Laparoscopic-assisted proximal gastrectomy for early gastric carcinomas

Novel reconstruction method using long and narrow gastric tube in laparoscopic proximal gastrectomy for cancer: a retrospective case series study

Background and objectives

To clarify the safety and feasibility of laparoscopic proximal gastrectomy (LPG) with our novel reconstruction methods.

Methods

Novel method is a reconstruction with a long and narrow gastric tube with widening of the proximal side created by linear stapler, and esophagogastrostomy is performed by linear stapler. In conventional method, esophagogastrostomy is performed by a circular stapler. Short- and long-term outcomes of a novel method were compared with those of conventional method.

Results

A total of 44 patients whom LPG was performed were enrolled in this retrospective study. No cases of anastomotic leakage and stenosis were observed in both groups. The cases of postoperative reflux esophagitis (Grade B or higher) at 1 year after operation in the Novel group were less than those in the Conventional group (17% vs. 44%).

Conclusion

LPG with novel reconstruction method can be easily performed, and may be feasible for the treatment of proximal gastric cancer.

Clinical outcomes of proximal gastrectomy with gastric tubular reconstruction and total gastrectomy for proximal gastric cancer: A matched cohort study

Background

Proximal gastrectomy with gastric tubular reconstruction is a surgical procedure that can preserve function in patients with proximal gastric cancer. However, whether gastric tubular reconstruction with proximal gastrectomy has certain advantage in some aspects over total gastrectomy is controversial. To evaluate the benefit of gastric tubular reconstruction after proximal gastrectomy, we compared gastric tubular reconstruction with total gastrectomy for proximal gastric cancer.

Method

A total of 351 patients were enrolled. Concurrent total gastrectomy patients matched with the Proximal gastrectomy group in age, sex, body mass index, clinical stage, and ASA score were selected by propensity score matching. Preoperative basic information, perioperative indicators, histopathological features, postoperative complications and nutritional status, reflux were compared between the two groups.

Results

There was no significant difference in the incidence of reflux between two groups (14.8% and 6.5% respectively, P = 0.085). There were significant differences between the two groups in bowel function recovery (2.29 ± 1.16 vs. 3.01 ± 1.22; P = 0.039) and start of soft diet (4.06 ± 1.81 vs. 4.76 ± 1.69; P = 0.047). There were no significant differences between the two groups in nutritional status one year after surgery. However, the decrease in serum hemoglobin in the TG group at 3 and 6 months after surgery was significantly higher than that in the PG group (P = 0.032 and 0.046, respectively). One month after surgery, %BW loss in TG group was significantly lower than that in the PG group (P = 0.024).

Conclusion

The Proximal gastrectomy group has better clinical outcome and gastric tubular reconstruction is simple, similar complications and reflux rates, gastric tubular reconstruction may be more suitable for proximal gastric cancer.

Indications and technical aspects of proximal gastrectomy

According to the World Health Organization, gastric cancer is the fifth most common type of tumor, and is the third most common cause of tumor-associated death. Although gastric cancer incidence rates have decreased in the past few decades, the prevalence of proximal gastric cancer has been steadily rising in developed countries. Techniques regarding the improvement of treatment options must thus be developed. This can be achieved through incorporating both a wider use of endoscopic surgery (endoscopic mucosal resection-EMR, endoscopic submucosal dissection-ESD) and a review of applied surgical interventions. Even though there is no single international consensus available, the Japanese Gastric Cancer Association (JGCA) recommends proximal gastrectomy with D1+ lymphadenectomy in early gastric tumors. Despite recommendations from Asian guidelines and the short term outcomes of the KLASS 05 trial, surgical treatments in Western countries still rely on total gastrectomy. This is mostly due to technical and oncological challenges regarding surgical interventions in a proximal gastrectomy. However, the residual stomach after a proximal gastrectomy has been shown to diminish the incidence of dumping syndrome and anemia, and even improve postoperative quality of life (QoL). Therefore, it is necessary to define the place of proximal gastrectomy in the treatment of gastric cancers.

Gastric Emptying is Accelerated in Patients With Gastric Tube Reconstruction Following Laparoscopic Proximal Gastrectomy

BACKGROUND

Laparoscopic proximal gastrectomy (LPG) is an attractive option for the treatment of early gastric cancer in the upper third of the stomach. No optimal method of reconstruction after LPG has been established because of problems associated with postoperative reflux. Gastric tube reconstruction, a type of esophagogastrostomy, is a simple procedure, but it is associated with a high frequency of reflux esophagitis (RE). We investigated the relationship between RE and gastric emptying, along with nutritional parameters.

SUBJECTS AND METHODS

We compared gastric emptying in patients who had undergone curative LPG with gastric tube reconstruction for gastric cancer with that of patients after total gastrectomy (TG), distal gastrectomy (DG) and of healthy volunteers and patients after DG. The LPG group was divided into an RE LPG-RE (+) group and a non-reflux esophagitis (non-RE) an LPG-RE (-) group, and we compared gastric emptying and indices of nutrition, such as body weight and laboratory findings, between those among LPG-RE (+), LPG-RE (-), and TG groups.

RESULTS

The time lag between ingestion and peak 13 CO 2 expiration (T lag) in the healthy volunteer group was significantly shorter in the LPG group longer than those in the healthy volunteer LPG group and TG group. The T lag was significantly shorter in the RE LPG-RE (+) group than in the non-RE LPG-RE (-) group. The percentage change in body weight percentage in the non-RE LPG-RE (-) group was significantly larger than that in the RE LPG-RE (+) group at 12 months after surgery. Both the serum albumin and hemoglobin levels in the non-RE LPG-RE (-) tended to be preserved compared with those in the RE LPG-RE (+) group and TG group.

CONCLUSIONS

Gastric emptying was accelerated after LPG, and was associated with RE. Our data suggest that RE could be associated with body weight loss after LPG.

Effectiveness and safety of self-pulling and latter transected Roux-en-Y reconstruction in totally laparoscopic distal gastrectomy

BACKGROUND

Self-pulling and latter transection (SPLT) reconstruction has been applied in total laparoscopic total gastrectomy and BI reconstruction (known as Delta SPLT) in total laparoscopic distal gastrectomy (TLDG) in some previous studies. This approach can reduce the technical difficulty of the surgery as well as the quantity of cartridges required, with manageable safety. Here, we used SPLT to complete Roux-en-Y reconstruction in TLDG and evaluated the safety and effectiveness of this novel method by comparing it with conventional Roux-en-Y reconstruction in laparoscopy-assisted distal gastrectomy (LADG).

METHODS

Patients with gastric cancer who underwent SPLT-TLDG or LADG between June 2019 and September 2021 were retrospectively analyzed. Baseline information and postoperative short-term surgical outcomes of the two groups were compared.

RESULTS

A total of 114 patients with gastric cancer were included in the study. Patients underwent SPLT-TLDG (n = 73, 64.0%) or LADG (n = 41, 36.0%). No patient underwent open surgery. There were no differences in patient demographics or tumor characteristics between the two groups. The mean intraoperative blood loss was 47.1 ± 34.3 ml in the SPLT-TLDG group, which was significantly less than that in the LADG group (P = 0.022). There were no significant differences in operation time, harvested lymph nodes, time to first flatus, time to liquid intake, or postoperative hospital stay between the two groups. Nine and five patients had short-term postoperative complications in the SPLT-TLDG and LADG groups, respectively.

CONCLUSION

We introduced a self-pulling and latter transected Roux-en-Y reconstruction (SPLT-RY) for use in TLDG. We showed that SPLT-RY reconstruction in TLDG is a safe and feasible surgical method in terms of short-term surgical outcomes and has the advantages of simplifying the reconstruction.

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.

Current status of proximal gastrectomy for gastric and esophagogastric junctional cancer: A review

Proximal gastrectomy (PG) is one of the function-preserving surgical methods for the treatment of upper gastric cancer. Favorable postoperative results have been reported in comparison with total gastrectomy. However, because there are challenges, such as postoperative reflux esophagitis, anastomotic stenosis, and residual food, appropriate selection of a reconstruction method is crucial. Some methods include esophagogastric anastomosis, including simple esophagogastrostomy, tube-like stomach esophagogastrostomy, side overlap with fundoplication by Yamashita, and double-flap technique, and reconstruction using the small intestine, including double-tract methods, jejunal interposition, and jejunal pouch interposition. However, standard reconstruction methods are yet to be established. PG has also been employed in early gastric cancer of the upper third of the stomach, and indications have also been extended to esophagogastric junction cancer, which has shown an increase in recent years. Although many retrospective studies have revealed the functional benefits or oncological safety of PG, the characteristics of each surgical procedure should be understood so that an appropriate reconstruction method, with a reflux prevention mechanism and minimal postoperative injury, can be selected.

Comparison of outcomes of laparoscopy-assisted and open proximal gastrectomy with jejunal interposition for early gastric cancer in the upper third of the stomach: A retrospective observational study

INTRODUCTION

Laparoscopy-assisted proximal gastrectomy with jejunal interposition (LAPG-JI) is not yet widely used because the three anastomotic procedures involved in this operation are technically complicated. This study aimed to describe our surgical procedure for LAPG-JI and assess its feasibility and safety.

METHODS

This was a retrospective study of 70 patients who had undergone proximal gastrectomy with jejunal interposition for gastric cancer in the upper third of the stomach between July 2007 and October 2016. Of these patients, 32 underwent LAPG-JI, and 38 underwent open proximal gastrectomy with jejunal interposition. Clinical characteristics and both surgical and postoperative outcomes were compared between LAPG-JI and open proximal gastrectomy with jejunal interposition.

RESULTS

The operation time was longer in the LAPG-JI group (189 vs 154 min, P < 0.001) and estimated blood loss was lower (30 vs 180 mL, P < 0.001). There were no differences in the rates of early (9.4% vs 13.2%) or late postoperative complications (12.5% vs 10.5%). No anastomotic leakage was observed in either group. In the LAPG-JI group, the time to first eating was shorter, and the white blood cell counts on postoperative days 1 and 7 and body temperature on postoperative day 3 were lower. The number of additional doses of postoperative analgesia was lower in the LAPG-JI group. Reflux esophagitis graded C according to the Los Angeles classification was observed in only one patient (3.1%) in the LAPG-JI group.

CONCLUSION

Although the operation time was longer in the LAPG-JI group, the procedure seemed to be feasible and safe. Also, it offered the advantages of laparoscopic surgery, including less invasiveness and quicker recovery.

Diagnostic accuracy of T stage of gastric cancer from the view point of application of laparoscopic proximal gastrectomy

The preoperative diagnosis of T stage is important in selecting limited treatments, such as laparoscopic proximal gastrectomy (LPG), which lacks the ability to palpate the tumor. Therefore, the present study examined the accuracy of preoperative diagnosis of the depth of tumor invasion in early gastric cancer from the view point of the indication for LPG. A total of 193 patients with cT1 gastric cancer underwent LPG with gastrointestinal endoscopic examinations and a series of upper gastrointestinal radiographs. The patients with pT1 were classified into the correctly diagnosed group (163 patients, 84.5%), and those with pT2 or deeper were classified into the underestimated group (30 patients, 15.5%). Factors that were associated with underestimation of tumor depth were analyzed. Tumor size in the underestimated group was significantly larger; the lesions were more frequently located in the upper third of the stomach and were more histologically diffuse, scirrhous, with infiltrative growth, and more frequent lymphatic and venous invasion. For upper third lesions, in univariate analysis, histology (diffuse type) was associated with underestimation of tumor depth. Multivariate analysis found that tumor size (≥20 mm) and histology (diffuse type) were independently associated with underestimation of tumor depth. gastric cancer in the upper third of the stomach with diffuse type histology and >20 mm needs particular attention when considering the application of LPG.

Function-preserving surgery for gastric cancer: current status and future perspectives

The number of early gastric cancer (EGC) cases has been increasing because of improved diagnostic procedures including endoscopy and screening systems. Therefore, function-preserving gastrectomy (FPG) for EGC with the expectation of better quality of life (QOL) after surgery may be increasingly utilized, due to its association with low rate of lymph node metastasis and excellent survival and the possibility of employing less invasive procedures such as laparoscopic gastrectomy in combination. Pylorus-preserving gastrectomy (PPG) with curative intent lymph node dissection is a representative FPG that has been used in EGC, and its superiorities, indications, limitations, and survival benefits have already been reported in several retrospective studies. Laparoscopic proximal gastrectomy (LAPG) has also been employed in EGC of the upper third of the stomach; however, LAPG was found to be associated with major issues in achieving a balance between swallowing and reflux prevention. In patients with EGC in the upper third of the stomach, laparoscopy-assisted subtotal gastrectomy with a preserved, albeit very small, stomach may provide a better QOL and fewer postoperative complications. FPG is recommended as a surgical treatment for EGC if the indication is accurately diagnosed and strictly confirmed; however, these techniques in laparoscopic surgery present technical difficulties to surgeons without a certain degree of skills. Although many retrospective studies revealed the functional benefits or oncological safety with FPG, further prospective studies using large case series are necessary to reveal the value of FPG compared with the conventional procedures.

Laparoscopic proximal gastrectomy for early gastric cancer

The incidence of proximal early gastric cancer (EGC) is increasing, and while laparoscopic proximal gastrectomy (LPG) has been performed as a surgical option, it is not yet the standard treatment, because there is no established common reconstruction method following proximal gastrectomy (PG). We reviewed the English-language literature to clarify the current status and problems associated with LPG in treating proximal EGC. This procedure is considered indicated for EGC located in the upper third of the stomach with clinical T1N0, but not when it can be treated endoscopically. No operative mortality or conversion to open surgery was reported in our review, suggesting that this procedure is technically feasible. The most frequent postoperative complication involved problems with anastomoses, possibly caused by the technical complexity of the reconstruction. Although various reconstruction methods following open PG (OPG) and LPG have been reported, there is no standard reconstruction method. Well-designed multicenter, randomized, controlled, prospective trials to evaluate the various reconstruction methods are necessary.

Proximal Gastrectomy for Gastric Cancer

Laparoscopic proximal gastrectomy (LPG) is theoretically a superior choice of minimally-invasive surgery and function-preserving surgery for the treatment of proximal early gastric cancer (EGC) over procedures such as laparoscopic total gastrectomy (LTG), open total gastrectomy (OTG) and open proximal gastrectomy (OPG). However, LPG and OPG are not popular surgical options due to three main concerns: the first, oncological safety; the second, functional benefits; and the third, anastomosis-related late complications (reflux symptoms and anastomotic stricture). Numerous recent studies have concluded that OPG and LPG present similar oncological safety profiles and improved functional benefits when compared with OTG and LTG. While OPG with modified esophagogastrostomy does not provide satisfactory results, OPG with modified esophagojejunostomy showed similar rates of anastomosis-related late complications when compared to OTG. At this stage, no standard reconstruction method post-LPG exists in the clinical setting. We recently showed that LPG with double tract reconstruction (DTR) is a superior choice over LTG for proximal EGC in terms of maintaining body weight and preventing anemia. However, as there is no definitive evidence in favor of LPG with DTR, a randomized clinical trial comparing LPG with DTR to LTG was recommended. This trial, the Korean Laparoscopic Gastrointestinal Surgery Study-05 (NCT01433861), is expected to assist surgeons in choice of surgical approach and strategy for patients with proximal EGC.

Novel laparoscopic procedure for treating proximal early gastric cancer: laparoscopy-assisted pylorus-preserving nearly total gastrectomy

PURPOSE

Pylorus-preserving nearly total gastrectomy (PPNTG) is a function-preserving gastrectomy for treating proximal early gastric cancer that prevents rapid gastric emptying and reflux. In this report, we present a surgical technique for performing laparoscopy-assisted PPNTG (LAPPNTG).

METHODS

The resection of the stomach was similar to that during conventional total gastrectomy, with the key difference being that the pyloric cuff was preserved to a length of 3-4 cm. Compared with standard total gastrectomy, the lymph node dissection along the right gastric vessels and the infrapyloric vessels were omitted. Reconstruction was performed with a jejunal interposition that was 30 cm in length, with preservation of the marginal vessels in a retrocolic fashion.

RESULTS

Thirteen patients with cT1 cN0 proximal gastric cancer underwent LAPPNTG at our institution. The median length of the operation and estimated blood loss were 329 min and 138 ml, respectively. All resected specimens had tumor-free margins, and the median number of removed lymph nodes was 40. There were no serious postoperative complications and no patients underwent conversion to laparotomy.

CONCLUSIONS

Performing LAPPNTG with a jejunal interposition is feasible and might be an appropriate treatment for proximal early gastric cancer.

Lower esophageal sphincter-preserving laparoscopy-assisted proximal gastrectomy in patients with early gastric cancer: a method for the prevention of reflux esophagitis

Although laparoscopy-assisted proximal gastrectomy (LAPG) with esophagogastrostomy for early gastric cancer (EGC) is technically feasible and oncologically safe, it has not been popularized because of the frequent occurrence of reflux esophagitis associated with loss of the lower esophageal sphincter (LES). Herein, we present surgical outcomes in patients with LES-preserving LAPG (LES-p LAPG), which may contribute to protecting against postoperative gastroesophageal reflux or stricture in the treatment of proximal EGC. From November 2009 to May 2010, LES-p LAPG was performed in nine patients with clinical EGC, located at the proximal one-third of the stomach with the upper margin of the tumor 3-4 cm from the esophagogastric junction. After the resection of the proximal stomach with D1 + β lymph node dissection, gastrogastrostomy was performed using a 25-mm circular stapler through a mini-laparotomy wound at the epigastrium. The median operating time was 137.5 min (range 120-180). The median number of retrieved lymph nodes and length of the proximal resection margin were 27 (range 7-49) and 2.4 cm (range 0.7-5), respectively. The postoperative complications included one gastrogastrostomy stricture and one case of leakage, which were managed by endoscopic balloon dilation and conservative treatment, respectively. None of the patients suffered from symptoms of reflux esophagitis during the follow-up period (median 15 months; range 8-28 months). This technique of LES-p LAPG for the treatment of proximal EGC could be a simple, safe, and useful technique to prevent esophageal reflux or stricture. This technique requires prospective validation.

A new technique for resecting gastric remnant cancer after proximal gastrectomy with jejunal interposition

Surgery for gastric remnant cancer after distal gastrectomy is well established; however, little is known about the removal of remnant gastric cancer following proximal gastrectomy with jejunal interposition. We introduce a surgical technique for removing remnant cancer under these circumstances. We used this technique to remove a total gastric remnant with radical lymph node dissection, while preserving the interposed jejunum for easy re-reconstruction by Roux-en-Y anastomosis, in five patients. The median operating time was 199 min and the median blood loss was 330 ml. There were no postoperative deaths or major complications and all five patients were discharged within 14 days after surgery. Our technique for total resection of the gastric remnant after proximal gastrectomy and re-reconstruction with preserved interposed jejunum is easy, safe, and effective.

Comparative study of laparoscopic vs open gastrectomy in gastric cancer management

AIM

To compare long-term results of gastric cancer patients undergoing laparoscopic and open gastrectomy in a single unit.

METHODS

From February 2000 to September 2004, all patients with adenocarcinoma of the stomach were assessed to entry in this longitudinal prospective non-randomized trial. Primary endpoint was cancer-related survival and secondary endpoints were overall survival, evaluation of surgical complications and mortality.

RESULTS

Fifty-eight patients were enrolled. Forty-seven patients were followed-up (range 11-103, median 38 mo). Four patients were lost at follow up. Twenty-two patients underwent a laparoscopic gastric surgery (LGS) and 25 had a standard open procedure (OGS). No statistical difference was found between the two groups in terms of 5 years cancer-related mortality rate (50% vs 52%, P = 1), and 5 years overall mortality rate (54.5% vs 56%, P = 1). Accordingly, cancer-related and overall survival probability by Kaplan-Meier method showed comparable results (P = 0.81 and P = 0.83, respectively). We found no differences in surgical complications in the 2 groups. There was no conversion to open surgery in this series.

CONCLUSION

LGS is as effective as OGS in the management of advanced gastric cancer. However LGS cannot be recommended routinely over OGS for the treatment of advanced gastric cancer.

A meta-analysis of prospective randomized trials comparing minimally invasive and open distal gastrectomy for cancer

Current literature suggests that minimally invasive distal gastrectomy (MIDG) may enhance post-operative recovery and decrease morbidity compared to open surgery (ODG) in patients with gastric cancer. A meta-analysis of six Prospective Randomized Trials comparing MIDG (343 patients) and ODG (323 patients) for gastric cancer was conducted. MIDG was associated with increased operative time, reduced blood loss and overall morbidity. There was not sufficient data to draw solid conclusions about the oncologic quality of MIDG.

Totally laparoscopic gastrectomy for gastric cancer: meta-analysis of short-term outcomes

INTRODUCTION

We present a review of the literature, together with a meta-analysis of short-term outcomes of totally laparoscopic gastrectomy (TLG) compared with open gastrectomy (OG).

MATERIAL & METHODS

We carried out a search in the Pubmed and Cochrane databases from September 2003 to May 2009. Controlled studies on early outcomes were included, both prospective and retrospective, randomized and non-randomized.

RESULTS

We found nine eligible studies, one of which was a randomized controlled trial (RCT), while eight were series of patients (three consecutive). The study group consisted of 1,492 patients, 828 of whom had been treated with TLG and 664 treated with OG. TLG for gastric cancer shows a 32.5% (p < 0.001) longer operative time than OG, whereas TLG demonstrated a 44% (p < 0.001) reduction in blood loss, a 34% (p < 0.001) reduction time to first flatus and a 33.7% reduced (p < 0.001) hospital stay. No notable differences were registered regarding morbidity and mortality rates, and no significant difference was observed between the two groups regarding the extent of the lymphadenectomy.

CONCLUSIONS

Despite a longer operative time for TLG, with a gastrointestinal recovery rate faster than the OG one for gastric cancer results, no notable differences were recorded between the two techniques for the morbidity and mortality rates and in the spread of the lymphadenectomy.

A meta-analysis of randomized controlled trials that compared laparoscopy-assisted and open distal gastrectomy for early gastric cancer

BACKGROUND

We conducted a meta-analysis to evaluate and compare the advantages of laparoscopy-assisted distal gastrectomy (LADG) over open distal gastrectomy (ODG) for treating early gastric cancer (EGC).

METHODS

We searched MEDLINE, EMBASE, Science Citation Index, and Cochrane Controlled Trial Register for relevant papers published between January 1990 and January 2010 by using the following search terms: laparoscopy-assisted gastrectomy, laparoscopic gastrectomy, and early gastric cancer. The following data were analyzed: operative time, estimated blood loss, number of harvested lymph nodes, time required for resumption of oral intake, duration of hospital stay, frequency of analgesic administration, complications, tumor recurrence, and mortality.

RESULTS

We selected four papers reporting randomized control studies (RCTs) that compared LADG with ODG for EGC. Our meta-analysis included 267 patients with EGC; of these, 134 and 133 had undergone LADG and ODG, respectively. The volume of intraoperative blood loss, frequency of analgesic administration, and rate of complications were significantly lesser for LADG than for ODG. However, the time required for resumption of oral intake and duration of hospital stay did not significantly differ between LADG and ODG. The operative time for LADG was significantly longer than that for ODG; further, the number of harvested lymph nodes was significantly lesser in the LADG group than in the ODG group.

CONCLUSION

LADG is advantageous over ODG because it results in lesser blood loss, is less painful, and is associated with a low risk of complications. Additional RCTs that compare LADG and ODG and investigate the long-term oncological outcomes of LADG are required to determine the advantages of LADG over ODG.

Meta-analysis of laparoscopy-assisted and open distal gastrectomy for gastric cancer

BACKGROUND

Laparoscopy-assisted distal gastrectomy (LADG) for gastric cancer is a minimally invasive technique. We performed a meta-analysis of five randomized clinical trials (RCTs) to evaluate and compare the benefits of LADG with those of open distal gastrectomy (ODG).

METHODS

The present meta-analysis was based on the comparison of LADG with ODG for gastric cancer. The following factors were examined: operative time, estimated blood loss, number of harvested lymph nodes, time to resumption of oral intake, duration of hospital stay, frequency of analgesic administration, complications, tumor recurrence, and mortality.

RESULTS

We selected five RCTs to compare LADG with ODG for gastric cancer. A total of 326 patients with gastric cancer were included in this meta-analysis of whom 164 underwent LADG and 162 underwent ODG. There was a significant difference in the volume of intraoperative blood loss, period of hospital stay, frequency of analgesic administration, and rate of complications between LADG and ODG. There was no difference in the resumption of oral intake, rate of tumor recurrence, and mortality. The operative time was significantly longer and the number of harvested lymph nodes was significantly smaller in LADG than in ODG.

CONCLUSION

LADG is significantly superior to ODG regarding the volume of blood loss, duration of hospital stay, level of pain, and risk of complications. There was no difference in the resumption of oral intake, rate of tumor recurrence, and mortality. However, LADG was significantly inferior to ODG regarding operative time and also had a smaller number of harvested lymph nodes.

Laparoscopic-assisted distal gastrectomy versus open distal gastrectomy for advanced gastric cancer

BACKGROUND

Laparoscopic-assisted gastric surgery has become an option for the treatment of early gastric cancer. However, there are few reports of laparoscopic surgery in the management of advanced gastric cancer. In this study we describe our experience with laparoscopic-assisted distal gastrectomy (LADG) for advanced gastric cancer (AGC).

METHODS

Between November 2004 and June 2007, 47 patients with AGC underwent LADG at our hospital, and 45 of those patients were enrolled in this study. These patients were compared with 83 patients who had AGC and underwent conventional open distal gastrectomy (ODG) during the same period.

RESULTS

Operation time was significantly longer in the LADG group than in the ODG group. Estimated blood loss in the LADG group was significantly less than in the ODG group. Time to ambulation and first flatus and duration of analgesic medication were significantly shorter in the LADG group. The morbidity and mortality rate were also lower than in the ODG group, with no statistically significant difference. The distance of the proximal resection margin showed no significant difference compared with ODG (6.3 +/- 0.9 versus 6.5 +/- 0.9 cm; p = 0.228). The mean number of nodes resected with LADG was 35.6 +/- 14.2, and that with ODG was 38.3 +/- 11.4 (p = 0.269). The mean follow-up for the LADG group was 23.6 months (range 9-40 months). In the LADG group, recurrence was observed in six patients (13.3%). Three patients had recurrence and died after 10 (IIIB), 11 (IIIA), and 13 (IIIB) months.

CONCLUSIONS

LADG with extended lymphadenectomy for AGC is a feasible and safe procedure and has several advantages. Moreover, this method can achieve a radical oncologic equivalent resection. Indications for LADG with extended lymphadenectomy could be expanded in the treatment of locally advanced gastric cancer.

Current status of minimal access surgery for gastric cancer

BACKGROUND

The aim was to conduct a systematic review of the literature on the subject of laparoscopic gastrectomy (LG) and determine the relative merits of laparoscopic (LG) and open gastrectomy (OG) for gastric carcinoma.

MATERIAL AND METHODS

A search of the Medline, Embase, Science Citation Index, Current Contents and PubMed databases identified individual retrospective and prospective series on LG (proximal, distal and total). Furthermore, all clinical trials that compared LG and OG published in the English language between January 1990 and the end of December 2006 were also identified. A large number of outcome variables were analysed for individual series and comparative trials between LG and OG and results discussed and tabulated.

RESULTS

The majority of the literature is published from Japan showing both oncological adequacy and safety of LG. The majority of early series and comparative studies have utilized laparoscopic resection for early and distal gastric cancer. However, with increasing advanced laparoscopic experience, advancement in digital technology and improvement in instrumentation, more advanced gastric cancers and more extensive procedures such as laparoscopic-assisted total gastrectomy and laparoscopy-assisted D2 dissection are becoming more common. To date lymph node harvesting, resection margins and complication rates seem to be equivalent to open procedures. Furthermore, the earlier fears of port-site metastases have not been borne out.

CONCLUSIONS

The available data suggests that LG seems to be associated with quicker return of gastrointestinal function, faster ambulation, earlier discharge from hospital, and comparable complications and recurrence rate to OG. However, the operating time for LG remains significantly longer compared to its open counterpart, although with experience it is achieving parity with OG. However, the majority of the comparative trials (if not all) probably do not have the power to detect differences in the outcome. As far as the RCT's (LG vs. OG) are concerned, the numbers of patients in such trials are small and the majority of patients were operated upon for early distal gastric cancer and, therefore, any meaningful conclusions regarding the advantages or disadvantages of LG for both the ECGs and extensive and advanced gastric tumours are difficult to justify.

Hemidouble stapling for esophagogastrostomy during laparoscopically assisted proximal gastrectomy

In esophagogastrostomy during laparoscopically assisted proximal gastrectomy, some problems have occurred; the main ones being reflux esophagitis and the technical difficulty in anastomosis. We have had good results with a hemidouble stapling technique; the center rod of circular stapler is pierced through the left end of the staple line of the stomach. The longest distance from the pylorus to the esophagogastrostomy can be fired in this position. The distance is longer, so alkaline esophagitis is rarer. When the center rod is pierced through the anterior or posterior gastric wall, the operator may be worried about ischemia of the area surrounded by the linear stapler and circular stapler. In hemidouble stapling, an ischemic area is not created at all structurally. Any surgeon can perform a reproducible anastomosis because the place pierced with the center rod is fixed. This technique is easy and safety to operate via minilaparotomy.

Laparoscopic Conversion of an Omega in a Roux-en-y Reconstruction After Mini-invasive Total Gastrectomy for Cancer

INTRODUCTION

Few cases of laparoscopic total gastrectomy have been published. Reconstruction of the digestive tract was generally accomplished with a Roux-en-y esophagojejunal mechanical anastomosis. Here we report the first 2 cases of laparoscopic conversion of an omega in a Roux-en-y reconstruction due to the occurrence of a severe alkaline esophagitis after mini-invasive total gastrectomy for cancer.

MATERIALS AND METHODS

Two male patients presented in 2004. One year prior, at another facility, they had undergone laparoscopic total gastrectomy for cancer, with reconstruction of digestive tract by means of an esophagojejeunostomy with a jejunal loop and Braun's side-to-side enteroanastomosis. They complained of daily symptoms of nausea, regurgitation, heartburn, and early postprandial fullness with reduction of appetite and weight loss of almost 15 kg. Instrumental examination diagnosed alkaline esophagitis. Intervention was performed via laparoscopic approach and the digestive reconstruction was reconfigured in a Roux-en-y type with a proximal limb of almost 60 cm.

RESULTS

Operative time was 135 to 180 minutes. No postoperative complications occurred. After 1-year follow-up, symptoms resolution and esophagitis healing have been observed in both patients.

CONCLUSIONS

Laparoscopic gastrectomy is gaining wide acceptance. In our opinion, a standardization of the technique is necessary: we believe Roux-en-y should be considered the preferred reconstruction route ensuring the best protection of the esophagus from alkaline reflux.

Laparoscopic gastrectomy with lymph node dissection for gastric cancer

Since 1991, laparoscopic surgery has been adopted for the treatment of gastric cancer, and it has been performed worldwide, especially in Japan and Korea. We reviewed the English-language literature to clarify the current status of and problems associated with laparoscopic gastrectomy with lymph node dissection as treatment for gastric cancer. In Japan, early-stage gastric cancer (T1/T2, N0) is considered the only indication for laparoscopic gastrectomy. As yet, there is little high-level evidence based on long-term outcome supporting laparoscopic gastrectomy for cancer, but reports have provided level 3 evidence that the procedure is technically safe, and that it yields better short-term outcomes than open surgery; that is, recovery is faster, hospital stay is shorter, there is less pain, and cosmesis is better. However, investigation into the oncological outcome of laparoscopic gastrectomy as treatment for cancer is lacking. To establish laparoscopic surgery as a standard treatment for gastric cancer, multicenter randomized controlled trials to compare the short- and long-term outcomes of laparoscopic surgery versus open surgery are necessary.

Laparoscopic surgical resection for early gastric cancer

This paper provides an overview of the current status of laparoscopic resection for early gastric cancer. According to many case-control studies, laparoscopic gastrectomy is feasible and safe, and in comparison with conventional open gastrectomy is associated with less pain, a quicker recovery of gastrointestinal function, and a better postoperative quality of life, with no negative influence on survival. Large randomized controlled trials of laparoscopic versus open gastrectomy are needed to establish the future role of laparoscopic surgery in the treatment of patients with gastric cancer.

Laparoscopic and open gastric resections for malignant lesions: a prospective comparative study

BACKGROUND

Whereas laparoscopy for benign diseases provides clear advantages over traditional surgery, the benefits of laparoscopic gastric resection for malignant diseases are less clear. The objectives of this study were to compare prospectively the clinical outcomes between completely laparoscopic and open total and partial gastrectomies for malignant diseases and to assess whether laparoscopic gastrectomies obtain adequate margins and follow oncologic principles.

METHODS

Between April 1995 and March 2004, a prospective comparative study was performed comparing eight patients who underwent laparoscopic total gastrectomy with 11 patients who underwent open total gastrectomy, and 16 patients who underwent laparoscopic partial gastrectomy with 17 who patients underwent open partial gastrectomy. Stage, extent of lymphadenectomy, and long-term follow-up were examined. The intraoperative and postoperative details of the two groups were compared.

RESULTS

The laparoscopic group patients had fewer intraoperative complications while the operative time was similar to that of the open group. Both ambulation and hospital stay were significantly shorter in the laparoscopic groups than in the open groups. The short-term morbidity was lower in the laparoscopic groups and there were no cases of death, whereas one case of postoperative death occurred after an open total gastrectomy. There was no need to convert to open surgery. The number of lymph nodes obtained in the laparoscopic and open procedures was not significantly different. In addition, all resected margins were tumor free in the laparoscopic group, whereas tumor involvement was presented in the margin of one specimen in the open group.

CONCLUSIONS

The totally laparoscopic approach to total and partial gastrectomies had good results and was proven to be a feasible and safe procedure. In addition, the laparoscopic procedures are superior to open surgeries in terms of faster postoperative recovery, shorter hospital stay, and better cosmetic outcomes. A totally laparoscopic approach for early and advanced gastric cancer can obtain adequate margins and follow oncologic principles.

Minimally invasive surgery for gastric tumors

Since 1991, laparoscopic surgery has been adopted for the treatment of gastric tumors, including gastric cancer and gastric gastro-intestinal submucosal tumor (GIST). Although laparoscopic gastric resection for gastric tumors has not been accepted worldwide, its use has definitively increased due to its reduced invasiveness. The most common procedures are laparoscopy-assisted distal gastrectomy (LADG) for cancer and laparoscopic gastric resection as a standard of care for gastric tumors, multicenter randomized controlled clinical trials are needed to evaluate its short- and long-term outcomes.

Completely laparoscopic total and partial gastrectomy for benign and malignant diseases: a single institute's prospective analysis

BACKGROUND

Laparoscopic surgery for gastrointestinal benign disease has gained worldwide acceptance; totally laparoscopic surgery for malignant diseases remains controversial. The purposes of this study were to examine prospectively our experience with laparoscopic gastric resections, to evaluate the surgical outcomes, and to discuss the role of these procedures in the treatment of benign and malignant diseases of the stomach. To the best of our knowledge, this is the largest prospective study of totally laparoscopic total and partial gastrectomies in Western countries.

STUDY DESIGN

Thirty-three patients who underwent totally laparoscopic gastric resection between April 1995 and January 2004 were studied prospectively. Eight patients underwent laparoscopic total gastrectomy and 25 patients had laparoscopic partial gastrectomy. There were 21 women and 12 men with a mean age of 71 +/- 10 years.

RESULTS

Twenty-one patients (63.6%) were operated on for malignant diseases and 12 patients (36.4%) had benign lesions. Conversion to laparotomy was not required in any case. Mean operative time was 138 +/- 40 minutes and mean blood loss was 58 +/- 85 mL. There were no major intraoperative complications except for one splenectomy, and there were no perioperative deaths. Two postoperative complications occurred; one patient developed an intraperitoneal abscess with a small duodenal fistula after total gastrectomy and was treated by peritoneal lavage and drain placement. The other patient developed delayed gastric emptying after subtotal gastrectomy and was managed conservatively. Mean ambulation time and mean hospital stay were 2.3 +/- 0.7 days and 14.6 +/- 5 days, respectively. All resected margins were tumor free. The mean number of retrieved lymph nodes for the malignant lesions was 22 +/- 12 (range 10 to 53).

CONCLUSIONS

This prospective trial demonstrated that totally laparoscopic total and partial gastric resections had good results and were feasible and safe procedures. In addition, we concluded that the totally laparoscopic approach for early and advanced gastric cancer can obtain adequate margins and follow oncologic principles.

Laparoscopic versus open subtotal gastrectomy for distal gastric cancer: five-year results of a randomized prospective trial

OBJECTIVE

The aim of this study was to compare technical feasibility and both early and 5-year clinical outcomes of laparoscopic-assisted and open radical subtotal gastrectomy for distal gastric cancer.

SUMMARY BACKGROUND DATA

The role of laparoscopic surgery in the treatment of gastric cancer has not yet been defined, and many doubts remain about the ability to satisfy all the oncologic criteria met during conventional, open surgery.

METHODS

This study was designed as a prospective, randomized clinical trial with a total of 59 patients. Twenty-nine (49.1%) patients were randomized to undergo open subtotal gastrectomy (OG), while 30 (50.9%) patients were randomized to the laparoscopic group (LG). Demographics, ASA status, pTNM stage, histologic type of the tumor, number of resected lymph nodes, postoperative complications, and 5-year overall and disease-free survival rates were studied to assess outcome differences between the groups.

RESULTS

The demographics, preoperative data, and characteristics of the tumor were similar. The mean number of resected lymph nodes was 33.4 +/- 17.4 in the OG group and 30.0 +/- 14.9 in the LG (P = not significant). Operative mortality rates were 6.7% (2 patients) in the OG and 3.3% (1 patient) in the LG (P = not significant); morbidity rates were 27.6% and 26.7%, respectively (P = not significant). Five-year overall and disease-free survival rates were 55.7% and 54.8% and 58.9% and 57.3% in the OG and the LG, respectively (P = not significant).

CONCLUSIONS

Laparoscopic radical subtotal gastrectomy for distal gastric cancer is a feasible and safe oncologic procedure with short- and long-term results similar to those obtained with an open approach. Additional benefits for the LG were reduced blood loss, shorter time to resumption of oral intake, and earlier discharge from hospital.

Videolaparoscopic total and subtotal gastrectomy with extended lymph node dissection for gastric cancer

BACKGROUND

Laparoscopic surgery has been used in the treatment of early gastric cancer with low mortality and morbidity and improvement in patient's quality of life. The purpose of the current study was to determine if these advantages persist after radical laparoscopic treatment of more advanced gastric cancer.

METHODS

A retrospective review of 44 patients after laparoscopic surgery for gastric cancer was performed.

RESULTS

Tumor stage was IA in 8 patients, IB in 12, II in 9, IIIA in 6, IIIB in 1, and IV in 8. Eight total and 36 subtotal R0 gastrectomies were performed (12 D(1) and 32 D(2)). The mean number of dissected lymph nodes was 38.1 +/- 21.5. Conversion rate was 7%. Operative mortality and morbidity were 7% and 12%, respectively. Three-year survival was 75%.

CONCLUSIONS

Laparoscopic radical total or subtotal gastrectomy with extended lymphadenectomy for gastric cancer is a feasible, safe, and oncologically effective procedure.