NOTES: The question for minimal resection and sentinel node in early gastric cancer

Thoracolaparoscopic radical resection of esophagogastric junction cancers with a NOSE-like approach to extract large specimens

To investigate the efficacy and safety of combined thoracoscopic and laparoscopic radical resection of esophagogastric junction cancers using a natural orifice specimen extraction-like approach for extraction of large surgical specimens. Patients who had esophagogastric junction cancers treated with thoracolaparoscopic resection using the natural orifice specimen extraction-like approach for specimen extraction were retrospectively enrolled. A 5-cm transverse incision on the abdominal wall at the middle of the superior pubic symphysis was made for surgical specimen extraction. The clinical, surgical, complications, and follow-up data were analyzed. A total of 162 patients were enrolled, and the surgery was successful in all patients (100%). The total surgical duration ranged 165 to 270 minutes, with blood loss 20 to 150 mL, hospital stay 8 to 22 days, first flatus time 2 to 7 days, extubation time of drainage tubes 1 to 26 days, first oral feeding time 5 to 10 days, number of lymph nodes resected 15 to 39, postoperative ambulation time 1 to 2 days, and postoperative residual rate of cancerous cells at the surgical margins 0. Postoperative complications occurred in 14 (8.6%), including anastomotic leakage in 4 (2.5%), anastomotic stenosis in 3 (1.9%), hydrothorax in 4 (2.5%), and incision infection in 3 (1.9%). At follow-up (mean 12 months), all patients were alive, and the transverse incision was a linear scar concealed in the suprapubic pubic hair area. The combined laparoscopic and thoracoscopic surgery for radical resection of carcinomas at the esophagogastric junction is safe and effective, and a transverse incision at the suprapubic symphysis for specimen extraction results in improved minimal invasiveness and cosmesis.

Preoperative Localization in Colonic Surgery (PLoCoS Study): a multicentric experience on behalf of the Italian Society of Colorectal Surgery (SICCR)

The aim of this prospective multicentric study was to compare the accurate colonic lesion localization ratio between CT and colonoscopy in comparison with surgery. All consecutive patients from 1st January to 31st December 2019 with a histologically confirmed diagnosis of dysplastic adenoma or adenocarcinoma with planned elective, curative colonic resection who underwent both colonoscopy and CT scans were included. Each patient underwent conventional colonoscopy and CT to stage the tumour, and the localization results of each procedure were registered. CT and colonoscopic localization were compared with surgical localization, adopted as the reference. Our analysis included 745 patients from 23 centres. After comparing the accuracy of colonoscopy and CT (for visible lesions) in localizing colonic lesions, no significant differences were found between the two preoperative tools (510/661 vs 499/661 correctly localized lesions, p = 0.518). Furthermore, after analysing only the patients who underwent complete colonoscopy and had a visible lesion on CT, no significant difference was observed between conventional colonoscopy and CT (331/427 vs 340/427, p = 0.505). Considering the intraoperative localization results as a reference, a comparison between colonoscopy and CT showed that colonoscopy significantly failed to correctly locate the lesions localized in the descending colon (17/32 vs 26/32, p = 0.031). We did not identify an advantage in using CT to localize colonic tumours. In this setting, colonoscopy should be considered the reference to properly localize lesions; however, to better identify lesions in the descending colon, CT could be considered a valuable tool to improve the accuracy of lesion localization.

Burgeoning study of sentinel-node analysis on management of early gastric cancer after endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD) represents an organ-preserving alternative to surgical resection of early gastric cancer. However, even with ESD yielding en-bloc resection specimens, there are concerns regarding tumor spread such as with larger lesions, ulcerated lesions, undifferentiated pathology and submucosal invasion. Sentinel node navigational surgery (SNNS) when combined with ESD offers a minimally invasive alternative to the traditional extended gastrectomy and lymphadenectomy if lack of lymph node spread can be confirmed. This would have a clear advantage in terms of potential complications and quality of life. However, SNNS, though useful in other malignancies such as breast cancer and melanoma, may not have a sufficient sensitivity for malignancy and negative predictive value in EGC to justify this as standard practice after ESD. The results of SNNS may improve with greater standardization and more involved dissection, technological innovations and more experience and validation such that the paradigm for post-ESD resection of EGC may change and include SNNS.

Natural orifice specimen extraction with laparoscopic radical gastrectomy for distal gastric cancer: A case report

BACKGROUND

This article introduces the surgical method and early experience in performing totally laparoscopic radical gastrectomy with transrectal specimen extraction for gastric cancer, and we evaluate the short-term effects and feasibility of this new procedure for gastric cancer in a 64-year-old male patient. This approach may provide new possibilities for gastric natural orifice specimen extraction (NOSE) surgery. In addition, we believe that this new procedure may further relieve pain, speed up recovery, and cause minimal physiological and psychological impact.

CASE SUMMARY

We performed NOSE gastrectomy in a male patient. Tumor resection, digestive tract reconstruction, and lymph node dissection were performed totally laparoscopically; the specimen was extracted from the natural orifice of the rectum-anus. This procedure reduced damage to the abdominal wall and decreased postoperative pain. We successfully performed radical gastrectomy without conversion and complications. Total operative time and blood loss were 176 min and 50 mL, respectively. The patient resumed normal activities of daily living on day 1 without pain, and passed flatus within 48 h. Postoperative hospital stay was 10 d. The number of resected lymph nodes was 0/43. During the follow-up, no stricture or anastomotic leakage was detected. Three months postoperatively, colonoscopy showed full recovery of the rectum without stricture or scar contracture. Computed tomography and laboratory test results showed no signs of tumor recurrence. There was no visible scar on the abdominal wall.

CONCLUSION

It is safe and reliable to perform totally laparoscopic radical gastrectomy with transrectal specimen extraction for distal gastric cancer patients.

Laparoscopic Gastrectomy and Transvaginal Specimen Extraction in a Morbidly Obese Patient with Gastric Cancer

Laparoscopic gastrectomy for cancer has some significant postoperative benefits over open surgery with similar oncologic outcomes. This procedure is more popular in the Far East countries where obesity is not a serious public health problem. In the Western countries, laparoscopic gastrectomy for cancer is not a common procedure, yet obesity is more common. Herein, we aimed to demonstrate the feasibility of laparoscopic gastrectomy for advanced gastric cancer in a morbidly obese patient. Additionally, we used natural orifice specimen extraction as an option to decrease wound-related complications, which are more prevalent in morbidly obese patients. In this case, we performed a fully laparoscopic subtotal gastrectomy with lymph node dissection and Roux-en-Y gastrojejunostomy with the specimen extracted through the vagina. To the best of our knowledge, this was the first report of a natural orifice surgery in a morbidly obese patient with gastric cancer.

Novel method for hybrid endo-laparoscopic full-thickness gastric resection using laparoscopic transgastric suture passer device

BACKGROUND

Current surgical methods for partial gastric full-thickness resections (FTRs) are limited by long operative times and risk of gastric content spillage, especially for lesions located at the posterior wall. We propose a simplified hybrid approach to FTR with reduced risk of spillage.

METHODS

Resection margins were marked by endoscopic electrocautery to simulate a gastric lesion in the upper third of the posterior wall in eight pigs. A custom-made laparoscopic "suture passer" was made of a sharpened bendable dissecting forceps. Full-thickness sutures were alternatively passed from the serosa side with the suture passer through the gastric wall and grabbed endoluminally using an endoscopic grasper and vice versa. These transgastric sutures formed either a purse string (PS; n = 4) or a continuous horizontal mattress (HM; n = 4). Sutures were then fastened from the laparoscopic side, resulting in external outpouching of the lesion. The pouch was transected using 45-mm linear staplers. Operative time, resection margins, and number of staplers were evaluated.

RESULTS

The combined approach allowed one to precisely place the sutures around the pseudo lesions, despite the inflated stomach, and it included all target markings. PS and HM methods were similar regarding time for transgastric suture (780 s ± 219.1 s vs. 765 s ± 179.2 s, p = .885), resection margins (1.3 ± 1.0 cm vs. 0.8 ± 0.6 cm, p = .248), and number of staplers (3.8 ± 1.0 vs 3.3 ± 0.5, p = .405). Stapling time (600 s ± 189.7 s vs. 330 s ± 24.5 s, p = .028) was significantly shorter in the HM technique.

CONCLUSION

FTR with laparo-endoscopic transgastric suture application was feasible in the animal model. This technique allows one to achieve accurate resection margins with minimal risk of spillage.

Current role of minimally invasive approaches in the treatment of early gastric cancer

Despite declining incidence, gastric cancer remains one of the most common cancers worldwide. Early detection in population-based screening programs has increased the number of cases of early gastric cancer, representing approximately 50% of newly detected gastric cancer cases in Asian countries. Endoscopic mucosal resection and endoscopic submucosal dissection have become the preferred therapeutic techniques in Japan and Korea for the treatment of early gastric cancer patients with a very low risk of lymph node metastasis. Laparoscopic and robotic resections for early gastric cancer, including function-preserving resections, have propagated through advances in technology and surgeon experience. The aim of this paper is to discuss the recent advances in minimally invasive approaches in the treatment of early gastric cancer.

Minimally invasive approaches for gastric cancer-Japanese experiences

Since development of laparoscopy-assisted distal gastrectomy with lymph node dissection in 1991 in Japan, laparoscopic gastrectomy (LAG) is improving and evolving. Recently, advanced LAG techniques including D2 lymph node dissection or anastomosis after total gastrectomy have been developed. Retrospective and prospective multicenter studies have been conducted for early and non-early gastric cancers to establish high-quality evidence. This review summarizes the current trends of minimally invasive approaches for gastric cancer based on current Japanese experiences.

Gastric adenocarcinoma surgery and adjuvant therapy

Gastric adenocarcinoma is one of the most common causes of death worldwide. Surgical resection remains the mainstay of therapy, offering the only chance for complete cure. Resection is based on the principles of obtaining adequate margins, with the extent of lymphadenectomy remaining controversial. Neoadjuvant and adjuvant therapies are used to reduce local recurrence and improve long-term survival. This article reviews the literature and provides a summary of surgical management options and neoadjuvant/adjuvant therapies for gastric adenocarcinoma.

NOTES-Natural orifice transluminal endoscopic surgery: Why not?

Since natural orifice transluminal endoscopic surgery (NOTES) was first described by Anthony Kalloo, it has attracted tremendous interest from surgeons and gastroenterologist all around the world. This special issue of the World Journal of Gastrointestinal Surgery explores the current possibilities and future potential of the most disruptive revolution in the field of surgery represented by the NOTES approach. In the future, new technologies developed for this approach and deeper insight into several gastrointestinal diseases will lead to the design of completely new interventional procedures and change the way we will operate, bringing us to the previously unimaginable goal of “no scar surgery”.