.4% of patients when the PB-EGJ length was ≤3 cm. The esophageal ΔPM was <2 cm.

Conclusions

New recommendations regarding the esophageal resection length required to ensure a pathologically negative PM in total gastrectomy are herein proposed.

Feasibility and Short-Term Outcomes of Three-Dimensional Hand-Sewn Esophago-Jejunal Anastomosis in Completely Laparoscopic Total Gastrectomy for Cancer

Laparoscopic total gastrectomy is on the rise. One of the most technically demanding steps of the approach is the construction of esophago-jejunal anastomosis. Several laparoscopic anastomotic techniques have been described, like linear stapler side-to-side or circular stapler end-to-side anastomosis; limited data exist regarding hand-sewn esophago-jejunal anastomosis. The study took place between January 2018 and June 2021. Patients enrolled in this study were adults with proximal gastric or esophago-gastric junction Siewert type III tumors that underwent 3D-assisted laparoscopic total gastrectomy. A hand-sewn esophago-jejunal anastomosis was performed in all cases laparoscopically. Forty consecutive cases were performed during the study period. Median anastomotic suturing time was 55 min, with intra-operative methylene blue leak test being negative in all cases. Median operating time was 240 min, and there were no conversions to open. The anastomotic leak rate and postoperative stricture rate were zero. The 30- and 90-day mortality rates were zero. Laparoscopic manual esophago-jejunal anastomosis utilizing a 3D platform in total gastrectomy for cancer can be performed with excellent outcomes regarding anastomotic leak and stricture rate. This anastomotic approach, although technically challenging, is safe and reproducible, with prominent results that can be disseminated in the surgical community.

Morbidity and Mortality of Laparoscopic vs Open Total Gastrectomy for Clinical Stage I Gastric Cancer: The CLASS02 Multicenter Randomized Clinical Trial

Importance

The safety of laparoscopic total gastrectomy (LTG) for the treatment of gastric cancer remains uncertain given the lack of high-level clinical evidence.

Objective

To compare the safety of LTG for clinical stage I gastric cancer with that of conventional open total gastrectomy (OTG).

Design, Setting, and Participants

The Chinese Laparoscopic Gastrointestinal Surgery Study (CLASS) Group CLASS02 study was a prospective, multicenter, open-label, noninferiority, randomized clinical trial that compared the safety of LTG vs OTG with lymphadenectomy for patients with clinical stage I gastric cancer. From January 2017 to September 2018, a total of 227 patients were enrolled. Final follow-up was in October 2018.

Interventions

Eligible patients were randomized to LTG (n = 113) or OTG (n = 114) by an interactive web response system.

Main Outcomes and Measures

The primary outcome was the morbidity and mortality within 30 days following surgeries between LTG and OTG with a noninferiority margin of 10%. The secondary outcomes were recovery courses and postoperative hospital stays.

Results

A total of 214 patients were analyzed for morbidity and mortality (105 patients in the LTG group and 109 patients in the OTG group). The mean (SD) age was 59.8 (9.4) years in the LTG group and 59.4 (9.2) years in the OTG group, and most were male (LTG group, 75 of 105 [71.4%]; OTG group, 80 of 109 [73.4%]). The overall morbidity and mortality rates were not significantly different between the groups (rate difference, -1.1%; 95% CI, -11.8% to 9.6%). Intraoperative complications occurred in 3 patients (2.9%) in the LTG group and 4 patients (3.7%) in the OTG group (rate difference, -0.8%; 95% CI, -6.5% to 4.9%). In addition, there was no significant difference in the overall postoperative complication rate of 18.1% in the LTG group and 17.4% in the OTG group (rate difference, 0.7%; 95% CI, -9.6% to 11.0%). One patient in the LTG group died from intra-abdominal bleeding secondary to splenic artery hemorrhage. However, there was no significant difference in mortality between the LTG group and the OTG group (rate difference, 1.0%; 95% CI, -2.5% to 5.2%), and the distribution of complication severity was similar between the 2 groups.

Conclusions and Relevance

The results of the CLASS02 trial showed that the safety of LTG with lymphadenectomy by experienced surgeons for clinical stage I gastric cancer was comparable to that of OTG.

Trial Registration

ClinicalTrials.gov Identifier: NCT03007550.

[Reconstruction following gastrectomy]

Minimally invasive surgical techniques with respect to the treatment of gastric cancer have progressed rapidly over the last few years. Especially in Asia, where the incidence of gastric cancer is ten times higher than in Europe, surgery for gastric cancer is steadily evolving, especially regarding laparoscopic and robot-assisted procedures. This review first discusses the different options for reconstruction of the gastrointestinal passage after gastrectomy, ranging from Billroth procedures to the latest developments, such as the double tract reconstruction. In particular, the possibility of function-preserving partial gastrectomy, such as proximal and distal gastric resection and the corresponding reconstruction techniques are presented. The latest studies and technical developments are presented, especially with respect to laparoscopically assisted, completely laparoscopic and robot-assisted gastrectomies.

Is Laparoscopic Gastrectomy More Advantageous for Elderly Patients Than for Young Patients with Resectable Advanced Gastric Cancer?

BACKGROUND

Laparoscopic gastrectomy (LG) is now practiced widely, but it is unclear whether LG is the appropriate approach for elderly patients with resectable advanced gastric cancer. The aim of this study was to examine whether LG is more or less advantageous for elderly patients than for young patients.

METHODS

We collected data on 571 consecutive patients who underwent gastrectomy for pT2-4 gastric cancer between January 2001 and December 2015. After adjustment with one-to-one propensity score matching, short-term and long-term outcomes were compared between the LG and open gastrectomy (OG) groups among young (age < 70 years) and elderly (age ≥ 70 years) patients.

RESULTS

The LG group had a significantly longer operative time (P < 0.001) and less blood loss (P < 0.001) than the OG group among young and elderly patients. There were no significant differences regarding complications. Although disease-specific survival was similar between the LG and OG groups among young and elderly patients, LG was associated with more favorable overall survival than OG only among elderly patients (hazard ratio 0.67; 95% confidence interval 0.35-1.26). Death from respiratory diseases occurred more frequently in the OG group (10.9%) than in the LG group (0%) for elderly patients (P = 0.012).

CONCLUSION

LG for resectable advanced gastric cancer was not inferior to OG in terms of both short-term and long-term outcomes regardless of patient age. In elderly patients, LG may improve overall survival by reducing mortality from respiratory diseases.

Robotic Gastrectomy Compared with Laparoscopic Gastrectomy for Clinical Stage I/II Gastric Cancer Patients: A Propensity Score-Matched Analysis

BACKGROUND

Robotic gastrectomy (RG) has been developed to address the drawbacks of laparoscopic gastrectomy (LG); however, whether or not RG is superior to conventional LG remains to be seen. The present study aimed to clarify the impact of RG on clinical stage I/II gastric cancer patients.

METHODS

The present study included 1208 patients with clinical stage I/II gastric cancer who had minimally invasive gastrectomy from January 2012 to March 2020 at the Shizuoka Cancer Center. The short- and long-term outcomes of RG and LG were compared after propensity score matching.

RESULTS

This study involved 835 LG and 345 RG patients. After propensity score matching, there were 342 patients each in the RG and LG groups, with an improved balance of confounding factors between the two groups. RG was associated with a significantly longer operative time and lower amylase concentration in the drainage fluid on the first postoperative day than LG. Furthermore, the incidence of intra-abdominal infectious complications in the RG was lower than that in the LG (4.4% vs. 9.4%; P = 0.015). The survival of the RG and LG groups was equivalent.

CONCLUSIONS

RG reduced the risk of intra-abdominal infectious complications in comparison with LG in the propensity score-matched analysis. Patients treated by the two approaches showed equivalent survival.

Total Amylase Value in Drains After Gastrectomy for Predicting Postoperative Pancreatic Fistula

Objective

Postoperative pancreatic fistula (POPF) is defined using the ratio of the amylase concentration in abdominal drainage fluid to the upper normal range of serum amylase level. However, we hypothesized that the total amylase value in discharge (AVD) on postoperative day (POD) 3 may be more sensitive for predicting grade II or higher severe POPF (sPOPF) and compared the predictive power of the conventional definition of POPF and AVD for sPOPF.

Methods

One hundred fifty-one patients who underwent gastrectomy between October 2011 and February 2013 were analyzed. A drainage tube was placed in all the cases through the stump of the right gastroepiploic vein and the front of the pancreas to the back of the anastomotic site. The drainage volume and amylase concentration in the discharge were examined on POD 1, 3, and 5. AVD was calculated by multiplying the volume by the amylase concentration.

Results

Eight patients (5.3%) developed sPOPF. In univariate analysis, both AVD and the amylase concentration ratio was significantly correlated with sPOPF (P = 0.002 and 0.007, respectively). AVD on POD 3 showed the best predictive performance compared with the amylase concentration ratio on POD 3 (area under the curve 0.876 versus 0.844). Based on the cutoff values calculated from the receiver operating characteristic curves, AVD was more specific than amylase concentration ratio in predicting sPOPF (specificity: 97.6% versus 86.0%; positive predictive value: 62.5% vs. 23.1%).

Conclusion

AVD on POD 3 is a more specific parameter than conventional amylase concentration ratio in predicting sPOPF.

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.

Long-term outcomes of robotic gastrectomy for clinical stage I gastric cancer: a single-center prospective phase II study

INTRODUCTION

The outcomes of robotic gastrectomy (RG) for gastric cancer remain unclear due to a lack of prospective studies. We had previously designed and conducted a prospective phase II study of RG that showed favorable short-term outcomes. Herein, we aimed to determine the long-term outcomes of RG for clinical stage I gastric cancer.

PATIENTS AND METHODS

This single-center, prospective phase II study enrolled patients with clinical stage I gastric cancer undergoing RG. The survival outcomes, which were the secondary endpoints of the study, were evaluated.

RESULTS

Between December 2012 and April 2015, 120 patients were enrolled in this study. The 5-year overall survival (OS) was 96.7% (95% confidence interval [CI] 91.5-98.7%). The 5-year recurrence-free (RFS) and disease-specific survival (DSS) rates were 96.7% (95% CI 91.5-98.7%) and 99.2% (95% CI 94.3-99.9%), respectively. When confining the analysis to distal and pylorus-preserving gastrectomy, the 5-year OS, RFS, and DSS were 98.1% (95% CI 92.7-99.5%), 98.1% (95% CI 92.7-99.5%), and 100%, respectively. Only one patient died due to relapse of gastric cancer, while three died from other causes.

CONCLUSIONS

Long-term outcomes of RG was comparable to those of open and laparoscopic gastrectomy when the surgeries were performed by experienced surgeons in a high-volume center.

D1-plus vs D2 nodal dissection in gastric cancer: a propensity score matched comparison and review of published literature

Background

The results of D1-plus lymphadenectomy following gastric resection are seldom investigated. The aim of this study was to compare results of D1-plus vs D2 resections and to provide a literature review.

Methods

Patients who underwent upfront R0 gastrectomy for adenocarcinoma from 2000 to 2016 in three Institutions were selected using propensity scores and categorized according to lymphadenectomy. Statistical analyses were performed for the nodal harvest (LNH) and survival. Published literature comparing D1-plus and D2 was reviewed and analyzed according to PICO and PRISMA guidelines.

Results

Two matched groups of 93 D1-plus and 93 D2 resections were selected. LNH was significantly greater in D2 vs D1-plus dissections (mean 31.2 vs 27.2, p 0.04), however LNH distribution was similar. The cumulative incidence curves for overall survival, disease free and disease specific events did not report significant differences, however Cox regression analysis disclosed that total gastrectomies (HR 1.8; 95% 1.0–2.9), advanced stages (HR 5.9; 95% 3.4–10.3) and D1-plus nodal dissection (HR 2.1; 95% 1.26–3.50) independently correlated with disease free survival. Literature review including 297 D1-plus and 556 D2 lymphadenectomies documented LNH in favor of D2 sub-group (SMD -0.772; 95%CI -1.222- -0.322).

Conclusion

D2 provided greater LNH than D1-plus dissections; prospective studies should aim to investigate long-term survival of D1-plus lymphadenectomy.

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.

[Comparison of efficiency and safety of laparoscopic manual esophagoenterostomy and esophagoenterostomy with mechanical anastomotic devices after laparoscopic gastrectomy for stomach cancer]

OBJECTIVE

To compare laparoscopic manual esophagoenterostomy and esophagoenterostomy with mechanical stapling anastomotic devices after laparoscopic gastrectomy for stomach cancer.

MATERIAL AND METHODS

There were 34 patients who underwent laparoscopic gastrectomy for stomach in 2015-2018. Roux-en-Y esophagoenterostomy was used to reconstruct the gastrointestinal tract. Manual anastomoses were performed in 18 patients (group 1), stapled anastomoses (endogia 45 mm, covidien, mansfield, ma, usa) - in 16 patients (group 2). There was no randomization. Surgery duration, length of icu-stay, terms of enteral nutrition initiation, postoperative complications, hospital-stay were analyzed.

RESULTS

Mean duration of surgery in the first group was 217 (184-302) min, in the second group - 201 (162-311) min. Duration of surgery in the first group was 1.08-fold higher than in the second group (95% CI 1.03-1.13, p=0.05). Mean blood loss was 145 ml in both groups. Mean icu-stay was 20.2 (17-42) hours in the first group and 21.1 (16.2-46) hours in the second group (ratio 0.96, 95% CI 0.92-1.01, p=0.06). Total enteral feeding (sipping) was initiated on the third day in both groups. Mean postoperative hospital-stay was 9.21 (6-13) days in the first group and 9.23 (6-12 days) days in the second group (ratio 0.99, 95% CI 0,95-1.02, p=0.06). Postoperative morbidity was 5.5% in the first group and 6.25% in the second group.

CONCLUSION

Laparoscopic manual esophagoenterostomy proposed by our surgical team does not have disadvantages in comparison with stapling anastomotic devices and these methods may be alternative to each other.

A Novel Technique of Hand-Sewn Purse-String Suturing by Double Ligation Method (DLM) for Intracorporeal Circular Esophagojejunostomy

Purpose

The optimal method for intracorporeal esophagojejunostomy remains unclear because a purse-string suture for fixing the anvil into the esophagus is difficult to perform with a laparoscopic approach. Therefore, this study aimed to evaluate our novel technique to fix the anvil into the esophagus.

Materials and Methods

This retrospective study included 202 patients who were treated at our institution with an intracorporeal circular esophagojejunostomy in a laparoscopy-assisted total gastrectomy with a Roux-en-Y reconstruction (166 cases) or a laparoscopy-assisted proximal gastrectomy with jejunal interposition (36 cases). After incising 3/4 of the esophageal wall, a hand-sewn purse-string suture was placed on the esophagus. Next, the anvil head of a circular stapler was introduced into the esophagus. Finally, the circular esophagojejunostomy was performed laparoscopically. The clinical characteristics and surgical outcomes were evaluated and compared with those of other methods.

Results

The average operation time was 200.3 minutes. The average hand-sewn purse-string suturing time was 6.4 minutes. The overall incidence of postoperative complications (Clavien–Dindo classification grade ≥II) was 26%. The number of patients with an anastomotic leakage and stenosis at the esophagojejunostomy site were 4 (2.0%) and 12 (6.0%), respectively. All patients with stenosis were successfully treated by endoscopic balloon dilatation. There was no mortality. Regarding the materials and devices for anvil fixation, only 1 absorbable thread was needed.

Conclusions

Our procedure for hand-sewn purse-string suturing with the double ligation method is simple and safe.

Single-arm confirmatory trial of laparoscopy-assisted total or proximal gastrectomy with nodal dissection for clinical stage I gastric cancer: Japan Clinical Oncology Group study JCOG1401

BACKGROUNDS

Laparoscopy-assisted distal gastrectomy (LADG) for gastric cancer is safe and feasible. In contrast, no prospective study evaluating the safety and efficacy of laparoscopy-assisted total gastrectomy (LATG) or laparoscopy-assisted proximal gastrectomy (LAPG) has been completed. We conducted a single-arm confirmatory trial to evaluate the safety of LATG/LAPG for clinical stage I (T1N0/T1N1/T2N0) proximal gastric cancer.

METHODS

The extent of lymphadenectomy was selected based on the Japanese Gastric Cancer Treatment Guidelines. The mini-laparotomy incision was required to be ≤ 6 cm. The primary endpoint was the proportion of grade 2-4 (CTCAE ver. 4.0) esophagojejunal anastomotic leakage. The planned sample size was 245 considering a threshold of 8% and one-sided alpha of 2.5%.

RESULTS

Between April 2015 and February 2017, 244 eligible patients were enrolled. LATG/LAPG was performed in 195/49. The proportion of conversions was 1.7%. Clinical T1N0/T1N1/T2N0 was 212/9/23. The extents of lymphadenectomy were as follows: D1+: 229; D2: 15. The median operation time was 309 min (IQR 265-353). The median blood loss was 30 ml (IQR 10-86). Grade 2-4 esophagojejunal anastomotic leakage was 2.5% (6/244; 95% CI 0.9-5.3). The overall proportion of in-hospital grade 3-4 adverse events was 29% (71/244). The proportions of intraabdominal abscess and pancreatic fistula were 3.7% and 2.0%, respectively. There were no treatment-related deaths.

CONCLUSIONS

This trial confirmed the safety of LATG/LAPG. After the non-inferiority of LADG is confirmed in our phase III trial (JCOG0912), LATG/LAPG is expected to be established as one of the standard treatments for clinical stage I gastric cancer.

Clockwise, Modularized Lymphadenectomy in Laparoscopic Gastric Cancer Surgery: a New Laparoscopic Surgery Model

BACKGROUND

The aim of the study is to present the clockwise, modularized lymphadenectomy model of laparoscopic gastrectomy for gastric cancer patients, which is based on our clinical practice experience in laparoscopic gastric cancer surgery.

METHODS

From Jan 2015 to July 2017, 116 patients who underwent laparoscopic gastrectomy were retrospectively collected and analyzed. According to the different resection models, patients were divided into two groups: traditional laparoscopic lymphadenectomy group (63 patients) and clockwise, modularized lymphadenectomy group (53 patients). Operation-related parameters were compared between the two groups.

RESULTS

The clockwise, modularized lymphadenectomy group had less dissection time (119.8 ± 19.1 min vs. 135.3 ± 23.8 min, p < 0.001) and less intraoperative blood loss (81.7 ± 42.9 ml vs. 91.4 ± 28.7 ml, p = 0.016) compared with the traditional laparoscopic lymphadenectomy group. Meanwhile, the clockwise, modularized lymphadenectomy group had more numbers of examined lymph nodes (40.5 ± 14.3 vs. 33.9 ± 11.0, p = 0.007) than the traditional laparoscopic lymphadenectomy group. Besides, there was no statistically significant difference in the postoperative complication rates between the two groups. The clockwise, modularized lymphadenectomy group had shorter postoperative hospital stay than the traditional laparoscopic lymphadenectomy group (8.7 ± 3.2 days vs. 10.4 ± 3.9 days, respectively, p < 0.001).

CONCLUSIONS

Through the adoption of the fixed sequence of lymphadenectomy, requirements and standard of lymphadenectomy of each lymph node station, and specific surgical skills for intraoperative exposure by the clockwise and modularized lymphadenectomy model, we can optimize and facilitate the laparoscopic gastric cancer surgery.

Introducing laparoscopic total gastrectomy for gastric cancer in general practice: a retrospective cohort study based on a nationwide registry database in Japan

BACKGROUND

Although laparoscopic total gastrectomy (LTG) is considered a technically demanding procedure with safety issues, it has been performed in several hospitals in Japan. Data from a nationwide web-based data entry system for surgical procedures (NCD) that started enrollment in 2011 are now available for analysis.

METHODS

A retrospective cohort study was conducted using data from 32,144 patients who underwent total gastrectomy and were registered in the NCD database between January 2012 and December 2013. Mortality and morbidities were compared between patients who received LTG and those who underwent open total gastrectomy (OTG) in the propensity score-matched Stage I cohort and Stage II-IV cohort.

RESULTS

There was no significant difference in mortality rate between LTG and OTG in both cohorts. Operating time was significantly longer in LTG while the blood loss was smaller. In the Stage I cohort, LTG, performed in 33.6% of the patients, was associated with significantly shorter hospital stay but significantly higher incidence of readmission, reoperation, and anastomotic leakage (5.4% vs. 3.6%, p < 0.01). In the Stage II-IV cohort, LTG was performed in only 8.8% of the patients and was associated with significantly higher incidence of leakage (5.7% vs. 3.6%, p < 0.02) although the hospital stay was shorter (15 days vs. 17 days, p < 0.001).

CONCLUSION

LTG was more discreetly introduced than distal gastrectomy, but remained a technically demanding procedure as of 2013. This procedure should be performed only among the well-trained and informed laparoscopic team.

Stenosis after esophagojejunostomy with the hemi-double-stapling technique using the transorally inserted anvil (OrVil™) in Roux-en-Y reconstruction with its efferent loop located on the patient's left side following laparoscopic total gastrectomy

BACKGROUND

The drawback of intracorporeal esophagojejunostomy with the double-stapling technique (DST) using a transorally inserted anvil (OrVil™, Covidien, Mansfield, MA, USA) following laparoscopic total gastrectomy (LTG) is not only the high incidence of stenosis but also the presence of intractable stenosis that is refractory to endoscopic treatments.

METHODS

From November 2013 to December 2016, 24 patients with gastric cancer underwent intracorporeal circular-stapled esophagojejunostomy with the hemi-double-stapling technique (hemi-DST) using the OrVil™ in antecolic Roux-en-Y reconstruction with its efferent loop located on the left side of the patient following LTG to prevent twisting of the esophagojejunostomy and lifted jejunum, which might cause intractable stenosis of the esophagojejunostomy.

RESULTS

In this patient series, no twisting of the esophagojejunostomy and lifted jejunum was encountered intraoperatively or postoperatively. Two stenoses of the esophagojejunostomy occurred. Because neither was involved with twisting and both were localized at the anastomotic plane, endoscopic treatments including balloon dilation and electrocautery incisional therapy were successful in both cases. There were no patients with intractable stenosis in this series.

CONCLUSIONS

Intracorporeal esophagojejunostomy with the hemi-DST using the OrVil™ in antecolic Roux-en-Y reconstruction with its efferent loop located on the left side of the patient can be one option for a circular stapling technique in LTG due to its prevention of intractable stenosis of the esophagojejunostomy that is refractory to endoscopic treatments.

Esophagojejunostomy With Linear Staplers in Laparoscopic Total Gastrectomy: Experience With 168 Cases in 5 Consecutive Years

PURPOSE

We evaluate surgical outcomes of intracorporeal esophagojejunostomy in laparoscopic total gastrectomy using 2 linear stapler methods.

MATERIALS AND METHODS

The functional end-to-end anastomosis (FEEA) method was chosen as a first choice. The overlap method was chosen in cases with esophageal invasion. We retrospectively analyzed the early and late surgical outcomes of consecutive 168 laparoscopic total gastrectomy cases from April 2011 to December 2016.

RESULTS AND CONCLUSIONS

The FEEA method was selected in 120 cases, and the overlap method was selected in 48 cases. The mean time of esophagojejunostomy for the FEEA and overlap method was 13.2 and 36.5 minutes, respectively. Two cases with FEEA method and 3 cases with overlap method experienced complications due to esophagojejunostomy leakage. These cases were treated without performing a reoperation. One case with FEEA method was complicated due to esophagojejunostomy stenosis. This case was endoscopically treated. Our procedures are safe and feasible.

Clinical Outcomes of Esophagojejunostomy in Totally Laparoscopic Total Gastrectomy: A Multicenter Study

PURPOSE

To examine the short-term outcomes of intracorporeal anastomosis during totally laparoscopic total gastrectomy retrospectively at multiple institutions.

PATIENTS AND METHODS

We collected data of the patients who had undergone totally laparoscopic total gastrectomy at 4 institutions. All patients received an intracorporeal esophagojejunostomy.

RESULTS

Of the 215 patients evaluated, 147 underwent functional end-to-end anastomosis (FEEA) as the intracorporeal esophagojejunostomy (FEEA group), and 68 patients received a circular stapler anastomosis (Circular group). The rate of tumor invasion to the esophagus was significantly higher in the Circular group than in the FEEA group (33% vs. 6%, respectively; P<0.0001). Univariate and multivariate analyses revealed that the circular stapler anastomosis and high preoperative BMI were statistically significant risk factors for postoperative leakage. However, the rates of complications and mortality were not significantly different between groups.

CONSIDERATION

Our results showed that each type of esophagojejunostomy is safe and feasible for patients with gastric cancer with acceptable morbidity and mortality.

Short-term outcomes and nutritional status after laparoscopic subtotal gastrectomy with a very small remnant stomach for cStage I proximal gastric carcinoma

BACKGROUND

Total or proximal gastrectomy is usually performed for early proximal gastric carcinoma, but the optimal type of gastrectomy is still unknown. We evaluated short-term outcomes and nutritional status after laparoscopic subtotal gastrectomy (LsTG) in comparison with laparoscopic total gastrectomy (LTG) and laparoscopic proximal gastrectomy (LPG).

METHODS

We analyzed 113 patients who underwent LsTG (n = 38), LTG (n = 48), or LPG (n = 27) for cStage I gastric cancer located in the upper third of the stomach. Postoperative morbidities, nutritional status including body weight, serum albumin, hemoglobin, the prognostic nutritional index (PNI), and endoscopic findings at 1 year after surgery were compared between LsTG and both LTG and LPG.

RESULTS

Operation time and intraoperative blood loss were similar among the three groups. The incidence of postoperative morbidities was lower in LsTG than in LTG. The degree of body weight loss was significantly smaller in LsTG than in LTG at 6 and 12 months. At 12 months, LsTG resulted in better serum albumin and PNI than LPG, and better hemoglobin than LTG. Endoscopic examination demonstrated that one LsTG patient and two LPG patients had reflux esophagitis. Remnant gastritis was observed more frequently in LPG than in LsTG. No LsTG patient had bile reflux, although it was observed in four LPG patients.

CONCLUSIONS

LsTG with a very small remnant stomach had favorable short-term outcomes and nutritional status compared with LTG and LPG, so it may be a better treatment option for cStage I proximal gastric carcinoma.

Impact of Body Mass Index on the Quality of Life after Total Gastrectomy for Gastric Cancer

Purpose

We evaluated the impact of postoperative body mass index (BMI) shifts on the quality of life (QoL) following total gastrectomy in patients with gastric cancer.

Materials and Methods

QoL data collected from the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ)-C30 and QLQ-STO22 questionnaires were obtained from 417 patients preoperatively and 1 year after surgery. Patients were divided into two groups based on changes in BMI: group 1 comprised patientswhose BMIrange category dropped, and group 2 included patients who maintained or rose to a higher category compared to their preoperative BMI category.

Results

There were 276 patients in group 1 and 141 in group 2. QoLs with respect to the global health status and functional scales were not significantly different between the groups 1 year after surgery. However, there were significantly greater decreases in QoL in group 1 due to gastrointestinal symptoms, such as nausea and vomiting (p=0.008), appetite loss (p=0.001), and constipation (p=0.038). Of the QLQ-STO22 parameters, dysphagia (p=0.013), pain (p=0.012), reflux symptoms (p=0.017), eating restrictions (p=0.007), taste (p=0.009), and body image (p=0.009) were associated with significantly worse QoL in group 1 than in group 2 1 year after surgery.

Conclusion

Patients have significantly different QoLs depending on the BMI shift after total gastrectomy. Efforts to reduce the gap in QoL should include intensive nutritional support and restoration of dietary behaviors. Appropriate clinical and institutional approaches, plus active medical interventions, are required for maintaining patients' BMIs after surgery.

The Advances of Laparoscopic Gastrectomy for Gastric Cancer

Laparoscopic gastrectomy is evolving. With the increasing expertise and experience of oncologic surgeons in the minimally invasive surgery for gastric cancer, the indication for laparoscopic gastrectomy is expanding to advanced cases. Many studies have demonstrated the benefits of minimally invasive surgery, including reduced risk of surgery-related injury, reduced blood loss, less pain, and earlier recovery. In order to establish concrete evidence for the suitability of minimal invasive surgery for gastric cancer, many multicenter RCTs, comparing the short- and long-term outcomes of laparoscopic versus open surgery, are in progress. Advances in laparoscopic gastrectomy are moving toward increasingly minimally invasive approaches that enable the improvement of the quality of life of patients, without compromising on oncologic safety.

Linear-Stapled Side-to-Side Esophagojejunostomy with Hand-Sewn Closure of the Common Enterotomy After Prophylactic and Therapeutic Total Gastrectomy

After total gastrectomy, anastomosis-related complications such as leak or stricture can be highly morbid. Between July 2005 and December 2015, a linear-stapled side-to-side esophagojejunostomy with hand-sewn closure of the common enterotomy (modified Orringer technique) was used for Roux-en-Y reconstruction after prophylactic total gastrectomy in 22 germline CDH1 mutation carriers and after therapeutic total gastrectomy in 18 patients diagnosed with gastric adenocarcinoma. All operations were performed by the same surgeon. No patient in either cohort developed a clinically evident anastomotic leak, one patient (2.5%) developed a contained radiographic leak that healed without intervention, and one patient (2.5%) developed an anastomotic stricture treated by endoscopic dilatation 7 months after operation. These rates were lower than radiographic leak and stricture rates in a comparison group of 32 patients who received a completely hand-sewn esophagojejunostomy (6.3 and 3.1%, respectively). Here, we describe how to perform the linear-stapled esophagojejunostomy anastomosis.

Amylase concentration in drainage fluid as a predictive factor for severe postoperative pancreatic fistula in patients with gastric cancer

PURPOSE

Postoperative pancreatic fistula (PPF) sometimes occurs after gastrectomy. We examined the risk factors for severe PPF and evaluated the predictive value of amylase concentration in drainage fluid.

METHODS

We retrospectively reviewed 591 patients who underwent curative gastrectomy for gastric cancer. A multivariate analysis was conducted to identify the risk factors for severe PPF. Receiver operating characteristic curves were used to identify the appropriate amylase cut-off value to predict severe PPF.

RESULTS

Severe PPF occurred in 23 (3.9%) cases. The multivariate analysis indicated that splenectomy (P = 0.009) was the only significant risk factor. The area under the curve of amylase in drainage fluid for predicting severe PPF on postoperative day (POD) 3 was much greater than that on POD 1 (0.972 vs. 0.894). When the cut-off values for amylase were determined to be 2900 U/L on POD 1 and 2100 U/L on POD 3, the risk ratio for severe PPF on POD 3 was higher than that on POD 1 (99.2 vs. 30.2).

CONCLUSIONS

Splenectomy was an independent risk factor for severe PPF. An amylase level of 2100 U/L on POD 3 may be a reliable cut-off value for the early diagnosis of patients at high risk of severe PPF.

Safety and feasibility of laparoscopic gastrectomy for gastric cancer patients with a history of abdominal surgery

PURPOSE

To assess the safety and feasibility of laparoscopic gastrectomy (LG) for gastric cancer patients with a history of abdominal surgery (HAS).

METHODS

This retrospective study analyzed data collected from gastric cancer patients with HAS, who underwent LG between 2004 and 2015. We compared the clinicopathological features that correlated with conversion to open surgery and the development of severe postoperative complications (Clavien-Dindo classification of grade III or higher).

RESULTS

Of the 41 patients identified, 6 (14.6%) required conversion to open surgery. The incidence of conversion to open surgery was associated with a history of lower gastrointestinal tract surgery (p = 0.009), attempted laparoscopic total gastrectomy (p = 0.002), and excessive blood loss (p < 0.001). Severe postoperative complications developed in six patients (14.6%). Although the development of complications was associated with high postoperative serum C-reactive protein, the type of past abdominal surgery was not significantly correlated with severe complications.

CONCLUSIONS

LG was feasible for gastric cancer patients with a HAS, but for those with a history of lower abdominal surgery or those who require total gastrectomy, surgeons should carefully consider the indications for LG.

Feasibility and Safety of Laparoscopy-Assisted Subtotal Gastrectomy for Gastric Cancer Invading the Upper Stomach

This study evaluated the feasibility and safety of laparoscopy-assisted subtotal gastrectomy preserving a minimal remnant stomach for clinical T1 gastric cancer invading the upper stomach. Forty-three consecutive patients who underwent laparoscopy-assisted subtotal gastrectomy preserving a minimal remnant stomach were examined. In addition to the conventional laparoscopy-assisted distal gastrectomy, some short and posterior gastric arteries were resected. A minimal remnant stomach-jejunum anastomosis was made by using a circular stapler with regular anvil or transoral anvil. Transoral anvil was selected in 19 patients, and regular anvil was used in 24 patients. The median operation time was 288 minutes, and the median blood loss was 50 mL. Conversion to open surgery was required in 2 patients due to bleeding. No patient required conversion to open surgery due to the difficulty of the anastomosis. Nine patients developed postoperative complications, including grade 3 duodenal stump leakage in 1 patient and grade 2 anastomotic bleeding in another patient. No mortality was observed. Laparoscopy-assisted subtotal gastrectomy preserving a minimal remnant stomach is safe and feasible for early gastric cancer invading the upper stomach.

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

BACKGROUND

Surgical site infection (SSI), particularly organ/space SSI, remains a clinically important issue even after laparoscopic gastrectomy (LG) for gastric cancer (GC). This study aimed to identify specific clinical and surgical factors associated with organ/space SSI after LG.

METHODS

This was a retrospective study of 407 patients who underwent LG for clinical stage I GC. SSI was defined according to the National Nosocomial Infection Surveillance System. The incidence and treatment outcomes of either incisional or organ/space SSI after LG were examined, and the risk factors for each type of SSI were identified using univariate and multivariate analyses.

RESULTS

Organ/space SSI was observed in 21 patients (5.2 %), while incisional SSI was detected in 18 patients (4.4 %). Although no mortality was observed, the occurrence of either incisional or organ/space SSI significantly prolonged postoperative hospital stays (p = 0.000 and 0.000, respectively); however, organ/space SSI required more re-operations and re-admissions, and eventually longer total hospital stays than incisional SSI (p = 0.036). Intra-abdominal abscess around the pancreas was the main cause of organ/space SSI, while no anastomotic leakage was observed. Multivariate analyses identified male gender (odds ratio (OR) 3.385; 95 % confidence interval (CI) 1.073-15.07, p = 0.037), chronic liver disease (OR 8.897; 95 % CI 2.502-28.99, p = 0.001), and total gastrectomy (TG) (OR 3.817; 95 % CI 1.380-10.24, p = 0.011) as independent risk factors for organ/space SSI, while TG (OR 3.130; 95 % CI 1.102-8.768, p = 0.033) and operation time ≥320 min (OR 3.732; 95 % CI 1.109-16.98, p = 0.033) were independently associated with incisional SSI.

CONCLUSIONS

Male gender, chronic liver disease, and TG are independent risk factors for organ/space SSI after LG for GC; thus, meticulous surgical procedures need to be performed among patients with these specific risk factors.

The effects of laparoscopic spleen-preserving splenic hilar lymphadenectomy on the surgical outcome of proximal gastric cancer: a propensity score-matched, case-control study

BACKGROUND

The evidence regarding the long-term results of laparoscopic spleen-preserving splenic hilar lymphadenectomy (LSPL) has only been rarely reported. The aim of this study was to investigate the feasibility and oncologic efficacy of LSPL for locally advanced proximal gastric cancer.

METHODS

From May 2007 to December 2012, we prospectively collected and retrospectively analyzed the data of 548 patients who underwent laparoscopic radical total gastrectomy due to proximal gastric cancer. The patients were grouped according to spleen-preserving splenic hilar lymphadenectomy (200 in the D2 group and 348 in the D2-group). The short- and long-term outcomes were compared between the two groups after propensity score matching.

RESULTS

Before matching, TNM stages were significantly different between the D2 and D2-groups. After propensity score matching, the two groups were well balanced in clinicopathologic characteristics. After matching, the time for lymph node dissection was longer in the D2 group, but a greater number of lymph nodes were dissected; the estimated blood loss, time to first flatus and duration of hospital stay were similar in the two groups. Furthermore, no significant differences in morbidity and mortality were found. Before matching, the 3-year overall survival (OS) and disease-free survival (DFS) rates of the D2 group were comparable with those of the D2-group (62.4 vs. 57.7 %, p = 0.076). After matching, the 3-year OS remained comparable, but the D2 group showed significantly longer 3-year DFS (61.6 vs. 53.7 %, p = 0.034). Stratified analysis showed that, in stage III patients, the D2 group had better 3-year DFS. Multivariate Cox regression showed that age (p = 0.003), operation (p = 0.001) and pN stage (p < 0.001) were independent prognostic factors.

CONCLUSIONS

LSPL is a safe and feasible procedure, and patients with stage III proximal gastric cancer might obtain higher 3-year DFS rates.

Non-Randomized Confirmatory Trial of Laparoscopy-Assisted Total Gastrectomy and Proximal Gastrectomy with Nodal Dissection for Clinical Stage I Gastric Cancer: Japan Clinical Oncology Group Study JCOG1401

Several prospective studies on laparoscopy-assisted distal gastrectomy for early gastric cancer have been initiated, but no prospective study evaluating laparoscopy-assisted total gastrectomy or laparoscopy-assisted proximal gastrectomy has been completed to date. A non-randomized confirmatory trial was commenced in April 2015 to evaluate the safety of laparoscopy-assisted total gastrectomy and laparoscopy-assisted proximal gastrectomy for clinical stage I gastric cancer. A total of 245 patients will be accrued from 42 Japanese institutions over 3 years. The primary endpoint is the proportion of patients with anastomotic leakage. The secondary endpoints are overall survival, relapse-free survival, proportion of patients with completed laparoscopy-assisted total gastrectomy or laparoscopy-assisted proximal gastrectomy, proportion of patients with conversion to open surgery, adverse events, and short-term clinical outcomes. The UMIN Clinical Trials Registry number is UMIN000017155.

Functional Advantages of Proximal Gastrectomy with Jejunal Interposition Over Total Gastrectomy with Roux-en-Y Esophagojejunostomy for Early Gastric Cancer

BACKGROUND

The postoperative functional advantages of a proximal gastrectomy over a total gastrectomy remain debatable. The aim of this study was to evaluate the functional outcomes of a proximal gastrectomy with jejunal interposition (PG-JI), compared with those for a total gastrectomy with Roux-en-Y esophagojejunostomy (TG-RY), in patients with early gastric cancer.

METHODS

Between 2007 and 2012, 65 patients underwent PG-JI and 117 underwent TG-RY for cT1 gastric cancer. Various parameters, including body weight, serum hemoglobin level, and interview-based symptoms, were prospectively evaluated in these patients. In patients who underwent PG-JI, the postoperative endoscopic findings were also assessed.

RESULTS

All the surgeries were performed via a laparotomy alone. During a median postoperative follow-up of 42 months (range, 12-78 months), PG-JI offered significant reductions in body weight loss (12.5 ± 5.8 vs. 17.4 ± 6.4 %, P < 0.001), serum hemoglobin decline (7.0 ± 5.7 vs. 9.7 ± 5.4 %, P = 0.002), and dumping symptoms (11 % [7/65] vs. 30 % [35/117], P = 0.003), while being associated with similar incidences of anastomotic stricture (9 % [6/65] vs. 8 % [9/117], P = 0.781), small bowel obstruction (0 % [0/65] vs. 2 % [2/117], P = 0.538), stasis symptoms (51 % [33/65] vs. 44 % [51/117], P = 0.358), and reflux symptoms (34 % [22/65] vs. 23 % [27/117], P = 0.121), compared with TG-RY. Four cases of gastric remnant cancer and no cases of endoscopic reflux esophagitis were found after PG-JI.

CONCLUSIONS

PG-JI has clear functional advantages over TG-RY, although it requires active surveillance for remnant gastric cancer.

Intracorporeal esophagojejunostomy after totally laparoscopic total gastrectomy: A single-center 7-year experience

AIM: To assess the efficacy and safety of intracorporeal esophagojejunostomy in patients undergoing laparoscopic total gastrectomy (LTG) for gastric cancer.

METHODS: A retrospective review of 81 consecutive patients who underwent LTG with the same surgical team between November 2007 and July 2014 was performed. Four types of intracorporeal esophagojejunostomy using staplers or hand-sewn suturing were performed after LTG. Data on clinicopatholgoical characteristics, occurrence of complications, postoperative recovery, anastomotic time, and operation time among the surgical groups were obtained through medical records.

RESULTS: The average operation time was 288.7 min, the average anastomotic time was 54.3 min, and the average estimated blood loss was 82.7 mL. There were no cases of conversion to open surgery. The first flatus was observed around 3.7 d, while the liquid diet was started, on average, from 4.9 d. The average postoperative hospital stay was 10.1 d. Postoperative complications occurred in 14 patients, nearly 17.3%. However, there were no cases of postoperative death.

CONCLUSION: LTG performed with intracorporeal esophagojejunostomy using laparoscopic staplers or hand-sewn suturing is feasible and safe. The surgical results were acceptable from the perspective of minimal invasiveness.

Short-Term Outcomes of Laparoscopic Total Gastrectomy Performed by a Single Surgeon Experienced in Open Gastrectomy: Review of Initial Experience

Purpose

Laparoscopic total gastrectomy (LTG) is more complicated than laparoscopic distal gastrectomy, especially during a surgeon's initial experience with the technique. In this study, we evaluated the short-term outcomes of and learning curve for LTG during the initial cases of a single surgeon compared with those of open total gastrectomy (OTG).

Materials and Methods

Between 2009 and 2013, 134 OTG and 74 LTG procedures were performed by a single surgeon who was experienced with OTG but new to performing LTG. Clinical characteristics, operative parameters, and short-term postoperative outcomes were compared between groups.

Results

Advanced gastric cancer and D2 lymph node dissection were more common in the OTG than LTG group. Although the operation time was significantly longer for LTG than for OTG (175.7±43.1 minutes vs. 217.5±63.4 minutes), LTG seems to be slightly superior or similar to OTG in terms of postoperative recovery measures. The operation time moving average of 15 cases in the LTG group decreased gradually, and the curve flattened at 54 cases. The postoperative complication rate was similar for the two groups (11.9% vs. 13.5%). No anastomotic or stump leaks occurred.

Conclusions

Although LTG is technically difficult and operation time is longer for surgeons experienced in open surgery, it can be performed safely, even during a surgeon's early experience with the technique. Considering the benefits of minimally invasive surgery, LTG is recommended for early gastric cancer.

Comparison of outcomes after laparoscopy-assisted and open total gastrectomy for early gastric cancer

BACKGROUND

The aim of this study was to compare the results of laparoscopy-assisted total gastrectomy with those of open total gastrectomy for early gastric cancer.

METHODS

Patients with gastric cancer who underwent total gastrectomy with curative intent in three Korean tertiary hospitals between January 2003 and December 2010 were included in this multicentre, retrospective, propensity score-matched cohort study. Cox proportional hazards regression models were used to evaluate the association between operation method and survival.

RESULTS

A total of 753 patients with early gastric cancer were included in the study. There were no significant differences in the matched cohort for overall survival (hazard ratio (HR) for laparoscopy-assisted versus open total gastrectomy 0.96, 95 per cent c.i. 0.57 to 1.65) or recurrence-free survival (HR 2.20, 0.51 to 9.52). The patterns of recurrence were no different between the two groups. The severity of complications, according to the Clavien-Dindo classification, was similar in both groups. The most common complications were anastomosis-related in the laparoscopy-assisted group (8.0 per cent versus 4.2 per cent in the open group; P = 0.015) and wound-related in the open group (1.6 versus 5.6 per cent respectively; P = 0.003). Postoperative death was more common in the laparoscopy-assisted group (1.6 versus 0.2 per cent; P = 0.045).

CONCLUSION

Laparoscopy-assisted total gastrectomy for early gastric cancer is feasible in terms of long-term results, including survival and recurrence. However, a higher postoperative mortality rate and an increased risk of anastomotic leakage after laparoscopic-assisted total gastrectomy are of concern.

A systematic review of laparoscopic total gastrectomy for gastric cancer

BACKGROUND

Laparoscopic total gastrectomy (LTG) has been performed since 1999. Although surgical outcomes have been reported from Japan, Korea, China, and many Western countries, the effectiveness of this technique has not been conclusively established. This study therefore aimed to review the literature systematically.

METHODS

Our search of the research literature identified 150 studies, which were mostly retrospective and from single institutions.

RESULTS

There has recently been a remarkable increase in the number of studies from Korea, and the number of patients included in studies has increased since 2009. In most studies, the surgical procedures were longer, blood loss was reduced, and the number of retrieved lymph nodes was the same in the LTG group as in the open total gastrectomy group. The incidence of postoperative complications and that of inflammation during postoperative recovery were the same in these two groups.

CONCLUSIONS

During LTG, the method used for esophagojejunostomy is important for surgical reliability and to reduce postoperative complications. There has been rapid development of new techniques from the level of esophagojejunostomy through a small skin incision to the high level of intracorporeal esophagojejunostomy using various techniques. A nationwide prospective phase II study is urgently needed to establish the value of LTG.

Comparison of the major postoperative complications between laparoscopic distal and total gastrectomies for gastric cancer using Clavien-Dindo classification

BACKGROUND

Laparoscopy-assisted total gastrectomy (LATG) has not been as popular as laparoscopy-assisted distal gastrectomy (LADG) because of its undetermined safety and postoperative complications compared with LADG. Therefore, LATG requires further study.

PATIENTS AND METHODS

A total of 663 patients who underwent LADG or LATG for gastric cancer in a single institution from April 2004 to April 2014 were included. The clinicopathologic characteristics and risk factors related to major complications (Clavien-Dindo grade ≥ IIIa) were analyzed between the LADG (n = 569) and LATG groups (n = 94).

RESULTS

The incidence of major postoperative complications was significantly higher for LATG (LADG vs. LATG: 8.1 vs. 18.1 %, P = 0.002). Although postoperative bleeding was not different between the groups (3.2 vs. 3.2 %, P = 0.991), the incidence of bowel leakage was significantly higher for LATG (2.6 vs. 6.8 %, P = 0.028). Leakage from the anastomosis site was more frequent following LATG (5.3 %) compared with LADG (0.5 %) (P < 0.001). Leakage from the duodenal stump tended to be more frequent, though not significant, for LADG (2.0 vs. 1.1 %, P = 0.602). Advanced gastric cancer, LATG, and longer operation time were significant factors that affected the incidence of postoperative complications in a univariate analysis. In multivariate analysis, there were no independent risk factors, but LATG was nearly a significant, independent risk factor (odds ratio 1.89; 95 % CI 0.965-3.71, P = 0.063).

CONCLUSION

More major complications were observed for LATG, particularly with esophagojejunostomy. These results show that LATG is more invasive than LADG in terms of the postoperative morbidity. More caution and experience are needed when performing LATG.

The overlap method is a safe and feasible for esophagojejunostomy after laparoscopic-assisted total gastrectomy

Background

Laparoscopic procedures are increasingly being applied to gastric cancer surgery, including total gastrectomy for tumors located in the upper gastric body. Even for expert surgeons, esophagojejunostomy after laparoscopy-assisted total gastrectomy (LATG) can be technically challenging. We perform the overlap method of esophagojejunostomy after LATG for gastric cancer. However, technical questions remain. Is the overlap method safer and more useful than other anastomosis techniques, such as methods using a circular stapler? In addition, while we perform this overlap reconstruction after LATG in a deep and narrow operative field, can the overlap method be performed safely regardless of body habitus? This study aimed to evaluate these issues retrospectively and to review the literature.

Methods

From October 2005 to August 2013, we performed LATG with lymph-node dissection and Roux-en-Y reconstruction using the overlap method in 77 patients with gastric cancer. This study examined pre-, intra- and postoperative data.

Results

Mean operation time, time to perform anastomosis, and estimated blood loss were 391.4 min, 36.3 min, and 146.9 ml, respectively. There were no deaths, and morbidity rate was 13%, including one patient (1%) who developed anastomotic stenosis. Mean postoperative hospitalization was 13.4 days. Surgical outcomes did not differ significantly by body mass index.

Conclusions

First, the overlap method for esophagojejunostomy after LATG is safe and useful. Second, this method can be performed irrespective of the body type of the patient. In particular, in a deep and narrow operative field, the overlap method is more versatile than other anastomosis methods. We believe that the overlap method can become a standard reconstruction technique for esophagojejunostomy after LATG.

Totally laparoscopic total gastrectomy for gastric cancer: literature review and comparison of the procedure of esophagojejunostomy

There has been a recent increase in the use of totally laparoscopic total gastrectomy (TLTG) for gastric cancer. However, there is no scientific evidence to determine which esophagojejunostomy (EJS) technique is the best. In addition, both short- and long-term oncological results of TLTG are inconsistent. We reviewed 25 articles about TLTG for gastric cancer in which at least 10 cases were included. We analyzed the short-term results, relationships between EJS techniques and complications, long-term oncological results, and comparative study results of TLTG. TLTG was performed in a total of 1170 patients. The mortality rate was 0.7%, and the short-term results were satisfactory. Regarding EJS techniques and complications, circular staplers (CSs) methods were significantly associated with leakage (4.7% vs. 1.1%, p < 0.001) and stenosis (8.3% vs. 1.8%, p < 0.001) of the EJS as compared with the linear stapler method. The long-term oncological prognosis was acceptable in patients with early gastric cancers and without metastases to lymph nodes. Although TLTG tended to increase surgical time compared with open total gastrectomy and laparoscopy-assisted total gastrectomy, it reduced intraoperative blood loss and was expected to shorten postoperative hospital stay. TLTG is found to be safer and more feasible than open total gastrectomy and laparoscopy-assisted total gastrectomy. At present, there is no evidence to encourage performing TLTG for patients with advanced gastric cancer from the viewpoint of long-term oncological prognosis. Although the current major EJS techniques are CS and linear stapler methods, in this review, CS methods are significantly associated with leakage and stenosis of the EJS.

Novel method for esophagojejunal anastomosis after laparoscopic total gastrectomy: Semi-end-to-end anastomosis

AIM: To test a new safe and simple technique for circular-stapled esophagojejunostomy in laparoscopic total gastrectomy (LATG).

METHODS: We selected 26 patients with gastric cancer who underwent LATG and Roux-en-Y gastrointestinal reconstruction with semi-end-to-end esophagojejunal anastomosis.

RESULTS: LATG with semi-end-to-end esophagojejunal anastomosis was successfully performed in all 26 patients. The average operation time was 257 ± 36 min, with an average anastomosis time of 51 ± 17 min and an average intraoperative blood loss of 88 ± 46 mL. The average postoperative hospital stay was 8 ± 3 d. There were no complications and no mortality in this series.

CONCLUSION: The application of semi-end-to-end esophagojejunal anastomosis after LATG is a safe and feasible procedure, which can be easily performed and has a short operation time in terms of anastomosis.

Is laparoscopic total gastrectomy a safe operation? A review of various anastomotic techniques and their outcomes

Laparoscopic distal gastrectomy is an accepted option for gastric cancer surgery; however, laparoscopic total gastrectomy (LTG) is not widely performed. There is concern about the safety of the operation due to the difficulty of extracorporeal reconstruction through a mini-laparotomy. Efforts have been made to establish an intracorporeal anastomotic technique for esophagojejunostomy. This article reviews the current techniques available for laparoscopic esophagojejunostomy and their surgical outcomes. Several different techniques using either circular or linear staplers have been reported; however, the apparent superiority of any particular method has not been confirmed. The incidence of anastomosis-related complications varied among studies, but different techniques all successfully achieved excellent outcomes. The overall complication rate of LTG was similar to that of open total gastrectomy, suggesting that LTG is a safe and feasible option. However, the feasibility of LTG with D2 lymph node dissection for advanced upper gastric cancer needs to be confirmed in further studies, because most of the patients included in the LTG studies were diagnosed with early stages of disease.

Evaluation of the safety and efficacy of esophagojejunostomy after totally laparoscopic total gastrectomy using a trans-orally inserted anvil: a single-center comparative study

BACKGROUND

Although laparoscopic surgery is frequently performed for the treatment of gastric cancer, laparoscopic total gastrectomy is not widely performed because of its technical difficulty. Since December 2007 we have performed esophagojejunostomy after totally laparoscopic total gastrectomy (TLTG) in more than 110 cases in our institution by using a circular stapler with a trans-orally inserted anvil. We performed a single-center comparative study to evaluate the safety and efficacy of esophagojejunostomy using a trans-orally inserted anvil in patients who underwent TLTG for the treatment of gastric cancer.

METHODS

In the present study, we examined 329 patients with gastric cancer who underwent esophagojejunostomy using a circular stapler after total gastrectomy. Data on the clinicopathological features, operative time, amount of intraoperative blood loss, and incidence of anastomosis-related complications among the surgical groups were obtained by reviewing the medical records, which were then analyzed.

RESULTS

Approximately 67% of the patients were men, and the average patient age was 64.0 years (range 26-93 years). In addition, 166 (50.5%) and 163 (49.5%) patients underwent open and laparoscopic surgery, respectively. Leakage following esophagojejunostomy was noted in 7 (4.2%) of 166 patients who underwent total gastrectomy with open laparotomy, and 0 of 46 patients who underwent laparoscopic-assisted total gastrectomy (LATG). However, only 2 (1.7%) of 117 patients who underwent TLTG using a trans-orally inserted anvil exhibited leakage following esophagojejunostomy. Anastomotic stenosis of the esophagojejunostomy was observed in 5 (3.0%) of 166 patients who underwent total gastrectomy with open laparotomy, 2 (4.3%) of 46 patients who underwent LATG, and 2 (1.7%) of 117 patients who underwent TLTG using a trans-orally inserted anvil.

CONCLUSIONS

We believe that esophagojejunostomy using a trans-orally inserted anvil after TLTG for gastric cancer is a safe and useful surgical procedure.

Systematic review and meta-analysis of laparoscopy-assisted and open total gastrectomy for gastric cancer

AIM: To evaluate the safety and efficacy of laparoscopy-assisted total gastrectomy (LATG) and open total gastrectomy (OTG) for gastric cancer.

METHODS: A comprehensive search of PubMed, Cochrane Library, Web of Science and BIOSIS Previews was performed to identify studies that compared LATG and OTG. The following factors were checked: operating time, blood loss, harvested lymph nodes, flatus time, hospital stay, mortality and morbidity. Data synthesis and statistical analysis were carried out using RevMan 5.1 software.

RESULTS: Nine studies with 1221 participants were included (436 LATG and 785 OTG). Compared to OTG, LATG involved a longer operating time [weighted mean difference (WMD) = 57.68 min, 95%CI: 30.48-84.88; P < 0.001]; less blood loss [standard mean difference (SMD) = -1.71; 95%CI: -2.48 - -0.49; P < 0.001]; earlier time to flatus (WMD= -0.76 d; 95%CI: -1.22 - -0.30; P < 0.001); shorter hospital stay (WMD = -2.67 d; 95%CI: -3.96 - -1.38, P < 0.001); and a decrease in medical complications (RR = 0.41, 95%CI: 0.19-0.90, P = 0.03). The number of harvested lymph nodes, mortality, surgical complications, cancer recurrence rate and long-term survival rate of patients undergoing LATG were similar to those in patients undergoing OTG.

CONCLUSION: Despite a longer operation, LATG can be performed safely in experienced surgical centers with a shorter hospital stay and fewer complications than open surgery.