Laparoscopic Total Gastrectomy for Remnant Gastric Cancer: A Single-institution Experience and Systematic Literature Review

The safety, feasibility, and oncological outcomes of laparoscopic completion total gastrectomy for remnant gastric cancer: a prospective study with 3-year follow-up (FUGES-004 study)

BACKGROUND

The efficacy of laparoscopic completion total gastrectomy (LCTG) for remnant gastric cancer (RGC) remains controversial.

METHODS

The primary outcome was postoperative morbidity within 30 days after surgery. Secondary outcomes included 3-year disease-free survival (DFS), 3-year overall survival (OS), and recurrence. Inverse probability treatment weighted (IPTW) was used to balance the baseline between LCTG and OCTG.

RESULTS

Final analysis included 46 patients with RGC who underwent LCTG at the FJMUUH between June 2016 and June 2020. The historical control group comprised of 160 patients who underwent open completion total gastrectomy (OCTG) in the six tertiary teaching hospitals from CRGC-01 study. After IPTW, no significant difference was observed between the LCTG and OCTG groups in terms of incidence (LCTG vs. OCTG: 28.0 vs. 35.0%, P =0.379) or severity of complications within 30 days after surgery. Compared with OCTG, LCTG resulted in better short-term outcomes and faster postoperative recovery. However, the textbook outcome rate was comparable between the two groups (45.9 vs. 32.8%, P =0.107). Additionally, the 3-year DFS and 3-year OS of LCTG were comparable to those of OCTG (DFS: log-rank P =0.173; OS: log-rank P =0.319). No significant differences in recurrence type, mean recurrence time, or 3-year cumulative hazard of recurrence were observed between the two groups (all P >0.05). Subgroup analyses and concurrent comparisons demonstrated similar trends.

CONCLUSIONS

This prospective study suggested that LCTG was noninferior to OCTG in both short-term and long-term outcomes. In experienced centers, LCTG may be considered as a viable treatment option for RGC.

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.

The Effect of Surgical Approach on Clinical Outcomes in 535 Patients with Remnant Gastric Cancer

Purpose: This study aimed to evaluate the effect of laparoscopic gastrectomy (LG) and open gastrectomy (OG) on clinical outcomes in patients with remnant gastric cancer (RGC). Materials and Methods: The databases of PubMed, EMBASE, and Cochrane Library were used to search for eligible studies from inception to April 1st, 2023. Hazard ratios (HRs), mean difference (MD), odds ratios (OR), and 95% confidence intervals (CIs) were pooled up to analyze. The Newcastle-Ottawa Scale (NOS) scores were used to evaluate the quality of the included studies. This study was performed with RevMan 5.3 (The Cochrane Collaboration, London, United Kingdom) software. Results: A total of 11 studies involving 535 RGC patients were included in this study. In terms of basic information, we found that the OG group had a higher American Society of Anesthesiologists (ASA) grade (≥2) (OR = 0.24, I2 = 54%, 95% CI = 0.08-0.71, P = .01) than the LG group. In terms of postoperative outcomes, we found that the LG group had longer operative time (MD = 33.95, I2 = 58%, 95% CI = 15.05-52.85, P < .01), shorter postoperative hospital stay (MD = 5.08, I2 = 84%, 95% CI = -9.74 to -0.42, P = .03), shorter length of incision (MD = -7.15, I2 = 94%, 95% CI = -10.99 to -3.31, P < .01), earlier food intake (MD = -3.09, I2 = 76%, 95% CI = -4.84 to -1.35, P < .01), and earlier time to first flatus (MD = -0.84, I2 = 0%, 95% CI = -1.09 to -0.59, P < .01). We found that there was no statistically significant difference in overall survival (HR = 0.96, I2 = 0%, 95% CI = 0.48-1.93, P = .92) between the LG group and the OG group. Conclusion: LG for RGC patients had longer surgical time, shorter postoperative hospital stay, shorter length of incision, earlier food intake, and earlier time to first flatus.

Laparoscopic completion gastrectomy: A single-institution case series and systematic review of the literature

INTRODUCTION

Completion gastrectomy with lymphadenectomy for remnant gastric cancer (RGC) is currently the gold standard for patients with resectable disease. Multiple surgical approaches can be adopted; however, there exists no agreement on the best choice due to the low incidence of RGC. With its anticipated increase in prevalence, we thus sought to evaluate the feasibility and efficacy of the laparoscopic approach versus conventional laparotomy via a pooled analysis of existing literature.

METHODS

A retrospective review of five consecutive patients who underwent laparoscopic completion gastrectomy from August 2017 to June 2022 was performed following Institutional Review Board waiver. A comprehensive systematic review of literature on laparoscopic completion gastrectomy from the Pubmed, Embase, MEDLINE, Web of Science and Cochrane databases was conducted to supplement the experience from our institution.

RESULTS

Four patients had prior benign gastric disease and one had prior gastric cancer. Two patients experienced severe postoperative complications but there were otherwise no reports of conversion to laparotomy or mortality. Mean operative duration was 295 minutes. Mean duration to oral intake and discharge was 6.8 and 14.6 days respectively. Results from our pooled analysis of 591 cases suggested that the laparoscopic approach was associated with longer operative durations but delivered fewer postoperative complications, shorter duration to dietary resumption and shorter lengths of stay over conventional laparotomy.

CONCLUSION

Laparoscopic completion gastrectomy is indeed a more challenging procedure due to the presence of dense adhesions from previous surgery. However, the procedure can be performed safely with superior outcomes as compared to conventional laparotomy.

3D laparoscopic-assisted vs open gastrectomy for carcinoma in the remnant stomach: A retrospective cohort study

BACKGROUND

Three-dimensional (3D) laparoscopic technique has gradually been applied to the treatment of carcinoma in the remnant stomach (CRS), but its clinical efficacy remains controversial.

AIM

To compare the short-term and long-term results of 3D laparoscopic-assisted gastrectomy (3DLAG) with open gastrectomy (OG) for CRS.

METHODS

The clinical data of patients diagnosed with CRS and admitted to the First Medical Center of Chinese PLA General Hospital from January 2016 to January 2021 were retrospectively collected. A total of 84 patients who met the inclusion and exclusion criteria were enrolled. All their clinical data were collected and a database was established. All patients were treated with 3DLAG or OG by experienced surgeons and were divided into two groups based on the different surgical methods mentioned above. By using outpatient and telephone follow-up, we were able to determine postoperative survival and tumor status. The postoperative short-term efficacy and 1-year and 3-year overall survival (OS) rates were compared between the two groups.

RESULTS

Among 84 patients with CRS, 48 were treated with OG and 36 with 3DLAG. All patients successfully completed surgery. There was no significant difference between the two groups in terms of age, gender, body mass index, ASA score, initial disease state (benign or malignant), primary surgical anastomosis method, interval time of carcinogenesis, and tumorigenesis site. Patients in the 3DLAG group experienced less intraoperative blood loss (188.33 ± 191.35 mL vs 305.83 ± 303.66 mL; P = 0.045) and smaller incision (10.86 ± 3.18 cm vs 20.06 ± 5.17 cm; P < 0.001) than those in the OG group. 3DLAGC was a more minimally invasive method. 3DLAGC retrieved significantly more lymph nodes than OG (14.0 ± 7.17 vs 10.73 ± 6.82; P = 0.036), whereas the number of positive lymph nodes did not differ between the two groups (1.56 ± 2.84 vs 2.35 ± 5.28; P = 0.413). The complication rate (8.3% vs 20.8%; P = 0.207) and intensive care unit admission rate (5.6% vs 14.5%; P = 0.372) were equivalent between the two groups. In terms of postoperative recovery, the 3DLAGC group had a lower visual analog score, shorter indwelling time of gastric and drainage tubes, shorter time of early off-bed motivation, shorter time of postoperative initial flatus and initial soft diet intake, shorter postoperative hospital stay and total hospital stay, and there were significant differences, showing better short-term efficacy. The 1-year and 3-year OS rates of OG group were 83.2% [95% confidence interval (CI): 72.4%-95.6%] and 73.3% (95%CI: 60.0%-89.5%) respectively. The 1-year and 3-year OS rates of the 3DLAG group were 87.3% (95%CI: 76.4%-99.8%) and 75.6% (95%CI: 59.0%-97.0%), respectively. However, the 1-year and 3-year OS rates were similar between the two groups, which suggested that long-term survival results were comparable between the two groups (P = 0.68).

CONCLUSION

Compared with OG, 3DLAG for CRS achieved better short-term efficacy and equivalent oncological results without increasing clinical complications. 3DLAG for CRS can be promoted safely and effectively in selected patients.

Robot-assisted completion gastrectomy preserving interposed jejunum in remnant gastric cancer following a proximal gastrectomy reconstructed by jejunal interposition: A case report

Minimally invasive completion gastrectomy is technically demanding and comprises a variety of procedures depending on the previous operation. We present herein a case of robot-assisted completion gastrectomy preserving the interposed jejunum in remnant gastric cancer following a proximal gastrectomy reconstructed by jejunal interposition. A 76-year-old, male patient experienced newly developed stage cT1bN0M0 gastric cancer in the distal remnant stomach 5 years after his initial proximal gastrectomy. Endoscopic submucosal dissection was not feasible because of tumor depth and poor cancer cell differentiation. The robotic approach was chosen because of the early cancer stage, prior laparoscopic surgery, and the patient's advanced age. The interposed jejunum was successfully preserved, and a new overlap anastomosis was created between it and the retrocolic Roux-en-Y limb. Robot-assisted completion gastrectomy was safely performed even after a proximal gastrectomy with jejunal interposition.

Laparoscopic Completion Total Gastrectomy for Remnant Gastric Cancer

Background: Remnant gastric cancer (RGC) is increasing due to past use of subtotal gastrectomy to treat benign diseases, improvements in the detection of gastric cancer, and increased survival rates after gastrectomy for gastric cancer. Laparoscopic access provides the advantages and benefits of minimally invasive surgery. However, laparoscopic completion total gastrectomy (LCTG) for RGC is technically demanding, even for experienced surgeons. Because of its rarity and heterogeneity, no standard surgical strategy has been established and few surgeons will develop technical expertise to carry out this procedure. Aim: To describe our standard technique, giving surgeons a head start in LCTG and report the early experience with this stepwise approach. Materials and Methods: We detail all the steps involved in the procedure, including trocar placement and surgical description. Results: Between 2009 and 2019, a total of 8 patients with past history of RGC were operated with this technique. All patients had been previously operated by open method, 7 due to peptic ulcer disease and 1 due to gastric cancer. Their mean age at the time of the first surgery was 38.9 years (range 25-56 years) and the mean interval between the first and the second gastrectomy was 32.1 years (range 13.6-49). Billroth II was the previous reconstruction in all cases. A 5-trocar technique was used followed by total gastrectomy with side-to-side stapled intracorporeal esophagojejunostomy anastomosis and Roux-en-Y reconstruction. The mean operation time was 272 minutes (range 180-330) and median blood loss was 247 mL (range 50-500). There was no conversion and no major intraoperative complication. Major postoperative complications occurred in 3 patients. Conclusion: Completion total gastrectomy for RGC is a morbid procedure and laparoscopic access is technically feasible, hopefully carrying the benefits of faster recovery, reduced postoperative pain, and wound complications. By standardizing the approach, the learning curve may be shortened and better results achieved.