Advantage of completely laparoscopic gastrectomy with linear stapled reconstruction: a long-term follow-up study

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Analysis of the safety and efficacy of the self-pulling and latter transected technique in modified overlap anastomosis in total laparoscopic total gastrectomy

Background

Laparoscopic total gastrectomy plus lymph node dissection is an effective treatment method for patients with gastric cancer. With the development and popularization of laparoscopic techniques in recent years, surgeons have become more skilled in laparoscopic techniques. Totally laparoscopic total gastrectomy (TLTG) has been developed; however, digestive tract reconstruction remains difficult, especially with anastomosis of the esophagus and jejunum. Using the self-pulling and latter transection (SPLT) method combined with a linear stapler has effectively solved the problem of narrow space in esophagojejunostomy. Here, we examined the safety and effectiveness of the SPLT technique in TLTG compared with SPLT with traditional esophagojejunostomy overlap anastomosis.

Methods

We retrospectively analyzed all patients with gastric cancer admitted to the Department of Gastrointestinal Surgery of the Second Affiliated Hospital of Fujian Medical University from September 2020 to September 2023. In total, 158 patients met the inclusion criteria and were included. Patients were grouped according to whether the lower esophagus was transected after self-pulling. Patient demographics, tumor characteristics, surgical conditions, and postoperative results between the two groups were statistically analyzed.

Results

A total of 158 patients were included in the study. All patients underwent TLTG and completed intracavitary anastomosis. There were 70 cases (44%) in the SPLT-Overlap group and 88 cases (56%) in the traditional overlap group. There was no significant difference in demographic and oncological characteristics between the two groups. The operation time (P = 0.002) and esophageal jejunum anastomosis time (P<0.001) were significantly shorter in the SPLT-Overlap group compared with the traditional overlap group. The intraoperative blood loss of the SPLT-Overlap group was 80.29 ± 36.36 ml, and the intraoperative blood loss of the traditional overlap group was 101.40 ± 46.68 ml. The difference was statistically significant (P=0.003). The SPLT-Overlap group also achieved a higher upper cutting edge (P =0.03). There was no significant difference between the two groups in terms of the incision size, postoperative hospital stay, time to first flatus, time to first liquid intake, drainage tube removal time, and esophagojejunal anastomotic diameter. There were 15 and 19 cases of short-term postoperative complications in the SPLT-Overlap and traditional Overlap groups, respectively. All patients received R0 resection, and no secondary surgery or death occurred.

Conclusion

We applied SPLT to overlap anastomosis. Short-term, SPLT has good safety and feasibility in TLTG. It can effectively shorten the time of digestive tract reconstruction, simplify the reconstruction procedure, and make the digestive tract reconstruction simple and fast; at the same time, a safe cutting edge can be obtained.

A meta-analysis evaluating wound infections and other complications following distal versus complete gastrectomy for gastric cancer

A meta-analysis investigation was carried out to measure the wound infections (WIs) and other postoperative problems (PPs) of distal gastrectomy (DG) compared with total gastrectomy (TG) for gastric cancer (GC). A comprehensive literature investigation till February 2023 was used and 1247 interrelated investigations were reviewed. The 12 chosen investigations enclosed 2896 individuals with GC in the chosen investigations' starting point, 1375 of them were TG, and 1521 were DG. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were utilized to compute the value of the WIs and other PPs of DG compared with TG for GC by the dichotomous approaches and a fixed or random model. TG had significantly higher overall PP (OR, 1.58; 95% CI, 1.15-2.18, p = 0.005), WIs (OR, 1.69; 95% CI, 1.07-2.67, p = 0.02), peritoneal abscess (PA) (OR, 2.99; 95% CI, 1.67-5.36, p < 0.001), anastomotic leakage (AL) (OR, 1.90; 95% CI, 1.21-2.97, p = 0.005) and death (OR, 2.26; 95% CI, 1.17-4.37, p = 0.02) compared to those with DG in individuals with GC. TG had significantly higher overall PP, WIs, PA, AL and death compared to those with DG in individuals with GC. However, care must be exercised when dealing with its values because of the low sample size of some of the nominated investigations for the meta-analysis.

Total gastrectomy as a risk factor for postoperative loss of skeletal muscle in minimally invasive surgery for patients with gastric cancer

PURPOSE

Loss of skeletal muscle mass after gastrectomy for gastric cancer leads to decreased quality of life and poor postoperative survival. However, few studies have examined the postoperative loss of skeletal muscle mass following minimally invasive gastrectomy. This study investigated the impact of minimally invasive total gastrectomy (MI-TG) on changes in skeletal muscle mass during the early postoperative period.

METHODS

Patients who underwent MI-TG or minimally invasive distal or proximal gastrectomy (MI-nonTG) for cStage I-III gastric cancer were retrospectively analyzed (n = 58 vs. 182). Their body composition was measured before surgery and 2 months after surgery. Multivariable linear regression analysis was performed to clarify the impact of the surgical procedure on skeletal muscle index changes using clinically relevant covariates.

RESULTS

Skeletal muscle mass decreased more in the MI-TG group than in the MI-nonTG group (median [interquartile range]; -5.9% [-10.6, -3.7] vs -4.5% [-7.3, -1.9], P = 0.004). In multivariable linear regression analysis using clinically relevant covariates, MI-TG was an independent risk factor for postoperative loss of skeletal muscle mass (coefficient - 2.6%, 95% CI -4.5 to -0.68, P = 0.008).

CONCLUSIONS

Total gastrectomy was a risk factor for loss of skeletal muscle mass during the early postoperative period. If oncologically feasible, proximal or distal gastrectomy with a small remnant stomach should be considered.

Intracorporeal linear‑stapled gastroduodenostomy in totally laparoscopic distal gastrectomy for gastric cancer: Consideration of the intraoperative management of the duodenal wall between the transecting staple line and anastomotic staple line (Review)

The first part of the duodenum consists of the intraperitoneal segment, called the duodenal bulb, and the retroperitoneal segment. Regarding the blood supplying the duodenal bulb, which is the portion utilized in anastomosing the duodenum and remnant stomach following distal gastrectomy, the arterial pedicles branching off from the gastroduodenal artery are reported to reach the posterior wall first and then spread over the anterior wall, where they anastomose. When performing intracorporeal linear-stapled gastroduodenostomy following totally laparoscopic distal gastrectomy, the blood supply of the duodenal wall between the transecting staple line and anastomotic staple line needs to be considered because both transection of the duodenal bulb and the gastroduodenostomy are performed using an endoscopic linear stapler and the duodenal wall between the staple lines can be ischemic after the anastomosis. Since it needs to be decided intraoperatively whether this duodenal site is preserved or removed, the present review discusses the technical differences among several procedures for intracorporeal linear-stapled gastroduodenostomy, classifying them into two groups on the basis of the intraoperative management of this duodenal site. When this site is preserved, the blood supply of the duodenal wall needs to be retained with certainty. On the other hand, when this site is removed, the ischemic portion of the duodenal wall needs to be identified and removed. Furthermore, in both groups, an adequate anastomotic area needs to be secured. In conclusion, surgeons need to be familiar with the anatomical features of the duodenal bulb, including its blood perfusion and shape, when carrying out intracorporeal linear-stapled gastroduodenostomy.

Effectiveness and safety of self-pulling and latter transected reconstruction in totally laparoscopic total gastrectomy: a comparison with laparoscopic-assisted total gastrectomy

BACKGROUND

In some earlier studies, self-pulling and later transection (SPLT) esophagojejunostomy (E-J) was incorporated into total laparoscopic total gastrectomy (TLTG) procedures. Its effectiveness and safety, however, remain unknown. This study compared (SPLT)-E-J in TLTG with conventional E-J in laparoscopic-assisted total gastrectomy (LATG) in order to assess the short-term safety and efficacy of (SPLT)-E-J in TLTG.

METHODS

This research analyzed patients with gastric cancer who received SPLT-TLTG or LATG between January 2019 and December 2021 in the First Affiliated Hospital of Chongqing Medical University. Baseline data and postoperative short-term surgical outcomes were obtained retrospectively and compared between the two groups.

RESULTS

A total of 83 patients who underwent SPLT-TLTG (n = 40, 48.2%) or LATG (n = 43, 51.8%) were included in this study. There were no differences between the two groups in terms of patient demographics or tumor characteristics. No statistically significant differences were observed between the two groups in terms of operation time, intraoperative blood loss, harvested lymph nodes, postoperative complications, postoperative decrease in hemoglobin and albumin levels, or postoperative hospital stay. Five and seven patients experienced short-term postoperative complications in the SPLT-TLTG and LATG groups, respectively.

CONCLUSIONS

SPLT-TLTG is a dependable and safe surgical method for the treatment of gastric cancer. Its short-term outcomes were similar to those of conventional E-J in LATG and had advantages regarding surgical incision and simplification of reconstruction.

Application of Overlap Gastroduodenostomy in Billroth I Anastomosis after Totally Laparoscopic Distal Gastrectomy for Gastric Cancer

Delta-shaped gastroduodenostomy (DSGD) and overlap gastroduodenostomy (OGD) are the two most widely used intracorporeal Billroth I anastomosis methods after distal gastrectomy. In this study, we compared the short-term outcomes of DSGD and OGD in total laparoscopic distal gastrectomy (TLDG). In a retrospective cohort study, we examined 92 gastric cancer patients who underwent TLDG performed by the same surgeon between January 2014 and June 2018. All patients underwent Billroth I reconstruction (OGD, n = 45; DSGD, n = 47) and D2 lymph node dissection. We retrospectively reviewed the surgical outcomes, clinical pathological results, and endoscopy results. Laparoscopic surgery was successfully performed in both groups without conversion to open surgery. The demographic and clinical characteristics were similar between the two groups (P > 0.05). There were no significant differences between the two groups in operation time (158.9 ± 13.6 min vs. 158.8 ± 14.8 min, P=0.955), anastomotic time (19.4 ± 3.0 min vs. 18.8 ± 2.9 min, P=0.354), intraoperative blood loss (88.9 ± 25.4 mL vs. 83.7 ± 24.3 mL, P=0.321), number of lymph node dissections (31.0 ± 7.1 vs. 29.2 ± 7.5, P=0.229), length of hospital stay (8.8 ± 2.7 days vs. 9.1 ± 3.0 days, P=0.636), fluid intake time (3.1 ± 0.7 days vs. 3.2 ± 0.7 days, P=0.914), and morbidity of postoperative complications (6.7% [3/45] vs. 10.6% [5/47], P=0.499). Endoscopy performed 6 months postoperatively showed that the residual food (P=0.033), gastritis (P=0.029), and bile (P=0.022) classification score significantly decreased in the OGD group, and there were no significant differences 12 months postoperatively. OGD is a safe and effective reconstruction technique with comparable postoperative surgical outcomes and endoscopy results when compared with those of DSGD.

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.

Efficacy and Safety of Totally Laparoscopic Gastrectomy Compared with Laparoscopic-Assisted Gastrectomy in Gastric Cancer: A Propensity Score-Weighting Analysis

Objectives

To compare the short- and long-term outcomes of totally laparoscopic gastrectomy (TLG) with laparoscopic-assisted gastrectomy (LAG) in gastric cancer (GC) patients and evaluate the efficacy and safety of TLG.

Methods

This retrospective study was based on GC patients who underwent laparoscopic radical gastrectomy in the Qilu Hospital from January 2017 to December 2020. The groups’ variables were balanced by using the propensity score-based inverse probability of treatment weighting (PS-IPTW). The primary outcomes were 3-year relapse-free survival (RFS) and 3-year overall survival (OS). Postoperative recovery and complications were the secondary outcomes.

Results

A total of 250 GC patients were included in the study. There were no significant differences in baseline and pathological features between the TLG and the LAG groups after the PS-IPTW. TLG took around 30 min longer than LAG, while there were more lymph nodes obtained and less blood loss throughout the procedure. TLG patients had less wound discomfort than LAG patients in terms of short-term prognosis. There were no significant differences between groups in the 3-year RFS rate [LAG vs. TLG: 78.86% vs. 78.00%; hazard ratio (HR) = 1.14, 95% confidence interval (CI), 0.55–2.35; p = 0.721] and the 3-year OS rate (LAG vs. TLG: 78.17% vs. 81.48%; HR = 0.98, 95% CI, 0.42–2.27; p = 0.955). The lymph node staging was found to be an independent risk factor for tumor recurrence and mortality in GC patients with laparoscopic surgery. The subgroup analysis revealed similar results of longer operation time, less blood loss, and wound discomfort in totally laparoscopic distal gastrectomy, while the totally laparoscopic total gastrectomy showed benefit only in terms of blood loss.

Conclusion

TLG is effective and safe in terms of short- and long-term outcomes, with well-obtained lymph nodes, decreased intraoperative blood loss, and postoperative wound discomfort, which may be utilized as an alternative to LAG.

A Modified Anastomosis Technique for Esophagojejunostomy after Laparoscopy-Assisted Total Gastrectomy: A Single Team Preliminary Experience

RESULTS

There were no significant differences between the cRY group and pRY group regarding age, sex, BMI, neoadjuvant therapy, preoperative comorbidities, history of laparotomy, ASA score, tumor location, pathological stage, total operative time, incision length, blood loss, time-to-first flatus, time-to-first soft diet, and postoperative hospital stays. The proportions of patients who received a 21 mm stapler were higher in the cRY group (7/44) than that in the pRY group (0/68) (P = 0.003). 7 anastomotic complications were reported (6 in the cRY group versus 1 in pRY group; P = 0.028) of which five (83.3%) in the cRY were anastomotic stenosis versus none in the pRY group (P = 0.044).

CONCLUSIONS

The application of pant-shaped anastomosis for esophagojejunostomy after LTG is a safe and feasible procedure and has an advantage when the jejunum diameter is small.

Comparison of reverse puncture device and overlap in laparoscopic total gastrectomy for gastric cancer

BACKGROUND

Intracorporeal oesophagojejunostomy is one of the key steps in laparoscopic total gastrectomy (LTG). At present, there is no widely accepted anastomosis technique in oesophagojejunostomy.

MATERIALS AND METHODS

We retrospectively studied 63 patients with gastric cancer who underwent LTG. Two types of anastomosis techniques have been applied during LTG: the reverse puncture device (RPD) (28 patients) and overlap (35 patients).

RESULTS

A total of 63 patients (51 males and 12 females: mean age = 58 years and mean body mass index [BMI] = 26.3 kg/m2) were enrolled in this study. There were no significant difference in age, BMI, duration of surgery, duration of anastomosis, blood loss, post-operative hospital stay, tumour location, tumour size, degree of tumour differentiation, Borrmann type, total number of lymph nodes, number of positive lymph nodes, hospital stay, hospitalisation costs, intra-operative complications, post-operative complications and prognosis between the RPD group and the overlap group. RPD group showed a significant advantage in terms of the distance between the top border of tumours and the top resection margin (P < 0.001). We further found that the oesophageal lateral negative surgical margin distance of the upper gastric cancer in the RPD group was significantly longer than that in the overlap group (P < 0.001).

CONCLUSIONS

Both the RPD and overlap techniques are safe and applicable in LTG. However, RPD has the advantage of obtaining an adequate safe margin compared with that of overlap technique, especially in patients with gastro-oesophageal junction carcinoma.

A Novel Nomogram for Prediction of Early Postoperative Complications of Total Gastrectomy for Gastric Cancer

Background

Accurate prediction of postoperative complications is especially important for the formulation of treatment plans for patients with total gastrectomy (TG) for gastric cancer (GC). The purpose of this study was to establish a risk assessment model for early postoperative complications.

Methods

This retrospective study involved 363 patients with GC who underwent TG from January 2019 to December 2020. The influencing factors were explored by univariate and multivariable logistic regression; then, a nomogram was established and verified by internal verification.

Results

Linear stapler (OR=2.501, P=0.030), age (OR=1.052, P =0.024), blood transfusion (yes) (OR=2.450, P =0.021), one-time consumables for surgery (or=1.000, P =0.022), number of total lymph nodes (OR=1.060, P =0.011) and number of positive lymph nodes (OR=1.054, P =0.029) were independent risk factors for early postoperative complications in TG, and nomogram model was constructed. The C-index of primary cohort, modeling cohort and validation cohort was 0.787, 0.754 and 0.912. The calibration curves showed good accuracy.

Conclusion

This study used the indicators available before and during surgery to establish a nomogram model for early postoperative complications of total gastrectomy for gastric cancer, which found that linear stapler (LS), blood transfusion, one-time consumables for surgery, number of total lymph nodes and number of positive lymph nodes were factors.

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.

A Multicenter Retrospective Study Comparing Surgical Outcomes Between the Overlap Method and Functional Method for Esophagojejunostomy in Laparoscopic Total Gastrectomy: Analysis Using Propensity Score Matching

BACKGROUND

This study aimed to compare the postoperative outcomes after laparoscopic total gastrectomy (LTG) with esophagojejunostomy (EJS) performed using the overlap method or the functional method in a multicenter retrospective study with propensity score matching.

METHODS

We retrospectively enrolled all patients who underwent curative LTG for gastric cancer at 6 institutions between January 2004 and December 2018. Patients were categorized into the overlap group (OG) or functional group (FG) based on the type of anastomosis used in EJS. Patients in the groups were matched using the following propensity score covariates: age, sex, body mass index, American Society of Anesthesiologists physical status, extent of lymph node dissection, and Japanese Classification of Gastric Carcinoma stage. The surgical results and postoperative outcomes were compared.

RESULTS

We identified 69 propensity score-matched pairs among 440 patients who underwent LTG. There was no significant between-group difference in the median operative time, intraoperative blood, or number of lymph nodes resected. In terms of postoperative outcomes, the rates of all complications [Clavien-Dindo (CD) classification ≥II; OG 13.0 vs. FG 24.6%, respectively; P=0.082], complications more severe than CD grade III (OG 8.7 vs. FG 18.8%, respectively; P=0.084), and the occurrence of EJS leakage and stenosis more severe than CD grade III (OG 7.3% vs. FG 2.9%, P=0.245; OG 1.5 vs. FG 8.7%, P=0.115, respectively) were comparable. The median follow-up period was 830 days (range, 18 to 3376 d), and there were no differences in overall survival between the 2 groups.

CONCLUSIONS

There was no difference in surgical outcomes and overall survival based on the type of anastomosis used for EJS after LTG. Therefore, selection of anastomosis in EJS should be based on each surgeon's preference and experience.

Recanalization in Uncut Roux-en-Y Reconstruction: An Animal Experiment and a Clinical Study

Background: Because of the challenge of jejunal closure recanalization, uncut Roux-en-Y reconstruction remains controversial. This study aimed to investigate the incidence of recanalization after uncut Roux-en-Y reconstruction in pigs and a small number of patients.

Methods: Twenty miniature pigs were subjected to distal gastrectomy and uncut Roux-en-Y reconstruction using various rows of linear staplers to block the intestine. The pigs were sacrificed, and the incidence of recanalization was investigated 1 month after the operation. From December 2018 to June 2019, 10 patients with gastric cancer who had undergone elective laparoscopy-assisted distal gastrectomy and uncut Roux-en-Y reconstruction were included in this study. The primary study outcome was recanalization of the afferent limb, demonstrated by gastrointestinal radiography 1, 3, and 6 months after surgery. Various numbers of staple lines across the afferent jejunal limb were applied for closure: 2 staple lines in 2 pigs, 4 staple lines in 6 pigs, 6 staple lines in 8 pigs, and 8 staple lines in 4 pigs.

Results: Complete recanalization was detected in all 20 pigs 1 month postoperatively. Recanalization was detected in five cases (50%) by gastrointestinal radiography. Among them, 1 case of recanalization was found in the 1st month after the operation, 2 cases were found in the 3rd month, and another 2 cases were found in the 6th month. Bile reflux was detected by endoscopy in 2 patients with recanalization.

Conclusions: The occurrence of afferent limb recanalization after uncut Roux-en-Y reconstruction is high, and using additional staplers alone cannot decrease the incidence of recanalization. Based on our study, uncut Roux-en-Y reconstruction is not recommended.

Functional Outcomes of Delta-Shaped Anastomosis After Laparoscopic Distal Gastrectomy

BACKGROUND

We invented a simple and secure method of intracorporeal gastroduodenostomy, the delta-shaped anastomosis (DA), using endoscopic linear stapler only and standardized the DA procedure by resecting two-thirds of the stomach based on the anatomical landmarks. This study aimed to evaluate the feasibility of the standardized DA as the standard reconstruction procedure after a laparoscopic distal gastrectomy assessing functional outcomes including postoperative complications, body weight loss, nutritional status, and endoscopic findings.

METHODS

The medical records of 349 patients with gastric cancer who underwent laparoscopic distal gastrectomy from April 2011 to December 2017 at our hospital were retrospectively reviewed. Functional outcomes were assessed according to nutritional status and endoscopic findings.

RESULTS

The operation time was shorter and complication rate was lower in the standardized DA than those in Billroth-II (BII) and Roux-en-Y (RY). The body weight loss in DA was 10% 1 year postoperatively and remained stable during the follow-up period, which showed no significant difference. The endoscopic findings showed the ratio of residual food in DA was lower than that in RY (DA:RY = 13.3%:13.6% and 8.4%:33.3% at 1 and 3 years postoperatively, respectively). Severe gastritis was extremely rare in DA (6.7% at 1 year and 15.6% at 3 years postoperatively). Bile reflux was more often found in DA than RY (DA:RY = 19.9%:4.8% and 26.6%:0% at 1 and 3 years postoperatively, respectively). Reflux esophagitis was found 10% of DA only.

CONCLUSIONS

Functional outcomes of the standardized DA were satisfactory and feasible. Our intracorporeal Billroth-I reconstruction, by resecting two-thirds of the stomach, can be one of the standard reconstruction methods after a laparoscopic distal gastrectomy.

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

Background

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

Methods

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

Discussion

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

Trial Registration

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

Comparison of short-term outcomes between robotic and laparoscopic gastrectomy for gastric cancer: a propensity score-matching analysis

Robotic gastrectomy (RG) is increasingly performed based on expected benefits in short-term outcomes. However, it is still unclear if RG has any advantages over laparoscopic gastrectomy (LG). A retrospective cohort study was performed in patients who underwent minimally invasive gastrectomy between January 2012 and January 2020. A total of 366 patients were enrolled and short-term outcomes were compared between RG and LG. Propensity score matching was conducted to reduce selection bias based on age, sex, body mass index, performance status, physical status, clinical T, clinical N, clinical M, tumor location, neoadjuvant chemotherapy, type of gastrectomy, and extent of lymphadenectomy. A propensity score-matching algorithm was used to select 93 patients for each group. Estimated blood loss was smaller (0 vs. 37 mL, P = 0.001), length of hospital stay was shorter (10 vs. 12 days, P = 0.012), and the time until starting a soft diet was shorter (3 vs. 4 days, P = 0.001) in RG compared to LG. The overall complication rate was also lower in RG (9.7% vs 14.0%), but the difference was not significant. There was no mortality in either group. Total gastrectomy was an independent risk factor for postoperative complications. RG can be safely performed with a similar complication rate to that in LG and may permit faster postoperative recovery and a shorter hospital stay.

Long-Term Results and Current Problems in Laparoscopic Gastrectomy: Single-Center Experience

Introduction: The study aims to evaluate the long-term results of patients who underwent laparoscopic gastrectomy for gastric cancer in Ankara University Medical Faculty, Surgical Oncology Clinic, within 5 years. Materials and Methods: We retrospectively reviewed the data of patients who underwent laparoscopic gastrectomy for gastric cancer at the Surgical Oncology Clinic of Ankara University Medical Faculty between January 2014 and September 2019. One hundred forty-six patients were included in the study. Results: Fifty-one (34.9%) of the patients were female; 95 (65.1%) were male. The mean ± standard deviation and median (minimum-maximum) values of the patients were 60.92 ± 14.13 and 64.00 (22.00-93.00), respectively (Table 1). Eighty-seven (59.6%) cases were located in the antrum, 29 (19.9%) were in the cardia region, and 30 (20.5%) were in the corpus region. Overall, 106 (72.6%) of 146 patients were alive, while 40 (27.4%) were ex. The mean survival was 21.8 months (0-69). Postoperative mortality was seen in 9 patients (6.2%) and our disease-free survival rate was 70.5%. Recurrence occurred in 14 (9.6%) of all patients. [Table: see text] Conclusion: In conclusion, although laparoscopic gastrectomy is a reliable and feasible method for gastric cancer, the standardization of laparoscopic surgery is required in clinics.

The Learning Curve of Linear-Shaped Gastroduodenostomy Associated with Totally Laparoscopic Distal Gastrectomy

BACKGROUND

Linear-shaped gastroduodenostomy (LSGD) is a new method of intracorporeal reconstruction that is simpler to perform and associated with a lower rate of bile reflux than delta-shaped anastomosis. Here, we analyzed the learning curve of LSGD in totally laparoscopic distal gastrectomy.

METHODS

The cumulative sum method was used to retrospectively analyze consecutive gastric cancer patients undergoing intracorporeal gastroduodenostomy after distal gastrectomy between January 2009 and May 2016. The duration of surgery, postoperative complications, hospital stay, and endoscopic findings in the postoperative period and the first, third, and fifth year were evaluated according to the two phases of the learning curve (learning period versus mastery period).

RESULTS

Data from 222 patients were included in the analysis. The LSGD learning period was 29 cases. The surgical time in mastery period was significantly shorter than the learning period (124.9 ± 34.5 versus 168.2 ± 42.0 min, p < 0.001). The incidence of minor complications was significantly reduced after the learning period (p = 0.041), although there was no statistically significant difference in the rate of major complications. The long-term endoscopic findings showed that the presence of residual food decreased over the time (p = 0.022).

CONCLUSIONS

LSGD can be mastered easily after a reasonable number of cases and was associated with safe and satisfactory short- and long-term outcomes before and after learning curve.

The safety and feasibility of laparoscopic gastrectomy for gastric cancer in very elderly patients: short-and long-term outcomes

PURPOSE

It remains unclear whether laparoscopic gastrectomy (LG) for gastric cancer is a suitable treatment for very elderly (VE) patients. We aimed to assess the safety and feasibility of LG for gastric cancer in VE patients.

METHODS

We reviewed 226 consecutive patients who underwent LG between January 2010 and December 2016. We compared VE patients (age ≥ 80, n = 38) with non-elderly patients (age ≤ 79, n = 188).

RESULTS

An ASA-PS score ≥ 2 was more common in VE group (86.8 vs. 48.9%; P < 0.01). There were no significant differences in the operating time, blood loss, postoperative hospital stay, or postoperative morbidity between the groups. The 3-year survival rate and 3-year disease-specific survival rate were lower in the VE group (53.7 vs. 85.6%; P < 0.0001, 78.5 vs. 92.4%; P = 0.0116). A univariate analysis showed that PS scores ≥ 2, Charlson comorbidity index ≥ 4, and pN stage were independent predictors of decreased overall survival rates in the VE group. A multivariate analysis showed total gastrectomy, a Charlson comorbidity index ≥ 4, and the pN stage to be independent predictors in the VE group.

CONCLUSION

LG for gastric cancer is, thus, considered to be safe for patients aged 80 years or older. Total gastrectomy, a Charlson comorbidity index ≥ 4, and the pN stage were independent risk factors for a poor prognosis in these patients.

Intracorporeal esophagojejunostomy using a linear stapler in laparoscopic total gastrectomy: comparison with circular stapling technique

BACKGROUND

Laparoscopic total gastrectomy for gastric cancer is feasible but less commonly performed compared to laparoscopic distal gastrectomy due to technical difficulties such as reconstruction. There is no standard esophagojejunal anastomosis technique in laparoscopic total gastrectomy due to a lack of evidence.

METHODS

We retrospectively analyzed data from 213 patients with gastric cancer who underwent laparoscopic total gastrectomy from October 2012 to December 2016. Of these, 109 and 104 patients underwent esophagojejunostomy with linear and circular stapling, respectively. We compared short-term postoperative outcomes, including surgical complications and anastomosis costs between both groups.

RESULTS

The mean operation time in the linear stapler group was longer than the circular stapler group (Linear stapler, 235.3 ± 57.9 vs. Circular stapler, 217.1 ± 55.8 min; P = 0.021); however, D2 lymph node dissection was performed more in the linear stapler group (Linear stapler, 36.7% vs. Circular stapler, 23.1%; P = 0.030). There were two anastomosis leakages in each group (Linear stapler, 1.8% vs. Circular stapler, 1.9%; P > 0.999). Anastomosis stenosis only occurred in the circular stapler group (Linear stapler, 0% vs. Circular stapler, 7.7%; P = 0.003). Although the linear stapling technique used more stapler cartridges (Linear stapler, 7.6 ± 1.1 vs. Circular stapler, 4.8 ± 0.9; P < 0.001), costs related to anastomosis were lower in the linear stapler group (Linear stapler, 1,904,679 ± 342,116 vs. Circular stapler, 2,246,150 ± 427,136KRW; P < 0.001).

CONCLUSIONS

Esophagojejunostomy with the linear stapling technique reduces anastomosis stenosis in laparoscopic total gastrectomy. It can be recommended as a safe and more cost-effective method for esophagojejunal anastomosis.

Left Dorsal Wall Anastomosis Compared with Parallel-Line Anastomosis for Intracorporeal Overlap Esophagojejunostomy during Laparoscopic Total Gastrectomy

Purpose

This study evaluated the safety and efficacy of totally laparoscopic total gastrectomy (TLTG) with esophagojejunostomy by comparing left dorsal wall anastomosis (LDA) with parallel-line anastomosis (PA) methods.

Methods

We retrospectively reviewed 28 patients who underwent laparoscopic total gastrectomy (LTG) for gastric cancer from January 2017 to September 2018. The patients were divided into two groups according to type of operation: 15 patients underwent PA and 13 underwent LDA. Clinico­pathologic characteristics and surgical outcomes in the two groups were compared and analyzed.

Results

Surgical outcomes of estimated blood loss, operation time, and length of postoperative stay were similar between the two groups. In addition, there was no statistical difference in total operation time (186.5±37.0 min vs. 209.0±36.9 min, p=0.121) between the two groups. However, compared with the PA group, the LDA group required fewer additional stitches for reinforcement (p=0.002).

Conclusion

Intracorporeal reconstruction of esophagojejunostomy using an LDA method may be a feasible and easy technique for TLTG compared with the PA method. Additional studies with larger sample sizes are needed to further support these results.

Modified delta-shaped gastroduodenostomy consisting of linear stapling and single-layer suturing with the operator positioned between the patient's legs: A technique preventing intraoperative duodenal injury and postoperative anastomotic stenosis

Background

The drawback of the delta-shaped gastroduodenostomy (DSG) in totally laparoscopic distal gastrectomy (TLDG) is the presence of intraoperative duodenal injury and postoperative anastomotic stenosis, which can occur due to a relatively short duodenal bulb diameter.

Materials and methods

From June 2013 to June 2019, 35 patients with gastric cancer underwent TLDG with a modified DSG consisting of linear stapling and single-layer hand suturing in our institution. All anastomotic procedures were performed by the right hand of the operator positioned between the patient’s legs. Linear stapling of the posterior walls of the remnant stomach and duodenum without creating a gap was performed using a 45-mm linear stapler, considering the prevention of intraoperative duodenal injury. The stapler entry hole was closed using a single-layer full-thickness hand suturing technique with knotted sutures and a knotless barbed suture. We described the clinical data and outcomes in the present retrospective patient series.

Results

No intraoperative duodenal injury occurred in any of the 35 patients. The median staple length at linear stapling of the posterior walls of the remnant stomach and duodenum was 41.7 ± 4.2 (30–45) mm, and 2 patients (5.7%) had a staple length of 30 mm. There were no incidences of postoperative anastomotic stenosis.

Conclusions

We suggest that a modified DSG consisting of linear stapling and single-layer hand suturing performed by an operator positioned between the patient’s legs can be one option for B-Ⅰ reconstruction following TLDG because it can aid in preventing both intraoperative duodenal injury and postoperative anastomotic stenosis.

Linear or circular stapler? A propensity score-matched, multicenter analysis of intracorporeal esophagojejunostomy following totally laparoscopic total gastrectomy

BACKGROUND

Presently, there is no consensus as to what procedure of intracorporeal esophagojejunostomy (EJS) in totally laparoscopic total gastrectomy (TLTG) is best to reduce postoperative complications. The aim of this study was to demonstrate the superiority of linear stapled reconstruction in terms of anastomotic-related complications for EJS in TLTG.

METHODS

We collected data on 829 consecutive gastric cancer patients who underwent TLTG reconstructed by the Roux-en-Y method with radical lymphadenectomy between January 2010 and December 2016 in 13 hospitals. The patients were divided into two groups according to reconstruction method and matched by propensity score. Postoperative EJS-related complications were compared between the linear stapler (LS) and the circular stapler (CS) groups.

RESULTS

After matching, data from 196 patients in each group were analyzed. The overall incidence of EJS-related complications was significantly lower in the LS group than in the CS group (4.1% vs. 11.7%, p = 0.008). The incidence of EJS anastomotic stenosis during the first year after surgery was significantly lower in the LS group than in the CS group (1.5% vs. 7.1%, p = 0.011). The incidence of EJS bleeding did not differ significantly between the groups, although no bleeding was observed in the LS group (0% vs. 2.0%, p = 0.123). The incidence of EJS leakage did not differ significantly between the groups (2.6% vs. 3.6%, p = 0.771).

CONCLUSION

The use of linear stapled reconstruction is safer than the use of circular stapled reconstruction for intracorporeal EJS in TLTG because of its lower risks of stenosis.

Feasibility of Linear-Shaped Gastroduodenostomy during the Performance of Totally Robotic Distal Gastrectomy

Purpose

Although linear-shaped gastroduodenostomy (LSGD) was reported to be a feasible and reliable method of Billroth I anastomosis in patients undergoing totally laparoscopic distal gastrectomy (TLDG), the feasibility of LSGD for patients undergoing totally robotic distal gastrectomy (TRDG) has not been determined. This study compared the feasibility of LSGD in patients undergoing TRDG and TLDG.

Materials and Methods: All c

onsecutive patients who underwent LSGD after distal gastrectomy for gastric cancer between January 2009 and December 2017 were analyzed retrospectively. Propensity score matching (PSM) analysis was performed to reduce the selection bias between TRDG and TLDG. Short-term outcomes, functional outcomes, learning curve, and risk factors for postoperative complications were analyzed.

Results

This analysis included 414 patients, of whom 275 underwent laparoscopy and 139 underwent robotic surgery. PSM analysis showed that operation time was significantly longer (163.5 vs. 132.1 minutes, P<0.001) and postoperative hospital stay significantly shorter (6.2 vs. 7.5 days, P<0.003) in patients who underwent TRDG than in patients who underwent TLDG. Operation time was the independent risk factor for LSGD after intracorporeal gastroduodenostomy. Cumulative sum analysis showed no definitive turning point in the TRDG learning curve. Long-term endoscopic findings revealed similar results in the two groups, but bile reflux at 5 years showed significantly better improvement in the TLDG group than in the TRDG group (P=0.016).

Conclusions

LSGD is feasible in TRDG, with short-term and long-term outcomes comparable to that in TLDG. LSGD may be a good option for intracorporeal Billroth I anastomosis in patients undergoing TRDG.

Functional Outcomes of Billroth I Gastroduodenostomy Using Linear Staplers in Totally Laparoscopic Distal Gastrectomy

BACKGROUND/AIM

This study examined whether functional outcomes of linear-stapled Billroth I (LS-BI) in totally laparoscopic distal gastrectomy (TLDG) are comparable to those of circular-stapled Billroth I (CS-BI) in laparoscopy-assisted distal gastrectomy (LADG).

PATIENTS AND METHODS

This was a retrospective study of patients with gastric cancer undergoing TLDG with LS-BI (n=50) or LADG with CS-BI (n=50). Postoperative endoscopic findings of the remnant stomach and nutritional status were evaluated.

RESULTS

The occurrence of grade 2 or more severe remnant gastritis in the LS-BI group (46.0%) was significantly higher than that in the CS-BI group (18.0%) (p=0.005), whereas there was no significant difference in the incidence of residual food and bile reflux between the two groups. Postoperative changes in body weight, and serum albumin and total protein levels were similar between the two groups.

CONCLUSION

TLDG with LS-BI may be a good alternative to LADG with CS-BI because of its comparable nutritional outcomes, but with a higher occurrence of remnant gastritis.

Esophagojejunal Anastomosis after Laparoscopic Total Gastrectomy for Gastric Cancer: Circular versus Linear Stapling

Purpose

No standard technique has been established for esophagojejunal anastomosis during laparoscopic total gastrectomy (LTG) for gastric cancer owing to the technical difficulty and high complication rate of this procedure. This study was performed to compare the short-term outcomes of circular and linear stapling methods after LTG.

Materials and Methods

A total of 106 patients treated between July 2010 and July 2018 were divided into 2 groups according to the following anastomosis procedures: hemi-double-stapling technique (HDST; circular stapling method; group C, n=77) or overlap method (linear stapling method; group L, n= 29). The clinicopathological features and postoperative outcomes, including complications, were analyzed. Multivariate analysis was performed using a logistic regression model to identify the independent risk factors for anastomotic complications.

Results

The incidence of anastomotic complications was significantly higher in group C than in group L (28.0% vs. 6.9%, P=0.031). The incidence of anastomosis leakage did not differ between the groups (6.5% vs. 6.9%, P=1.000). However, anastomosis stricture occurred only in group C (13% vs. 0%, P=0.018). Multivariate analysis showed that the anastomosis type was significantly related to the risk of anastomotic complications (P=0.045).

Conclusions

The overlap method was superior to the HDST with respect to anastomotic complications, especially anastomosis stricture.

Uncut Roux-en-Y Reconstruction in a Laparoscopic Distal Gastrectomy: A Single-Center Study of 228 Consecutive Cases and Short-Term Outcomes

Aims. We have established a procedure for uncut Roux-en-Y gastrojejunostomy after laparoscopic distal gastrectomy. This study aimed to evaluate the safety and technical feasibility of the procedure for patients with distal gastric cancer according to the short-term outcomes. Methods. Two hundred and twenty-eight consecutive patients who underwent a laparoscopic distal gastrectomy with uncut Roux-en-Y gastrojejunostomy from September 2014 to August 2018 were reviewed retrospectively. All the laparoscopic operations were performed successfully without conversion to open surgery. Results. The mean operative duration was 178.28 ± 32.82 minutes, the mean anastomotic process duration was 28.22 ± 7.50 minutes, the average blood loss was 48.97 ± 29.16 mL, and the overall number of lymph nodes harvested was 37.16 ± 11.47. The mean time of out-of-bed ambulation, anal exsufflation, liquid-diet intake, and duration of hospital stay were 41.99 ± 18.37 hours, 69.57 ± 23.17 hours, 5.06 ± 1.09 days, and 8.77 ± 2.42 days, respectively. Fifteen patients suffered postoperative complications, and the overall incidence rate was 6.58% (15/228). Seventeen patients experienced afferent recanalization, the mean time of which was 11 months after the operation. Conclusion. The laparoscopic uncut Roux-en-Y reconstruction is safe and technically feasible, and it has inspiring short-term outcomes for patients undergoing distal gastrectomy.

Short-Term Outcomes of Intracorporeal Delta-Shaped Gastroduodenostomy Versus Extracorporeal Gastroduodenostomy after Laparoscopic Distal Gastrectomy for Gastric Cancer

Background

Billroth I anastomosis is one of the most common reconstruction methods after distal gastrectomy for gastric cancer. Intracorporeal Billroth I (ICBI) anastomosis and extracorporeal Billroth I (ECBI) anastomosis are widely used in laparoscopic surgery. Here we compared ICBI and ECBI outcomes at a major gastric cancer center.

Methods

We retrospectively analyzed data from 2,284 gastric cancer patients who underwent laparoscopic distal gastrectomy between 2009 and 2017. We divided the subjects into ECBI (n=1,681) and ICBI (n=603) groups, compared the patients' clinical characteristics and surgical and short-term outcomes, and performed risk factor analyses of postoperative complication development.

Results

The ICBI group experienced shorter operation times, less blood loss, and shorter hospital stays than the ECBI group. There were no clinically significant intergroup differences in diet initiation. Changes in white blood cell counts and C-reactive protein levels were similar between groups. Grade II-IV surgical complication rates were 2.7% and 4.0% in the ECBI and ICBI groups, respectively, with no significant intergroup differences. Male sex and a body mass index (BMI) ≥30 were independent risk factors for surgical complication development. In the ECBI group, patients with a BMI ≥30 experienced a significantly higher surgical complication rate than those with a lower BMI, while no such difference was observed in the ICBI group.

Conclusion

The surgical safety of ICBI was similar to that of ECBI. Although the chosen anastomotic technique was not a risk factor for surgical complications, ECBI was more vulnerable to surgical complications than ICBI in patients with a high BMI (≥30).

Feasibility of robotic radical gastrectomy using a monopolar device for gastric cancer

PURPOSES

Laparoscopic gastrectomy using ultrasonic devices occasionally causes postoperative pancreatic fistula. Robotic gastrectomy using monopolar scissors may reduce intraoperative injury to the pancreas. We evaluated the safety and feasibility of robotic gastrectomy.

METHODS

A multicenter prospective study was conducted to evaluate the surgical outcomes of robotic gastrectomy. The primary endpoints were the incidence of intraoperative and postoperative complications and operative mortality.

RESULTS

A total of 115 patients were enrolled. The clinical T stages were T1 in 68 patients and T2 or higher in 47 patients. The types of surgery included distal gastrectomy (n = 72), total gastrectomy (n = 39), and proximal gastrectomy (n = 4). Two patients developed intraoperative complications (1.7%), but no cases required conversion to open surgery. The amylase concentration in drainage fluid was higher in cases with pancreatic compression, especially in those with compression for longer than 20 min. Postoperative complications of Clavien-Dindo grade ≥ II occurred in 11 patients (9.6%). There was no mortality. A multivariate analysis indicated that a high body mass index and pancreatic compression by an assistant for longer than 20 min were independent risk factors for postoperative complications (P = 0.029 and P = 0.010).

CONCLUSIONS

Robotic gastrectomy using monopolar scissors is safe and feasible. Robotic dissection without compression of the pancreas may reduce postoperative complications.

Three-dimensional Stereoscopic Visualization Shortens Operative Time in Laparoscopic Gastrectomy for Gastric Cancer

Laparoscopic gastrectomy for gastric cancer is now widely accepted and has become a standard surgery. This study investigated the advantages of three-dimensional (3D) stereoscopic visualization for laparoscopic gastrectomy over a conventional two-dimensional (2D) planar screen. The primary outcome of this study was operative time. Ninety-four consecutive cases of gastric cancer patients who underwent laparoscopic total gastrectomy (LTG) (25 cases) or laparoscopic distal gastrectomy (LDG) (69 cases) were enrolled in this study before and after the introduction of the 3D system. Operative time was significantly shorter in the 3D groups for both LTG (351 vs. 406 min, P = 0.026) and LDG (269 vs. 344 min, P < 0.01). During intracorporeal procedures, dissection time was significantly shorter in the 3D groups for both LTG (183 vs. 232 min, P = 0.011) and LDG (161 vs. 213 min, P < 0.01), although the time needed for anastomosis was similar between the groups. However, operators preferred intracorporeal knot-tying as a ligature for anastomosis under 3D (LTG, P = 0.012; LDG, P < 0.01). These data suggest that 3D stereoscopic visualization shortens the operative time of laparoscopic gastrectomy by reducing the intracorporeal dissection time.

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

Background and objective

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

Methods

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

Results

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

Conclusions

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

Internal hernia after gastrectomy for gastric cancer in minimally invasive surgery era

BACKGROUND

The incidence and clinical presentation of internal hernia after gastrectomy have been changing in the minimally invasive surgery era. This study aimed to analyze the clinical features and risk factors for internal hernia after gastrectomy for gastric cancer.

METHODS

We retrospectively analyzed internal hernia after gastrectomy for gastric cancer in 6474 patients between January 2003 and December 2016 at Seoul National University Bundang Hospital. Multivariable logistic regression was performed to evaluate risk factors.

RESULTS

Internal hernias identified by computed tomography or surgical exploration were 111/6474 (1.7%) and the median interval time was 450 days after gastrectomy. Fourteen (0.9%) of the 1510 patients who underwent open gastrectomy and 97 (2.0%) of the 4964 patients who underwent laparoscopic gastrectomy developed internal hernia. Of the 6474 patients, internal hernia developed in 0 (0%), 9 (1.1%), 40 (3.1%), 56 (3.3%), 6 (2.3%), and 0 (0%) patients who underwent Billroth I, Billroth II, Roux-en-Y, uncut Roux-en-Y, double tract, and esophagogastrostomy reconstructions, respectively. Fifty-nine (53.2%) of 111 patients with symptomatic hernia underwent surgery. Of the 59 internal hernias, treated surgically, 32 (53.2%), 27 (45.8%), and 0 (0%) were identified in jejunojejunostomy mesenteric, Petersen's, and transverse colon mesenteric defects, respectively. In multivariate analysis, non-closure of mesenteric defects (P < 0.01), laparoscopic approach (P < 0.01), and totally laparoscopic approach (P = 0.03) were independent risk factors for internal hernia.

CONCLUSIONS

The potential spaces such as Petersen's, jejunojejunostomy mesenteric, and transverse colon mesenteric defects should be closed to prevent internal hernia after gastrectomy for gastric cancer.

The crossover technique for intracorporeal esophagojejunostomy following laparoscopic total gastrectomy: a simple and safe technique using a linear stapler and two barbed sutures

BACKGROUND

Totally laparoscopic gastrectomy (LG) is preferred over open gastrectomy because it allows safe anastomosis, a small wound, and early bowel recovery. However, esophagojejunostomy (EJS) following laparoscopic total gastrectomy (LTG) remains technically challenging. To popularize LTG, a secure method of reconstruction must be developed. We present a simple and safe technique for intracorporeal EJS following LTG.

METHODS

Our modified technique for intracorporeal EJS as a part of Roux-en-Y reconstruction following LTG incorporates an isoperistaltic stapled EJS with closure of the entry hole using two unidirectional barbed sutures. First, a side-to-side isoperistaltic EJS is created between the dorsal and left side of the esophagus and the jejunal arm. Second, the opening for the stapler is closed with a two-layer continuous suture using two 15-cm 3-0 V-Loc suture devices. The full-thickness inner layer closure commences from the sides of the staple lines and progresses toward the center of the enterotomy. During suturing, the remaining thread is utilized to apply tension and lift the enterotomy. Once the full-thickness layer closure is complete at the center of the enterotomy, suturing of the second seromuscular layer is started in the forward direction toward each corner to give a crossover-shaped suturing line.

RESULTS

From February 2012 to October 2017, 27 patients with gastric cancer underwent LTG with intracorporeal stapled EJS as a part of Roux-en-Y reconstruction. All procedures were successfully performed without any intra- or postoperative anastomosis-related complications. No conversion to other procedures was required. The mean suturing time was 19.1 ± 9.5 min. The mean postoperative time to tolerating a liquid diet was 3.3 days, and the mean hospital stay was 12.1 days.

CONCLUSIONS

We herein report our procedure for intracorporeal EJS using a linear stapler and barbed sutures. This technique is simple and feasible and has acceptable morbidity.

A New Robot-assisted Billroth-I Reconstruction: Details of the Technique and Early Results

BACKGROUND

Laparoscopic surgery for gastric tumor is considered a demanding procedure because of lymph node dissection and reconstruction. Billroth-I (B-I) reconstruction after laparoscopic distal gastrectomy is commonly performed extracorporeally because of the complexity of an intracorporeal procedure. Robotic surgery overcomes some limitations of laparoscopy, allowing to reproduce the basic maneuvers of open surgery. We describe a new technique to perform robotic B-I anastomosis.

METHODS

Between January 2012 and February 2015, 5 patients underwent distal gastrectomy with intracorporeal B-I-stapled anastomosis. Patient demographics, tumor characteristics, histopathologic features, and perioperative data were analyzed.

RESULTS

Median operative time was 170 minutes (145 to 180 min). There were no conversions. Contrast swallow was routinely performed on the third postoperative day. Median postoperative hospitalization was 7 days (range: 6 to 8). No major complications or mortality were observed.

CONCLUSIONS

Robotic distal gastrectomy with intracorporeal B-I anastomosis is a safe and promising technique in selected cases of gastric tumors.

Circular versus linear stapling in esophagojejunostomy after laparoscopic total gastrectomy for gastric cancer: a propensity score-matched study

PURPOSE

We used propensity score matching to compare the complication rates after laparoscopic total gastrectomy (LTG) with esophagojejunostomy (EJS) performed using a circular or a linear stapler.

METHODS

We retrospectively enrolled all patients who underwent curative LTG between November 2004 and March 2016. Patients were categorized into the circular and linear groups according to the stapler type used for the subsequent EJS. Patients in the groups were matched using the following propensity score covariates: age, sex, body mass index, American Society of Anesthesiologists physical status, extent of lymph node dissection, and Japanese Classification of Gastric Carcinoma stage. Clinicopathological characteristics and surgical outcomes were compared.

RESULTS

We identified 66 propensity score-matched pairs among 379 patients who underwent LTG. There was no significant between-group difference in the median operative time, extent of lymph node dissection, number of lymph nodes resected, rate of conversion to open surgery, or number of surgeries performed by a surgeon certified by the Japanese Society of Endoscopic Surgery. In the circular and linear groups, the rate of all complications (Clavien-Dindo [CD] classification ≥ I; 21 vs. 26%, respectively; p = 0.538), complications more severe than CD grade III (14 vs. 14%, respectively; p = 1.000), and occurrence of EJS leakage and stenosis more severe than CD grade III (5 vs. 2%, p = 0.301; 9 vs. 8%, p = 0.753, respectively) were comparable.

CONCLUSIONS

There is no difference in the postoperative complication rate related to the type of stapler used for EJS after LTG.

National Trend in Laparoscopic Gastrectomy for Gastric Cancer: Analysis of the National Register in Chile

INTRODUCTION

The laparoscopic approach for the treatment of gastric cancer has many advantages. However, outside Asia there are few large case series.

AIM

To evaluate postoperative morbidity, long-term survival, changes in indication, and the results of laparoscopic gastrectomy.

METHODS

We included all patients treated with a laparoscopic gastrectomy from 2005 to 2014. We compared results across 2 time periods: 2005-2011 and 2012-2014. Median follow-up was 39 months.

RESULTS

Two hundred and eleven patients underwent a laparoscopic gastrectomy (median age 64 years, 55% male patients). In 135 (64%) patients, a total gastrectomy was performed. Postoperative morbidity occurred in 29%. A significant increase in the indication of laparoscopic surgery for stages II-III (32 vs. 45%; p = 0.04) and higher lymph node count (27 vs. 33; p = 0.002) were observed between the 2 periods. The 5-year overall survival was 72%. According to the stage, the 5-year overall survival was 85, 63, and 54% for stage I, II, and III respectively (p < 0.001).

CONCLUSIONS

There was an acceptable rate of postoperative complications and the long-term survival was in accordance with the disease stage. There was a higher indication of laparoscopic surgery in stages II-III disease, and higher lymph node count in the latter period of this study.

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.

Combat with esophagojejunal anastomotic leakage after total gastrectomy for gastric cancer: A critical review of the literature

Esophagojejunal anastomotic leakage (EJAL) is considered to be one of the most serious complications after total gastrectomy (TG), despite improvements in surgical instruments and technique. The occurrence of EJAL would cause poorer quality of life, prolonged hospital stay, and increased surgery-related costs and mortality. Although there is ever-increasing knowledge about EJAL, the optimal management is controversial. In the present review, we aim to demonstrate the effective management by focus on the possible risk factors, potentially useful preventive strategies, and several kinds of treatments in esophagojejunal anastomotic leakage after total gastrectomy for gastric cancer.

Two-Layer Hand-Sewn Esophagojejunostomy in Totally Laparoscopic Total Gastrectomy for Gastric Cancer

Purpose

Different esophagojejunostomy (EJ) reconstruction methods are used after totally laparoscopic total gastrectomy (TLTG), and none is considered a standard technique. This report describes a 2-layer hand-sewn EJ technique during TLTG; we also evaluated postoperative morbidity associated with this technique.

Materials and Methods

This retrospective cohort study included all consecutive patients who underwent TLTG for gastric cancer (GC) from 2012 to 2016 at 2 affiliated teaching hospitals. All participating surgeons performed standardized intracorporeal 2-layer hand-sewn EJ.

Results

We included 51 patients who underwent TLTG for GC and standardized EJ anastomosis. Twenty-seven (53%) were male, and the median age was 60 (36–87) years. The average operative time was 337±71 minutes and intraoperative bleeding was 160±107 mL. There were no open conversions related to EJ. Postoperative morbidity was observed in 9 (17.0%) patients. There was no postoperative mortality. EJ leakage was observed in 2 patients (3.8%) and 1 patient (1.9%) developed EJ stenosis. Patients with leakage were managed non-operatively and the patient with stenosis required endoscopic dilation. The median length of hospital stay was 8 (6–29) days.

Conclusions

Two-layer hand-sewn EJ during TLTG for GC is a feasible and safe technique. This method avoids a laparotomy for reconstruction and the disadvantages associated with laparoscopic introduction of mechanical staplers for EJ, and provides an alternative for alimentary tract reconstruction after TLTG.