Totally laparoscopic 95% gastrectomy for cancer: technical considerations

Complete mesogastric excision for gastric cancer: is it the future of gastric cancer surgery?

Gastric cancer remains undoubtedly one of the most common and deadly cancers worldwide. The global incidence shows wide geographic variation with a high prevalence in Asia. Besides that, there are evident differences in epidemiology, histopathology, tumor location, diagnosis and treatment strategy between east and west countries. Gastric cancer represents an aggressive disease, with many factors influencing its development and also recurrence after surgical resection. New knowledge of disease spread and new routes of metastases are now emerging and the 'novel' concept of complete mesogastric excision for gastric cancer is under consideration and debate. This article aims to analyze and highlight this new concept after a careful literature review, offering also a view toward the future.

Is Prognostic Nutritional Index an Indicator for Postoperative 90-Day Mortality in Laparoscopic Gastric Cancer Surgery?

Gastic cancer is a life-threatening malignancy in the world. The aim of this study was to investigate the clinical significance of the prognostic nutritional index (PNI) as a guiding marker for gastric cancer patients with laparoscopic gastrectomy. We retrospectively examined the medical records of 138 gastric cancer patients who had adenocarcinoma pathological diagnosis and operated laparoscopically. Patients were divided into two groups (survived and death) and these groups were compared with clinical and laboratory parameters results. The PNI was calculated as 10 × serum albumin (g/dL) + 0.005 × total lymphocyte count (per mm³). Logistic regression analyses were performed to identify the risk factors of 90-day mortality. The median age of the study cohort was 62.5 (19-91) years, 98 (71%) were males, and 9 (6.5%) patients died during the 90-day after laparoscopic gastrectomy. The PNI levels were significantly lower in death group compared with survived group 37.5 (25-47.1) to 46.9 (22.8-64.9). The PNI (Odds Ratio = 0.81, 95% Confidence Interval 0.70-0.92, p = 0.003) was found as an independent factor for 90-day mortality in multivariate analysis. Receiver operating characteristic (ROC) curve analysis showed that 45.15 is the best-cutoff value for 90-day mortality after laparoscopic gastrectomy. 90-day mortality rate of PNI > 45.15 was 2.2% and PNI ≤ 45.15 was 13.6% found. Lower PNI is associated with increased 90-day mortality in laparoscopic gastrectomy for gastric cancer. The PNI may be a useful marker for predicting the 90-day mortality of gastric cancer patients after laparoscopic gastrectomy.

Gastrectomía laparoscópica casi total con preservación de la rama ascendente de la arteria gástrica izquierda y un 5 % de remanente gástrico. ¿Existe relación con las complicaciones de la anastomosis?

Introducción. Al realizar una gastrectomía distal, el remanente gástrico es irrigado por los vasos gástricos cortos. En este estudio presentamos una serie de casos de gastrectomía distal laparoscópica, con la variante de preservar la rama superior de la arteria gástrica izquierda, con un remanente gástrico pequeño. Métodos. Estudio observacional con intensión analítica, seguimiento de una cohorte retrospectiva de pacientes con cáncer gástrico sometidos a gastrectomía distal radical laparoscópica entre enero 2017 y junio 2019. Se incluyeron todos los pacientes con cáncer gástrico a quienes se les realizó gastrectomía distal radical por laparoscopia. Se estudiaron variables clínicas de los pacientes, variables intraoperatorias, información relacionada con el informe de patología y las complicaciones de la anastomosis gastro-yeyunal. Resultados. Se revisó un total de 61 historias clínicas de pacientes sometidos a gastrectomía distal por laparoscopia, entre quienes se encontró la preservación de la rama ascendente de la arteria gástrica izquierda en el 73,8 % de los pacientes (n=45). El promedio de ganglios resecados fue de 24. Se presentaron un total de 10 complicaciones, ocho relacionadas con la anastomosis (tres estenosis, cuatro filtraciones y un paciente con hemorragia del tracto digestivo superior), y dos con colecciones intrabdominales. En el análisis estadístico no se encontró relación entre la preservación de la rama ascendente de la arteria gástrica izquierda con la presencia de complicaciones. Discusión. La variación que presentamos de la técnica de la gastrectomía distal por laparoscopia cumple con los requisitos oncológicos en los pacientes con cáncer gástrico y no se relaciona con complicaciones de la anastomosis gastró-yeyunal.

Short-term results of near-total (95%) laparoscopic gastrectomy

INTRODUCTION

Total gastrectomy is a surgery with significant perioperative morbidity and mortality, being considered the treatment of choice in proximal gastric cancer. First described in 1980, our group reported and standardized totally laparoscopic 95% gastrectomy in 2014. This technique aims to reduce the complications of total gastrectomy while maintaining oncological radicality. We present the initial results from a cohort of consecutive cases after performing the technique for 4 years at 2 hospital centers.

METHODS

A prospective observational study was carried out in 67 patients with laparoscopic 95% gastrectomy between 2014 and 2017. The main objective has been to detect complications (Clavien Dindo> IIIa), focusing on anastomotic leaks as the most important. The secondary objective was to assess the quality of oncological surgery.

RESULTS

Sixty-seven consecutive patients were included, in whom 95% totally laparoscopic gastrectomy was performed. There was no case of anastomotic leak. Two patients (2.98%) had one or more Clavien Dindo complications equal to or greater than IIIa. The total hospital stay was 6 (3-13) days. R0 radical resection was performed in all patients.

CONCLUSIONS

95% gastrectomy allows selected patients to meet the oncological standards of resection in proximal gastric cancer in a reproducible and safe manner, reducing perioperative risks such as anastomotic leakage. It is a non-comparative observational prospective study, so more studies are needed to assess the standardization of the technique.

The principles of the surgical management of gastric cancer

Surgery is the only curative therapy for gastric cancer but most operable gastric cancer presents in a locally advanced stage characterized by tumor infiltration of the serosa or the presence of regional lymph node metastases. Surgery alone is no longer the standard treatment for locally advanced gastric cancer as the prognosis is markedly improved by perioperative chemotherapy. The decisive factor for optimum treatment is the multidisciplinary team specialized in gastric cancer. However, despite multimodal therapy and adequate surgery only 30% of gastric cancer patients are alive at 3 years. This article reviewed the principles of the surgical management of gastric cancer (minimally invasive or open) and how this may optimize multimodal treatment.