Laparoscopically assisted total gastrectomy with lymph node dissection for upper and middle gastric cancer

Short-Term Outcomes Analysis Comparing Open, Lap-Assisted, Totally Laparoscopic, and Robotic Total Gastrectomy for Gastric Cancer: A Network Meta-Analysis

BACKGROUND/OBJECTIVES

Total gastrectomy (TG) is the cornerstone treatment for gastric cancer (GC). While open TG (OTG) with D2 lymphadenectomy remains the gold standard, alternative techniques such as lap-assisted TG (LATG), totally laparoscopic TG (TLTG), and robotic TG (RTG) have been reported with promising outcomes. The present analysis aimed to compare the short-term outcomes of different techniques for TG comprehensively in the setting of GC.

METHODS

A systematic review and network meta-analysis were performed. The primary outcomes were overall complications (OC), severe postoperative complications (SPCs), and anastomotic leak (AL). Pooled effect-size measures included risk ratio (RR), weighted mean difference (WMD), and 95% credible intervals (CrIs).

RESULTS

Sixty-eight studies (44,689 patients) were included. Overall, 52.4% underwent OTG, 6.5% LATG, 39.2% TLTG, and 1.9% RTG. Both TLTG (RR 0.82; 95% CrI 0.73-0.92) and RTG (RR 0.75; 95% CrI 0.59-0.95) showed a reduced rate of postoperative OC compared to OTG. SPCs and AL RR were comparable across all techniques. Despite the longer operative time, LATG, TLTG, and RTG showed reduced intraoperative blood loss, time to first flatus, ambulation, liquid diet resumption, and hospital stay compared to OTG.

CONCLUSIONS

Minimally invasive approaches seem to be associated with improved OC and functional outcomes compared to OTG.

Surgical outcomes and prognosis of intracorporeal versus extracorporeal esophagojejunostomy after laparoscopic total gastrectomy for gastric cancer: a propensity score-matching study

This study compared the surgical outcomes and long-term prognosis of intracorporeal and extracorporeal esophagojejunostomy after laparoscopic total gastrectomy (LTG) for gastric cancer patients. In total 228 clinical stage I gastric cancer patients undergoing LTG were enrolled from January 2012 and December 2022. Each case in the totally laparoscopic total gastrectomy (TLTG) group was 1:1 propensity score-matched to control cases in the laparoscopy-assisted total gastrectomy (LATG) group. In total, 95 and 93 LATG and TLTG patients were included after propensity score matching (PSM). Clinicopathological features, surgical outcomes, and survival variables were compared, and risk factors for postoperative complications were analyzed. Patient characteristics were well balanced between the LATG and TLTG groups after PSM. The TLTG group showed less blood loss, decreased frequency of analgesic use, and shorter duration of analgesic use. The TLTG group had significantly lower rates of intestinal obstruction and surgical site infection. Larger tumor size and advanced pTNM stage were independent risk factors for postoperative complications. There was no significant difference in overall survival (OS). Compared with LATG, TLTG was associated with better surgical outcomes and fewer postoperative surgical complications in gastric cancer patients although there was no significant difference in OS.

[Technique and Study Results of Laparoscopic Gastrectomy for Gastric Cancer]

The aim of this paper was to describe the technique of laparoscopic gastrectomy for gastric carcinoma and to present a review of current international studies on this topic.The first part describes and documents a standard laparoscopic gastrectomy for carcinoma. In the second part, after an EMBASE and PubMed search, a total of 123 quality-relevant randomised (RCT) and non-randomised (non-RCT) studies on laparoscopic gastrectomy are identified from a primary total of 3,042 hits by systematic narrowing. The study results are then summarised conclusively for the target criteria of feasibility, outcome, oncological quality, morbidity and mortality.Both, laparoscopic subtotal resection for distal gastric carcinomas and laparoscopic gastrectomy can now be performed safely and with few complications. In a recent literature review of a total of 15 RCTs with 5,576 patients (laparoscopic 2,793 vs. open 2,756), there were no significant differences in terms of feasibility, intraoperative outcome and oncological quality (R0 and lymph node harvest). Surgical morbidity and mortality were comparable. Patients after laparoscopic surgery showed a significantly faster early postoperative recovery with a lower overall morbidity. In contrast, the operating time was significantly longer - by a mean of 45 min - compared to the open technique. The advantages of the laparoscopic technique were equally evident in studies on early gastric carcinoma and advanced carcinomas (>T2).Laparoscopic gastrectomy for gastric carcinoma is safe to perform and shows better early postoperative recovery. Complication rates, morbidity and mortality as well as long-term oncological results are comparable with open surgery.

Comparison of Short-Term Outcomes After Robotic Versus Laparoscopic Radical Gastrectomy for Advanced Gastric Cancer in Elderly Individuals: A Propensity Score-Matching Study

BACKGROUND

Robotic gastrectomy (RG) has been widely used to treat gastric cancer. However, whether the short-term outcomes of robotic gastrectomy are superior to those of laparoscopic gastrectomy (LG) for elderly patients with advanced gastric cancer has not been reported.

METHODS

The study enrolled of 594 elderly patients with advanced gastric cancer who underwent robotic or laparoscopic radical gastrectomy. The RG cohort was matched 1:3 with the LG cohort using propensity score-matching (PSM).

RESULTS

After PSM, 121 patients were included in the robot group and 363 patients in the laparoscopic group. Excluding the docking and undocking times, the operation time of the two groups was similar (P = 0.617). The RG group had less intraoperative blood loss than the LG group (P < 0.001). The time to ambulation and first liquid food intake was significantly shorter in the RG group than in the LG group (P < 0.05). The incidence of postoperative complications did not differ significantly between the two groups (P = 0.14). Significantly more lymph nodes were dissected in the RG group than in the LG group (P = 0.001). Postoperative adjuvant chemotherapy was started earlier in the RG group than in the LG group (P = 0.02).

CONCLUSIONS

For elderly patients with advanced gastric cancer, RG is safe and feasible. Compared with LG, RG is associated with less intraoperative blood loss; a faster postoperative recovery time, allowing a greater number of lymph nodes to be dissected; and earlier adjuvant chemotherapy.

A nonrandomized controlled trial: long-term outcomes of LATG/LAPG for cStage I gastric cancer: Japan Clinical Oncology Group Study JCOG1401

BACKGROUND

A previous report confirmed the safety of laparoscopy-assisted total and proximal gastrectomies (LATG and LAPG) (JCOG1401). This report demonstrates the 5-year relapse-free survival (RFS) and overall survival (OS) after long-term follow-up to confirm the efficacy of these surgical methods as key secondary endpoints for cStage I gastric cancer.

METHODS

This study enrolled patients who had histologically proven gastric adenocarcinoma and were diagnosed with clinical T1N0, T1N(+), or T2N0 tumors according to the 14th edition of the Japanese Classification of Gastric Carcinoma (3rd English edition).

RESULTS

Between April 2015 and February 2017, 246 patients were enrolled, although one patient was excluded because of misregistration. Meticulous follow-up was continued for > 5 years for each patient, and the data were analyzed in March 2022. The 5-year RFS was 90.0% (95% confidence interval [CI] 85.5-93.2%), and the 5-year OS was 91.2% (95% CI 86.9-94.2%) in all enrolled patients. Grade 3 or 4 late postoperative complications were detected in 12.7% of patients.

CONCLUSIONS

This single-arm study showed that the long-term outcomes of LATG/LAPG for cStage I gastric cancer were acceptable, which is considered one of the standard treatments when performed by experienced surgeons. Trail registration UMIN000017155 ( http://www.umin.ac.jp/ctr/ ).

[Evidence in minimally invasive oncological gastric surgery]

BACKGROUND

The aim of this study was to systematically review the current evidence on laparoscopic and robotic distal and total gastrectomy in comparison to open surgery.

MATERIAL AND METHODS

A systematic search of EMBASE and PubMed was conducted and 197 randomized (RCT) and non-randomized (non-RCT) studies were identified. An evaluation of early gastric cancer (EGC) and advanced (AGC) gastric cancer was carried out.

RESULTS

For EGC and laparoscopic distal resection (LDG) and total gastrectomy (LTG) a total of 10 RCT and 6 non-RCT, including 4329 patients (laparoscopic 2010 vs. open 2319) were identified. At a high evidence level (1+, 1++) there was no significant difference in terms of feasibility, intraoperative outcome and oncological quality, mortality and long-term oncological outcome compared to open gastrectomy (OG). After LDG and LTG patients showed a significantly faster early postoperative recovery and lower total morbidity. In contrast, the operation times were significant longer compared to ODG and OTG. For distal AGC and LDG in 6 RCT, including 2806 patients (LDG 1410 vs. ODG 1369) comparable results could be found also with a high evidence level (1++). The evidence for LTG in cases of AGC was lower (2-, 2+). Currently ,only 6 non-RCT with a total of 1090 patients (LTG 539 vs. OTG 551) are available, which showed comparable results to LDG but further high-quality RCTs are necessary. Robotic gastrectomy (RG) is currently being evaluated. According to the first studies RG for EGC seems to be equivalent to LDG; however, the evidence is currently low (3 to 2-).

Robotic gastric surgery: a monocentric case series and review of the literature

INTRODUCTION

The technical complexity of D2 lymphadenectomy and esophago-jejunal anastomosis are the main factors that limit the application of laparoscopic surgery in the treatment of gastric cancer. Robotic assisted gastric surgery provides potential technical advantages over conventional laparoscopy but an improvement in clinical outcomes after robotic surgery has not been demonstrated yet.

EVIDENCE ACQUISITION

Data from 128 consecutive patients who had undergone robotic gastrectomy for gastric cancer at our center institution from April 2017 to June 2020 where retrospectively reviewed from a prospectively updated database. A narrative review was then carried out on PubMed, Embase and Scopus using the following keywords: "gastric cancer," "robotic surgery," "robotic gastrectomy" and "robotic gastric surgery".

EVIDENCE SYNTHESIS

Ninety-eight patients underwent robotic distal gastrectomy and 30 underwent robotic total gastrectomy. The mean value of estimated blood loss was 99.5 ml. No patients required conversion to laparoscopy or open surgery. The median number of retrieved lymph nodes was 42. No tumor involvement of the proximal or distal margin was found in any patient. The median time to first flatus and first oral feeding was on postoperative day 3 and 5, respectively. We registered 6 leakages (4.6%), namely, 1 duodenal stump leakage and 5 anastomotic leakages. No 30-day surgical related mortality was recorded. The median length of hospital stay was 10.5 days (range 4-37).

CONCLUSIONS

Published data and our experience suggest that the robotic approach for gastric cancer is safe and feasible with potential advantages over conventional laparoscopy.

A multicenter non-randomized phase III study of sentinel node navigation surgery for early gastric cancer

This prospective multicenter non-randomized phase III study aims to evaluate the long-term outcome of sentinel node navigation surgery for early gastric cancer compared with conventional distal or total gastrectomy. Clinically diagnosed primary T1N0M0 gastric cancer patients with a single lesion (≤40 mm) and without previous endoscopic treatment will be enrolled in this study. Sentinel nodes are identified by dye and radioisotope tracers and are subjected to intraoperative rapid pathology. For patients with negative sentinel node metastasis, individualized surgery consisting of limited stomach resection and sentinel node basin dissection is performed, while standard gastrectomy with D2 lymph node dissection is employed for the positive sentinel node patients. A total of 225 patients will be accrued from 13 hospitals that have experience in sentinel node mapping. The primary endpoint is 5-year relapse-free survival. The secondary endpoints are overall survival, sentinel node detection rate, diagnostic accuracy for sentinel node, distribution of sentinel nodes and metastatic sentinel node/non-sentinel node, and postoperative quality of life.

Long-Term Results and Current Problems in Laparoscopic Gastrectomy: Single-Center Experience

Introduction: The study aims to evaluate the long-term results of patients who underwent laparoscopic gastrectomy for gastric cancer in Ankara University Medical Faculty, Surgical Oncology Clinic, within 5 years. Materials and Methods: We retrospectively reviewed the data of patients who underwent laparoscopic gastrectomy for gastric cancer at the Surgical Oncology Clinic of Ankara University Medical Faculty between January 2014 and September 2019. One hundred forty-six patients were included in the study. Results: Fifty-one (34.9%) of the patients were female; 95 (65.1%) were male. The mean ± standard deviation and median (minimum-maximum) values of the patients were 60.92 ± 14.13 and 64.00 (22.00-93.00), respectively (Table 1). Eighty-seven (59.6%) cases were located in the antrum, 29 (19.9%) were in the cardia region, and 30 (20.5%) were in the corpus region. Overall, 106 (72.6%) of 146 patients were alive, while 40 (27.4%) were ex. The mean survival was 21.8 months (0-69). Postoperative mortality was seen in 9 patients (6.2%) and our disease-free survival rate was 70.5%. Recurrence occurred in 14 (9.6%) of all patients. [Table: see text] Conclusion: In conclusion, although laparoscopic gastrectomy is a reliable and feasible method for gastric cancer, the standardization of laparoscopic surgery is required in clinics.

Laparoscopic versus open resection for elderly patients with gastric cancer: a double-center study with propensity score matching method

PURPOSE

The applicability of laparoscopic-assisted radical gastrectomy for elderly patients with gastric cancer is still not well clarified. The aim of this double-center study was to explore the feasibility and effectiveness of laparoscopic-assisted radical gastrectomy on elderly patients with gastric cancer.

METHODS

We prospectively collected data of patients who underwent gastrectomy for cancer in two centers from June 2016 to December 2019. Propensity score matching was performed at a ratio of 1:1 to compare the laparoscopic-assisted radical gastrectomy group and open radical gastrectomy group. Univariate analyses and multivariate logistic regression analyses evaluating the risk factors for total, surgical, and medical complications were performed.

RESULTS

A total of 481 patients with gastric cancer met the inclusion criteria and were included in this study. After propensity score analysis, 258 patients were matched each other (laparoscopic-assisted radical gastrectomy (LAG) group, n = 129; open radical gastrectomy (OG) group, n = 129). LAG group had lower rate of surgical complications (P = 0.009), lower rate of severe complications (P = 0.046), shorter postoperative hospital stay (P = 0.001), and lower readmission rate (P = 0.039). Multivariate analyses revealed that anemia, Charlson comorbidity index, and combined resection were independent risk factors in the LAG group, whereas body mass index and American Society of Anesthesiology grade in the OG group.

CONCLUSION

Laparoscopic-assisted radical gastrectomy was relative safe even effective in elderly gastric cancer patients. We should pay attention to the different risk factors when performing different surgical procedures for gastric cancer in elderly patients.

Comparative outcomes between totally laparoscopic total gastrectomy with the modified overlap method for early gastric cancer and advanced gastric cancer: review of 149 consecutive cases

Introduction

Totally laparoscopic total gastrectomy (TLTG) for advanced gastric cancer (AGC) has not been conclusively substantiated.

Aim

To evaluate TLTG treatment of AGC by comparing its effectiveness and surgical outcomes to those of TLTG treatment of early gastric cancer (EGC).

Material and methods

We performed TLTG with the (modified) overlap method for 149 gastric cancer cases between March 2012 and December 2018. We evaluated clinicopathologic characteristics, complications (including esophagojejunostomy site complications), and surgical outcomes. We also evaluated these variables in terms of their associations with EGC and AGC.

Results

Ninety-two males and 57 females, with a mean age of 60.7 years, were included. The mean operation time was 147.7 min. The mean number of harvested lymph nodes was 39.6. Thirteen (8.7%) patients experienced early complications, and 6 (4.0%) experienced late complications (Clavien-Dindo classification ≥ III). Eight (5.4%) patients underwent reoperation, and 8 (5.4%) were readmitted due to complications. There were no statistically significant differences in operation time, hospital stay, or surgical mortality between EGC and AGC. However, there were significant differences in early complications, late complications, rate of reoperation, and rate of readmission between EGC and AGC.

Conclusions

Although it has some limitations, TLTG with the (modified) overlap method for AGC treatment is feasible, safe, and associated with favorable outcomes.

Short- and long-term survival after laparoscopic versus open total gastrectomy for gastric adenocarcinoma: a National database study

BACKGROUND

The use of laparoscopic total gastrectomy for gastric cancer remains controversial. Our objective was to compare outcomes of laparoscopic total gastrectomy (LTG) vs. open total gastrectomy (OTG) for gastric adenocarcinoma using a national cancer database.

METHODS

The National Cancer Database (2010-2014) was analyzed for total gastrectomy cases performed for gastric adenocarcinoma. Patient demographics and surgical outcomes were stratified by stage and compared based on laparoscopic vs. open surgical approach. Primary outcome measures included 30-day and 90-day mortality and Kaplan-Meier curves to estimate long-term survival.

RESULTS

There were 2584 cases analyzed, including 592 (22.9%) stage I, 710 (27.5%) stage II, and 1282 (49.6%) stage III cases. The distribution of LTG vs. OTG cases was 156 (26.4%) vs. 436 (73.6%) for stage I, 163 (23.0%) vs. 547 (77.0%) for stage II, and 241 (18.8%) vs. 1041 (81.2%) for stage III. For all stages analyzed, there was no difference between laparoscopic vs. open approach for adjusted 30-day mortality (stage I: adjusted odds ratio (AOR) 0.52, p = 0.75; stage II: AOR 1.36, p > 0.99; stage III: AOR 0.46, p = 0.29) or 90-day mortality (stage I: AOR 0.46, p = 0.99; stage II: AOR 1.17, p = 0.99; stage III: 0.57, p = 0.29). There was no difference between LTG vs. OTG 5-year Kaplan-Meier estimated survival curves for any stage (stage I: p = 0.20; stage II: p = 0.83; stage III: p = 0.46). When compared to OTG, LTG had a similar hazard ratio (HR) for mortality (HR 0.89 p = 0.20).

CONCLUSIONS

Laparoscopic total gastrectomy and OTG have comparable 30-day mortality, 90-day mortality, and long-term survival.

Totally laparoscopic proximal gastrectomy with double tract reconstruction: outcomes of 37 consecutive cases

Introduction

Proximal gastrectomy is an alternative treatment modality for gastric cancer in the upper third of the stomach. Though several reconstruction methods have been introduced, there is no standardization. We investigated the outcomes of laparoscopic proximal gastrectomy with double tract reconstruction (LPG-DTR).

Aim

To investigate the outcomes of LPG-DTR.

Material and methods

We evaluated 37 patients who underwent curative LPG with DTR between December 2013 and December 2018. Less than half of the proximal stomach was laparoscopically resected. We performed LPG-DTR after resection.

Results

A total of 37 patients were included in this study, 25 (70%) of whom were male and 12 (30%) of whom were female. Overall, 31 (83.7%) patients were diagnosed with gastric cancer, 5 (13.5%) with gastrointestinal stromal tumors, and 1 (2.8%) with leiomyoma. There were 3 (9.6%) complications. However, there were no complications of grade 3 or above. We did not observe postoperative mortality or recurrence after surgery. All patients underwent postoperative endoscopic surveillance successfully. None of the patients had postoperative reflux esophagitis or stenosis. The body weight and hemoglobin levels of the patients were lowest 12 months after surgery and gradually increased thereafter. Similarly, their vitamin B₁₂ levels were lowest 6 months after surgery. However, iron been increased after surgery until 24 months after surgery.

Conclusions

LPG-DTR is a favorable treatment modality for gastric cancer in the upper third of the stomach.

Surgical and Long-Term Survival Outcomes After Laparoscopic and Open Total Gastrectomy for Locally Advanced Gastric Cancer: A Propensity Score-Matched Analysis

BACKGROUND

To compare the surgical and long-term survival outcomes of laparoscopic and open total gastrectomy (OTG) for locally advanced gastric cancer (AGC).

METHODS

We retrospectively evaluated 308 and 900 patients in pathological locally AGC who underwent laparoscopic total gastrectomy (LTG) or OTG between June 2008 and December 2014. We compared surgical and long-term outcomes between the two groups using propensity score matching method.

RESULTS

The LTG group showed a longer operation time (261.42 vs. 171.00 min, P = 0.001), less blood loss (185.47 vs. 217.84 ml, P = 0.000), earlier time to first flatus (3.47 vs. 4.12 days, P = 0.000), earlier time to start liquid diet (3.76 vs. 4.27 days, P = 0.000), and shorter postoperative hospital stay (7.56 vs. 8.22 days, P = 0.007). The overall complication rate was 15.2% in the LTG group and 17.2% in the OTG (P = 0.503). No significant difference was observed in overall survival (OS) and disease-free survival (DFS) between LTG and OTG (60.5% vs. 57.1%, P = 0.337; 57.4% vs. 54.4%, P = 0.341).

CONCLUSIONS

Compared to OTG, LTG provides surgical benefits and comparable survival outcomes for patients with locally AGC.

Robot-Assisted Total Gastrectomy: Preliminary Evaluation

Background: Laparoscopic total gastrectomy with extended lymphadenectomy is a technically demanding surgical procedure with steep learning curve that has limited its widespread use. The aim of this study was to evaluate the feasibility of the robotic approach in total gastrectomy for cancer. We present our experience of 17 consecutive patients who underwent robotic total gastrectomy with intracorporal sutured Roux-en-Y esophagojejunostomy and jejuno jejunostomy between 2014 and 2017. Methods: Data were collected, and patients' demographics and outcomes were examined retrospectively. Results: Seventeen patients with a median age of 68 years (range 32-81) were identified (10 males, 7 females). Mean operative time was 198 minutes (range 108-277) including mean anastomosis time of 25 minutes (range 18-35). There was no conversion to open surgery or requirement for perioperative blood transfusion. Median length of hospital stay was 9 days (range 2-30). Two patients developed postoperative complications including one anastomotic leakage treated conservatively and one internal hernia requiring surgical revision. There was no 90-day mortality or readmission. Conclusion: Robot-assisted total gastrectomy is feasible and reproducible. It overcomes several laparoscopic technical difficulties especially regarding anastomosis. It has the potential to become an alternative to open gastrectomy for gastric cancer. Nevertheless, further follow-up and randomized clinical trials are needed to evaluate mid-term and long-term outcomes of this approach.

A feasibility study of laparoscopic total gastrectomy for clinical stage I gastric cancer: a prospective multi-center phase II clinical trial, KLASS 03

BACKGROUND

With improved short-term surgical outcomes, laparoscopic distal gastrectomy has rapidly gained popularity. However, the safety and feasibility of laparoscopic total gastrectomy (LTG) has not yet been proven due to the difficulty of the technique. This single-arm prospective multi-center study was conducted to evaluate the use of LTG for clinical stage I gastric cancer.

METHODS

Between October 2012 and January 2014, 170 patients with pathologically proven, clinical stage I gastric adenocarcinoma located at the proximal stomach were enrolled. Twenty-two experienced surgeons from 19 institutions participated in this clinical trial. The primary end point was the incidence of postoperative morbidity and mortality at postoperative 30 days. The severity of postoperative complications was categorized according to Clavien-Dindo classification, and the incidence of postoperative morbidity and mortality was compared with that in a historical control.

RESULTS

Of the enrolled patients, 160 met criteria for inclusion in the full analysis set. Postoperative morbidity and mortality rates reached 20.6% (33/160) and 0.6% (1/160), respectively. Fifteen patients (9.4%) had grade III or higher complications, and three reoperations (1.9%) were performed. The incidence of morbidity after LTG in this trial did not significantly differ from that reported in a previous study for open total gastrectomy (18%).

CONCLUSIONS

LTG performed by experienced surgeons showed acceptable postoperative morbidity and mortality for patients with clinical stage I gastric cancer.

Robotic total gastrectomy with π-shaped esophagojejunostomy using a linear stapler as a novel technique

OBJECTIVE

To evaluate the intraoperative and short-term postoperative outcomes of a novel robotic intracorporeal π-shaped esophagojejunostomy (EJS) after D2 total gastrectomy (TG) using the Da Vinci robotic surgical system for intracorporeal anastomosis after TG.

BACKGROUND

Intracorporeal π-shaped EJS, using a linear stapler, was recently reported for laparoscopic total gastrectomy in patients with gastric cancer. However, robotic intracorporeal π-shaped EJS using a linear stapler has not been reported. This report aimed to describe the use of a novel technique for π-shaped EJS using the Da Vinci robotic system.

METHODS

Robotic intracorporeal π-shaped esophagojejunostomy after total gastrectomy was performed in 11 consecutive patients diagnosed with early gastric cancer, and their perioperative outcomes were analyzed.

RESULTS

All the operations were successful without conversion to open or laparoscopic surgery and postoperative complications. The total number of patients was 11 (7 males and 4 females). The mean age of the patients was 63.36 ± 10.56 years old. Seven patients were diagnosed with cardia cancer, 3 patients were diagnosed with gastric body cancer, and 1 patient was diagnosed with gastric antrum cancer. The patients' mean proximal resection margin was 3.18 ± 1.17 cm, the distal resection margin was 6.18 ± 1.40 cm, the mean length of the incision was 4.55 ± 0.69 cm, the mean operative time was 287.27 ± 30.69 min, the mean day of first flatus was 3.27 ± 0.79 days, the mean day of the start of diet was 2.91 ± 0.94 days, the mean postoperative hospital stay was 11.45 ± 5.13 days, and the mean operative blood loss was 47.27 ± 31.33 ml. No complications were observed during anastomosis, and the median anastomosis time was 19.5 min. The mean number of lymph node dissections was 17.91 ± 4.59, the mean number of positive lymph nodes was 0.45 ± 0.69, all patients were diagnosed with stage I-II gastric cancer, and the mean maximum diameter of the tumor was 2.67 ± 1.30 cm. All the patients had a smooth hospital discharge.

CONCLUSION

A novel robotic gastrectomy with intracorporeal π-shaped EJS for esophagojejunal anastomosis described and shows acceptable resulted. This technique has the potential to offer better short-term surgical outcomes and overcomes the drawbacks of laparoscopy with a decreased risk of complications during and after surgery.

A New Robot-assisted Billroth-I Reconstruction: Details of the Technique and Early Results

BACKGROUND

Laparoscopic surgery for gastric tumor is considered a demanding procedure because of lymph node dissection and reconstruction. Billroth-I (B-I) reconstruction after laparoscopic distal gastrectomy is commonly performed extracorporeally because of the complexity of an intracorporeal procedure. Robotic surgery overcomes some limitations of laparoscopy, allowing to reproduce the basic maneuvers of open surgery. We describe a new technique to perform robotic B-I anastomosis.

METHODS

Between January 2012 and February 2015, 5 patients underwent distal gastrectomy with intracorporeal B-I-stapled anastomosis. Patient demographics, tumor characteristics, histopathologic features, and perioperative data were analyzed.

RESULTS

Median operative time was 170 minutes (145 to 180 min). There were no conversions. Contrast swallow was routinely performed on the third postoperative day. Median postoperative hospitalization was 7 days (range: 6 to 8). No major complications or mortality were observed.

CONCLUSIONS

Robotic distal gastrectomy with intracorporeal B-I anastomosis is a safe and promising technique in selected cases of gastric tumors.

Short-term outcomes in minimally invasive versus open gastrectomy: the differences between East and West. A systematic review of the literature

OBJECTIVE

Minimally invasive surgical techniques for gastric cancer are gaining more interest worldwide. Several Asian studies have proven the benefits of minimally invasive techniques over the open techniques. Nevertheless, implementation of this technique in Western countries is gradual. The aim of this systematic review is to give insight in the differences in outcomes and patient characteristics in Asian countries in comparison to Western countries.

METHODOLOGY

An extensive systematic search was conducted using the Medline, Embase, and Cochrane databases. Analysis of the outcomes was performed regarding operative results, postoperative recovery, complications, mortality, lymph node yield, radicality of the resected specimen, and survival. A total of 12 Asian and 8 Western studies were included.

RESULTS

Minimally invasive gastrectomy shows faster postoperative recovery, fewer complications, and similar outcomes regarding mortality in both the Eastern and Western studies. However, patient characteristics such as age and BMI differ between these populations. Comparison of overall outcomes in minimally invasive and open procedures between East and West showed differences in complications, mortality, and number of resected lymph nodes in favor of the Asian population.

CONCLUSION

Improved outcomes are observed following minimally invasive gastrectomy in comparison to open procedures in both Western and Asian studies. There are differences in patient characteristics between the Western and Asian populations. Overall outcomes seem to be in favor of the Asian population. These differences may fade with centralization of care for gastric cancer patients in the West and increasing surgical experience.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Comparison of Short-term and Long-term Clinical Outcomes Between Laparoscopic and Open Total Gastrectomy for Patients With Gastric Cancer

Background and Purpose:

Validation of laparoscopic total gastrectomy (LTG) for patients with gastric cancer has not been fully investigated. In particular, the technique for esophagojejunostomy remains controversial. We performed 103 cases of LTG for patients with gastric cancer between 2007 and 2013, in which all esophagojejunostomy reconstruction was performed with intracorporeal circular stapling esophagojejunostomy using the OrVil system except for the first 3 cases. The purpose of this study is to retrospectively analyze the clinical usefulness of LTG with intracorporeal circular stapling esophagojejunostomy using the OrVil system and oncological feasibility of LTG as compared with open total gastrectomy (OTG).

Patients and Method:

We retrospectively analyzed clinical course of consecutive 100 operations with LTG in comparison with consecutive 53 operations with OTG for patients with gastric cancer. As an estimation of short-term outcome, operative time, blood loss, postoperative hospital days and postoperative data of blood and drain examination were included. Moreover, relapse-free survival time and overall survival time stratified by each stage were calculated by log-rank test as an estimation of prognostic relevance.

Results:

Blood loss and postoperative hospital stay of LTG were significantly less than that of OTG. Postoperative complications were equivalent between the 2 groups and no patient died within 1 month post-LTG. Only 1 patient had recurrence and died for carcinomatosa peritonitis 50 months after LTG (median follow-up period: 44 mo).

Conclusions:

Our experience revealed that LTG with intracorporeal circular stapling esophagojejunostomy using the OrVil system could be performed safely and with acceptable oncological outcome for patients with gastric cancer.

Minimally Invasive Versus Open Total Gastrectomy for Gastric Cancer: A Systematic Review and Meta-analysis of Short-Term Outcomes and Completeness of Resection : Surgical Techniques in Gastric Cancer

Minimally invasive surgical techniques for gastric cancer are gaining more acceptance worldwide as an alternative to open resection. In order to assess the role of minimally invasive and open techniques in total gastrectomy for cancer, a systematic review and meta-analysis was performed. Articles comparing minimally invasive versus open total gastrectomy were reviewed, collected from the Medline, Embase, and Cochrane databases. Two different authors (JS and NW) independently selected and assessed the articles. Outcomes regarding operative results, postoperative recovery, morbidity, mortality, and oncological outcomes were analyzed. Statistical analysis portrayed the weighted mean difference (WMD) with a 95 % confidence interval and odds ratio (OR). Out of 1242 papers, 12 studies were selected, including a total of 1360 patients, of which 592 underwent minimally invasive total gastrectomy (MITG). Compared to open total gastrectomy (OTG), MITG showed a longer operation time (WMD: 48.06 min, P < 0.00001), less operative blood loss (WMD: −160.70 mL, P < 0.00001), faster postoperative recovery, measured as shorter time to first flatus (WMD −1.05 days, P < 0.00001), shorter length of hospital stay (WMD: −2.43 days, P = 0.0002), less postoperative complications (OR 0.66, P = 0.02), similar mortality rates (OR 0.60, P = 0.52), and similar rates in lymph node yield (WMD −2.30, P = 0.06). Minimally invasive total gastrectomy showed faster postoperative recovery and less postoperative complications, whereas completeness of the resection was similar in both groups. Duration of surgery was longer in the minimally invasive group. Only comparative non-randomized studies were available, further emphasizing the need for a prospective randomized trial comparing MITG and OTG.

Restoration of gastrointestinal motility ameliorates nutritional deficiencies and body weight loss of patients who undergo laparoscopy-assisted proximal gastrectomy

BACKGROUND

Esophagogastrostomy after proximal gastrectomy (PG) is a simple and safe reconstruction, but it leads to a high incidence of reflux esophagitis and impairs postoperative quality of life. We have already reported gastric tube (GT) reconstruction after PG and performed it on more than 100 patients. No studies have reported long-term outcomes after PG-GT. The aim of this study was to investigate long-term outcomes, including nutrition indices, such as body weight, serum albumin, total protein, hemoglobin, and ferritin after PG, and observe recovery of upper gastrointestinal tract motility.

METHODS

We analyzed body weight loss and laboratory findings at our outpatient clinic at 1, 6, 12, 24, 36, 48, and 60 months postoperatively. Manometric recording was carried out at 1, 2, 3, 4, and 5 years after surgery.

RESULTS

The percentage change in body weight in the PG-GT group was significantly larger than that in the PG-JI and TG-RY groups at 2.5, 3, 4, and 5 years after surgery. The levels of hemoglobin and ferritin in the PG-GT and PG-JI groups were significantly higher than those in the TG-RY group at all time points except 6 months after surgery. In the fasted state, the phase III originated at the gastric tube was propagated to the duodenum 3 years after surgery. In the fed state, phasic contractions of the duodenum were in harmony with gastric tube contractions 3 years after surgery.

CONCLUSIONS

PG-GT is the least invasive procedure, and restoration of gastrointestinal motilities in the gastric tube and duodenum may ameliorate body weight loss and nutritional status, including anemia, in patients after PG.

Comparison of laparoscopy-assisted and open radical gastrectomy for advanced gastric cancer: A retrospective study in a single minimally invasive surgery center

Laparoscopy-assisted gastrectomy (LAG) has gained international acceptance for the treatment of early gastric cancer (EGC). However, the use of laparoscopic surgery in the management of advanced gastric cancer (AGC) has not attained widespread acceptance. This retrospective large-scale patient study in a single center for minimally invasive surgery assessed the feasibility and safety of LAG for T2 and T3 stage AGC. A total of 628 patients underwent LAG and 579 patients underwent open gastrectomy (OG) from Jan 2004 to Dec 2011. All cases underwent radical lymph node (LN) dissection from D1 to D2+. This study compared short- and long-term results between the 2 groups after stratifying by pTNM stages, including the mean operation time, volume of blood loss, number of harvested LNs, average days of postoperative hospital stay, mean gastrointestinal function recovery time, intra- and post-operative complications, recurrence rate, recurrence site, and 5-year survival curve. Thirty-five patients (5.57%) converted to open procedures in the LAG group. There were no significant differences in retrieved LN number (30.4 ± 13.4 vs 28.1 ± 17.2, P = 0.43), proximal resection margin (PRM) (6.15 ± 1.63 vs 6.09 ± 1.91, P = 0.56), or distal resection margin (DRM) (5.46 ± 1.74 vs 5.40 ± 1.95, P = 0.57) between the LAG and OG groups, respectively. The mean volume of blood loss (154.5 ± 102.6 vs 311.2 ± 118.9 mL, P < 0.001), mean postoperative hospital stay (7.6 ± 2.5 vs 10.7 ± 3.6 days, P < 0.001), mean time for gastrointestinal function recovery (3.3 ± 1.4 vs 3.9 ± 1.5 days, P < 0.001), and postoperative complications rate (6.4% vs 10.5%, P = 0.01) were clearly lower in the LAG group compared to the OG group. However, the recurrence pattern and site were not different between the 2 groups, even they were stratified by the TNM stage. The 5-year overall survival (OS) rates were 85.38%, 79.70%, 57.81%, 34.60% and 88.31%, 75.49%, 56.84%, 33.08% in patients with stage Ib, IIa, IIb, and IIIa, respectively, in the LAG and OG groups. There were no statistically significant differences in the OS rate for patients with the same TNM stage between the 2 groups. LAG with radical LN dissection is a safe and technically feasible procedure for the treatment of AGC staged below T3.

Short-term outcomes of intracorporeal esophagojejunostomy using the transorally inserted anvil versus extracorporeal circular anastomosis during laparoscopic total gastrectomy for gastric cancer: a propensity score matching analysis

BACKGROUND

To assess the short-term outcomes of intracorporeal Roux-en-Y esophagojejunostomy using the transorally inserted anvil (OrVil) compared with extracorporeal circular Roux-en-Y anastomosis during laparoscopic total gastrectomy (LTG) for gastric cancer.

METHODS

From January 2011-April 2014, a total of 165 consecutive patients with gastric cancer underwent either intracorporeal Roux-en-Y esophagojejunostomy (n = 25) using the Orvil or extracorporeal circular anastomosis (n = 140) during LTG. After generating propensity scores with six covariates, including gender, age, body mass index (BMI), Eastern Cooperative Oncology Group performance status, tumor location, and tumor size, 25 patients undergoing the OrVil method (intracorporeal group) were one-to-one matched with 25 patients undergoing the extracorporeal method (extracorporeal group). The short-term outcomes were compared between the two groups.

RESULTS

Both groups were balanced regarding baseline variables. The total operative time was not significantly different between the two groups (216.5 ± 24.9 min versus 224.0 ± 30.5 min, P = 0.344), whereas either the duration of anvil insertion (9.9 ± 2.4 min versus 12.9 ± 2.0 min, P < 0.001) or reconstruction completion (44.4 ± 9.4 min versus 50.1 ± 5.4 min, P = 0.012) in the intracorporeal group was less. The mean length of minilaparotomy in the intracorporeal group was shorter (5.6 ± 0.4 cm versus 7.2 ± 1.7 cm, P < 0.001). No significant differences were observed in intraoperative complication rate, estimated blood loss, length of proximal margin, or postoperative recovery course (including the time to first flatus, liquid resumption, liquid, and soft diet) between the two groups. No patients suffered from anastomosis-related complications. The overall morbidity rates of 28.0% in the intracorporeal group and 32.0% in the extracorporeal group were comparable (P = 0.758).

CONCLUSIONS

Intracorporeal Roux-en-Y esophagojejunostomy using the transorally inserted anvil system may be a safe procedure during LTG for gastric cancer. However, a longer follow-up in a well-designed randomized controlled trial is necessary to more thoroughly evaluate this technique.

Laparoscopic gastric cancer surgery: Current evidence and future perspectives

Laparoscopic gastrectomy has been widely accepted as a standard alternative for the treatment of early-stage gastric adenocarcinoma because of its favorable short-term outcomes. Although controversies exist, such as establishing clear indications, proper preoperative staging, and oncologic safety, experienced surgeons and institutions have applied this approach, along with various types of function-preserving surgery, for the treatment of advanced gastric cancer. With technical advancement and the advent of state-of-the-art instruments, indications for laparoscopic gastrectomy are expected to expand as far as locally advanced gastric cancer. Laparoscopic gastrectomy appears to be promising; however, scientific evidence necessary to generalize this approach to a standard treatment for all relevant patients and care providers remains to be gathered. Several multicenter, prospective randomized trials in high-incidence countries are ongoing, and results from these trials will highlight the short- and long-term outcomes of the approach. In this review, we describe up-to-date findings and critical issues regarding laparoscopic gastrectomy for gastric cancer.

Assessing the safety and efficacy of full robotic gastrectomy with intracorporeal robot-sewn anastomosis for gastric cancer: A randomized clinical trial

BACKGROUND

Robotic gastrectomy is increasingly used in gastric cancer patients. This study assessed the safety and efficacy of full robotic gastrectomy with intracorporeal robot-sewn anastomosis for gastric cancer.

METHODS

Three hundred and eleven patients were randomized into an open gastrectomy group or a robotic gastrectomy group, and digestive restorations were performed under direct vision and with intracorporeal robot-sewn anastomosis, respectively. Length of postoperative hospital stay, number of lymph node dissections, surgical duration, blood loss, and complication rate after surgery were recorded.

RESULTS

There were no significant differences in the number of lymph node dissections (30.9 ± 10.4 vs. 29.3 ± 9.7 days, P = 0.281) or complication rates (10.3 vs. 9.3%, P = 0.756) between the two groups. Surgical duration was significantly longer in the robotic gastrectomy group than in the open gastrectomy group (242.7 ± 43.8 vs. 192.4 ± 31.5 min, P = 0.002), whereas blood loss was less (94.2 ± 51.5 vs. 152.8 ± 76.9 ml, P < 0.001), length of postoperative hospital stay was shorter (5.6 ± 1.9 vs. 6.7 ± 1.9 days, P = 0.021), and postoperative restoration of bowel function was earlier (2.6 ± 1.1 vs. 3.1 ± 1.2 days, P = 0.028).

CONCLUSION

Full robotic gastrectomy with intracorporeal robot-sewn anastomosis for gastric cancer is safe and does not increase the complication risk during or after surgery. J. Surg. Oncol. 2016;113:397-404. © 2016 Wiley Periodicals, Inc.

The learning curve associated with laparoscopic total gastrectomy

BACKGROUND

Although the frequency of laparoscopic total gastrectomy (LTG) has been increasing, the procedure requires considerable experience because of its technical difficulty and the concern for oncological safety. This study intended to define the learning curve associated with the procedure.

METHODS

All 256 cases of LTG performed from June 2003 to December 2012 were enrolled. The cases were divided into ten groups of 25 cases based on when they occurred. The learning curve was defined using the moving average method. LTG, performed in the absence of other procedures (pure-LTG, 132 cases), was extracted from the ten groups, and the mean operative time and estimated blood loss (EBL) were compared to define the learning curve. Retrieved lymph nodes, hospital stay, and complications were compared across the phases of the learning curve. LTG with spleen resection, performed in the absence of other procedures (pure-srLTG, 53 cases), was also analyzed by the same method.

RESULTS

A three-phase learning curve of LTG was defined: the first two groups, the following two groups, and the final six groups (mean operative time: 223.0, 244.8, and 207.8 min, respectively, p = 0.003; mean EBL: 94.6, 237.0, and 116.5 ml, respectively, p < 0.001). The rates of complications and open conversions were similar across the three phases. There were no significant differences in mean operative time, EBL, retrieved LNs, hospital stay, or complication rates between pure-LTG and pure-srLTG, after completing the respective learning curves.

CONCLUSIONS

Experience with approximately 100 LTG cases was required to complete learning of the procedure.

Laparoscopy-assisted versus open distal gastrectomy for gastric cancer in elderly patients: a retrospective comparative study

BACKGROUND

With the current increased longevity in elderly population, surgeons can expect to operate more frequently on elderly patients with both malignancies and comorbid medical conditions. This study aimed to compare the surgical and early postoperative outcomes of laparoscopy-assisted distal gastrectomy (LADG) with those of open distal gastrectomy (ODG) for gastric cancer in patients 70 years of age or older.

METHODS

Retrospective analysis based on a prospectively collected database of elderly patients who underwent laparoscopy-assisted distal gastrectomy or ODG from February 2013 to January 2014. Preoperative patient baseline parameters, surgical and oncological outcomes, postoperative complications and pathologic results were analyzed in this report.

RESULTS

Distal gastrectomy was performed for 50 patients with the age of 70 years or older, using laparoscopic surgery for 23 patients (LADG group) and open surgery for 27 patients (ODG group). The mean age of LADG group was 76.6 years and ODG group 80.0 years. The comparison between the two groups revealed statistically similar results regarding age, gender, BMI, ASA class, history of previous surgeries, CCI and pathologic characteristics. The LADG group was characterized by less intraoperative blood loss (LADG group 100 mL vs. ODG group 250 mL, P < 0.001), less narcotic use (LADG group 1 day vs. ODG group 3 days, P < 0.001), faster bowel function recovery (time to first flatus: LADG group 51.6 h vs. ODG group 67.2 h, P < 0.001; days to oral intake: LADG group 6.1 days vs. ODG group 7.9 days, P = 0.002) and shorter postoperative hospital stay (LADG group 12 days vs. ODG group 16 days, P < 0.001). There was no significant difference in postoperative complication rate (overall complication rate: LADG group 21.7 % vs. ODG group 25.9 %, P = 0.730), survival rate (P = 0.719), postoperative recurrence and metastasis rate between the patients who underwent LADG and ODG.

CONCLUSIONS

LADG for gastric cancer is feasible, efficacious and safe in elderly patients and may be superior to conventional open resection as regards some surgical outcomes.

Eleven-year experience with 3000 cases of laparoscopic gastric cancer surgery in a single institution: analysis of postoperative morbidities and long-term oncologic outcomes

BACKGROUND

The present study summarizes the 11-year laparoscopic gastric cancer surgery experience of a single institution in South Korea and evaluates the current trends of laparoscopic gastric cancer surgery through our experience.

METHODS

A total of 3000 minimally invasive gastric cancer surgeries were performed at Seoul National University Bundang Hospital between May 2003 and January 2014. The types of laparoscopic gastrectomy used, surgical techniques, postoperative morbidities, and long-term oncologic outcomes were analyzed.

RESULTS

The proportion of challenging procedures such as laparoscopic total gastrectomy and laparoscopic gastrectomy for patients with advanced gastric cancer increased during the study period. The frequency of laparoscopic function-preserving gastrectomy for patients with early-stage cancer also increased. The overall rate of complications was 16.7 %; surgical and systemic complication rates were 11.8 and 6.2 %, respectively. There was one case of postoperative mortality due to delayed bleeding after discharge. Male gender, high BMI, long operating times, combined resection of other organs, and total and proximal gastrectomies were independent predictors of surgical morbidities; however, pathologic T-stage was not a predictable factor. Accumulated experience in laparoscopic surgery decreased the surgical complication rates of total and proximal gastrectomies more than it did in distal gastrectomy over time. The 5-year overall survival rates of patients in advanced stages and those who underwent laparoscopic total gastrectomy were comparable to those reported previously.

CONCLUSIONS

Our results indicate the trends toward the expansion of laparoscopic approaches to technically demanding procedures and an increased use of laparoscopic function-preserving surgeries for patients with EGC with acceptable outcomes.

Laparoscopic gastrectomy in Western European patients with advanced gastric cancer

BACKGROUND

The advantage of laparoscopic gastrectomy compared to open gastrectomy has been established in Asian patient series with early gastric cancer. However, its feasibility in Western European patients with locally advanced gastric cancer is unknown.

METHODS

Between 2006 and 2014 70 consecutive patients with advanced gastric cancer underwent laparoscopic gastrectomy with D2 lymph node dissection. A Billroth II reconstruction was performed after distal gastrectomy. In case of total gastrectomy a jejunal J-pouch reconstruction was performed.

RESULTS

Total gastrectomy was performed in 56 patients and distal gastrectomy in 14 patients. Perioperative chemotherapy was administered in 45/70 (64%) patients. A radical resection was achieved in 63/70 (90%). The median number of dissected lymph nodes was 17 (2-62). The median intraoperative blood loss was 305 (30-2700) milliliters. The median postoperative hospital stay was 11 (5-91) days. The 30-day mortality was 4.3%.

CONCLUSIONS

Laparoscopic gastrectomy can be performed in Western European patients with advanced gastric cancer and meets the oncologic standard with low intraoperative blood loss and short hospital stay.

Short-term outcomes of totally laparoscopic total gastrectomy: experience with the first consecutive 112 cases

INTRODUCTION

Although laparoscopic distal gastrectomy has become a viable treatment option for gastric cancer, laparoscopic total gastrectomy remains in limited use.

PURPOSE

The present study was designed to evaluate the short-term outcomes of totally laparoscopic total gastrectomy (TLTG).

METHODS

The records of 112 consecutive patients who underwent TLTG for gastric cancer between September 2006 and November 2012 were reviewed, and surgical outcomes were retrospectively investigated.

RESULTS

Neoadjuvant chemotherapy was given to 21 patients (18.8 %). The degree of lymphadenectomy was D1+ in 83 patients (74.1 %) and D2 in 29 (25.9 %). The operation time was 359 min, median intraoperative blood loss was 85 ml, and median total number of harvested lymph nodes was 64. Grade II or higher postoperative complications developed in 25 patients (22.3 %). On univariate analysis, pathologic stages IB to IV (versus stage IA) overlapped esophagojejunostomy (versus functional end-to-end esophagojejunostomy) and operation time >360 min (versus ≤360 min) were related to postoperative morbidity. In the multivariate analysis, operative time and pathologic stage were independent risk factors for postoperative complications.

CONCLUSIONS

TLTG is feasible and can be performed with acceptable postoperative morbidity. A longer operating time and more advanced pathologic stage were significantly associated with higher postoperative morbidity.

Robotic gastrectomy for gastric cancer

Robotic surgery for gastric cancer overcomes technical difficulties with laparoscopic gastrectomy. Its benefits include reduced intraoperative bleeding and shorter hospital stays; it is also easier to learn. Because accuracy increases during lymphadenectomy, a larger number of lymph nodes is likely to be retrieved using robotic gastrectomy. Higher costs and longer operation times have hindered the widespread adaptation and use of robotic surgery. In this review, we summarize the current status and issues regarding robotic gastrectomy.

Current status of randomized controlled trials for laparoscopic gastric surgery for gastric cancer in Korea

Laparoscopic gastrectomy for gastric cancer has rapidly gained popularity as a result of the increased incidence of early gastric cancer in Korea. Although laparoscopic gastrectomy has been considered as an investigational treatment because of the lack of solid evidence of efficacy and safety, it is increasingly regarded as a standard treatment for early gastric cancer. Moreover, solid evidence is anticipated from two studies in Korea, KLASS 01 and KLASS 02, the latter of which examines the suitability of laparoscopic gastrectomy for advanced gastric cancer. The use of cutting-edge techniques for laparoscopic gastrectomy enables surgeons to deliver various treatment options that offer the best possible quality of life after gastrectomy. In this review, we summarize the current status of clinical trials on laparoscopic gastrectomy in Korea and examine future perspectives regarding laparoscopic gastrectomy for the treatment of gastric cancer.

Minimally invasive gastrectomy for cancer: current utilization in US academic medical centers

BACKGROUND

Internationally, the utilization of minimally invasive techniques for gastric cancer resection has been increasing since first introduced in 1994. In the USA, the feasibility and safety of these techniques for cancer have not yet been demonstrated.

METHODS

The University HealthSystem Consortium database was queried for gastrectomies performed between 2008 and 2013. Any adult patient with an abdominal visceral malignancy that necessitated gastric resection was included in the cohort. Clinicopathological and in-hospital outcome metrics were collected for open, laparoscopic, and robotic procedures.

RESULTS

Open gastrectomies comprised 89.5% of the total study group, while 8.2% of procedures were performed laparoscopically, and 2.3% were performed with robotic assistance. When accounting for disparities in patient severity of illness and risk of mortality subclass designations, there were no significant differences in mean length of stay, 30-day readmission, and in-hospital mortality between the three groups; however, mean total cost was highest in the robotic-assisted group (P = 0.017). Overall, complication rates were also similar; however, there was a higher incidence of superficial infection in the laparoscopic group (P = 0.013) and a higher incidence of venous thromboembolism in the robotic group (P = 0.038).

CONCLUSION

Despite widespread adoption for benign indications, minimally invasive gastrectomy for cancer remains underutilized in the USA. In these patients, laparoscopic and robot-assisted gastrectomies appear to be comparable to open resection with respect to overall complications, length of stay, 30-day readmission, and in-hospital mortality. However, when employing minimally invasive techniques, infection and thromboembolism risk reduction strategies should be emphasized in the operative and postoperative periods.

Intracorporeal esophagojejunostomy using the double stapling technique after laparoscopic total gastrectomy: A retrospective case-series study

AIM: To introduce a simple and safe anvil insertion technique to esophagus during laparoscopic total gastrectomy (LTG).

METHODS: Between July 2010 and December 2012, 58 consecutive patients with early gastric cancer underwent LTG were enrolled. We performed a simple and safe Roux-en-Y esophagojejunostomy using the double stapling technique to all patients. Then patients’ characteristics, perioperative outcome and histopathologic data were analyzed retrospectively.

RESULTS: The mean age and body mass index were 59.3 ± 9.7 years and 22.7 ± 2.6 kg/m². The mean operation, reconstruction and anvil insertion times (from gastric incision to linear stapling) were 251.8 ± 57.0, 43.1 ± 2.8 and 4.2 ± 1.9 min, respectively. Intraoperative blood loss was 204.6 ± 156.3 mL and there was no open conversion. The postoperative complications were in 8 cases (delayed gastric emptying in 4 cases, pulmonary complication in 2 cases, pancreatitis in 1 case, anastomotic stricture in 1 case). Anastomotic stricture occurred after discharge and was recovered by endoscopic intervention. The patients were discharged at a mean of 9.6 ± 2.0 d after surgery. Neither leakage nor bleeding from the esophagojejunostomy occurred postoperatively. The mean proximal margin of specimen was 2.7 ± 2.8 cm

CONCLUSION: Roux-en Y esophagojejunostomy using the double stapling technique is simple and rapid, and it may offer a solid, alternative reconstruction method for LTG or proximal gastrectomy.

Laparoscopic-assisted total gastrectomy versus open total gastrectomy for upper and middle gastric cancer in short-term and long-term outcomes

PURPOSE

In recent years, laparoscopy-assisted distal gastrectomy has become the recognized procedure for treatment of early gastric cancer because of improved cosmesis and reduced postoperative pain. However, there are a few reports of laparoscopic-assisted total gastrectomy (LATG) performed for gastric cancer in the upper third or middle third stomach due to the difficulties of surgical techniques and the safety of oncologic short-term and long-term outcomes.

METHODS

Between January 2006 and December 2009, 84 patients with upper third or middle third gastric cancer underwent LATG or conventional open total gastrectomy (OTG). Of these patients, 34 patients underwent LATG and they were compared with patients who underwent OTG regarding short-term and long-term outcome.

RESULTS

The proximal margins (P=0.343) and distal margins (P=0.685) did not differ between the LATG and OTG groups. Postoperative morbidity occurred in 8 (16.0%) OTG and 6 (17.6%) LATG cases and postoperative mortality occurred 2 (4.0%) and 0 (0.0%) cases of OTG and LATG, respectively. Recurrence occurred in 8 (16.0%) cases and 1 (2.9%) case in the OTG and LATG group, respectively (P=0.077). The 5-year survival rate in the OTG group was 77.5% and in the LATG was 93.2% with no significant difference (P=0.082).

CONCLUSIONS

Our results confirm that LATG with extended lymphadenectomy for middle or upper early and locally advanced gastric cancer can achieve a radical oncologic resection equivalent to that of OTG. In addition, LATG is a feasible and safe procedure, and has several advantages over conventional OTG.

Long-term survival outcomes of laparoscopic versus open gastrectomy for gastric cancer: a systematic review and meta-analysis

Many meta-analyses have confirmed the technical feasibility and favorable short-term surgical outcomes of laparoscopic gastrectomy (LG) for gastric cancer patients, but the long-term survival outcome of LG remains controversial compared with open gastrectomy (OG). This study aimed to compare the 5-year overall survival (OS), recurrence, and gastric cancer-related death of LG with OG among gastric cancer patients. PubMed was searched to February 2014. The resectable gastric cancer patients who underwent curative LG or OG were eligible. The studies that compared 5-year OS, recurrence, or gastric cancer-related death in the LG and OG groups were included. A meta-analysis, meta-regression, sensitivity analysis, subgroup analysis, and stage-specific analysis were performed to estimate the survival outcome between the two groups and identify the potential confounders. Quality assessment was based on a tailored comparability scoring system. Twenty-three studies with 7336 patients were included. The score of comparability between two groups and the extent of lymphadenectomy were two independent confounders. Based on the well-balanced studies, the 5-year OS (OR = 1.07, 95% CI 0.90-1.28, P = 0.45), recurrence (OR = 0.83, 95% CI 0.68-1.02, P = 0.08), and gastric cancer-related death (OR = 0.86, 95% CI 0.65-1.13, P = 0.28) rates were comparable in LG and OG. Several subsets such as the publication year, study region, sample size, gastrectomy pattern, extent of lymphadenectomy, number of nodes harvested, and proportion of T1-2 or N0-1 did not influence the estimates, if they were well balanced. Particularly, the stage-specific estimates obtained comparable results between the two groups. Randomized controlled trials comparing LG with OG remain sparse to assess their long-term survival outcomes. The major contributions of this systematic review compared with other meta-analyses are a comprehensive collection of available long-term survival outcomes within a much larger number of observations and a more precise consideration of confounders. Current knowledge indicates that the long-term survival outcome of laparoscopic gastric cancer surgery is comparable to that of open surgery among early or advanced stage gastric cancer patients, and LG is acceptable with regard to oncologic safety.

The overlap method is a safe and feasible for esophagojejunostomy after laparoscopic-assisted total gastrectomy

BACKGROUND

Laparoscopic procedures are increasingly being applied to gastric cancer surgery, including total gastrectomy for tumors located in the upper gastric body. Even for expert surgeons, esophagojejunostomy after laparoscopy-assisted total gastrectomy (LATG) can be technically challenging. We perform the overlap method of esophagojejunostomy after LATG for gastric cancer. However, technical questions remain. Is the overlap method safer and more useful than other anastomosis techniques, such as methods using a circular stapler? In addition, while we perform this overlap reconstruction after LATG in a deep and narrow operative field, can the overlap method be performed safely regardless of body habitus? This study aimed to evaluate these issues retrospectively and to review the literature.

METHODS

From October 2005 to August 2013, we performed LATG with lymph-node dissection and Roux-en-Y reconstruction using the overlap method in 77 patients with gastric cancer. This study examined pre-, intra- and postoperative data.

RESULTS

Mean operation time, time to perform anastomosis, and estimated blood loss were 391.4 min, 36.3 min, and 146.9 ml, respectively. There were no deaths, and morbidity rate was 13%, including one patient (1%) who developed anastomotic stenosis. Mean postoperative hospitalization was 13.4 days. Surgical outcomes did not differ significantly by body mass index.

CONCLUSIONS

First, the overlap method for esophagojejunostomy after LATG is safe and useful. Second, this method can be performed irrespective of the body type of the patient. In particular, in a deep and narrow operative field, the overlap method is more versatile than other anastomosis methods. We believe that the overlap method can become a standard reconstruction technique for esophagojejunostomy after LATG.

Esophageal reinforcement with an extracellular scaffold during total gastrectomy for gastric cancer

BACKGROUND

Esophagojejunal (EJ) anastomotic leaks after total gastrectomy (TG) for malignancy lead to significant morbidity and mortality, thus affecting long-term survival. Preclinical and clinical trials have shown promise in utilizing degradable extracellular matrix (ECM) scaffolds in buttressing anastomoses. We describe our experience buttressing the EJ anastomosis after TG with a ECM scaffold.

METHODS

From February 2012 to January 2014, a total of 37 consecutive patients underwent TG buttressing of the EJ anastomosis with the degradable ECM scaffold composed of a porcine urinary bladder called MatriStem (ACell Inc.). The scaffold was circumferentially wrapped around the EJ anastomosis. The primary end point was the EJ leak rate, while the secondary end point was the EJ stricture rate.

RESULTS

The mean ± SD age and body mass index were 59 ± 16 years and 28.1 ± 4.9 kg/m(2), respectively. Most patients were male (51 %), white (78 %), and former smokers (51 %). Over half (59 %) underwent neoadjuvant chemotherapy. A minimally invasive TG was performed in 70 % of patients. Signet ring was the most common tumor type (48 %), and most patients had midstage disease (59 %). The mean number of lymph nodes procured was 36 ± 16. Eighteen patients (49 %) experienced a complication, mostly minor. One patient (2.7 %) developed an EJ leak, while three patients (8 %) developed an EJ stricture. Median follow-up was 7 months (range 2-12 months). There was no operative or in-hospital mortality.

DISCUSSION

The use of urinary bladder matrix scaffolds may be helpful in decreasing the incidence of EJ anastomotic leak and/or stricture. A prospective phase II trial at our institution is currently under way.

A multi-institutional analysis of open versus minimally-invasive surgery for gastric adenocarcinoma: results of the US gastric cancer collaborative

BACKGROUND

Surgical experience with minimally invasive surgery (MIS) has increased; however, published reports on MIS resection of gastric adenocarcinoma are limited.

METHODS

Between 2000 and 2012, 880 patients who underwent surgical resection of gastric adenocarcinoma were identified from a multi-institutional database. Clinicopathological characteristics, operative details, and outcomes were stratified by operative approach (open vs. MIS) and analyzed.

RESULTS

Overall, 70 (8 %) patients had a MIS approach. Patients who underwent a MIS resection were more likely to have a smaller tumor (open 4.5 cm vs. MIS 3.0 cm, p < 0.001). MIS resections were associated with lower estimated blood loss (open 250 cc vs. MIS 150 cc) and longer operative time (open 232 min vs. MIS 271 min) compared with open surgery (both p < 0.05). An R0 resection was achieved in most patients (open 90.9 % vs. MIS 98.6 %, p = 0.03) and median lymph node yield was good in both groups (open 17 vs. MIS 14, p = 0.10). MIS had a similar incidence of complications (open 33.1 % vs. MIS 20 %, p = 0.07) and a similar length of stay (open 9 days vs. MIS 7 days, p = 0.13) compared with open surgery. In the propensity-matched analysis, median recurrence-free and overall were not impacted by operative approach.

CONCLUSION

An MIS approach to gastric cancer was associated with adequate lymph node retrieval, a high incidence of R0 resection, and comparable long-term oncological outcomes versus open gastrectomy.

Laparoscopic total gastrectomy using the transorally inserted anvil (OrVil™): a preliminary, single institution experience

Laparoscopic total gastrectomy (LTG) is not a commonly performed procedure due to the difficulty associated with surgical reconstruction. We present our preliminary results after intracorporeal circular stapling esophagojejunostomy using the newly developed transorally inserted anvil (OrVil™, Covidien, MA, USA). Between 2008 and June 2013, 51 patients underwent laparoscopic gastrectomy with D2 lymph node dissection for gastric cancer. A total of 12 patients underwent LTG: of these, 5 received an intracorporeal linear side-to-side esophagojejunal anastomosis and the remaining 7 underwent intracorporeal circular stapling esophagojejunostomy using the OrVil™ system. Short-term outcomes were compared between the two groups. There were no intraoperative complications or conversions to open surgery in any patients. The mean operative time was significantly shorter in the OrVil™ than in the side-to-side group (261.4 ± 12.0 vs 333.0 ± 15.0 minutes, respectively, p = 0.005). Postoperative fluorography revealed no anastomosis leakage or stenosis in either groups. All patients resumed an oral liquid diet on postoperative day 5 and the mean postoperative hospital stay was 9 days. Intracorporeal circular stapling esophagojejunostomy using the OrVil™ system is technically feasible and safe in LTG. This technique may be considered a simple and time-saving alternative to the side-to-side linear esophagojejunostomy.

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.

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

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

Robotic spleen-preserving total gastrectomy for gastric cancer: comparison with conventional laparoscopic procedure

BACKGROUND

Robotic systems recently have been introduced to overcome technical limitations of conventional laparoscopic surgery, especially for complex procedures. Laparoscopic spleen-preserving total gastrectomy with D2 lymph node (LN) dissection (LTGD2) is one of the most complicated procedures. We hypothesized that robotic LN dissection would be more thorough and accurate. We compared robotic spleen-preserving total gastrectomy with D2 LN dissection (RTGD2) with LTGD2 to investigate the impact of robotics.

METHODS

Clinicopathologic characteristics and short-term and long-term outcomes of RTGD2 (n = 51) versus LTGD2 (n = 58) in gastric adenocarcinoma patients were extracted from a prospectively designed database and analyzed retrospectively.

RESULTS

There was no difference of patients' characteristics between groups. Mean operation time of RTGD2 was longer than LTGD2 (p < 0.001), and no differences in tumor histology, size, location, and TNM stage were seen. Total retrieved LNs from RTGD2 was similar to LTGD2 (mean 47.2 vs. 42.8, respectively), as were retrieved LNs at splenic hilum (1.3 vs. 0.8). However, mean numbers of retrieved LNs along the splenic artery from RTGD2 was higher than LTGD2 (2.3 vs. 1.0, respectively; p = 0.013), as was also the case at the splenic hilum and artery (3.6 vs. 1.9, p = 0.014). Postoperative complication (16 vs. 22 %, p = 0.374) and overall and disease-free survival between the two groups were not significantly different (p = 0.767 and p = 0.666, respectively).

CONCLUSIONS

Robotic spleen-preserving total gastrectomy with D2 LN dissection is feasible. Operation time and retrieved total LNs and splenic hilar LNs in the robotic procedure are acceptable.