Totally laparoscopic distal gastrectomy with D2 lymphadenectomy and Billroth II gastrojejunostomy for gastric cancer: short- and medium-term results of 139 consecutive cases from a single institution

Endoscopic resection and laparoscopic lymph node dissection for early gastric cancer beyond conventional endoscopic treatment indications: a 10-year outcome study

BACKGROUND

Endoscopic full-thickness gastric resection (EFTGR) with laparoscopic regional lymph node dissection (LLND) and endoscopic submucosal dissection (ESD) with LLND have been investigated as treatment options for early gastric cancer beyond the absolute indications for ESD. However, comparative studies on the long-term outcomes of these procedures are lacking. This study aimed to analyze and compare the 10-year outcomes of both procedures in a real clinical setting.

METHODS

Between January 2009 and December 2013, 28 and 37 patients diagnosed with EGC beyond the absolute indications for ESD were treated with EFTGR with LLND and ESD with LLND, respectively. In both procedures, the dye was injected into the tumor. However, after injection and LLND, EFTGR was performed immediately in the EFTGR with LLND group, whereas LLND was followed by ESD in the ESD with LLND group. The primary endpoint was the 10-year survival rate.

RESULTS

The EFTGR with LLND group had one case of local recurrence (3.6%) and mortality (3.6%) each, while the ESD with LLND group had none (0.0% for both); however, the differences were not statistically significant (P = 0.247 for each). Furthermore, there was no significant difference in complications such as ischemia and anastomosis leakage between the groups (P = 0.247).

CONCLUSIONS

When the procedures were properly applied, EFTGR with LLND and ESD with LLND did not increase the 10-year mortality in patients with EGC beyond the absolute ESD indications compared with conventional radical gastrectomy.

Comparative efficacy of uncut Roux-en-Y and Billroth II anastomosis in gastrointestinal reconstruction following laparoscopic radical gastrectomy for distal gastric cancer

This study retrospectively analyzed the clinical efficacy of Uncut Roux-en-Y and Billroth II anastomoses in gastrointestinal reconstruction following laparoscopic D2 radical gastrectomy for distal gastric cancer. The primary objective was to compare the postoperative outcomes, including quality of life and complication rates, between the 2 surgical techniques. One hundred patients diagnosed with distal gastric cancer were enrolled between June 2020 and May 2023. Patients underwent laparoscopic D2 gastrectomy and were categorized into either the Uncut Roux-en-Y or Billroth II anastomosis groups based on the technique used for gastrointestinal reconstruction. The inclusion and exclusion criteria were strictly followed. Surgical parameters, quality of life assessed using the Visick grading index, and postoperative complications were also evaluated. Statistical analyses were performed using SPSS version 27.0. The groups were comparable in terms of demographic and baseline clinical parameters. The Uncut Roux-en-Y group had a significantly longer duration of surgery (P < .001). However, there were no statistically significant differences in other surgical parameters. According to the Visick grading index, patients in the Uncut Roux-en-Y group reported a significantly better quality of life than those in the Billroth II group (P < .05). Additionally, Uncut Roux-en-Y was associated with a significantly lower incidence of dumping syndrome and bile reflux (P < .05). Although Uncut Roux-en-Y anastomosis requires longer surgical time, it offers significant advantages in terms of postoperative quality of life and reduced rates of dumping syndrome and bile reflux. Our findings suggest that Uncut Roux-en-Y may be a superior option for gastrointestinal reconstruction after laparoscopic D2 gastrectomy for distal gastric cancer.

Comparison of laparoscopic proximal gastrectomy with double-tract reconstruction and laparoscopic total gastrectomy for proximal gastric cancer with stage cT1-2

ABSTRACT

This study aimed to evaluate the feasibility and nutritional benefits of laparoscopic proximal gastrectomy (LPG) with double-tract reconstruction (DTR) in comparison with laparoscopic total gastrectomy (LTG).The demographic, clinical, and pathological data and postoperative nutritional status of patients undergoing LPG with DTR (n = 21) or LTG (n = 26) at Sir Run Run Shaw Hospital between January 2016 and January 2019 were retrospectively reviewed and compared.The operative time in the LPG group was slightly longer than that in the LTG group; however, the difference was not statistically significant. Blood loss was not significantly different between groups. The mean number of retrieved lymph nodes was higher in the LTG group than in the LPG group (P = .02). The time to first flatus, postoperative hospital stay, and postoperative complications were comparable between the groups. During the 3-year postoperative follow-up, a statistically significant decrease in hemoglobin level was observed in the LTG group. There were no differences between the two groups of patients before and after the operation regarding albumin levels. The mean vitamin B12 level was higher in the LPG group than in the LTG group from 12 to 18 months postoperatively.LPG with DTR is an acceptable procedure for patients with upper gastric cancer. LPG with DTR has numerous potential advantages in preserving the physiological and nutritional functions of the remnant stomach and the conservation of the gastric reservoir.

The effect and clinical significance of using nathanson liver retractor on liver function tests in laparoscopic gastric cancer surgery

ABSTRACT Aim: There are very few studies in the literature investigating the changes caused by the Nathanson retractors in liver function tests (LFT) after LG and its clinical significance. The present study investigated the changes made by the Nathanson retractor used during LG on LFT and its clinical significance. Material and Method: The data of 236 patients, who underwent radical gastrectomy for primary gastric cancer at Surgical Oncology Unit in the period between January 2015 and January 2020 were retrospective studied. The patients were divided into two groups: laparoscopic gastrectomy (LG; 136 cases) and open gastrectomy (OG; 106 cases). Patients who have undergone cholecystectomy, with primary or secondary liver tumors, with chronic hepatic disease, who have preoperative high ALT, AST and bilirubin values were excluded from the study. LFT were measured preoperatively and postoperative day 1 (LFT1), LFT3, LFT5 and LFT7. LFT: ALT, AST and Total bilirubin (BIL). Results: ALT1, ALT3, ALT5, ALT7 ALT values and AST1, AST3, AST5 AST values of the patients in the LG group were found to be significantly higher (P <0.001). Mean total bilirubin values of the groups were similar (P >0.05). In order to evaluate how the increase in LFT due to the use of the Nathanson retractors reflected on the patients' clinic, we divided the patients who underwent LG into two groups based on ALT increase in ALT1: Normal and Elevated. The in-hospital mortality rates (P = 0.080) and oral nutrition time (P = 0.913) of the groups were similar. No liver infarction developed in any of the groups. The duration of stay in the ICU was significantly longer in individuals with elevated LFT (P = 0.019). Conclusion: Although the use of the Nathanson retractor during LG causes an increase in liver function tests, this does not cause major clinical problems in patients. Key Words: Gastrectomy; gastric cancer; laparoscopy; liver enzymes; liver dysfunciton

Assessment of Robotic Versus Laparoscopic Distal Gastrectomy for Gastric Cancer: A Randomized Controlled Trial

OBJECTIVE

To evaluate the short-term outcomes of patients with GC who received RDG or LDG.

SUMMARY BACKGROUND DATA

Despite the increasing use of RDG in patients with GC, its safety and efficacy compared to those of LDG have not been elucidated in a randomized controlled trial.

METHODS

Three hundred patients with cT1-4a and N0/+ between September 2017 and January 2020 were enrolled in this randomized controlled trial at a high-volume hospital in China. The short-term outcomes were compared between the groups.

RESULTS

The modified intention-to-treat analysis included data from 283 patients (RDG group: n = 141) and (LDG group: n = 142). Patients in the RDG group exhibited faster postoperative recovery, milder inflammatory responses, and reduced postoperative morbidity (9.2% vs 17.6%, respectively, P = 0.039). Higher extraperigastric lymph nodes (LNs) were retrieved in the RDG group (17.6 ± 5.8 vs 15.8 ± 6.6, P = 0.018) with lower noncompliance rate (7.7% vs 16.9%, respectively, P = 0.006). Additionally, patients in the RDG group were more likely to initiate adjuvant chemotherapy earlier [median (interquartile range) postoperative days: 28 (24-32) vs 32 (26-42), P = 0.003]. Although total hospital costs were higher in the robotic group than in the laparoscopic group, the direct cost was lower for RDG than for LDG (all P < 0.001).

CONCLUSIONS

RDG is associated with a lower morbidity rate, faster recovery, milder inflammatory responses, and improved lymphadenectomy. Additionally, faster postoperative recovery in the RDG group enables early initiation of adjuvant chemotherapy. Our results provide evidence for the application of RDG in patients with GC.

Laparoscopic versus open pancreatic resection for ductal adenocarcinoma: separate propensity score matching analyses of distal pancreatectomy and pancreaticoduodenectomy

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) is a leading causes of cancer mortality worldwide. Currently, laparoscopic pancreatic resection (LPR) is extensively applied to treat benign and low-grade diseases related to the pancreas. The viability and safety of LPR for PDAC needs to be understood better. Laparoscopic distal pancreatectomy (LDP) and pancreaticoduodenectomy (LPD) are the two main surgical approaches for PDAC. We performed separate propensity score matching (PSM) analyses to assess the surgical and oncological outcomes of LPR for PDAC by comparing LDP with open distal pancreatectomy (ODP) as well as LPD with open pancreaticoduodenectomy (OPD).

METHODS

We assessed the data of patients who underwent distal pancreatectomy (DP) and pancreaticoduodenectomy (PD) for PDAC between January 2004 and February 2020 at our hospital. A one-to-one PSM was applied to prevent selection bias by accounting for factors such as age, sex, body mass index, and tumour size. The DP group included 86 LDP patients and 86 ODP patients, whereas the PD group included 101 LPD patients and 101 OPD patients. Baseline characteristics, intraoperative effects, postoperative recovery, and survival outcomes were compared.

RESULTS

Compared to ODP, LDP was associated with shorter operative time, lesser blood loss, and similar overall morbidity. Of the 101 patients who underwent LPD, 10 patients (9.9%) required conversion to laparotomy. The short-term surgical advantage of LPD is not as apparent as that of LDP due to conversions. Compared with OPD, LPD was associated with longer operative time, lesser blood loss, and similar overall morbidity. For oncological and survival outcomes, there were no significant differences in tumour size, R0 resection rate, and tumour stage in both the DP and PD subgroups. However, laparoscopic procedures appear to have an advantage over open surgery in terms of retrieved lymph nodes (DP subgroup: 14.4 ± 5.2 vs. 11.7 ± 5.1, p = 0.03; PD subgroup 21.9 ± 6.6 vs. 18.9 ± 5.4, p = 0.07). These two groups did not show a significant difference in the pattern of recurrence and overall survival rate.

CONCLUSIONS

Laparoscopic DP and PD are feasible and oncologically safe procedures for PDAC, with similar postoperative outcomes and long-term survival among patients who underwent open surgery.

Esophageal Suspension Method for Hand-Sewn Esophagojejunostomy After Totally Laparoscopic Total Gastrectomy: A Simple, Safe, and Feasible Suturing Technique

Background: Totally laparoscopic total gastrectomy (TLTG) not only is difficult to operate but also has high technical requirements and a long learning curve. Therefore, it has not been widely carried out yet, and esophagojejunostomy is one of its difficulties. Relevant studies have shown that intracorporeal hand-sewn esophagojejunostomy is safe, feasible and low-cost, but it is complicated and time-consuming and requires a high-suture technique. This study introduces a simple, safe and feasible hand-sewn technique.

Methods: The clinical data of 32 patients with the esophageal suspension method for hand-sewn esophagojejunostomy (suspension group) after TLTG were collected from February 2018 to June 2019. During the same period, 32 patients with traditional hand-sewn esophagojejunostomy (traditional group) after TLTG were used as the control group.

Results: The operative time, anastomosis time, exhaust time and hospitalization time of the suspension group were shorter than those of the traditional group. The intraoperative blood loss in the suspension group was less than that in the traditional group. There were no postoperative complications associated with the suspension group.

Conclusion: For those who have some experience in laparoscopic suture technique, the esophageal suspension method for hand-sewn esophagojejunostomy after TLTG is a simple, safe, and feasible suture technique.

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.

Evolution of Laparoscopic Pancreatic Resections for Pancreatic and Periampullary Diseases: Perioperative Outcomes of 605 Patients at a High-Volume Center

Background: Laparoscopic pancreatectomy (LP) is increasingly performed with several institutional series and comparative studies reported. We have applied LP to a variety of pancreatic resections since 2004. This article is to report results of 15-year practice of 605 LPs for pancreatic and periampullary diseases. Methods: Patients with benign or malignant diseases in the pancreas and periampullary region, who underwent LP from June 2004 to June 2018, were retrospectively reviewed. The demographics and indications, and intraoperative and perioperative outcomes were evaluated. Results: A total of 605 consecutive LPs were analyzed, including 237 (39.2%) distal pancreatectomy with splenectomy (DPS), 116 (19.2%) spleen-preserving distal pancreatectomy (SPDP), 30 (5.0%) enucleation (EN), 30 (5.0%) central pancreatectomy (CP), 186 (30.7%) pancreatoduodenectomy (PD), and 6 (1.0%) pancreatoduodenectomy with total pancreatectomy (PDTP). The most common pathologic finding was pancreatic ductal adenocarcinomas (146, 24.1%). Conversion to open procedure was required in 22 patients (3.6%) (12 with PD, 8 with DPS, 1 with CP, and 1 with PDTP). The mean operative time was 241.5 ± 105.5 minutes (range 50-550 minutes) for the entire population and 367.1 ± 61.8 minutes (range 230-550 minutes) for PD. Clinically significant pancreatic fistula (ISGPF grade B and C) rate was 12.4% for the entire cohort and 16.1% for PD. Rate of Clavien-Dindo III-V complications was 17.4% for the entire cohort and 23.7% for PD. Ninety-day mortality was observed only in the cohort of patients undergoing PD (n = 4). Conclusions: The LP procedure appears to be technically safe and feasible, with an acceptable rate of morbidity when performed at our experienced, high-volume center. However, PD has less favorable outcomes and needs further evaluation.

Application of Laparoscopic Gastrectomy in Obese Patients (BMI≥30 kg/m2) with Gastric Cancer: A Comparison With Open Gastrectomy Regarding Short-term Outcomes

OBJECTIVE

Few studies have compared the surgical outcomes of laparoscopic (LG) and open (OG) gastrectomy in obese patients (BMI≥30 kg/m) with gastric cancer. The current study aimed to investigate the short-term outcomes of LG in this group of patients.

METHODS

A total of 33 LG cases and 23 OG cases (BMI≥30 kg/m) were identified from our gastric cancer database. Clinicopathologic features, operative details, laboratory examination, and postoperative outcomes were compared between both groups. Regression analysis was used to determine the effects of BMI on intraoperative outcomes.

RESULTS

The 2 groups had comparable clinicopathologic characteristics. LG was associated with significantly lesser blood loss, whereas both also groups had a similar operative time, and number of harvested lymph nodes. However, regression analysis indicated that increased BMI affected the operative time and blood loss in patients that underwent OG but had little effect on patients who received LG. The elevation of inflammatory factors (WBC, CRP) was lower in LG than in OG, postoperatively. Postoperative hepatic (alanine aminotransferase, total bilirubin, albumin) and renal (creatinine, blood urea nitrogen) functions in the LG group were not worse than in the OG group. The time to first flatus, initiation of diet, hospitalization, and postoperative complications seemed superior in LG than in OG, but these differences were not statistically significant.

CONCLUSION

LG can be safely performed in obese gastric cancer patients. Compared with conventional OG, LG is less invasive and is characterized by less blood loss and milder surgical trauma. LG is also less adversely affected by increased BMI.

Totally laparoscopic versus open total gastrectomy for gastric cancer: A case-matched study about short-term outcomes

Although surgical outcomes of totally laparoscopic total gastrectomy (TLTG) have been reported from several centers, the effectiveness of this technique has not been conclusively established. The aim of this study was to investigate the feasibility, safety, and efficacy of TLTG for gastric cancer.A prospectively collected and retrospectively analyzed data were used by comparing the short-term surgical outcomes of 124 patients who underwent TLTG with those of 124 patients who underwent open total gastrectomy (OTG) between March 2007 and March 2016.The 2 groups were well matched with respect to age, sex, body mass index, ASA score, and tumor stage. There was no significant difference with regard to the operation time but TLTG showed significantly less intraoperative blood loss (115.5 ± 70.2 vs 210.5 ± 146.7 mL, P < .01). Total numbers of retrieved lymph nodes were similar in the 2 groups. Postoperatively, no significant differences were found for morbidity or mortality. The time to first flatus, initiate oral intake, and postoperative hospital stay were significantly shorter in the TLTG group than in the OTG group (3.2 ± 1.0 vs 4.1 ± 1.2 days; 4.4 ± 1.2 vs 5.6 ± 2.0 days; and 8.9 ± 3.1 vs 11.3 ± 4.5 days, respectively; P < .01).TLTG for gastric cancer is technically safe, feasible, and minimally invasive compared with OTG. A prospective randomized trial is needed to establish the value of TLTG.

Robotic versus laparoscopic Gastrectomy for gastric cancer: a systematic review and updated meta-analysis

Background

Advanced minimally invasive techniques including robotic surgery are being employed with increasing frequency around the world, primarily in order to improve the surgical outcomes of laparoscopic gastrectomy (LG). We conducted a systematic review and meta-analysis to evaluate the feasibility, safety and efficacy of robotic gastrectomy (RG).

Methods

Studies, which compared surgical outcomes between LG and RG, were retrieved from medical databases before May 2017. Outcomes of interest were estimated as weighted mean difference (WMD) or risk ratio (RR) using the random-effects model. The software Review Manage version 5.1 was used for all calculations.

Results

Nineteen comparative studies with 5953 patients were included in this analysis. Compared with LG, RG was associated with longer operation time (WMD = −49.05 min; 95% CI: -58.18 ~ −39.91, P < 0.01), less intraoperative blood loss (WMD = 24.38 ml; 95% CI: 12.32 ~ 36.43, P < 0.01), earlier time to oral intake (WMD = 0.23 days; 95% CI: 0.13 ~ 0.34, P < 0.01), and a higher expense (WMD = −3944.8 USD; 95% CI: -4943.5 ~ −2946.2, P < 0.01). There was no significant difference between RG and LG regarding time to flatus, hospitalization, morbidity, mortality, harvested lymph nodes, and cancer recurrence.

Conclusions

RG can be performed as safely as LG. However, it will take more effort to decrease operation time and expense.

Three-Port Versus Five-Port Laparoscopic Distal Gastrectomy for Early Gastric Cancer Patients: A Propensity Score Matched Case-Control Study

AIM

The aim of this study was to evaluate the feasibility and safety of three-port laparoscopic distal gastrectomy (TP-LDG) as a reduced port laparoscopic gastrectomy.

MATERIALS AND METHODS

We retrospectively identified 146 patients preoperatively diagnosed with early gastric cancer who underwent five-port laparoscopic distal gastrectomy (FP-LDG) or TP-LDG between May 2013 and July 2016. A propensity score matching analysis was used to create patient groups (48 patients in each group) matched for sex, age, body mass index, previous abdominal surgery history, and American Society of Anesthesiologist score. The short-term surgical outcomes between TP-LDG and FP-LDG were compared.

RESULTS

The TP-LDG group had a statistically shorter umbilical wound length [3.4 (range, 3.0-4.0) cm vs. 3.9 (range, 3.7-4.0) cm, p = .000], shorter operative time [230 (range, 190-310) min vs. 250 (range, 180-320) min, p = .036], and lower estimated blood loss [68 (range, 20-180) mL vs. 80 (range, 40-150) mL, p = .005] compared to that in the FP-LDG group. However, there was no specific superiority regarding inflammatory profiles. Complication rates were also similar (8.4% TP-LDG vs. 12.6% FP-LDG, p = .504).

CONCLUSIONS

TP-LDG is a feasible and safe surgical procedure for the patients with early gastric cancer and provides the benefit of better cosmesis.

Short-term outcomes of laparoscopic total gastrectomy for gastric cancer: a comparative study with laparoscopic distal gastrectomy at a high-volume center

BACKGROUND

Laparoscopic distal gastrectomy (LDG) for gastric cancer has gradually gained popularity. However, laparoscopic total gastrectomy (LTG) has been reported rarely when compared with LDG. This study was designed to evaluate the surgical outcomes as well as the morbidity and mortality of LTG compared with LDG to confirm the feasibility and safety of LTG.

MATERIAL AND METHODS

We reviewed the data of patients at our institution undergoing LTG (n = 448) or LDG (n = 956) for gastric cancer between January 2008 and July 2016. Then the clinical characteristics and perioperative clinical outcomes of the two groups were compared.

RESULTS

Except for tumor size and stage, there were no statistically significant differences in the clinicopathological parameters between the groups. LTG was associated with significantly longer operation time, late time to postoperative diet, and longer hospital stay compared with the LDG group. Overall complications developed in 60 patients (13.4%) and surgical complications in 48 patients (10.7%) after LTG. Postoperative complications were less frequent in the LDG group than in the LTG group (8.4% versus 13.4%, p < .01), and fewer surgical complications were observed with LDG than with LTG (7.5% versus 10.7%, p = .05).

CONCLUSIONS

The results of LTG were favorable even though are not inferior to those of LDG. LTG for gastric cancer is technically feasible and safe. However, because of the limits of this study, other high-quality studies are needed for further evaluation.

Laparoscopic gastrectomy in obese gastric cancer patients: a comparative study with non-obese patients and evaluation of difference in laparoscopic methods

Background

Obesity is a growing epidemic around the world, and obese patients are generally regarded as high risk for surgery compared with normal weight patients. The purpose of this study was to evaluate the influence of obesity on the surgical outcomes of laparoscopic gastrectomy (LG) for gastric cancer.

Methods

We reviewed data for all patients undergoing LG for gastric cancer at our institute between October 2004 and December 2016. Patients were divided into non-obese and obese groups and the perioperative outcomes were compared. Furthermore, a subgroup analysis was conducted to evaluate which of the two commonly used methods of LG, laparoscopic-assisted gastrectomy (LAG) and totally laparoscopic gastrectomy (TLG), is more suitable for obese patients.

Results

A total of 1691 patients, 1255 non-obese and 436 obese or overweight patients, underwent LG during the study period. The mean operation time was significantly longer in the obese group than in the non-obese group (209.9 ± 29.7 vs. 227.2 ± 25.7 min, P < 0.01), and intraoperative blood loss was significantly lower in the non-obese group (113.4 ± 34.1 vs. 136.9 ± 36.7 ml, P < 0.01). Time to first flatus, time to oral intake, and postoperative hospital stay were significantly shorter in the non-obese group than in the obese group (3.3 ± 0.8 vs. 3.6 ± 0.9 days; 4.3 ± 1.0 vs. 4.6 ± 1.0 days; and 9.0 ± 2.2 vs. 9.6 ± 2.2 days, respectively; P < 0.01). 119 (9.5%) of the non-obese patients had postoperative complications as compared to 44 (10.1%) of the obese patients (P = 0.71). In the subgroup analysis of all patients, TLG showed improved results for early surgical outcomes compared to LAG, mainly due to its advantages in obese patients.

Conclusions

Obesity is associated with long operation time, increased blood loss, and slow recovery after laparoscopic gastric resection but does not affect intraoperative security or effectiveness. TLG may have less negative results in obese patients than LAG due to a variety of reasons. Our analysis shows that TLG is more advantageous, with regard to early surgical outcomes, for obese patients.

Short-term surgical outcomes of laparoscopy-assisted versus totally laparoscopic Billroth-II gastrectomy for gastric cancer: a matched-cohort study

BACKGROUND

To evaluate feasibility and benefits of intracorporeal anastomosis, we compared short-term surgical outcomes between laparoscopy-assisted distal gastrectomy (LADG) and totally laparoscopic distal gastrectomy (TLDG) with Billroth-II (B-II) anastomosis for gastric cancer.

METHODS

Sixty patients underwent attempted B-II TLDG from 2011 through 2013. Patients who underwent B-II LADG prior to 2011 were matched to TLDG cases for demographics, comorbidities, tumor characteristics, and TNM stage. Perioperative and short-term surgical outcomes were compared between the two groups.

RESULTS

Clinicopathological characteristics of both groups were comparable. The B-II TLDG group had a shorter hospital stay (9.4 vs. 12.0 days, P = 0.038) and average incision size was smaller (3.5 vs. 5.4 cm, P = 0.030) than in the B-II LADG group. Anastomotic leakage was not recorded in either group, and there were no differences in the rates of perioperative complications and in inflammatory parameters between the two groups.

CONCLUSIONS

This study suggests that B-II TLDG is feasible, compared to B-II LADG, and that it has several advantages over LADG, including a smaller incision, a shorter hospital stay, and more convenience during surgery. However, prospective randomized controlled studies are still needed to confirm that B-II TLDG can be used as a standard procedure for LDG.

Short-term outcomes of laparoscopic local resection for gastric submucosal tumors: a single-center experience of 266 patients

Background

Laparoscopic resections for submucosal tumors (SMTs) of the stomach have been developed rapidly over the past decade. Several types of laparoscopic methods for gastric SMTs have been created. We assessed the short-term outcomes of two commonly used types of laparoscopic local resection (LLR) for gastric SMTs and reported our findings.

Methods

We retrospectively analyzed the clinicopathological results of 266 patients with gastric SMTs whom underwent LLR between January 2006 and September 2016. 228 of these underwent laparoscopic exogastric wedge resection (LEWR), the remaining 38 patients with the tumors near the esophagogastric junction (EGJ) or antrum underwent laparoscopic transgastric resection (LTR).

Results

All the patients underwent laparoscopic resections successfully. The mean operation times of LEWR and LTR were 90.2 ± 37.2 min and 101.7 ± 38.5 min respectively. The postoperative length of hospital stays for LEWR and LTR were 5.1 ± 2.1 days and 5.3 ± 1.7 days respectively. There was a low complication rate (4.4%) and zero mortality in our series.

Conclusion

ELWR is technically feasible therapy of gastric SMTs. LTR is secure and effective for gastric intraluminal SMTs located near the EGJ or antrum.

Totally laparoscopic gastrectomy using intracorporeally stapler or hand-sewn anastomosis for gastric cancer: a single-center experience of 478 consecutive cases and outcomes

BACKGROUND

Totally laparoscopic gastrectomy (TLG) using intracorporeal anastomosis has gradually become mature thanks to the advancements of laparoscopic surgical instruments and the accumulation of operative experience. The goal of this study is to review our institution's experience with TLG for the treatment of gastric cancer.

METHODS

A retrospective study was conducted to examine the short-term outcomes of TLG using intracorporeally stapler or hand-sewn anastomosis performed at Sir Run Run Shaw Hospital between March 2007 and June 2015. The details of intracorporeal anastomosis were described, and the clinicopathological data, surgical outcomes, and postoperative complications were evaluated.

RESULTS

Four hundred seventy-eight patients were included in the study. Generally speaking, the patients could be divided into stapler or hand-sewn groups according to whether intracorporeal anastomosis was performed by only hand-sewn technique (n = 97) or only stapling devices (n = 381). For overall patients, the mean operation time and anastomotic time were 225.7 and 30.0 min, respectively. Postoperative complications were observed in 65 patients. All of the patients recovered well without perioperative death by conservative or surgical management.

CONCLUSIONS

TLG using intracorporeally stapler or hand-sewn anastomosis is a reasonable option for the treatment of gastric cancer, with early data showing acceptable perioperative outcomes.

Totally laparoscopic versus laparoscopic-assisted total gastrectomy for upper and middle gastric cancer: a single-unit experience of 253 cases with meta-analysis

BACKGROUND

Laparoscopic-assisted total gastrectomy (LATG) is the most commonly used methods of laparoscopic gastrectomy for upper and middle gastric cancer. However, totally laparoscopic total gastrectomy (TLTG) is unpopular because reconstruction is difficult, especially for the intracorporeal esophagojejunostomy. We adopted TLTG with various types of intracorporeal esophagojejunostomy. In this study, we compared LATG and TLTG to evaluate their outcomes.

METHODS

From March 2006 to September 2015, 253 patients with upper and middle gastric cancer underwent laparoscopic total gastrectomy (LTG), 145 patients underwent LATG, and 108 patients underwent TLTG. The clinicopathological characteristics and postoperative outcomes were retrospectively compared between the two groups. Furthermore, a systematic review and meta-analysis were conducted.

RESULTS

The operation time and estimated blood loss were similar between the groups. There were no significant differences in first flatus, diet initiation, and postoperative hospital stay. The surgical complication rates were 17.2% (25/145) and 13.9% (15/108) in the LATG and TLTG groups, respectively. The meta-analysis also revealed no significant differences in the operation time, estimated blood loss, time to first flatus, length of hospital stay, overall, and anastomosis-related complications among the groups.

CONCLUSIONS

TLTG is a feasible choice for gastric cancer patients, with comparable results to the LATG approach.

Intracorporeal esophagojejunostomy after totally laparoscopic total gastrectomy: A single-center 7-year experience

AIM: To assess the efficacy and safety of intracorporeal esophagojejunostomy in patients undergoing laparoscopic total gastrectomy (LTG) for gastric cancer.

METHODS: A retrospective review of 81 consecutive patients who underwent LTG with the same surgical team between November 2007 and July 2014 was performed. Four types of intracorporeal esophagojejunostomy using staplers or hand-sewn suturing were performed after LTG. Data on clinicopatholgoical characteristics, occurrence of complications, postoperative recovery, anastomotic time, and operation time among the surgical groups were obtained through medical records.

RESULTS: The average operation time was 288.7 min, the average anastomotic time was 54.3 min, and the average estimated blood loss was 82.7 mL. There were no cases of conversion to open surgery. The first flatus was observed around 3.7 d, while the liquid diet was started, on average, from 4.9 d. The average postoperative hospital stay was 10.1 d. Postoperative complications occurred in 14 patients, nearly 17.3%. However, there were no cases of postoperative death.

CONCLUSION: LTG performed with intracorporeal esophagojejunostomy using laparoscopic staplers or hand-sewn suturing is feasible and safe. The surgical results were acceptable from the perspective of minimal invasiveness.

Comparing the short-term outcomes of intracorporeal esophagojejunostomy with extracorporeal esophagojejunostomy after laparoscopic total gastrectomy for gastric cancer

Background

Totally laparoscopic distal gastrectomy (TLDG) using intracorporeal anastomosis has gradually developed due to advancements in laparoscopic surgical instruments. However, totally laparoscopic total gastrectomy (TLTG) with intracorporeal esophagojejunostomy (IE) is still uncommon because of technical difficulties. Herein, we evaluated various types of IE after TLTG in terms of the technical aspects. We compared the short-term operative outcomes between TLTG with IE and laparoscopy-assisted total gastrectomy (LATG) with extracorporeal esophagojejunostomy (EE).

Methods

Between March 2006 and December 2014, a total of 213 patients with gastric cancer underwent TLTG and LATG. Overall, 92 patients underwent TLTG with IE, and 121 patients underwent LATG with EE. Generally, there are two methods of IE: mechanical staplers (circular or linear staplers) and hand-sewn sutures. Surgical efficiencies and outcomes were compared between two groups. We also described various types of IE using a subgroup analysis.

Results

The mean operation times were similar in the two groups, as was the number of retrieved lymph nodes. However, the mean estimated blood loss of TLTG was statistically lower than LATG. There were no significant differences in time to first flatus, the time to restart oral intake, the length of the hospital stay after operation, and postoperative complications. Four types of IE have been applied after TLTG, including 42 cases of hand-sewn IE. The overall mean operation time and the mean anastomotic time in TLTG were 279.5 ± 38.4 min and 52.6 ± 18.9 min respectively. There was no case of conversion to open procedure. Postoperative complication occurred in 16 patients (17.4 %) and no postoperative mortality occurred.

Conclusions

IE is a feasible procedure and can be safely performed for TLTG with the proper laparoscopic expertise. It is technically feasible to perform hand-sewn IE after TLTG, which can reduce the cost of the laparoscopic procedure.

Systematic review and meta-analysis of totally laparoscopic versus laparoscopic assisted distal gastrectomy for gastric cancer

BACKGROUND

Totally laparoscopic distal gastrectomy (TLDG) has been developed in the hope of improving surgical quality and overcoming the limitations of conventional laparoscopic assisted distal gastrectomy (LADG) for gastric cancer. The aim of this study was to determine the extent of evidence in support of these ideals.

METHODS

A systematic review of the two operation types (LADG and TLDG) was carried out to evaluate short-term outcomes including duration of operation, retrieved lymph nodes, estimated blood loss, resection margin status, technical postoperative complications, and hospital stay.

RESULTS

Twelve non-randomized observational clinical studies involving 2,255 patients satisfied the eligibility criteria. Operative time was not statistically different between groups (P > 0.05). The number of retrieved lymph nodes and the resection margin length in TLDG were comparable with those in LADG. Estimated blood loss was significantly less in TLDG than that in LAG (P < 0.01). Compared to LADG, TLDG also involved lesser postoperative hospital stay (P < 0.01) and earlier time to soft diet intake (P < 0.05). Time to flatus and postoperative complications were similar for those two operative approaches.

CONCLUSIONS

TLDG may be a technically safe, feasible, and favorable approach in terms of better cosmesis, less blood loss, and faster recovery compared with LADG.

Immunoglobulin G4-associated cholangitis mimicking cholangiocarcinoma treated by laparoscopic choledochectomy with intracorporeal Roux-en-Y hepaticojejunostomy

Immunoglobulin G4 (IgG4)-associated disease is a recently recognized disease entity that is characterized by elevated serum IgG4 concentrations, abundant IgG4 lymphoplasmacytic infiltration, and dramatic steroid responses. IgG4-associated cholangitis is one manifestation of IgG4-associated disease. However, it is clinically challenging to make a preoperative differentiation between this rare disease and cholangiocarcinoma, especially for those with serum concentrations of IgG4 in the normal range. This article reports on a 57-year-old man with jaundice and upper abdominal discomfort. Imaging examination showed biliary stricture that closely resembled cholangiocarcinoma, and the patient’s serum IgG4 concentration was normal. The patient underwent a laparoscopic choledochectomy with Roux-en-Y hepaticojejunostomy using an intracorporeal hand-sewn technique. He recovered quickly without any complications. We also present our experience in laparoscopic intracorporeal hand-sewn hepaticojejunostomy.

Totally laparoscopic gastrectomy for gastric cancer: A systematic review and meta-analysis of outcomes compared with open surgery

AIM: To systematically review the surgical outcomes of totally laparoscopic gastrectomy (TLG) vs open gastrectomy (OG) for gastric cancer.

METHODS: A systematic search of PubMed, Embase, Cochrane Library, and Web of Science was conducted. All original studies comparing TLG with OG were included for critical appraisal. Data synthesis and statistical analysis were carried out using RevMan 5.1 software.

RESULTS: One RCT and 13 observational studies involving 1532 patients were included (721 TLG and 811 OG). TLG was associated with longer operation time [weighted mean difference (WMD) = 58.04 min, 95%CI: 37.77-78.32, P < 0.001], less blood loss [WMD = -167.57 min, 95%CI: -208.79-(-126.34), P < 0.001], shorter hospital stay [WMD = -3.75 d, 95%CI: -4.88-(-2.63), P < 0.001] and fewer postoperative complications (RR = 0.71, 95%CI: 0.58-0.86, P < 0.001). The number of harvested lymph nodes, surgical margin, mortality and cancer recurrence rate were similar between the two groups.

CONCLUSION: TLG may be a technically safe, feasible and favorable approach in terms of better cosmesis, less blood loss and faster recovery compared with OG.

Three cases of laparoscopic total gastrectomy with intracorporeal esophagojejunostomy for gastric cancer in remnant stomach

Gastric cancer in remnant stomach is a rare tumor but with poor prognosis. Compared with conventional open surgery, laparoscopic gastrectomy has potential benefits for these patients due to advantages resulting from its minimally invasive approach. Herein, we report on three patients with gastric cancer in remnant stomach who underwent laparoscopic total gastrectomy with intracorporeal esophagojejunostomy successfully. The operative time was 280, 250 and 225 minutes, the estimated blood loss was 100, 80 and 50 ml and the length of postoperative hospital stay was seven, eight and nine days respectively. Our experience has suggested that laparoscopic total gastrectomy with intracorporeal esophagojejunostomy can be a safe, feasible and promising option for patients with gastric cancer in remnant stomach.

Comparison of short-term surgical outcomes between totally laparoscopic and laparoscopic-assisted distal gastrectomy for gastric cancer: a 10-y single-center experience with meta-analysis

BACKGROUND

Laparoscopic-assisted distal gastrectomy (LADG) and totally laparoscopic distal gastrectomy (TLDG) are two commonly used methods of laparoscopic gastrectomy for gastric cancer. This study aimed to compare the short-term surgical outcomes of these two methods.

METHODS

A prospectively maintained gastric cancer database between October 2004 and February 2014 was reviewed and 115 patients underwent LADG and 198 patients underwent TLDG were included. The clinical characteristics and perioperative clinical outcomes of two groups were compared. Moreover, a systematic review and meta-analysis were conducted.

RESULTS

The mean operation time and blood loss were similar in two groups, as was the number of retrieved lymph nodes. There was no significant difference in time to first flatus, the time to restart oral intake, the length of the hospital stay after surgery, and postoperative complications. The meta-analysis revealed no significant differences in the operative time, surgical margin, time to first flatus, length of hospital stay, mortality, overall, and anastomosis-related complications among the groups. However, the intraoperative blood loss was lower in TLDG (weighted mean difference = 21.50 mL; 95% confidence interval: 9.79-33.22; P < 0.01), and number of retrieved lymph nodes was higher in TLDG (weighted mean difference = -1.56; 95% confidence interval: -2.69 to -0.44; P < 0.01).

CONCLUSIONS

TLDG is safe and feasible compared with LADG. However, it is difficult to identify the clinical advantages of TLDG over LADG based on our study. Thus, the choice of surgical approach mainly depends on the patient conditions and the preference of the patients or surgeons.

Laparoscopic spleen-preserving distal pancreatectomy for pancreatic neoplasms: A retrospective study

AIM: To describe the clinical characteristics, technical procedures, and outcomes of patients undergoing laparoscopic spleen-preserving distal pancreatectomy (LSPDP) for benign and malignant pancreatic neoplasms.

METHODS: The clinical data of 38 patients who underwent LSPDP in the Sir Run Run Shaw Hospital between January 2003 and August 2013 were analyzed retrospectively. Surgical techniques for LSPDP included preservation of the splenic artery and vein (Kimura’s technique) and ligation of the splenic pedicle with preservation of the short gastric vessels (Warshaw’s technique).

RESULTS: There were no conversions to open surgery in the 38 patients. Splenic vessels were conserved during spleen-preserving pancreatectomy, except in two patients who underwent resection of the splenic vessels and preservation only of the short gastric vessels. The mean operation time was 123.2 ± 52.4 min, the mean intraoperative blood loss was 78.2 ± 39.5 mL, and the mean postoperative hospital stay was 7.6 ± 2.9 d. The overall rate of postoperative complications was 18.4% (7/38), and the rate of clinical pancreatic fistula was 13.2% (5/38). All postoperative complications were treated conservatively. The postoperative pathological diagnoses were 22 cases of benign pancreatic disease and 16 cases of borderline or low-grade malignant lesions. During a median follow-up of 38 mo (range: 5-133 mo), no recurrence was observed.

CONCLUSION: LSPDP is a safe, feasible and effective procedure for the treatment of benign and low-grade malignant tumors of the distal pancreas.

Upper lesser curvature skeletonization in radical distal gastrectomy

BACKGROUND

To investigate the metastatic status of lymph nodes numbers (no.) 1, 3a, and 3b groups in radical distal gastrectomy with upper lesser curvature skeletonization and the risk factors for lesser curvature regional node (LCRN) metastasis.

METHODS

Data on patients who underwent radical distal gastrectomy were retrospectively collected between May 2010 and September 2013. Clinicopathologic features and surgical outcomes were compared between the LCRN (+) and (-) groups. The correlations among the no. 1, 3a and 3b groups, and other groups were analyzed. Univariate and multivariate analyses were performed to identify the independent risk factors for LCRN metastasis.

RESULTS

A total of 112 patients were analyzed. In all, 45.5% had metastatic LCRNs, and 59.8% were node positive overall. The LCRN (+) and (-) groups had significantly different features, including gender; tumor size; histologic grade; Lauren classification; gross type; and T, N, and TNM stages. The positivity rates of the no. 1, 3a, and 3b groups were 4.5%, 38.4%, and 32.1%, respectively, and the no. 1, 3a, and 3b groups were comprehensively correlated with the D2-tier groups. In the univariate and multivariate analyses, only stage T3-4 and positive no. 4d nodes were documented as independent risk factors, whereas no. 5 and 11p nodes trended toward a positive correlation.

CONCLUSIONS

LCRNs have high frequencies of metastasis in lower gastric cancers, and in the present study, these groups of lymph nodes tended to be associated with each other as an entity in the lesser curvature region. Upper lesser curvature skeletonization can be recommended as a standard procedure in radical distal gastrectomy to thoroughly clear the gastric stump, especially in the case of stage T3-4 or suspicious no. 4d nodes.

Laparoscopy-assisted versus open gastrectomy with D2 lymph node dissection for advanced gastric cancer: a meta-analysis

A raising number of surgeons have chosen laparoscopy-assisted gastrectomy (LAG) as an alternative to open gastrectomy (OG) with D2 lymph node dissection for treatment of advanced gastric cancer (ADG). But no meta-analysis has been performed to evaluate the value of LAG versus OG with regard to safety and efficacy for treatment of ADG. A comprehensive literature research was performed in PubMed, Web of Science and Embase to identify studies that compared LAG and OG with D2 lymph node dissection for treatment of ADG. Data of interest were checked and subjected to meta-analysis with RevMan 5.1 software. 11 studies with 1904 patients (982 in LAG and 922 in OG) were enrolled. Pooled risk ratios (RR) and weighted mean difference (WMD) with 95% confidence intervals (CI) were appropriately derived from random-effects models or fixed-effects models. Compared with OG, LAG was associated with less blood loss (WMD = -144.47; P < 0.05), shorter time of first flatus time (WMD = -0.91; P < 0.05) and postoperative hospital stay (WMD = -3.27; P < 0.05), and lower morbidity (RR = 0.70; P < 0.05), but longer operation time (WMD = 41.78; P < 0.05). No significant differences were noted in terms of harvested lymph nodes (WMD = 1.85; P = 0.09), pathological N stage (χ(2) 3.97; P = 0.26), tumor size (WMD = -0.05; P = 0.81), mortality (RR 0.82; P = 0.76), cancer recurrence rate (RR 0.77; P = 0.18) and 3-year overall survival rate (RR 1.09; P = 0.18). Compared with OG, LAG with D2 lymph node dissection for ADG had the advantages of minimal invasion, faster recovery, and fewer complications, and it could achieve the same degree of radicality, harvested lymph nodes, short-term and long-term prognosis as OG, though the operation time was slightly longer.

Short-term surgical and long-term survival outcomes after laparoscopic distal gastrectomy with D2 lymphadenectomy for gastric cancer

Background

Laparoscopic distal gastrectomy (LDG) for gastric cancer has gradually gained popularity. However, the long-term oncological outcomes of LDG have rarely been reported. This study aimed to investigate the survival outcomes of LDG, and evaluate the early surgical outcomes of laparoscopy-assisted distal gastrectomy (LADG) and totally laparoscopic distal gastrectomy (TLDG).

Methods

Clinical outcomes of 240 consecutive patients with gastric cancer who underwent LDG at our institution between October 2004 and April 2013 were analyzed. Early surgical outcomes of LADG and TLDG were compared and operative experiences were evaluated.

Results

Of the 240 patients, 93 underwent LADG and 147 underwent TLDG. There were 109 T1, 36 T2, 31 T3, and 64 T4a lesions. The median follow-up period was 31.5 months (range: 4–106 months). Tumor recurrence was observed in 40 patients and peritoneal recurrence was observed most commonly. The 5-year disease-free survival (DFS) and overall survival (OS) rates according to tumor stage were 90.3% and 93.1% in stage I, 72.7% and 67.6% in stage II, and 34.8% and 41.5% in stage III, respectively. No significant differences in early surgical outcomes were noted such as operation time, blood loss and postoperative recovery between LADG and TLDG (P >0.05).

Conclusions

LDG for gastric cancer had acceptable long-term oncologic outcomes. The early surgical outcomes of the two commonly used LDG methods were similar.