Techniques and complications of laparoscopy-assisted distal gastrectomy (LADG) for gastric cancer

Impact of Age and Comorbidity on the Short-Term Surgical Outcome after Laparoscopy-Assisted Distal Gastrectomy for Adenocarcinoma

The aim of this study was to determine whether age and comorbidity are valuable risk factors of the short-term surgical outcome after laparoscopy-assisted distal gastrectomy (LADG) in patients with adenocarcinoma. A series of 387 patients who underwent LADG at three university hospitals between March 2006 and December 2010 were retrospectively studied. To compare the short-term surgical outcomes of LADG of elderly patients with those of younger patients, patients were categorized into an elderly group (older than 70 years of age) and a younger group (70 years of age or younger). For another comparative analysis to identify risk factors of postoperative complications after LADG, patients were categorized into two groups: those with complications and those without complications. With the exception of sex ratio and comorbidity rate, two age groups were nonsignificantly different in terms of demographic, operative, pathologic, and short-term surgical outcome data. Our data support the safety and feasibility of LADG in elderly patients. However, our data show that comorbidity is an important predictor of postoperative systemic complications after LADG. Patients with an age-adjusted Charlson comorbidity index (CCI) of 3 or greater were found to be at a greater risk of developing systemic complications, which suggests that age-adjusted CCI is a useful predictor of systemic complications after LADG and that it could be used routinely for the perioperative care of aged patients with comorbidity. We recommend age-adjusted CCI be used in comparative clinical research studies on the surgical outcomes across surgeons and hospitals.

Assessing safety and feasibility of 'pure' laparoscopic total gastrectomy for advanced gastric cancer in the West. Review article

BACKGROUND

Gastric cancer is reported to be the fourth most common cancer and the second leading cause of cancer-related death worldwide. Minimally invasive surgical treatment for gastric cancer is a very challenging approach which offers undoubtedly important advantages.

MATERIALS AND METHODS

There is intense debate concerning the minimally invasive surgical approach for advanced gastric cancer especially in the Western population. A careful literature search was conducted in order to clarify the feasibility and safety of pure laparoscopic total gastrectomy in the West.

RESULTS

Herewith we aim to summarize the current scientific evidence assessing the feasibility and short-term outcomes of laparoscopic gastrectomy for advanced gastric cancer in the West. A lack of data from Western institutions regarding minimally invasive surgical approach for gastric cancer is yet a reality. Nevertheless, the laparoscopic procedure appears to provide satisfactory short-term oncologic outcomes and improved postoperative outcomes.

CONCLUSION

It is obvious that future well-conducted trials on long-term results are necessary for Western patients in order safe conclusions to be reached regarding a potential definitive 'place' for laparoscopy in the curative gastric cancer treatment.

Laparoscopic Reinforcement Suture (LARS) on Staple Line of Duodenal Stump Using Barbed Suture in Laparoscopic Gastrectomy for Gastric Cancer: a Prospective Single Arm Phase II Study

Purpose

Laparoscopic gastrectomy is accepted as a standard treatment for patients with early gastric cancer in Korea, Japan, and China. However, duodenal stump leakage remains a fatal complication after gastrectomy. We conducted a prospective phase II study to evaluate the safety of the new technique of laparoscopic reinforcement suture (LARS) on the duodenal stump.

Materials and Methods

The estimated number of patients required for this study was 100 for a period of 18 months. Inclusion criteria were histologically proven gastric adenocarcinoma treated with laparoscopic distal or total gastrectomy and Billroth II or Roux-en-Y reconstruction. The primary endpoint was the incidence of duodenal stump leakage within the first 30 postoperative days. The secondary endpoints were early postoperative outcomes until discharge.

Results

One hundred patients were enrolled between February 2016 and March 2017. The study groups consisted of 65 male and 35 female patients with a mean age (years) of 62.3. Of these, 63 (63%) patients had comorbidities. The mean number of retrieved lymph nodes was 38. The mean operation time was 145 minutes including 7.8 minutes of mean LARS time. There was no occurrence of duodenal stump leakage. Thirteen complications occurred, with one case of reoperation for splenic artery rupture and one case of mortality.

Conclusions

Based on the results of this prospective phase II study, LARS can be safely performed in a short operation period without development of duodenal stump leakage. A future randomized prospective controlled trial is required to confirm the surgical benefit of LARS compared to non-LARS.

Laparoscopic reinforcement suture on staple-line of duodenal stump using barbed suture during laparoscopic gastrectomy for gastric cancer

Purpose

Duodenal stump fistula (DSF) is a serious complication after gastrectomy for gastric cancer. Although risk evaluation and management of DSF were presented by some investigators, there was no technical attempt has been made to prevent DSF during laparoscopic gastrectomy until now.

Methods

Consecutive 99 patients were enrolled from April 2014 to February 2016 in 2 institutes. All patients were performed laparoscopic gastrectomy for gastric cancer. After cutting of duodenal stump, laparoscopic reinforcement suture (LARS) commenced with continuous invagination method or interrupted method by barbed suture. Clinicopathologic features and postoperative outcomes were analyzed.

Results

Fifty-six patients had comorbidity including 5 patients with duodenal ulcer. Most patients were performed distal gastrectomy with B-II, and 10 patients total gastrectomy with Roux en Y esophagojejunostomy. Although there were 2 esophagojejunostomy leakage and 1 artificial lesser curvature leakage, DSF did not occurred at all in this study. Mean operation time was 3 hours and mean LARS procedure time was 8 minutes.

Conclusion

LARS of duodenal stump can be considered as one of prevention methods of DSF during laparoscopic gastrectomy for gastric cancer. So this new technique will be necessary to appropriately evaluate by prospective randomized controlled trial in the future.

Real-time Vessel Navigation Using Indocyanine Green Fluorescence during Robotic or Laparoscopic Gastrectomy for Gastric Cancer

Purpose

Identification of the infrapyloric artery (IPA) type is a key component of pylorus-preserving gastrectomy. As the indocyanine green (ICG) fluorescence technique is known to help visualize blood vessels and flow during reconstruction, we speculated that this emerging technique would be helpful in identifying the IPA type.

Materials and Methods

From August 2015 to February 2016, 20 patients who underwent robotic or laparoscopic gastrectomy were prospectively enrolled. After intravenous injection of approximately 3 mL of ICG (2.5 mg/mL), a near-infrared fluorescence apparatus was applied. The identified shape of the IPA was confirmed by examining the actual anatomy following infrapyloric dissection.

Results

The mean interval time between ICG injection and visualization of the artery was 22.2 seconds (range, 14–30 seconds), and the mean duration of the arterial phase was 16.1 seconds (range, 9–30 seconds). The overall positive predictive value (PPV) of ICG fluorescence in identifying the IPA type was 80% (16/20). The IPA type was incorrectly predicted in four patients, all of whom were obese with a body mass index (BMI) of more than 25 kg/m².

Conclusions

Our preliminary results indicate that intraoperative vascular imaging using the ICG fluorescence technique may be helpful for robotic or laparoscopic pylorus-preserving gastrectomy.

Robot-assisted laparoscopic gastrectomy for gastric cancer

Phase III evidence in the shape of a series of randomized controlled trials and meta-analyses has shown that laparoscopic gastrectomy is safe and gives better short-term results with respect to the traditional open technique for early-stage gastric cancer. In fact, in the East laparoscopic gastrectomy has become routine for early-stage gastric cancer. In contrast, the treatment of advanced gastric cancer through a minimally invasive way is still a debated issue, mostly due to worries about its oncological efficacy and the difficulty of carrying out an extended lymphadenectomy and intestinal reconstruction after total gastrectomy laparoscopically. Over the last ten years the introduction of robotic surgery has implied overcoming some intrinsic drawbacks found to be present in the conventional laparoscopic procedure. Robot-assisted gastrectomy with D2 lymphadenectomy has been shown to be safe and feasible for the treatment of gastric cancer patients. But unfortunately, most available studies investigating the robotic gastrectomy for gastric cancer compared to laparoscopic and open technique are so far retrospective and there have not been phase III trials. In the present review we looked at scientific evidence available today regarding the new high-tech surgical robotic approach, and we attempted to bring to light the real advantages of robot-assisted gastrectomy compared to the traditional laparoscopic and open technique for the treatment of gastric cancer.

Clinical features of postoperative anastomotic bleeding after gastrectomy and efficacy of endoscopic hemostasis: a case-control study

BACKGROUND

Postoperative anastomotic bleeding (PAB) is relatively rare; however, it can be lethal if not treated immediately. The aim of our study was to investigate the clinical features of PAB and the efficacy of endoscopic hemostasis (EH) for PAB.

METHODS

Between January 2004 and May 2013, 16,591 patients underwent gastrectomy for gastric cancer at Asan Medical Center. Among them, 36 patients who experienced PAB within 2 months after the gastrectomy were enrolled as a case group. Each subject was matched at a ratio of 1:5 with randomly selected patients without bleeding during the same period (n = 180, control group). The clinical outcomes and risk factors for patients with PAB were compared with those of the control group, and the results of EH were evaluated retrospectively.

RESULTS

The incidence of PAB was 0.22% (n = 36), and the median duration from gastrectomy to PAB was 34.5 h (interquartile range, 12.3-132.8 h). EH was attempted in 25 patients (69.4%); surgery was performed in 6 patients (16.7%); and conservative management was applied in 5 patients (13.9%). PAB-related death occurred in three patients (8.3%; one in each treatment modality). Among 25 patients with primary EH, 16 were treated successfully (64%) and hemoclip was the most commonly used endoscopic tool (52%). In the multivariate analysis, the type of gastrectomy was found to be a risk factor for PAB (odds ratio 3.448, 95% confidence interval, 1.138-10.448, p = .029).

CONCLUSIONS

Although PAB is an infrequent and potentially life-threatening complication, endoscopy can be considered as a useful method to avoid additional surgery in properly selected patients.

Afferent Loop Syndrome After Subtotal Gastrectomy With Billroth-II Reconstruction: Etiology and Treatment

The aim of this study was to evaluate the clinical characteristics, treatment, and prognosis of afferent loop syndrome (ALS) following radical subtotal gastrectomy with B-II reconstruction in gastric cancer patients. ALS is an infrequent mechanical complication, which occurs after reconstruction of Billroth-II (B-II) gastrojejunostomy or Roux-en-Y esophagojejunosotomy. From 2002 through 2010, 672 patients who had undergone subtotal gastrectomy with B-II reconstruction for gastric cancer were enrolled. Clinical data, symptom interval, cause, and treatment of 13 ALS patients were reviewed. The body mass index (BMI) of patients who suffered ALS was significantly less than that of patients who did not (P = 0.0244). And, there were significant differences in rates of recurrence (P = 0.0032) and follow-up duration (P = 0.0119) between the two groups. Acute ALS within 1 month occurred in 5 patients (38.5%). Obstructive jaundice or acute pancreatitis occurred in 4 patients (30.1%). The most frequent cause was anastomosis inflammation (6 patients). Only 2 patients required surgery. Most patients with ALS were treated conservatively with or without percutaneous transhepatic biliary drainage (PTBD). Clinical suspicion is of significant importance because ALS is not common and the symptoms are nonspecific. ALS occurs more frequently in low BMI patients than high. PTBD can be considered as a primary treatment option for ALS if rupture of the afferent loop is not present.

Robot-assisted surgery for gastric cancer

Minimally invasive surgery for gastric cancer is a relatively new research field, with convincing results mostly stemming from Asian countries. The use of the robotic surgery platform, thus far assessed as a safe procedure, which is also easier to learn, sets the background for a wider spread of minimally invasive technique in the treatment of gastric cancer. This review will cover the literature published so far, analyzing the pros and cons of robotic surgery and highlighting the remaining study questions.

Assessing the safety and efficacy of full robotic gastrectomy with intracorporeal robot-sewn anastomosis for gastric cancer: A randomized clinical trial

BACKGROUND

Robotic gastrectomy is increasingly used in gastric cancer patients. This study assessed the safety and efficacy of full robotic gastrectomy with intracorporeal robot-sewn anastomosis for gastric cancer.

METHODS

Three hundred and eleven patients were randomized into an open gastrectomy group or a robotic gastrectomy group, and digestive restorations were performed under direct vision and with intracorporeal robot-sewn anastomosis, respectively. Length of postoperative hospital stay, number of lymph node dissections, surgical duration, blood loss, and complication rate after surgery were recorded.

RESULTS

There were no significant differences in the number of lymph node dissections (30.9 ± 10.4 vs. 29.3 ± 9.7 days, P = 0.281) or complication rates (10.3 vs. 9.3%, P = 0.756) between the two groups. Surgical duration was significantly longer in the robotic gastrectomy group than in the open gastrectomy group (242.7 ± 43.8 vs. 192.4 ± 31.5 min, P = 0.002), whereas blood loss was less (94.2 ± 51.5 vs. 152.8 ± 76.9 ml, P < 0.001), length of postoperative hospital stay was shorter (5.6 ± 1.9 vs. 6.7 ± 1.9 days, P = 0.021), and postoperative restoration of bowel function was earlier (2.6 ± 1.1 vs. 3.1 ± 1.2 days, P = 0.028).

CONCLUSION

Full robotic gastrectomy with intracorporeal robot-sewn anastomosis for gastric cancer is safe and does not increase the complication risk during or after surgery. J. Surg. Oncol. 2016;113:397-404. © 2016 Wiley Periodicals, Inc.

Feasibility of hyperthermic pressurized intraperitoneal aerosol chemotherapy in a porcine model

BACKGROUND

Peritoneal carcinomatosis is an unmet therapeutic need. Several types of intraperitoneal chemotherapy have been introduced. However, hyperthermic intraperitoneal chemotherapy has limited drug distribution and poor peritoneal penetration. Pressurized intraperitoneal aerosol chemotherapy (PIPAC) does not have the benefits of hyperthermia. We developed a device to apply hyperthermic PIPAC (H-PAC) and evaluated its feasibility in a porcine model.

METHODS

The device for H-PAC consisted of a laparoscopic aerosol spray and a heater to create hyperthermic capnoperitoneum. We operated on five pigs for the development of the new device and on another five pigs as a survival model. After a pilot experiment of the survival model (Pig A), a hyperthermic pressurized intraperitoneal aerosol of indocyanine green was administered after insertion of three trocars (Pig B) and laparoscopy-assisted distal gastrectomy (LADG) (Pig C) without chemotherapeutic agents. After that, H-PAC with cisplatin was administered after insertion of three trocars (Pig D) and LADG (Pig E). Autopsies were performed on postoperative day 7.

RESULTS

Median operation time was 85 min (80-110 min). Intraperitoneal temperature was constant for 1 h of H-PAC (38.8-40.2 °C). All five pigs were healthy and survived for 7 days. Median weight loss was 0.2 kg. Autopsy tissues of stomach, peritoneum, and jejunum were intact in all five pigs.

CONCLUSIONS

H-PAC was feasible and safe in a porcine model.

Anatomy and influence of the splenic artery in laparoscopic spleen-preserving splenic lymphadenectomy

AIM: To investigate the splenic hilar vascular anatomy and the influence of splenic artery (SpA) type in laparoscopic total gastrectomy with spleen-preserving splenic lymphadenectomy (LTGSPL).

METHODS: The clinical anatomy data of 317 patients with upper- or middle-third gastric cancer who underwent LTGSPL in our hospital from January 2011 to December 2013 were collected. The patients were divided into two groups (concentrated group vs distributed group) according to the distance between the splenic artery’s furcation and the splenic hilar region. Then, the anatomical layout, clinicopathologic characteristics, intraoperative variables, and postoperative variables were compared between the two groups.

RESULTS: There were 205 patients with a concentrated type (64.7%) and 112 patients with a distributed type (35.3%) SpA. There were 22 patients (6.9%) with a single branch of the splenic lobar vessels, 250 (78.9%) with 2 branches, 43 (13.6%) with 3 branches, and 2 patients (0.6%) with multiple branches. Eighty seven patients (27.4%) had type I splenic artery trunk, 211 (66.6%) had type II, 13 (4.1%) had type III, and 6 (1.9%) had type IV. The mean splenic hilar lymphadenectomy time (23.15 ± 8.02 vs 26.21 ± 8.84 min; P = 0.002), mean blood loss resulting from splenic hilar lymphadenectomy (14.78 ± 11.09 vs 17.37 ± 10.62 mL; P = 0.044), and number of vascular clamps used at the splenic hilum (9.64 ± 2.88 vs 10.40 ± 3.57; P = 0.040) were significantly lower in the concentrated group than in the distributed group. However, the mean total surgical time, mean total blood loss, and the mean number of harvested splenic hilar lymph nodes were similar in both groups (P > 0.05 for each comparison). There were also no significant differences in clinicopathological and postoperative characteristics between the groups (P > 0.05).

CONCLUSION: It is of value for surgeons to know the splenic hilar vascular anatomy when performing LTGSPL. Patients with concentrated type SpA may be optimal patients for training new surgeons.

Robot-assisted gastrectomy for gastric cancer: current status and technical considerations

BACKGROUND

Robot-assisted gastrectomy has been reported as a safe alternative to the conventional laparoscopy or open approach for treating early gastric carcinoma. To date, however, there are a limited number of published reports available in the literature.

METHODS

We assess the current status of robotic surgery in the treatment of gastric cancer, focusing on the technical details and oncological considerations.

RESULTS

In gastric surgery, the biggest advantage of robotic surgery is the ease and reproducibility of D2-lymphadenectomy. Reports show that even the intracorporeal digestive restoration is facilitated by use of the robotic approach, particularly following total gastrectomy. Additionally, the accuracy of robotic dissection is confirmed by decreased blood loss, as reported in series comparing robot-assisted with laparoscopic gastrectomy. The learning curve and technical reproducibility also appear to be shorter with robotic surgery and, consequently, robotics can help to standardize and diffuse minimally invasive surgery in the treatment of gastric cancer, even in the later stages. This is important because the application of minimally invasive surgery is limited by the complexity of performing a D2-lymphadenectomy. The potential to reproduce D2-lymphadenectomy, enlarged resections, and complex reconstructions provides robotic surgery with an important role in the therapeutic strategy of advanced gastric cancer.

CONCLUSIONS

While published reports have shown no significant differences in surgical morbidity, mortality, or oncological adequacy between robot-assisted and conventional laparoscopic gastrectomy, more studies are needed to assess the indications and oncological effectiveness of robotic use in the treatment of gastric carcinoma. Herein, the authors assess the current status of robotic surgery in the treatment of gastric cancer, focusing on the technical details and oncological considerations.

Totally intracorporeal delta-shaped B-I anastomosis following laparoscopic distal gastrectomy using the Tri-Staple™ reloads on the manual Ultra handle: a prospective cohort study with historical controls

BACKGROUND

A delta-shaped anastomosis in totally laparoscopic Billroth I gastrectomy could be performed easily and sufficiently using only laparoscopic linear staplers. However, the restricted maneuverability and severe blurring of these staplers along with their limited hemostability induced strain. In this study, we determined the feasibility and safety of performing delta-shaped anastomosis using the Endo GIA™ Reloads with Tri-Staple™ Technology combined with Endo GIA™ Ultra Universal stapler (Tri-Staple) with a particular focus on short-term surgical outcomes.

METHODS

We performed a single-institutional prospective interventional study (UMIN 000008014). The Tri-Staple was prospectively used on 23 consecutive patients who underwent a curative totally laparoscopic Billroth I gastrectomy with delta-shaped anastomosis. These patients were matched with the 19 patients previously treated using the ENDOPATH(®) ETS Articulating Linear Cutters (ETS) on clinical and demographic characteristics.

RESULTS

There were no differences between the groups in anastomosis-related local complications, morbidity, non-anastomosis-related local complications, total systemic complications, and short-term outcomes with the exception of significantly reduced blood loss in the Tri-Staple group (ETS vs. Tri-Staple: 37 [10-306] vs. 15 [5-210] mL, p = 0.02). Intraoperative bleeding from the staple line was significantly reduced in the Tri-Staple group. The postoperative drain indwelling period (ETS vs. Tri-Staple, 6 [4-10] vs. 4 [2-43] days, p = 0.032), fasting period (5 [3-7] vs. 3 [3-24] days, p = 0.022), and hospital stay (14 [10-47] vs. 11 [6-58] days, p = 0.025) were significantly shorter in the Tri-Staple group. There was no mortality in this series. Acceleration assessed as indices of blurring of stapler tip might have a significant adverse influence on staple-line bleeding at stapling sites.

CONCLUSION

Totally laparoscopic Billroth I distal gastrectomy using Tri-Staple was feasible and safe with favorable short-term surgical outcomes. Reduced blurring while stapling may be a novel endpoint which newly developed stapling devices should target.

Dropped omental fat post laparoscopy-assisted distal gastrectomy with omentectomy mistaken for malignant peritoneal seeding on sonography

We report the sonographic findings in a case of dropped omental fat post laparoscopy-assisted distal gastrectomy with omentectomy for stomach cancer mistaken for malignant intraperitoneal seeding. Gray-scale sonography revealed an ovoid-shaped hyperechoic mass with central poorly defined hypoechoic portion in the right perihepatic space. Color Doppler sonography showed no blood flow within the mass. Contrast-enhanced CT scan of the liver revealed an oval-shaped fatty mass with a CT number of -100 HU

Comparison of short-term clinical outcomes between robotic and laparoscopic gastrectomy for gastric cancer: a meta-analysis of 2495 patients

BACKGROUND

Laparoscopic gastrectomy (LG) is being increasingly used to treat gastric cancer. However, there are still several technical disadvantages limiting its use. Robotic gastrectomy (RG) is an emerging minimally invasive technique that overcomes some of these limitations. This study compares RG with LG in the treatment of gastric cancer by performing a systematic review and meta-analysis of all published literature.

MATERIALS AND METHODS

Comparative studies published between January 1991 and April 2013 in the major databases were systematically searched. Evaluated end points were operative, postoperative, and oncological outcomes. Pooled odds ratios and weighted mean differences with 95% confidence intervals were calculated using either the fixed-effects model or random-effects model.

RESULTS

Nine nonrandomized comparative studies with 2495 patients were included, of which 736 procedures were robotic and 1759 were laparoscopic. RG was associated with a lower intraoperative blood loss and a shorter time to oral intake compared with LG. However, it was associated with a significantly longer operative time and shorter distal resection margin. In addition, there was no significant difference in the number of retrieved lymph nodes, proximal resection margin, rate of conversion to open surgery, overall morbidity, anastomotic leakage, anastomotic stenosis, intestinal obstruction, time to first flatus, length of hospital stay, and perioperative mortality rates between the two groups.

CONCLUSIONS

RG is comparable to LG, with respect to safety, technical feasibility, and oncological effectiveness in the treatment of gastric cancer. However, there is a need for well-designed prospective randomized controlled studies comparing the two procedures with long-term follow-up, to inform future practice.

[Robotic hepatobiliary and gastric surgery]

Hepatobiliary surgery is a challenging surgical subspecialty that requires highly specialized training and an adequate level of experience in order to be performed safely. As a result, minimally invasive hepatobiliary surgery has been met with slower acceptance as compared to other subspecialties, with many surgeons in the field still reluctant about the approach. On the other hand, gastric surgery is a very popular field of surgery with an extensive amount of literature especially regarding open and laparoscopic surgery but not much about the robotic approach especially for oncological disease. Recent development of the robotic platform has provided a tool able to overcome many of the limitations of conventional laparoscopic hepatobiliary surgery. Augmented dexterity enabled by the endowristed movements, software filtration of the surgeon's movements, and high-definition three-dimensional vision provided by the stereoscopic camera, allow for steady and careful dissection of the liver hilum structures, as well as prompt and precise endosuturing in cases of intraoperative bleeding. These advantages have fostered many centers to widen the indications for minimally invasive hepatobiliary and gastric surgery, with encouraging initial results. As one of the surgical groups that has performed the largest number of robot-assisted procedures worldwide, we provide a review of the state of the art in minimally invasive robot-assisted hepatobiliary and gastric surgery.The English full-text version of this article is available at SpringerLink (under supplemental).

Surgical stress after robot-assisted distal gastrectomy and its economic implications

BACKGROUND

There is a lack of reports evaluating the outcomes of robotic gastrectomy and conventional laparoscopic surgery. The aim of this study was to compare the surgical stress response and costs of robot-assisted distal gastrectomy (RADG) with those of laparoscopy-assisted distal gastrectomy (LADG).

METHODS

This prospective study compared a cohort of patients who had RADG with a cohort that underwent conventional LADG for early gastric cancer between March 2010 and May 2011. The surgical outcomes including Eastern Cooperative Oncology Group performance status and complications, surgical stress response and overall costs were compared between the two groups.

RESULTS

Thirty patients were enrolled in the RADG group and 120 in the LADG group. There were no conversions. Median duration of operation was longer in the RADG group (218 (interquartile range 200-254) versus 140 (118-175) min; P < 0·001). Postoperative abdominal drain production was less (P = 0·001) and postoperative performance status was worse (P < 0·001) in the RADG group. C-reactive protein (CRP) levels on postoperative days 1 and 3, and interleukin (IL) 6 level on the third postoperative day, were lower in the LADG compared with the RADG group (CRP: P = 0·002 and P = 0·014 respectively; IL-6: P < 0·001). Costs for robotic surgery were much higher than for laparoscopic surgery (difference €3189).

CONCLUSION

RADG did not reduce surgical stress compared with LADG. The substantial RADG costs due to robotic system expenses may not be justified.

Comparative evaluation of two reconstructive methods following laparoscopic assisted subtotal gastrectomy in dogs

BACKGROUND

Laparoscopic gastrectomy is a new and technically challenging surgical procedure with potential benefit. The objective of this study was to investigate clinical and para-clinical consequences following Roux-en-Y and Jejunal Loop interposition reconstructive techniques for subtotal gastrectomy using laparoscopic assisted surgery.

RESULTS

Following resection of the stomach attachments through a laparoscopic approach, stomach was removed and reconstruction was performed with either standard Roux-en-Y (n = 5) or Jejunal Loop interposition (n = 5) methods. Weight changes were monitored on a daily basis and blood samples were collected on Days 0, 7 and 21 post surgery. A fecal sample was collected on Day 28 after surgery to evaluate fat content. One month post surgery, positive contrast radiography was conducted at 5, 10, 20, 40, 60 and 90 minutes after oral administration of barium sulfate, to evaluate the postoperative complications. There was a gradual decline in body weight in both experimental groups after surgery (P < 0.05). There was no difference in blood parameters at any time after surgery between the two methods (P > 0.05). Fecal fat content increased in the Roux-en-Y compared to the Jejunal loop interposition technique (P < 0.05). No major complications were found in radiographs and gastric emptying time was similar between the two groups (P > 0.05).

CONCLUSION

Roux-en-Y and Jejunal loop interposition techniques might be considered as suitable approaches for reconstructing gastro-intestinal tract following gastrectomy in dogs. The results of this study warrant further investigation with a larger number of animals.

Risk factors associated with delayed gastric emptying after subtotal gastrectomy with Billroth-I anastomosis using circular stapler for early gastric cancer patients

Purpose

Gastric surgery may potentiate delayed gastric emptying. Billroth I gastroduodenostomy using a circular stapler is the most preferable reconstruction method. The purpose of this study is to analyze the risk factors associated with delayed gastric emptying after radical subtotal gastrectomy with Billroth I anastomosis using a stapler for early gastric cancer.

Methods

Three hundred and seventy-eight patients who underwent circular stapled Billroth I gastroduodenostomy after subtotal gastrectomy due to early gastric cancer were analyzed retrospectively. One hundred and eighty-two patients had Billroth I anastomosis using a 25 mm diameter circular stapler, and 196 patients had anastomosis with a 28 or 29 mm diameter circular stapler. Clinicopathological features and postoperative outcomes were evaluated and compared between the two groups. Delayed gastric emptying was diagnosed by symptoms and simple abdomen X-ray with or without upper gastrointestinal series or endoscopy.

Results

Postoperative delayed gastric emptying was found in 12 (3.2%) of the 378 patients. Among all the variables, distal margin and circular stapler diameter were significantly different between the cases with delayed gastric emptying and no delayed gastric emptying. There were statistically significant differences in sex, body mass index, comorbidity, complication, and operation type according to circular stapler diameter. In both univariate and multivariate logistic regression analyses, only the stapler diameter was found to be a significant factor affecting delayed gastric emptying (P = 0.040).

Conclusion

In this study, the circular stapler diameter was one of the most significant predictable factors of delayed gastric emptying for Billroth I gastroduodenostomy. The use of a 28 or 29 mm diameter circular stapler rather than a 25 mm diameter stapler in stapled gastroduodenostomy for early gastric cancer can reduce postoperative delayed gastric emptying associated with anastomosic stenosis or edema with relative safety.

Preoperative assessment of perigastric vascular anatomy by multidetector computed tomography angiogram for laparoscopy-assisted gastrectomy

PURPOSE

We aimed at investigating the efficacy of multidetector computed tomography (MDCT) angiogram reconstructed using the maximum intensity projection (MIP) technique for the assessment of perigastric vascular anatomy before laparoscopy-assisted gastrectomy (LAG) for gastric cancer.

METHODS

Seventy-one patients who underwent LAG were enrolled in the study. Contrast-enhanced scans of the portal venous phase were performed by a MDCT scanner. The CT images were reconstructed using thin-slab MIP. The anatomic variations in the inflow and the location of the left gastric vein (LGV) were detected. The patterns of perigastric arterial origins were divided according to Michels' classification. The intraoperative blood loss on LAG was compared before and after MDCT angiography was introduced in the study.

RESULTS

The LGV flowed into the portal vein in 31 patients; the splenic vein, 25 patients; and the junction of these two veins, 15 patients. The LGV passed to the dorsal and ventral sides of the common hepatic artery in 30 and 13 patients and to the dorsal and ventral sides of the splenic artery in 8 and 20 patients, respectively. Michels' type II was found in one patient; type V, in three patients; and type VI, in two patients. The LGV location detected by MDCT was confirmed during surgery in all cases. Intraoperative blood loss after introduction of the MDCT angiography was significantly less than that before its introduction (p = 0.0032).

CONCLUSIONS

An MDCT angiogram reconstructed using the MIP technique is effective for assessing the perigastric vascular anatomy before LAG for gastric cancer.

Laparoscopic resection for gastric carcinoma: Western experience

There has been much speculation regarding differences in outcome for patients who have gastric cancer in the Eastern versus Western world. Among other factors, these differences have contributed to a unique cohort of patients and experience in the Western staging/evaluation of gastric cancer and in the application of minimally invasive approaches for treatment. This review summarizes the current state of laparoscopic approaches for the staging and treatment of gastric adenocarcinoma for patients presenting in Western countries, with their associated unique presentation, comorbidities, and outcomes.

Comparison of long-term prognosis of laparoscopy-assisted gastrectomy and conventional open gastrectomy with special reference to D2 lymph node dissection

BACKGROUND

Laparoscopy-assisted gastrectomy (LAG) is becoming widely used for early gastric cancer. However, how the curability and long-term prognosis of LAG and open gastrectomy (OG) for early and advanced gastric cancer compare remains unclear. This study assessed short- and long-term outcomes after LAG with lymph node dissection in early and advanced gastric cancer.

METHODS

A total of 332 patients who underwent LAG or OG for early and advanced gastric cancer from January 2001 through December 2010 were reviewed retrospectively. The mean operating time, estimated mean blood loss, number of dissected lymph nodes, and survival rates were compared between LAG and OG for early and advanced gastric cancer.

RESULTS

Overall, 47.6% (158/332) of patients underwent LAG; D1, D1+ lymph node dissection was carried out in 77.2%, with D2 dissection in 22.8%. Only one patient required conversion to OG. Comparing LAG and OG with D1, D1+ lymph node dissection for early gastric cancer (EGC), mean operating time was significantly longer, estimated mean blood loss was significantly smaller, and the average number of retrieved lymph nodes was significantly greater with LAG. The rate of specific postoperative morbidity was 17.2% for LAG patients and 25.0% for OG patients, with no postoperative mortality. Survival and recurrence rates were not significantly different. Comparing LAG and OG with D2 lymph node dissection for advanced gastric cancer (AGC), mean operating time was significantly longer and estimated mean blood loss was significantly smaller with LAG, while the average number of retrieved lymph nodes, specific postoperative morbidity and mortality, and survival and recurrence rates were not significantly different.

CONCLUSIONS

LAG with D1, D1+ lymph node dissection for EGC is safe and equivalent to open gastrectomy in curability. Moreover, LAG with D2 lymph node dissection for AGC is comparable to OG with D2 lymph node dissection with regard to short- and long-term results.

Omental infarction caused by laparoscopy-assisted gastrectomy for gastric cancer: CT findings

AIM

To investigate the computed tomography (CT) imaging features of omental infarction in patients who underwent laparoscopy-assisted gastrectomy (LAG) for gastric cancer.

MATERIALS AND METHODS

A retrospective study was performed on 390 patients who underwent LAG for gastric cancer. Two radiologists evaluated the CT images for the presence of omental infarction. The CT pattern was characterized at initial presentation and the evolutional changes were evaluated. The initial CT appearance of omental infarctions were categorized into the following four types: type 1 (ill-defined, heterogeneous, fat density lesion); type 2 (well-defined fat density lesion with rim enhancement); type 3 (well-defined heterogeneous lesion with fat component); and type 4 (well-defined heterogeneous lesion without a fat component).

RESULTS

Of the 390 patients involved, nine patients (2.3%; six male and three female with a mean age of 57 years) were diagnosed with omental infarction. Infarctions averaged 4.1 cm (range 2-7.3 cm) in diameter. Among nine patients with omental infarction, two patients had type 1 lesions, two had type 2, two had type 3, and three type 4. All infarctions became smaller and better defined with evolution. In two patients who presented with type 1 lesions on initial CT, each lesion was progressed to type 2 and type 3 on follow-up CT. In two patients with type 3 lesions on initial CT, the lesions changed to type 4 on follow-up CT.

CONCLUSION

An awareness of the various CT features and evolutional changes in omental infarction after LAG for gastric cancer can help ensure the correct diagnosis and to avoid misdiagnosis for omental implants.

Comparative study of complete and partial omentectomy in radical subtotal gastrectomy for early gastric cancer

PURPOSE

Curative surgery for patients with advanced or even early gastric cancer can be defined as resection of the stomach and dissection of the first and second level lymph nodes, including the greater omentum. The aim of this study was to evaluate the short- and long- term outcomes of partial omentectomy (PO) as compared with complete omentectomy (CO).

MATERIALS AND METHODS

Seventeen consecutive open distal gastrectomies with POs were initially performed between February and July in 2006. The patients' clinicopathologic data and post-operative outcomes were retrospectively compared with 20 patients who underwent open distal gastrectomies with COs for early gastric cancer in 2005.

RESULTS

The operation time in PO group was significantly shorter than that in CO group (142.4 minutes vs. 165.0 minutes, p=0.018). The serum albumin concentration on the first post-operative day in PO group was significantly higher than CO group (3.8 g/dL vs. 3.5 g/dL, p=0.018). Three postoperative minor complications were successfully managed with conservative treatment. Median follow-up period between PO and CO was 38.1 and 37.7 months. All patients were alive without recurrence until December 30, 2009.

CONCLUSION

PO during open radical distal gastrectomy can be considered a more useful procedure than CO for treating early gastric cancer. To document the long-term technical and oncologic safety of this procedure, a large-scale prospective randomized trial will be needed.

Current status of robot-assisted gastric surgery

In an effort to minimize the limitations of laparoscopy, a robotic surgery system was introduced, but its role for gastric cancer is still unclear. The objective of this article is to assess the current status of robotic surgery for gastric cancer and to predict future prospects. Although the current study was limited by its small number of patients and retrospective nature, robot-assisted gastrectomy with lymphadenectomy for the treatment of gastric cancer is a feasible and safe procedure for experienced laparoscopic surgeons. Most studies have reported satisfactory results for postoperative short-term coutcomes, such as: postoperative oral feeding, gas out, hospital stay and complications, compared with laparoscopic surgery; the difference is a longer operation time. However, robotic surgery showed a shallow learning curve compared with the familarity of conventional open surgery; after the accumulation of several cases, robotic surgery could be expected to result in a similar operation time. Robotic-assisted gastrectomy can expand the indications of minimally invasive surgery to include advanced gastric cancer by improving the ability to perform lymphadenectomy. Moreover, ”total” robotic gastrectomy can be facilitated using a robot-sewing technique and gastric submucosal tumors near the gastroesophageal junction or pylorus can be resected safely by this novel technique. In conclusion, robot-assisted gastrectomy may offer a good alternative to conventional open or laparoscopic surgery for gastric cancer, provided that long-term oncologic outcomes can be confirmed.

Secondary omental infarction related to open and laparoscopic-assisted distal gastrectomy: report of two cases

Omental infarction occurring after open and laparoscopic-assisted distal gastrectomy with partial omentectomy for gastric cancer was a very rare disease in the past, but its incidence has increased as more partial omentectomies are now being performed. But there are few case reports or radiologic studies on its increasing incidence. It is necessary to differentiate omental infarction from carcinomatosis peritonei, since both have similar imaging findings. In this report, we describe two cases of omental infarction; each occurred after open and laparoscopic-assisted distal gastrectomy in early gastric cancer patients. Partial omentectomy was performed in both cases. Omental infarction following distal gastrectomy with partial omentectomy can be discriminated from carcinomatosis peritonei by comparing with different initial and follow up CT findings.

Full robotic gastrectomy with extended (D2) lymphadenectomy for gastric cancer: surgical technique and preliminary results

BACKGROUND

Widespread diffusion of minimally-invasive surgery for gastric cancer treatment is limited by the complexity of performing an extended D2-lymphadenectomy. This surgical step can be facilitated by using robot-assisted surgery. The aim of this study is to describe our technique and short-term results of a consecutive series of full robotic gastrectomies with D2-lymphadenectomy for gastric cancer, using the da Vinci Surgical System.

MATERIALS AND METHODS

Between May 2004 and December 2009, we performed 24 consecutive full robot-assisted total and subtotal gastrectomies with extended D2-lymphadenectomy for histologically-proven gastric adenocarcinoma. Data referring to 11 robot-assisted total gastrectomies and 13 subtotal gastrectomies were collected in a database and analyzed.

RESULTS

Median operative time was 267.50 min (255-305). Median intraoperative blood loss was 30 mL. Median number of harvested lymph nodes was 28 (23-34). Resection margins were negative in all cases. No conversions occurred. Surgery-related morbidity was 8%. Thirty-day mortality was 0%. Liquid diet started on postoperative d 5 (2-5). Median length of stay was 6 d (5-8).

CONCLUSIONS

Robot-assisted gastrectomy with D2-lymphadenectomy is a safe technique and allows achieving an adequate lymph node harvest and optimal R0-resection rates with low postoperative morbidity and the learning curve appears to be shorter than in laparoscopic surgery. Longer follow-up and randomized clinical trials are needed to define the role of robot-assistance in gastric cancer surgery.

Early postoperative anastomotic hemorrhage after gastrectomy for gastric cancer

BACKGROUND

Postoperative anastomotic hemorrhage is a relatively rare complication, but it is lethal if not treated immediately.

METHODS

Of 1400 patients with gastric cancer who underwent gastrectomy between September 2002 and December 2007, postoperative anastomotic hemorrhage was observed in 6 patients. The surgical procedures, bleeding sites, methods of hemostasis, and clinical courses of these 6 patients were analyzed.

RESULTS

Of the 1400 patients, 878, 72, and 450 underwent distal, proximal, and total gastrectomy, respectively. The bleeding sites were as follows: transection line of the stomach using a linear stapler (n = 1); gastroduodenostomy using a circular stapler (n = 3); gastrojejunostomy by hand-suture (n = 1); and esophagojejunostomy using a circular stapler (n = 1). Five patients achieved complete hemostasis with endoscopic treatment. One patient underwent re-operation for anastomotic hemorrhage without endoscopic therapy. Two patients had delayed gastric emptying, and one patient developed an intraabdominal abscess after hemostatic treatment.

CONCLUSION

Postoperative anastomotic hemorrhage is an infrequent but potentially life-threatening complication. Endoscopy appears to be useful for both the confirmation of bleeding and therapeutic intervention.

Robotic gastrectomy for gastric cancer: surgical techniques and clinical merits

BACKGROUND

Robotic gastrectomy in the setting of gastric cancer is reported by some investigators. However, no study has compared robotic surgery with open or laparoscopic surgery for patients with gastric cancer. This study aimed to determine the clinical benefits of robotic gastrectomy over open and laparoscopic gastrectomy for the treatment of gastric cancer.

METHODS

After the introduction of the da Vinci surgical system in November 2007 at the authors' hospital, 18 robotic gastrectomies were performed from 31 December 2007 to 30 June 2008. The prospective data from gastric cancer patients who underwent gastrectomies (16 robotic, 11 laparoscopic, and 12 open) during the same period were retrospectively analyzed.

RESULTS

Sex, age, comorbidity, extent of lymphadenectomy, pT stage, lymph node metastasis, and number of lymph nodes retrieved were similar among the three groups. The estimated blood loss was significantly less in the robotic gastrectomy group than in the open group (p = 0.0312), and the postoperative hospital stay in the robotic group was significantly shorter than in the open and laparoscopic gastrectomy groups (p < 0.001). Postoperative morbidity and time to first flatus were similar in the three groups. There was no open or laparoscopic conversion in the robotic group. No postoperative mortality occurred in any group.

CONCLUSION

Robotic gastrectomy for the treatment of gastric cancer is a feasible and safe procedure in the hands of experienced laparoscopic surgeons. Robotic gastrectomy offers better short-term surgical outcomes than the open and laparoscopic methods. Furthermore, this procedure may be a preferable alternative for the treatment of gastric cancer.

Robot-assisted gastrectomy with lymph node dissection for gastric cancer: lessons learned from an initial 100 consecutive procedures

OBJECTIVE

To evaluate the technical feasibility, effectiveness, and safety of robot-assisted gastrectomy (RAG) with lymphadenectomy, using the da Vinci system through analyses of our initial series of 100 consecutive patients.

SUMMARY BACKGROUND DATA

The application of robotic surgery was proven to be one of the best cutting-edge technologies for successful minimally invasive surgery by providing solutions to the many drawbacks of laparoscopic surgery, yet few reports have studied robotic surgery in gastric cancer.

METHODS

A review of a prospectively designed database at our institute from July 2005 to October 2007 revealed a series of 100 consecutive RAG patients with a preoperative diagnosis of early gastric cancer. Clinicopathologic characteristics and surgical outcomes were analyzed.

RESULTS

All operations were performed successfully without open or laparoscopic conversion. There were 33 total gastrectomies and 67 subtotal gastrectomies with D1+beta or extended lymphadenectomy (D2). The mean total operation time and console time were 231 and 150 minutes, respectively. There were 13 postoperative morbidities and 1 postoperative mortality. The first flatus was noted on postoperative day 2.9, soft diet was started on postoperative day 4.2, and the mean postoperative hospital stay was 7.8 days. Although all patients were diagnosed as early gastric cancer preoperatively, the final pathology report revealed that 19 patients exhibited a depth deeper than T2. The mean number of retrieved lymph nodes was 36.7 (range, 11-83). None of the specimens showed microscopic tumor involvement in the resection line.

CONCLUSIONS

This study demonstrated that RAG with lymphadenectomy can be applied safely and effectively for patients with gastric cancer.

Omentum-preserving gastrectomy for early gastric cancer

BACKGROUND

The omentum has variable functions in surgical procedures. Nevertheless, there is very little information about the effect of omentum on abdominal complications after gastrectomy. The purpose of the present study was to determine the outcome of omentum-preserving gastrectomy for early gastric cancer.

METHODS

We evaluated 1,116 patients who had a gastrectomy for early gastric cancer between the years 2004 and 2006; 992 patients underwent conventional gastrectomy (CG), and 124 patients had an omentum-preserving gastrectomy (OPG). These cases were analyzed retrospectively. The early and late abdominal complications were compared between the CG and OPG groups.

RESULTS

The results of the study show no significant differences between the early abdominal complications in the CG and OPG groups. However, the late abdominal complication rate in the OPG was significantly lower than the CG (p = 0.026). The most common risk factor associated with early abdominal complications was type of operation. The combination of CG and early abdominal complication represented a statistically significant risk for late abdominal complications (p = 0.026, 0.031 respectively).

CONCLUSION

The findings of this study demonstrate that the omentum-preserving gastrectomy in the treatment of early gastric cancer showed a lower rate of abdominal complications compared to the conventional gastrectomy.

The impact of comorbidity on surgical outcomes in laparoscopy-assisted distal gastrectomy: a retrospective analysis of multicenter results

OBJECTIVE

The purpose of this study was to evaluate the impact of comorbidities on the surgical outcomes in laparoscopy-assisted distal gastrectomy (LADG).

SUMMARY BACKGROUND DATA

Although laparoscopic gastrectomy is less invasive than conventional open surgery, surgeons are still concerned with surgical outcomes associated with comorbidity.

METHODS

We retrospectively collected data on 1324 patients who underwent LADG between April 1998 and December 2005 by 10 surgeons in 10 hospitals. After excluding 87 patients who had an unusual medical history or surgical methods, 1237 patients were enrolled for analysis to evaluate the effect of comorbidities on the surgical outcomes.

RESULTS

Seven patients (0.6%) died during their hospitalization, and postoperative complications occurred in 162 (13.1%) of 1237 patients. According to univariate analysis, gender, number of comorbidities, reconstruction type, and the surgeon's experience in laparoscopy-assisted gastrectomy (LAG) were related to postoperative local complications; age and comorbidity were related to systemic complications; and comorbidity was the only variable related to hospital mortality. Comorbidity was a predictive risk factor for local complications (odds ratio (OR): 1.79) and systemic complications (OR: 2.89) in multivariate analysis. The patients with pulmonary comorbidity were related to most types of immediate postoperative complications compared with other comorbidities.

CONCLUSIONS

Our study suggests that comorbidities of patients could be a predictive risk factor for surgical complication after LADG. Therefore, patients with early gastric cancer having comorbidity should be considered for one of the limited surgeries. In addition, surgeons should carefully assess patients with comorbidities with full perioperative attention.

Surgical complications and the risk factors of laparoscopy-assisted distal gastrectomy in early gastric cancer

BACKGROUND

Information on surgical complications of laparoscopy-assisted distal gastrectomy (LADG) and their risk factors is limited in the literature despite increasing popularity of this procedure. This study was performed to identify the surgical complications and their associated risk factors of LADG in early gastric cancer.

METHODS

LADG was performed in 347 gastric cancer patients from January 2002 to December 2006 at the Korean National Cancer Center by four surgeons with ample experience of open gastric surgery before LADG. LADG indications for cases of gastric cancer at our institution are preoperatively diagnosed cT1N0 or cT1N1, except in cases with an absolute indication for endoscopic resection. Lymph node dissection of more than D1 + beta was performed in all patients. Intraoperative and postoperative complications were reviewed and their risk factors were retrospectively analyzed by prospective database information.

RESULTS

Forty complications occurred in 34 patients (9.8%), but there was no mortality. Intraoperative complications occurred in nine patients (2.6%), and open conversion was performed in eight (2.3%) of these patients. Early and late postoperative complications occurred in 21 (6.1%) and 10 (2.9%) patients, respectively. The most serious complication was vascular injury resulting in bleeding or organ ischemia, which occurred in seven patients. Degree of lymph node dissection and surgical inexperience were found to be risk factors of surgical complication (P = .023, odds ratio 2.832, 95% confidence interval 1.155-6.946 vs. P = .028, odds ratio 2.975, 95% confidence interval 1.127-7.854).

CONCLUSIONS

Lymph node dissection during LADG should be performed cautiously to prevent surgical complications like vascular injuries, especially during the surgeon's early learning period.

Outcomes and survival after laparoscopic gastrectomy for adenocarcinoma. Analysis on 65 patients operated on by conventional or robot-assisted minimal access procedures

AIMS

Despite laparoscopic surgery for gastric cancer has gained worldwide acceptance, long term results and survival are seldom reported. This study was designed to assess long term outcomes after laparoscopic gastrectomy with D2 dissection. The short term results of conventional and robot-assisted minimally invasive procedures were also examined.

PATIENTS AND METHODS

The charts of 65 patients who underwent laparoscopic surgery for non-metastatic adenocarcinoma were reviewed retrospectively. This series included 35 patients with early gastric cancer (EGC) and 30 with advanced gastric cancer (AGC). A 4/5 laparoscopic subtotal gastrectomy (LSG) with D2 nodal clearance was the procedure of choice for distal cancers. Laparoscopic total gastrectomy (LTG) with modified D1 lymphadenectomy was performed for mid-proximal EGC.

RESULTS

Sixty gastrectomies were carried out laparoscopically, 56 LSG and 4 LTG. Conversion to laparotomy was required in 5 patients with distal cancer. No intraoperative complication was registered. Morbidity included 2 duodenal leaks that healed conservatively. Two postoperative deaths were registered. An average number 31.3+/-8.8 lymph nodes were collected. The mean hospital stay was 10 days (range 7-24). The mean follow up was 30 months (range 2-86) and the cumulative overall 5 year survival rate was 78%. Survival at 5 years for EGC was 94% and survival at 4 years for AGC was 53% (57% for non-converted patients).

CONCLUSIONS

Laparoscopic gastrectomy for cancer represents a valid alternative to open surgery with minimal morbidity and acceptable long term survival. Considering the risk of preoperative under diagnoses a D2 lymphadenectomy is suggested also for EGC. This study validated the effectiveness of minimally invasive technique in the management of gastric cancer.

Systematic review of minimally invasive resection for gastro-oesophageal cancer

BACKGROUND

This article reviews the evidence on the safety and efficacy of minimally invasive surgery for gastric and oesophageal cancer.

METHODS

An electronic search of the literature between 1997 and 2007 was undertaken to identify primary studies and systematic reviews; studies were retrieved and analysed using predetermined criteria. Information on the safety and efficacy of minimally invasive surgery for gastric and oesophageal cancer was recorded and analysed.

RESULTS

From 188 abstracts reviewed, 46 eligible studies were identified, 23 on oesophagectomy and 23 on gastrectomy. There were 35 case series, eight case-matched studies and three randomized controlled trials. Compared with the contemporary results of open surgery, reports on minimally invasive surgery indicate potentially favourable outcomes in terms of operative blood loss, recovery of gastrointestinal function and hospital stay. However, the quality of the data was generally poor, with many potential sources of bias.

CONCLUSION

Minimally invasive surgery is feasible but evidence of benefit is currently weak.