Intracorporeal Isosceles Right Triangle-shaped Anastomosis in Totally Laparoscopic Distal Gastrectomy. Surg Laparosc Endosc Percutan Tech. 2018;28:193-201. [PMID: 29738380 DOI: 10.1097/sle.0000000000000535]

Impact of the endoscopic surgical skill qualification system on the oncological safety of laparoscopic gastrectomy for gastric cancer: A single-center retrospective cohort study

BACKGROUND

This study aimed to investigate the laparoscopic gastrectomy (LG) performance of non-Endoscopic Surgical Skill Qualification System (ESSQS)-qualified surgeons under the ESSQS-qualified surgeon guidance and compare oncological outcomes of gastric cancer to LG performed by the ESSQS-qualified surgeons.

METHODS

This study enrolled 1,030 patients diagnosed with both clinical and pathological stage ≤ III gastric cancer and undergoing LG from January 2009 to June 2019. ESSQS-qualified surgeons served as the operator or the instructive assistant in all LG procedures involving them. A propensity score-matched analysis was used to retrospectively compare the long-term outcomes between the ESSQS-qualified and non-ESSQS-qualified surgeons.

RESULTS

Each group included 315 pairs after propensity score matching. The 3-year recurrence-free survival rates were 84.4% and 81.7% in the non-ESSQS and ESSQS groups, respectively. The difference was 2.7% (95% confidence interval: - 3.20%-8.44%, P < 0.001), and the non-ESSQS group statistically demonstrated noninferiority as the lower 95% confidence limit was greater than the prespecified margin of -10%, indicating the achieved primary endpoint. No significant differences in 5-year recurrence-free survival (non-ESSQS: 78.5% vs. ESSQS: 77.4%, P = 0.627) and 5-year overall survival (non-ESSQS: 80.9% vs. ESSQS: 79.3%, P = 0.475) were found between the two groups. The oncological outcomes stratified according to the presence of pathological stage I, II, and III disease did not significantly differ between the two groups.

CONCLUSIONS

LG performed by non-ESSQS-qualified surgeons achieved comparable oncological outcomes to the ESSQS-qualified surgeons, as long as ESSQS-qualified surgeons provided intraoperative instructions, in a high-volume center.

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.

Billroth-II modified with hinged anti-peristaltic afferent loop versus Roux-en-Y reconstruction after distal gastrectomy for gastric cancer: A propensity-score match analysis

BACKGROUND

This study aimed to evaluate the effectiveness of modified Billroth-II with a hinged anti-peristaltic afferent loop by comparing it with the Roux-en-Y method.

METHODS

We retrospectively analyzed 344 patients with gastric cancer who underwent distal gastrectomy between 2016 and 2021. Propensity score matching was conducted to balance baseline characteristics.

RESULTS

After propensity score matching, there were 117 patients in each group. The Billroth-II group was significantly better regarding operating time (184.7 vs 225.3 minutes), postoperative hospital stays (7.9 vs 9.2 days), and time to semi-solid diet tolerance (2.8 vs 3.8 days). The Billroth-II group demonstrated comparable results with the Roux-en-Y group in weight loss, hemoglobin changes, reflux esophagitis, food residue, and gastritis severity. Presentation of bile in gastric remnant was significantly higher in the Billroth-II group (42.9% vs 10.3%).

CONCLUSION

There were no significant differences in functional outcomes between Billroth-II and Roux-en-Y reconstructions. The Billroth-II was superior to Roux-en-Y in operating time, hospital stays, and time to semi-solid diet tolerance. The Billroth-II could be considered an acceptable alternative reconstruction after distal gastrectomy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Safe implementation of robotic distal gastrectomy performed by non-endoscopic surgical skill qualification system-qualified surgeons

PURPOSE

Robotic gastrectomy (RG) for gastric cancer (GC) was approved for national medical insurance coverage in April, 2018, since when its use has increased dramatically throughout Japan. However, the safety of RG performed by surgeons who are not Endoscopic Surgical Skill Qualification System (ESSQS)-qualified has yet to be established. We conducted this study to verify the short-term outcomes of the initial series of RG procedures performed by non-ESSQS-qualified surgeons.

METHODS

Between January, 2020 and December, 2021, 30 patients with clinical Stage I and II GC underwent RG performed by four non-ESSQS-qualified surgeons according to the Japan Society for Endoscopic Surgery guideline. We evaluated, retrospectively, the morbidity rates according to Clavien-Dindo (CD) classification grade II or higher.

RESULTS

Each operating surgeon completed all procedures without any serious intraoperative adverse events. The median operative time, console time, and estimated blood loss were 413 (308-547) min, 361 (264-482) min, and 25.5 (4-167) mL, respectively. No patient required conversion to laparoscopic or open surgery. Three (10%) patients suffered CD grade II complications postoperatively. The median postoperative hospitalization was 11 (8-51) days.

CONCLUSION

Non-ESSQS-qualified surgeons trained by expert RG surgeons could perform robotic distal gastrectomy safely for initial cases.

Totally laparoscopic resection using delta-shaped anastomosis of jejunal leiomyosarcoma with intussusception at the angle of Treitz: a case report

Background

A leiomyosarcoma of the gastrointestinal tract is extremely rare. We report a case of jejunal leiomyosarcoma with intestinal intussusception at the angle of Treitz that was successfully treated with laparoscopic resection followed by intracorporeal reconstruction using a delta-shaped anastomosis.

Case presentation

A 54-year-old man was referred to our hospital due to fatigue and loss of appetite. Blood tests showed anemia. Enteroscopy and subsequent enterography using meglumine sodium amidotrizoate showed easily hemorrhagic tumor (10 cm in diameter) in the jejunum just beyond the angle of Treitz. Contrast-enhanced computed tomography revealed jejunojejunal intussusception. Histopathological examination of a biopsy specimen revealed a leiomyosarcoma. Laparoscopic resection of the tumor without reduction of the intussusception was performed. The resected line of the proximal intestine was very close to the ligament of Treitz in the present case. Intracorporeal jejunojejunostomy was completed using a delta-shaped anastomosis, wherein anastomosis was performed between the posterior walls of the proximal and distal jejunums after minimal mobilization around the ligament of Treitz. The patient’s postoperative course was uneventful, and he was discharged at 10 days postoperatively. No recurrence has been observed within 2 years after surgery.

Conclusions

We present a case in which a totally laparoscopic surgery for leiomyosarcoma located at the angle of Treitz with jejunojejunal intussusception was performed successfully.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

INTRODUCTION

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

MATERIALS AND SURGICAL TECHNIQUES

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

DISCUSSION

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

Intracorporeal gastrojejunostomy in Roux-en-Y reconstruction with its efferent loop located on the patient's left side following totally laparoscopic distal gastrectomy: A case report

The drawback of intracorporeal gastrojejunostomy using only endoscopic linear staplers in antecolic Roux-en-Y (R-Y) reconstruction with its efferent loop located on the patient's left side following totally laparoscopic distal gastrectomy (TLDG) is the occurrence of anastomotic failure, even though this reconstruction system is assumed to prevent intraoperative and postoperative twisting of the gastrojejunostomy and lifted jejunum. This case report presents two patients with gastric cancer who underwent intracorporeal gastrojejunostomy consisting of linear stapling and hand suturing in antecolic R-Y reconstruction with its efferent loop located on the patient's left side following TLDG to prevent anastomotic failure of the gastrojejunostomy. After the sacrificed jejunum was created, linear stapling of the greater curvature of the remnant stomach and the lifted jejunum without dividing the jejunum was performed. After removing the sacrificed jejunum and creating a good view of the posterior side of the stapler entry hole, the stapler entry hole was closed from the posterior side to the anterior side, using a single-layer full-thickness and serosubmucosal hand suturing technique with knotted sutures and a knotless barbed suture. No anastomotic failure of the gastrojejunostomy occurred in either patient. Intracorporeal gastrojejunostomy consisting of linear stapling and hand suturing could be an option for gastrojejunostomy in antecolic R-Y reconstruction with its efferent loop located on the patient's left side following TLDG because it can aid in the prevention of anastomotic failure.

The safe performance of robotic gastrectomy by second-generation surgeons meeting the operating surgeon's criteria in the Japan Society for Endoscopic Surgery guidelines

BACKGROUND

Robotic gastrectomy (RG) for gastric cancer (GC) has gradually gained nationwide prominence following 2011 guidelines from the Japan Society for Endoscopic Surgery (JSES), including the surgeons' criteria and the proctor system. In this retrospective study, we examined the short-term outcomes of the initial series of RGs performed by second-generation operating surgeons trained within our institute.

METHODS

Between January 2017 and April 2020, five surgeons each performed RG in 20 patients with clinical stage III or lower GC in accordance with the JSES guidelines. We evaluated both the rate of Clavien-Dindo grade II or higher morbidities and the console time required to reach the learning plateau via cumulative summation (CUSUM) analysis.

RESULTS

We observed no mortality and 3% of morbidity following RG. Both the operative time (430 vs 387.5 min, P = 0.019) and console time (380 vs . 331.5 min, P = 0.009) were significantly shorter in the second 10 cases than in the initial 10 cases. We observed a remarkable trend in cases of distal gastrectomy (DG), in which the total operative time and console time were significantly shorter in the later cases. Our CUSUM analysis revealed that seven cases were required to achieve a learning plateau in RG when confined to DG.

CONCLUSIONS

Non-expert RG surgeons meeting the operating surgeon's criteria from the JSES who had trained under an expert RG surgeon safely performed RG in an initial 20 cases.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Hepatic Left Lateral Segment Inverting Method Offering a Wider Operative Field of View During Laparoscopic Proximal Gastrectomy

BACKGROUND

In laparoscopic proximal gastrectomy, the hepatic left lateral segment often obstructs the operative field of view, especially around the esophageal hiatus. Therefore, a safe retraction method is needed. The present study aimed to determine the effectiveness of inverting the hepatic left lateral segment in laparoscopic proximal gastrectomy.

METHODS

This was a retrospective review of 81 consecutive patients who underwent laparoscopic proximal gastrectomy. Patients were divided into two groups, i.e., the Nathanson liver retractor group (n = 41) and hepatic left lateral segment inverting group (n = 40). The unedited video recordings of the procedures and the patients' medical records were reviewed and compared.

RESULTS

The hepatic left lateral segment inverting method provided a more satisfactory view of the operative fields and a wider working space around the esophageal hiatus than the Nathanson liver retractor. No intraoperative hepatic congestion and significantly improved postoperative liver enzyme elevations were observed with hepatic left lateral segment inverting method compared with the Nathanson liver retractor method.

CONCLUSIONS

In laparoscopic proximal gastrectomy, the hepatic left lateral segment inverting method appears to provide improvements in both the operative field of view and liver protection compared with the Nathanson liver retractor method.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Laparoscopic gastrectomy using intracorporeally hand-sewn anastomosis of esophagojejunostomy, gastroduodenostomy, or gastrojejunostomy for gastric cancer

Laparoscopic gastrectomy (LG) using intracorporeal anastomosis has recently become more prevalent due to the advancements of laparoscopic surgical instruments. However, intracorporeally hand-sewn anastomosis (IHSA) is still uncommon because of technical difficulties. In this study, we evaluated various types of IHSA following LG with respect to the technical aspects and postoperative outcomes.Seventy-six patients who underwent LG using IHSA for treatment of gastric cancer between September 2014 and June 2018 were enrolled in this study. We described the details of IHSA in step-by-step manner, evaluated the clinicopathological data and surgical outcomes, and summarized the clinical experiences.Four types of IHSA have been described: one for total gastrectomy (Roux-en-Y) and 3 for distal gastrectomy (Roux-en-Y, Billroth I, and Billroth II). The mean operation time and anastomotic time was 288.7 minutes and 54.3 minutes, respectively. Postoperative complications were observed in 13 patients. All of the patients recovered well with conservative surgical management. There was no case of conversion to open surgery, anastomotic leakage, or mortality.LG using IHSA was safe and feasible and had several advantages compared to mechanical anastomosis. The technique lengthened operating time, but this could be mitigated by increased surgical training and experience.