Laparoscopic total gastrectomy in gastric cancer: our experience in 92 cases

Laparoscopic gastrectomy for stage II and III advanced gastric cancer: long‑term follow‑up data from a Western multicenter retrospective study

INTRODUCTION

There has been an increasing interest for the laparoscopic treatment of early gastric cancer, especially among Eastern surgeons. However, the oncological effectiveness of Laparoscopic Gastrectomy (LG) for Advanced Gastric Cancer (AGC) remains a subject of debate, especially in Western countries where limited reports have been published. The aim of this paper is to retrospectively analyze short- and long-term results of LG for AGC in a real-life Western practice.

MATERIALS AND METHODS

All consecutive cases of LG with D2 lymphadenectomy for AGC performed from January 2005 to December 2019 at seven different surgical departments were analyzed retrospectively. The primary outcome was diseases-free survival (DFS). Secondary outcomes were overall survival (OS), number of retrieved lymph nodes, postoperative morbidity and conversion rate.

RESULTS

A total of 366 patients with stage II and III AGC underwent either total or subtotal LG. The mean number of harvested lymph nodes was 25 ± 14. The mean hospital stay was 13 ± 10 days and overall postoperative morbidity rate 27.32%, with severe complications (grade ≥ III) accounting for 9.29%. The median follow-up was 36 ± 16 months during which 90 deaths occurred, all due to disease progression. The DFS and OS probability was equal to 0.85 (95% CI 0.81-0.89) and 0.94 (95% CI 0.92-0.97) at 1 year, 0.62 (95% CI 0.55-0.69) and 0.63 (95% CI 0.56-0.71) at 5 years, respectively.

CONCLUSION

Our study has led us to conclude that LG for AGC is feasible and safe in the general practice of Western institutions when performed by trained surgeons.

Robotic gastrointestinal surgery: learning curve, educational programs and outcomes

The use of the robotic platform for gastrointestinal surgery was introduced nearly 20 years ago. However, significant growth and advancement has occurred primarily in the last decade. This is due to several advantages over traditional laparoscopic surgery allowing for more complex dissections and reconstructions. Several randomized controlled trials and retrospective reviews have demonstrated equivalent oncologic outcomes compared to open surgery with improved short-term outcomes. Unfortunately, there are currently no universally accepted or implemented training programs for robotic surgery and robotic surgery experience varies greatly. Additionally, several limitations to the robotic platform exist resulting in a distinct learning curve associated with various procedures. Therefore, implementation of robotic surgery requires a multidisciplinary team approach with commitment and investment from clinical faculty, operating room staff and hospital administrators. Additionally, there is a need for wider distribution of educational modules to train more surgeons and reduce the associated learning curve. This article will focus on the implementation of the robotic platform for surgery of the pancreas, stomach, liver, colon and rectum with an emphasis on the associated learning curve, educational platforms to develop proficiency and perioperative outcomes.

Single/reduced port surgery vs. conventional laparoscopic gastrectomy: systematic review and meta-analysis

INTRODUCTION

The aim is to compare single port surgery (SPS)/reduced port surgery (RPS) versus conventional laparoscopy (CL) for gastrectomy for gastric cancer in terms of intra- and postoperative outcomes.

MATERIAL AND METHODS

After a search in Pubmed and Embase, six articles were included. Pooled analysis was used to evaluate the statistically significance for each variable.

RESULTS

Two hundred and thirty-three and 230 patients underwent SPS/RPS and CL, respectively. One hundred and eighty-eight patients and 45 patients underwent subtotal and total gastrectomy, respectively, using the SPS/RPS approach. One hundred and eighty-five patients and 45 patients underwent subtotal and total gastrectomy, respectively, by CL. In 85 patients, an extra trocar was systematically placed at the end of surgery. Statistically significant differences were not observed about preoperative staging. The pooled analysis regarding operative time, blood loss, postoperative complications, number of harvested lymph nodes and postoperative hospital stay showed that the only statistically significant difference between the two approaches is the shorter hospital stay in case of SPS/RPS.

CONCLUSIONS

SPS/RPS total or subtotal gastrectomy shows a lower postoperative hospital stay, with comparable operative time, blood loss, early postoperative complication rate and number of harvested lymph nodes in comparison to CL, provided extensive experience in minimally invasive gastrectomy is present. Abbreviations: AGC: advanced gastric cancer; BMI: body mass index; CI: confidence interval; CL: conventional laparoscopy; LESS: laparoendoscopic single site; MD: mean difference; NOS: Newcastle-Ottawa Scale; OR: odds ratio; PRISMA: Preferred Reporting Items for Systematic Review and Meta-Analysis; ROBIN-I: Risk Of Bias In Non-randomised Studies - of Interventions; RPS: reduced port surgery; RR: risk ratio; SILS: single incision laparoscopic surgery; SPS: single port surgery; WMD: weighted mean differences.

Splenic cystic lymphangiomatosis in association with omental varices and portal hypertension: A case report

RATIONAL

Lymphangiomatosis is rare and benign, and slowly proliferating lymphatic vessels of unknown etiology and visceral lymphangiomatosis involving the spleen is rare. Since lymphangiomatosis may be asymptomatic or present as a sense of fullness, splenic cystic lymphangiomatosis is a disease of little concern.

PATIENT CONCERNS

A 34-year-old woman suffering from progressive epigastric fullness after oral intake for two weeks.

DIAGNOSES

Physical examination showed a palpable mass which was more than 10 cm in size over the left hypochondrium. An abdominal computed tomography disclosed marked splenomegaly with multiple cystic lesions in the spleen, causing external compression with right-sided deviation of the adjacent organs and varices in the upper abdomen. Esophagogastroduodenoscopy revealed portal hypertensive gastropathy.

INTERVENTIONS

Conventional total splenectomy was performed in this patient because of an enlarged spleen and unknown etiology, preoperatively. Upon surgery, splenomegaly with polycystic content and varicose vessels over the omentum were noted. Autologous spleen transplantation was not performed because of limited orthotopic and vascularized spleen.

OUTCOMES

The patient is doing well 18 months after splenectomy.

LESSONS

This was a rare case presenting with splenic cystic lymphangiomatosis in association with omental varices and portal hypertension. Splenic cystic lymphangiomatosis should be considered in the differential diagnosis of patients with a palpable painless mass over the left hypochondrium.

Comparison of totally laparoscopic total gastrectomy using an endoscopic linear stapler with laparoscopic-assisted total gastrectomy using a circular stapler in patients with gastric cancer: A single-center experience

AIM

To evaluate the safety and efficacy of totally laparoscopic total gastrectomy (TLTG) with esophagojejunostomy using a linear stapler compared with laparoscopic-assisted total gastrectomy (LATG) using a circular stapler in gastric cancer patients.

METHODS

We retrospectively reviewed 687 patients who underwent laparoscopic total gastrectomy for gastric cancer at a single institution from August 2008 to August 2014. The patients were divided into two groups according to the type of operation: 421 patients underwent TLTG and 266 underwent LATG. Clinicopathologic characteristics and surgical outcomes in the two groups were compared and analyzed.

RESULTS

The TLTG group had higher mean ages at the time of operation (57.78 ± 11.20 years and 55.69 ± 11.96 years, P = 0.020) and more histories of abdominal surgery (20.2% and 12.4%, P = 0.008) compared with the LATG group. Surgical outcomes such as intraoperative and postoperative transfusions, combined operations, pain scores and administration of analgesics, and complications were similar between the two groups. However, compared with the LATG group, the TLTG group required a shorter operation time (149 min vs 170 min, P < 0.001), had lower postoperative hematocrit change (3.49% vs 4.04%, P = 0.002), less intraoperative events (3.1% vs 10.2%, P < 0.001), less intraoperative anastomosis events (2.4% vs 7.1%, P = 0.003), faster postoperative recovery such as median time to first flatus (3.30 d vs 3.60 d, P < 0.001), faster median commencement of soft diet (4.30 d vs 4.60 d, P < 0.001) and shorter length of postoperative hospital stay (6.75 d vs 7.02 d, P = 0.005).

CONCLUSION

The intracorporeal method for reconstruction of esophagojejunostomy using a linear stapler may be considered a feasible procedure comparing with extracorporeal anastomosis using circular stapler because TLTG is simpler and more straightforward than LATG. Therefore, TLTG can be recommended as an appropriate procedure for gastric cancer.

Comparison of laparoscopic versus open gastrectomy for advanced gastric cancer: an updated meta-analysis

BACKGROUND

Laparoscopic gastrectomy (LG) has been used as an alternative to open gastrectomy (OG) to treat early gastric cancer. However, the use of LG for advanced gastric cancer (AGC) has been in debate.

METHODS

Literature retrieval was performed by searching PubMed, EMBASE, and the Cochrane library up to July 2014. Potential studies comparing the surgical effects between LG with OG were evaluated and data were extracted accordingly. Meta-analysis was carried out using RevMan. The pooled risk ratio and weighted mean difference (WMD) with 95 % confidence interval (95 % CI) were calculated.

RESULTS

Overall, 26 studies were included in this meta-analysis. LG had some advantages over OG, including shorter hospitalization (WMD, -3.63, 95 % CI, -4.66 to -2.60; P < 0.01), less blood loss (WMD, -161.37, 95 % CI, -192.55 to -130.18; P < 0.01), faster bowel recovery (WMD, -0.78, 95 % CI, -1.05 to -0.50; P < 0.01), and earlier ambulation (WMD, -0.95, 95 % CI, -1.47 to -0.44; P < 0.01). In terms of surgical and oncological safety, LG could achieve similar lymph nodes (WMD, -0.49, 95 % CI, -1.78 to 0.81; P = 0.46), a lower complication rate [odds ratio (OR), 0.71, 95 % CI, 0.59 to 0.87; P < 0.01], and overall survival (OS) and disease-free survival (DFS) comparable to OG.

CONCLUSIONS

For AGCs, LG appeared comparable with OG in short- and long-term results. Although more time was needed to perform LG, it had some advantages over OG in achieving faster postoperative recovery. Ongoing trials and future studies could help to clarify this controversial issue.

Meta-analysis of the short-term outcomes of robotic-assisted compared to laparoscopic gastrectomy

OBJECTIVE

To compare the short-term outcomes of gastric cancer patients treated with robotic gastrectomy (RG) or laparoscopic gastrectomy (LG).

INTRODUCTION

Robotic gastrectomy (RG) has been used for gastric cancer since 2002. This meta-analysis evaluates the safety and efficacy of robotic gastrectomy (RG) and conventional laparoscopic gastrectomy (LG) for gastric cancer.

MATERIAL AND METHODS

Pubmed, Embase and The Cochrane Library were searched, and manual searches were performed up to March 31, 2013. Five non-randomized control trials that reported RG and LG for gastric cancer were included. Outcomes evaluated were operation time, number of retrieved LN, blood loss, the length of the resection margin, complications, length of postoperative hospital stay.

RESULTS

Of 1796 patients in five studies, 551 were allocated to RG and 1245 to LG. Operation time was significantly shorter in the latter group (weighted mean difference 42.9; 95 % confidence interval 20.87 to 64.92 min; p < 0.05). Blood loss weighted mean difference was -16.07 (95 % confidence interval -32.78 to 0.64 mL; p < 0.05) and postoperative stay weighted mean difference was -1.98 (95 % confidence interval -3.66 to -0.3 days; p < 0.05); both were less in the RG group. LN, length of the resection margin, and postoperative complications were similar in both groups.

CONCLUSION

It may be concluded that RG is a safe and comfortable alternative to LG and is justifiable in the light of clinical trials.

Treatment of early gastric cancer in the Western World

The incidence rate of gastric cancer is much higher in Asia than in the Western industrial nations. According to the different screening programs in Japan and Korea about fifty percent of treated patients had an early tumor stage. In contrast, European and American patients with gastric cancer had an advanced tumor stage. Therefore, the experience for the various therapeutic options for gastric cancer may be different between these regions. In this review we tried to point out the treatment modalities in Western industrial countries for early gastric cancer.