The impact of obesity on LADG for early gastric cancer

Preoperative visceral fat area predicts intraoperative adverse events during lymphadenectomy in laparoscopic gastrectomy for gastric cancer: a post hoc analysis

BACKGROUND

Visceral obesity has been increasingly recognized as a potential risk factor for surgical complications in gastric cancer surgery, yet its impact on lymphadenectomy during laparoscopic gastrectomy remains undefined. This study aimed to investigate the influence of visceral fat area (VFA) on intraoperative adverse events (iAEs) during lymphadenectomy in laparoscopic gastrectomy.

METHODS

A post hoc analysis was performed using data from two previous prospective studies ([NCT02327481] and [NCT01609309]). The patients were divided into high and low VFA groups based on preoperative computed tomography images at the umbilical level. All iAEs were reviewed from the surgical videos and graded using ClassIntra. The factors influencing iAEs were identified, and predictive models for iAEs were constructed.

RESULTS

This study included 490 patients, with 244 and 246 patients in the high and low VFA groups, respectively. Restricted cubic splines demonstrated a positive linear association between VFA and iAEs. Compared with the low VFA group, the high VFA group exhibited a significantly higher incidence of iAEs (29% vs. 12%, p < 0.001), primarily in the infrapyloric (9.0% vs. 2.0%) and suprapancreatic (23.4% vs. 9.3%) regions and higher rates of ClassIntra I-III. Multivariate logistic regression identified high VFA as an independent risk factor for iAEs (hazard ratio [HR] 2.16, 95% confidence interval [CI]: 1.22 - 3.83). Based on the VFA, nomograms were developed to predict iAEs (training area under the curve [AUC] 0.722, validation AUC 0.730). Meanwhile, a web-based calculator was developed to facilitate clinical application.

CONCLUSIONS

High preoperative VFA is independently correlated with iAEs after laparoscopic gastrectomy for gastric cancer. Nomograms based on VFA showed potential in predicting iAEs, helping identify high-risk patients early and facilitating tailored perioperative management.

Short-term outcomes of laparoscopic D2 lymphadenectomy versus D2 lymphadenectomy plus complete mesogastric excision in distal gastric cancer patients with high body mass index

BACKGROUND

The technical challenges and safety issues involving laparoscopic D2 lymphadenectomy plus complete mesogastric excision (D2 + CME) for high body mass index (BMI) patients are still unknown. This study was conducted to compare the short-term outcomes of laparoscopic D2 + CME and D2 lymphadenectomy in distal gastric cancer patients of different BMI status.

METHODS

We retrospectively analyzed the data of patients with gastric cancer who underwent laparoscopic-assisted distal gastrectomy (LADG) at our center between 2019 June and 2023 September. Patients who underwent traditional laparoscopic D2 lymphadenectomy were divided into the D2 group, while patients undergoing laparoscopic D2 + CME were divided into the D2 + CME group. In each group, patients were further subdivided based on their BMI into the high BMI group (H-BMI, BMI ≥ 25) and normal BMI (N-BMI, BMI<25) group. A comparison was made between the characteristics of patients and their short-term outcomes in the two subgroups, respectively. Propensity score matching (PSM) at 1:1 ratio was performed to further assess the short-term outcomes of patients with high BMI in two groups.

RESULTS

AII the qualified patients were divided into the D2 group (n = 329) and D2 + CME group (n = 261). In the subgroup analysis of early surgical outcomes of the D2 group, the high BMI subgroup had longer surgery time (p = 0.007), more blood loss (p = 0.006) and longer time to first flatus (p = 0.001), compared to the normal BMI subgroup. Conversely, in the D2 + CME group, significant differences were not observed in early surgical outcomes between the two subgroups(p > 0.05). PSM yielded 44 high BMI patients with comparable baseline characteristics into the A group and the B group. Compared to the A group, patients with high BMI in the B group who received laparoscopic D2 + CME had shorter surgery time(p<0.001), less blood loss(p = 0.004), more retrieved lymph nodes (LNs) (p = 0.016). No statistical differences were observed in terms of the first flatus time, pT stage, pN stage, pathological stage(pStage), vascular invasion, postoperative complications, or postoperative hospital stay(p > 0.05).

CONCLUSION

Our findings suggest the high BMI status had a significant impact on the early surgical results of laparoscopic conventional D2 lymphadenectomy. However, laparoscopic D2 + CME was unaffected by a high BMI. In addition, patients with high BMI benefit more from laparoscopic D2 + CME in terms of short-term outcomes. Laparoscopic D2 + CME is a recommended technique for distal gastric cancer patients with high BMI, which deserves further study and promotion.

Predictors of iatrogenic splenic injury in radical gastrectomy for gastric cancer

Background

Iatrogenic splenic injury (ISI) is a recognized complication in radical gastrectomy that may result in incidental splenectomy (IS). However, the predictors of such events remain largely unknown.

Methods

Medical records of the patients who underwent radical gastrectomy at our institution between January 2015 and December 2022 were retrospectively reviewed. Potential predictors of ISI and IS were collected and analyzed by multivariate logistic regression. Results were reported as an odds ratio (OR) with 95% confidence intervals (CI).

Results

A total of 2916 patients were included, of whom 211 patients (7.2%) suffered from ISI and 75 patients (2.6%) underwent IS. Multivariate analysis demonstrated that BMI≥25 (OR: 3.198 (2.356-4.326), p<0.001), total gastrectomy (OR: 2.201 (1.601-3.025), p<0.001), and the existence of "criminal fold" (OR: 13.899 (2.824-251.597), p=0.011) were independent predictive risk factors for ISI; whereas laparoscopic surgical approach (OR: 0.048 (0.007-0.172), p<0.001) was a protective factor for ISI. Moreover, the existence of "criminal fold" (OR: 15.745 (3.106-288.470), p=0.008) and BMI≥25 (OR: 2.498 (1.002-6.046), p=0.044) were identified as independent risk factors of ISI under laparoscopic gastrectomy. There was no association between sex, age, previous abdominal surgery, neoadjuvant therapy, outlet obstruction, tumor stage, nodal stage, and total lymph node retrieved and ISI.

Conclusions

BMI≥25 and total gastrectomy can predict high risk of ISI during radical gastrectomy. Laparoscopic surgery is superior to open gastrectomy in lowing the risk of ISI.

The Association Between Visceral Obesity and Postoperative Outcomes in Elderly Patients With Colorectal Cancer

Background

The impact of visceral obesity on the postoperative complications of colorectal cancer in elderly patients has not been well studied. This study aims to explore the influence of visceral obesity on surgical outcomes in elderly patients who have accepted a radical surgery for colorectal cancer.

Methods

Patients aged over 65 year who had undergone colorectal cancer resections from January 2015 to September 2020 were enrolled. Visceral obesity is typically evaluated based on visceral fat area (VFA) which is measured by computed tomography (CT) imaging. Univariate and multivariate analyses were performed to analyze parameters related to short-term outcomes.

Results

A total of 528 patients participated in this prospective study. Patients with visceral obesity exhibited the higher incidence of total (34.1% vs. 18.0%, P &lt; 0.001), surgical (26.1% vs. 14.6%, P = 0.001) and medical (12.6% vs. 6.7%, P = 0.022) complications. Based on multivariate analysis, visceral obesity and preoperative poorly controlled hypoalbuminemia were considered as independent risk factors for postoperative complications in elderly patients after colorectal cancer surgery.

Conclusions

Visceral obesity, evaluated by VFA, was a crucial clinical predictor of short-term outcomes after colorectal cancer surgery in elderly patients. More attentions should be paid to these elderly patients before surgery.

Robot-assisted laparoscopic subtotal gastrectomy for early-stage gastric cancer: Case series of initial experience

BACKGROUND

In the last decade's robotic gastrectomy (RG) has increasingly widespread as a valid minimally invasive option for treatment of gastric cancer. In literature, evidence of its routine use is not yet well established. The aims of this study are to report our initial experience and to present possible advantages of our hybrid operative technique for subtotal gastrectomy.

MATERIALS AND METHODS

Retrospectively, we analyzed data from 41 patients (22 male and 19 female) who underwent robot-assisted laparoscopic subtotal gastrectomy (RALG) with D2 lymphadenectomy using the da Vinci XI robotic system. Inclusion criteria were gastric cancer in the middle or lower portion of the stomach amenable of radical subtotal gastrectomy without preoperative suspicion of positive lymph-nodes or other organs involving and distant metastasis. All the procedures were performed by attending surgeons.

RESULTS

The mean operative time was 270 min with one case of conversion to open surgery. The mean age was 71.4 (IQR 68.2-76.8) with 43.9% of patients classified as ASA (American Society of Anesthesiologists) score ≥3. The median of lymph-nodes retrieved was 25 (IQR 19-35). No intra-operative complications occurred. Time to resume a soft diet was 5 days. Patients were hospitalized a median of 7 days. According to pathological AJCC-TNM, 21 patients were classified as advanced gastric cancer. Post-operative morbidity was recorded in 9 patients (21.9%) with major complications requiring surgical operation in 4 patients (9.8%). Elevated ASA score, fewer lymph-nodes retrieved and ICU recovery requirements were significant increased in patients with major complications.

CONCLUSION

The preliminary results demonstrated that robot-assisted laparoscopic subtotal gastrectomy is safe and feasible. In particular, we found that the da Vinci platform improves surgeon abilities to perform an adequate lymphadenectomy and digestive reconstruction. Further studies are necessary to better clarify the role of this high-cost technology in minimally invasive treatment of gastric cancer.

Metabolic syndrome predicts postoperative complications after gastrectomy in gastric cancer patients: Development of an individualized usable nomogram and rating model

Background

Metabolic syndrome (MetS), a public health problem, is reportedly related to an increased risk of postoperative complications after surgery. However, whether MetS have an effect on complications after gastric cancer (GC) surgery are unknown. This study aimed to investigate the effects of preoperative MetS on complications after gastrectomy.

Methods

Altogether, 718 gastric cancer patients who planned to receive radical gastrectomy between June 2014 and December 2016 were enrolled, demographic and clinicopathological characteristics were analyzed. Univariate and multivariate analyses were performed to identify potential risk factors for postoperative complications. A predictive model for postoperative complications was constructed in the form of a nomogram, and its clinical usefulness was assessed.

Results

Of the 628 patients ultimately included in the study (mean age 62.92 years, 450 men and 178 women), 84 were diagnosed with MetS preoperatively. Severe postoperative complications (Clavien‐Dindo grade ≥II) were significantly more common in patients with MetS (41.7% versus 23.7%, P < .001). Predictors of postoperative complications included MetS (odds ratio [OR] = 1.800, P = .023), age (OR = 1.418, P = .050), Charlson score (OR = 1.787, P = .004 for 1‐2 points) and anastomosis type (OR = 1.746, P = .007 for Billroth II reconstruction). The high‐risk rating had a high AUC (ROC I = 0.503, ROC Ib = 0.544, ROC IIa = 0.601, ROC IIb = 0.612, ROC IIc = 0.638, ROC III = 0.735), indicating that the risk‐rating model has good discriminative capacity and clinical usefulness.

Conclusions

MetS was an independent risk factor for complications after gastrectomy. The nomogram and rating model incorporating MetS, Billroth II anastomosis, age, and Charlson score was useful for individualized prediction of postoperative complications.

Impact of intra-peritoneal fat distribution on intra-operative bleeding volume with D2 lymphadenectomy in Chinese patients with gastric cancer

OBJECTIVE

To explore the quantitative measurements and evaluation of intra-peritoneal fat distribution by MDCT and its significance in predicting intra-operative bleeding volume during D2 lymphadenectomy in gastric cancer (GC) patients.

METHODS

From June 2016 to September 2017, GC patients scheduled for open gastrectomy with D2 lymph-node dissection were enrolled. According to the BMI, the subjects were then classified as normal BMI(BMI<25 kg/m²); overweight (BMI = 25-30 kg/m²) and obese (BMI≥30 kg/m²). According to the intraoperative blood loss (IBL), the patients were further separated into high IBL (IBL; ≥ 300 ml) or low IBL (<300 ml). Clinicopathological parameters between the groups were statistically compared and univariate and multivariate analysis were used to identify predictive factors such as intra-peritoneal fat areas (IFA) and intra-peritoneal fat areas ratio (IFAR) for high IBL.

RESULTS

A total of 226 patients were included in the study where 53 patients underwent distal while 173 underwent total gastrectomy. According to the BMI classification, there were 25 normal BMI, 108 overweight and 25 obese subjects. According to the IBL, there were 98 high IBL and 128 low IBL subjects. IFA and IFAR were significantly greater in the high IBL group than in the low IBL group. There was no significant difference in any other clinicopathological factors between the high IBL group and the low IBL group. Multivariate analysis revealed that high IFA and IFAR independently predicted high IBL.

CONCLUSION

The use of MDCT to evaluate the precise distribution of abdominal fat during preoperative examination can prompt surgeons to develop techniques to decrease intraoperative bleeding in obese patients. Nevertheless, it is yet necessary to be surgically more meticulous when dealing with patients with high IFA or high IFA/IFAR in order to improve the outcome of D2 gastrectomy.

Impact of Visceral Obesity and Sarcopenia on Short-Term Outcomes After Colorectal Cancer Surgery

BACKGROUND

With the increased prevalence of obesity and sarcopenia, those patients with both visceral obesity and sarcopenia were at higher risk of adverse outcomes.

AIM

The aim of this study was to ascertain the combined impact of visceral obesity and sarcopenia on short-term outcomes in patients undergoing colorectal cancer surgery.

METHODS

We conducted a prospective study from July 2014 to February 2017. Patients' demographic, clinical characteristics, physical performance, and postoperative short-term outcomes were collected. Patients were classified into four groups according to the presence of sarcopenia or visceral obesity. Clinical variables were compared. Univariate and multivariate analyses evaluating the risk factors for postoperative complications were performed.

RESULTS

A total of 376 patients were included; 50.8 and 24.5% of the patients were identified as having "visceral obesity" and "sarcopenia," respectively. Patients with sarcopenia and visceral obesity had the highest incidence of total, surgical, and medical complications. Patients with sarcopenia or/and visceral obesity all had longer hospital stays and higher hospitalization costs. Age ≥ 65 years, visceral obesity, and sarcopenia were independent risk factors for total complications. Rectal cancer and visceral obesity were independent risk factors for surgical complications. Age ≥ 65 years and sarcopenia were independent risk factors for medical complications. Laparoscopy-assisted operation was a protective factor for total and medical complications.

CONCLUSION

Patients with both visceral obesity and sarcopenia had a higher complication rate after colorectal cancer surgery. Age ≥ 65 years, visceral obesity, and sarcopenia were independent risk factors for total complications. Laparoscopy-assisted operation was a protective factor.

Impact of nutritional status on outcomes in laparoscopy-assisted gastrectomy

BACKGROUND

There is a high morbidity rate after digestive surgery in patients with nutritional disorders such as high body mass index and depletion of skeletal muscle.

MATERIALS AND METHODS

The ratio of psoas muscle area to trunk area was defined as the Psoas and All trunk Ratio (PandA Ratio) and used as an index of the balance between muscle and adipose tissue. This ratio was determined in 77 patients undergoing laparoscopy-assisted gastrectomy (LAG) for gastric cancer. Patients were classified into groups with and without postoperative complications. Clinicopathological factors were compared between the groups, and relationships of PandA Ratio with other nutritional indices were examined. PandA Ratios were also analyzed in males and females in each Clavien-Dindo grade.

RESULTS

Complications developed in 22 patients (28.6%) after LAG. The PandA Ratio was significantly lower in patients with complications in univariate (2.76 ± 0.22% versus 3.66 ± 0.14%, P = 0.0009) and multivariate (P = 0.0064) analyses. A low PandA Ratio was also associated with more severe complications in males.

CONCLUSIONS

Measurement of the areas of the psoas muscle and trunk on CT is useful for evaluation of the balance between skeletal and adipose tissue. The PandA Ratio derived from these measurements is a predictor of the clinical course after LAG in males.

Body Mass Index and Clinical Outcomes from Endoscopic Submucosal Dissection of Gastric Neoplasia

BACKGROUND AND AIM

Association between obesity and endoscopic resection outcomes has not been investigated. We sought to determine the clinical impact of obesity in patients who underwent endoscopic submucosal dissection (ESD) for gastric neoplasia.

METHODS

A total of 1571 consecutive patients with gastric neoplasia who underwent ESD between December 2010 and March 2016 were enrolled in this study. We retrospectively analyzed 1181 cases that were divided into three groups based upon body mass index (BMI, kg/m2) according to the criteria for Asia-Pacific populations: normal (<23, n = 411), overweight (≥23 and <25, n = 312), and obese (≥25, n = 458). Demographics, endoscopic findings, pathologic results, and clinical outcomes were analyzed.

RESULTS

No significant differences were observed between the three BMI groups in the following measures: the en-bloc resection rate, the complete resection rate, lymphovascular involvement or submucosal invasion of tumor cells, and adverse events. However, when comparing the obese and overweight groups with the normal group, mean procedure time was longer (P = 0.001) and the percentage of cases requiring more than 30 min, which was the overall mean procedure time, was greater (60.7, 53.2, and 50.1%, respectively; P = 0.006). The significantly associated factors with procedure durations longer than 30 min were obesity, longitudinal and circumferential location, large resection size (≥4 cm), cancer pathology, and submucosal layer invasion. In multivariate analyses, obesity was an independent predictor of long procedure time for gastric ESD.

CONCLUSION

Being obese or overweight did not directly affect clinical outcomes in gastric ESD. However, obesity was significantly associated with long procedure time. Our results suggest that gastric ESD can be performed safely and effectively in obese patients.

Advances in Laparoscopic and Robotic Gastrectomy for Gastric Cancer

Robot-assisted gastrectomy has been reported to be a safe alternative to both conventional laparoscopy and the open approach for treating early gastric carcinoma. Currently, there are a limited number of published reports on this technique in the literature. We assessed the current status of robotic and laparoscopic surgery in the treatment of gastric cancer and compared the operative outcomes, learning curves, and oncological outcome of the two approaches. Robotic gastrectomy offers benefits that include increased ease of performing D2 lymph node dissection and reduced blood loss compared with laparoscopic gastrectomy. However, the operative time is longer, and robotic gastrectomy is more costly for the patients. Regarding to the operative and oncological outcomes, there appears to be no significant differences between laparoscopic and robotic gastrectomies after the surgeon overcomes the associated learning curves. Sharing the available knowledge regarding laparoscopic and robotic gastrectomies could shorten these learning curves. For elder patients, minimally invasive surgery that decreases the postoperative recovery time should be considered the preferred treatment. Prospective randomized studies are required to compare the surgical and oncological outcomes among laparoscopic, robotic, and open surgeries for both early and advanced 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.

Is There any Role of Visceral Fat Area for Predicting Difficulty of Laparoscopic Gastrectomy for Gastric Cancer?

PURPOSE

Obesity is associated with morbidity following gastric cancer surgery, but whether obesity influences morbidity after laparoscopic gastrectomy (LG) remains controversial. The present study evaluated whether body mass index (BMI) and visceral fat area (VFA) predict postoperative complications.

MATERIALS AND METHODS

A total of 217 consecutive patients who had undergone LG for gastric cancer between May 2003 and December 2005 were included in the present study. We divided the patients into two groups ('before learning curve' and 'after learning curve') based on the learning curve effect of the surgeon. Each of these groups was sub-classified according to BMI (<25 kg/m(2) and ≥25 kg/m(2)) and VFA (<100 cm(2) and ≥100 cm(2)). Surgical outcomes, including operative time, quantity of blood loss, and postoperative complications, were compared between BMI and VFA subgroups.

RESULTS

The mean operative time, length of hospital stay, and complication rate were significantly higher in the before learning curve group than in the after learning curve group. In the subgroup analysis, complication rate and length of hospital stay did not differ according to BMI or VFA; however, for the before learning curve group, mean operative time and blood loss were significantly higher in the high VFA subgroup than in the low VFA subgroup (P=0.047 and P=0.028, respectively).

CONCLUSIONS

VFA may be a better predictive marker than BMI for selecting candidates for LG, which may help to get a better surgical outcome for inexperienced surgeons.

Effect of visceral fat area on outcomes of laparoscopyassisted distal gastrectomy for gastric cancer: subgroup analysis by gender and parameters of obesity

PURPOSE

The aim of this study was to investigate the impact of the visceral fat area (VFA) of patients with gastric cancer undergoing laparoscopic surgery on operative outcomes such as number of retrieved lymph nodes (LNs) and operative time.

METHODS

We retrospectively reviewed the medical records and the CT scans of 597 patients with gastric cancer who underwent laparoscopy assisted distal gastrectomy (LADG) with partial omentectomy and LN dissection (>D1 plus beta). Patients were stratified by gender, VFA, and body mass index (BMI), and the clinicopathologic characteristics and operative outcomes were evaluated. Multiple linear regression analysis was used to assess the effects of VFA and BMI on the number of retrieved LNs and operative time in male and female patients.

RESULTS

The mean number of retrieved LNs was significantly decreased for both male and female patients with high VFA. The operative time was significantly longer for both male and female patients with high VFA. The number of retrieved LNs had a statistically significant negative correlation with VFA in both men and women, but not with BMI. The operative time had a statistically significant positive correlation with VFA in men, whereas the operative time had a statistically significant positive correlation with BMI in women.

CONCLUSION

The preoperative VFA of male patients with gastric cancer who undergo LADG may affect the number of retrieved LNs and operative time. VFA was more useful than BMI for predicting outcomes of LADG.

Robot-assisted gastrectomy for gastric cancer: current status and technical considerations

BACKGROUND

Robot-assisted gastrectomy has been reported as a safe alternative to the conventional laparoscopy or open approach for treating early gastric carcinoma. To date, however, there are a limited number of published reports available in the literature.

METHODS

We assess the current status of robotic surgery in the treatment of gastric cancer, focusing on the technical details and oncological considerations.

RESULTS

In gastric surgery, the biggest advantage of robotic surgery is the ease and reproducibility of D2-lymphadenectomy. Reports show that even the intracorporeal digestive restoration is facilitated by use of the robotic approach, particularly following total gastrectomy. Additionally, the accuracy of robotic dissection is confirmed by decreased blood loss, as reported in series comparing robot-assisted with laparoscopic gastrectomy. The learning curve and technical reproducibility also appear to be shorter with robotic surgery and, consequently, robotics can help to standardize and diffuse minimally invasive surgery in the treatment of gastric cancer, even in the later stages. This is important because the application of minimally invasive surgery is limited by the complexity of performing a D2-lymphadenectomy. The potential to reproduce D2-lymphadenectomy, enlarged resections, and complex reconstructions provides robotic surgery with an important role in the therapeutic strategy of advanced gastric cancer.

CONCLUSIONS

While published reports have shown no significant differences in surgical morbidity, mortality, or oncological adequacy between robot-assisted and conventional laparoscopic gastrectomy, more studies are needed to assess the indications and oncological effectiveness of robotic use in the treatment of gastric carcinoma. Herein, the authors assess the current status of robotic surgery in the treatment of gastric cancer, focusing on the technical details and oncological considerations.

Robotic distal subtotal gastrectomy with D2 lymphadenectomy for gastric cancer patients with high body mass index: comparison with conventional laparoscopic distal subtotal gastrectomy with D2 lymphadenectomy

BACKGROUND

Minimally invasive surgery (MIS) has emerged as a treatment of choice for early-stage gastric cancer. However, applying MIS to gastric patients with high body mass index (BMI) is technically challenging, especially when performing D2 lymphadenectomy. Recently, robotic systems have been adopted to overcome the technical limitations of conventional laparoscopic surgery. Nevertheless, studies on the impact of the use of robotic systems to perform D2 lymphadenectomy in high BMI patients are lacking. Accordingly, this study was designed to compare the quality of lymphadenectomy, together with surgical outcomes, by robotic distal subtotal gastrectomy with D2 lymphadenectomy (RDGD2) to those by laparoscopic distal subtotal gastrectomy with D2 lymphadenectomy (LDGD2) in patients of different BMI status.

METHODS

Retrospective review of a prospectively collected database identified 400 gastric cancer patients who underwent either RDGD2 (n = 133) or LDGD2 (n = 267) between 2003 and 2010. Patients were categorized according to surgical approach and BMI. We compared clinicopathologic characteristics, as well as short-term and long-term outcomes, between surgery and BMI groups.

RESULTS

Regardless of BMI, RDGD2 required significantly longer operation time than LDGD2 (p = 0.001); meanwhile, RDGD2 showed significantly less blood loss than LDGD2 (p = 0.005). Between BMI groups, RDGD2 showed no significant difference in the rate of retrieving more than 25 lymph nodes (p = 0.181); however, LDGD2 was associated with a significantly lower rate of retrieving more than 25 lymph nodes in high BMI patients (p = 0.006). In high BMI patients, complications did not significantly differ between surgical approaches. As well, RDGD2 and LDGD2 demonstrated no statistically significant survival difference according to BMI status.

CONCLUSIONS

The benefits of a robotic approach were more evident in high BMI patients than in normal BMI patients when performing distal subtotal gastrectomy with D2 lymphadenectomy, particularly in terms of blood loss and consistent quality of lymphadenectomy. Robotic surgery could be an effective alternative to conventional laparoscopic surgery in treating gastric cancer patients with high BMI.

Short-term outcomes for laparoscopy-assisted distal gastrectomy for body mass index ≥30 patients with gastric cancer

BACKGROUND

Obesity is known to be a preoperative risk factor for gastric cancer surgery. This study aimed to investigate the influence of obesity on the surgical outcomes of laparoscopy-assisted distal gastrectomy (LADG) for gastric cancer.

METHODS

The clinical data of 131 patients with gastric cancer from January 2010-December 2013 were analyzed retrospectively. Perioperative outcomes were compared between 43 patients with a body mass index (BMI) ≥30 kg/m(2) (obese group) and 88 patients with a BMI <30 kg/m(2) (nonobese group) who underwent LADG.

RESULTS

Operation times were significantly longer for the obese group than for the nonobese group (234.1 ± 57.2 min versus 212.2 ± 43.5 min, P = 0.026). There were no statistically significant differences between two groups in terms of intraoperative blood loss, the number of retrieved lymph nodes, postoperative recovery, and postoperative complications (P > 0.05). During the follow-up period of 5 mo-49 mo (average, 36 mo), the overall survival rates were not significantly different between the two groups (80.0% [32/40] versus 81.9% [68/83], P > 0.05). The differences in recurrence and metastasis between the two groups were not statistically significant.

CONCLUSIONS

Our analysis revealed that LADG can be safely performed in patients with BMI ≥30. The procedure was considered to be difficult but sufficiently feasible.

Laparoscopic gastrectomy versus open gastrectomy for gastric cancer in patients with body mass index of 30 kg/m2 or more

BACKGROUND

High body mass index (BMI) and high visceral fat area (VFA) are known to be a preoperative risk factor for laparoscopic gastrectomy (LG) for gastric cancer. However, the impact of obesity on LG still remains controversial. In the present study, we compared the operative outcomes of LG with those of OG in patients with BMI of 30 kg/m(2) or more.

METHODS

Seventy-seven patients who underwent distal or total gastrectomy for gastric cancer were enrolled. The patients were divided into two groups by approach method; an OG group (n = 19) and a LG group (n = 62). Aquarius iNtuition(®) program was used to measure VFA. The operation time, estimated blood loss, complication rate, the number of retrieved lymph nodes, and patient survival were compared between two groups.

RESULTS

The mean BMI and VFA were 31.6 kg/m(2) and 195.3 cm(2). The complication rate was 42.1 % in OG group and 14.5 % in LG group, respectively (P = 0.010). LG group showed less estimated blood loss (P = 0.030) and fast recovery of bowel movement (P < 0.001). However, there were no significant differences in operation time, the number of retrieved lymph nodes, and the length of hospital stay between two groups. In subgroup analysis, there was significant correlation between estimated blood loss and VFA (R (2) = 0.113, P = 0.014), but there was no correlation between operation time and VFA (R(2) = 0.002, P = 0.734). In stage I, the 5-year survival was not different between two groups (P = 0.220).

CONCLUSION

LG showed better operative outcomes compared with OG, in terms of less estimated blood loss, fast recovery of bowel movement, and low complication rate, in patients with BMI of ≥ 30 kg/m(2) or more.

Impact of comorbidities on postoperative complications in patients undergoing laparoscopy-assisted gastrectomy for gastric cancer

Background

Comorbidity is a predictor of postoperative complications (PCs) in gastrectomy. However, it remains unclear which comorbidities are predictors of PCs in patients who undergo laparoscopy-assisted gastrectomy (LAG). Clinically, insufficient lymphadenectomy (LND) is sometimes performed in high-risk patients, although the impact on PCs and outcomes remains unclear.

Methods

We retrospectively studied 529 patients with gastric cancer (GC) who underwent LAG. PCs were defined as grade 2 or higher events according to the Clavien-Dindo classification. We evaluated various comorbidities as risk factors for PCs and examined the impact of insufficient LND on PCs in patients with risky comorbidities.

Result

A total of 87 (16.4%) patients had PCs. There was no PC-related death. On univariate analysis, heart disease, central nervous system (CNS) disease, liver disease, renal dysfunction, and restrictive pulmonary dysfunction were significantly associated with PCs. Both liver disease and heart disease were significant independent risk factors for PCs on multivariate analysis (odds ratio [OR] = 3.25, p = 0.022; OR = 2.36, p = 0.017, respectively). In patients with one or more risky comorbidity, insufficient LND did not significantly decrease PCs (p = 0.42) or shorten GC-specific survival (p = 0.25).

Conclusion

In patients who undergo LAG for GC, the presence of heart disease or liver disease is an independent risk factor for PC. Insufficient LND (for example, D1+ for advanced GC) might be permissible in high-risk patients, because although it did not reduce PCs, it had no negative impact on GC-specific survival.

Efficacy evaluation of subtotal and total gastrectomies in robotic surgery for gastric cancer compared with that in open and laparoscopic resections: a meta-analysis

PURPOSES

Robotic gastrectomy (RG), as an innovation of minimally invasive surgical method, is developing rapidly for gastric cancer. But there is still no consensus on its comparative merit in either subtotal or total gastrectomy compared with laparoscopic and open resections.

METHODS

Literature searches of PubMed, Embase and Cochrane Library were performed. We combined the data of four studies for RG versus open gastrectomy (OG), and 11 studies for robotic RG versus laparoscopic gastrectomy (LG). Moreover, subgroup analyses of subtotal and total gastrectomies were performed in both RG vs. OG and RG vs. LG.

RESULTS

Totally 12 studies involving 8493 patients met the criteria. RG, similar with LG, significantly reduced the intraoperative blood loss than OG. But the duration of surgery is longer in RG than in both OG and LG. The number of lymph nodes retrieved in RG was close to that in OG and LG (WMD = -0.78 and 95% CI, -2.15-0.59; WMD = 0.63 and 95% CI, -2.24-3.51). And RG did not increase morbidity and mortality in comparison with OG and LG (OR = 0.92 and 95% CI, 0.69-1.23; OR = 0.72 and 95% CI, 0.25-2.06) and (OR = 1.06 and 95% CI, 0.84-1.34; OR = 1.55 and 95% CI, 0.49-4.94). Moreover, subgroup analysis of subtotal and total gastrectomies in both RG vs. OG and RG vs. LG revealed that the scope of surgical dissection was not a positive factor to influence the comparative results of RG vs. OG or LG in surgery time, blood loss, hospital stay, lymph node harvest, morbidity, and mortality.

CONCLUSIONS

This meta-analysis highlights that robotic gastrectomy may be a technically feasible alternative for gastric cancer because of its affirmative role in both subtotal and total gastrectomies compared with laparoscopic and open resections.

Does overweight affect outcomes in patients undergoing gastrectomy for cancer? A meta-analysis of 25 cohort studies

OBJECTIVE

Overweight was regarded as one of the risk factors for poor outcome after gastrectomy, but its influence on the surgical and postoperative outcomes of gastrectomy was unclear.

METHODS

Comprehensive searches were conducted to include cohort studies which evaluated the influence of overweight on the surgical and postoperative outcomes of gastrectomy. Data was analyzed by RevMan 5.0.

RESULTS

Twenty-five cohort studies (18 518 patients) were included. Overweight patients were associated with longer operation time (mean difference 20.88, 95% confidence interval 14.07, 27.69), more intraoperative blood loss (mean difference 35.45, 95% confidence interval 9.24, 61.67), and less retrieved lymph nodes (mean difference -2.17, 95% confidence interval -3.51, -0.83) than normal patients undergoing laparoscopy-assisted gastrectomy. And overweight patients were associated with longer operation time (mean difference 26.31, 95% confidence interval 21.92, 30.70), more intraoperative blood loss (mean difference 130.02, 95% confidence interval 75.49, 184.55), less retrieved lymph nodes (mean difference -3.18, 95% confidence interval -4.74, -1.61), longer postoperative hospital stay (mean difference 2.37, 95% confidence interval 0.03, 4.70) and more postoperative complications (risk ratio 1.53, 95% confidence interval 1.29, 1.80) than normal patients in open gastrectomy.

CONCLUSIONS

Overweight might affect the clinical results of both laparoscopy-assisted and open gastrectomy, especially for open gastrectomy.

Low molecular-weight heparin for thromboprophylaxis in patients undergoing gastric cancer surgery: an experience from one Korean institute

Purpose

This study evaluated the efficacy for preventing venous thromboembolism (VTE) and adverse effects of low-molecular-weight heparin (LMWH) in order to launch a prospective clinical trial in Korea.

Methods

We reviewed the medical records of 108 consecutive patients who underwent gastric cancer surgery. These patients were divided into 2 groups according to the type of thromboprophylaxis: group A, LMWH combined with intermittent pneumatic compression (IPC); group B, IPC alone. The postoperative outcomes of the two groups were compared.

Results

Symptomatic VTE was observed in only 1 patient (0.9%) from group B. Postoperative bleeding was more common in group A than in group B (10.9% vs. 7.5%), although the difference was not significant (P = 0.055). Most bleeding episodes were minor and managed conservatively without intervention. Only a high body mass index was associated with a significantly increased risk of postoperative bleeding (odds ratio, 1.45; 95% confidence interval, 1.12-2.43; P = 0.051).

Conclusion

A 40 mg of enoxaparin sodium is a safe and feasible dose for prevention of VTE. With the results of this study, we are planning a prospective randomized clinical trial to investigate the clinical efficacy of LMWH thromboprophylaxis in gastric cancer patients in Korea.

Comparison of three different minimally invasive procedures of distal gastrectomy for Nonoverweight patients with T1N0-1 gastric cancer

Laparoscopic-assisted distal gastrectomy has recently come to be a standard procedure for the treatment of early gastric cancer (1 - 5) in select patients. The minimal invasiveness associated with laparoscopic procedures for the resection of gastrointestinal cancer has been repeatedly explained in part by the short incision that is required. (6 - 11) We used two different approaches to perform distal gastrectomies for the resection of gastric cancer as minimally invasive alternatives to a standard laparoscopic approach prior to our surgical team's complete mastery of the skills required for laparoscopic oncological surgery for gastric cancer. (9 , 12) If the minimal invasiveness associated with laparoscopic-assisted gastrectomy can be explained by the small incision, a gastrectomy via a small incision without the use of a pneumoperitoneum may provide a similar outcome in patients. However, to our knowledge, such a comparison has not been previously made. We compared the minimal invasiveness of three different approaches (minilaparotomy, minilaparotomy approach with laparoscopic assistance, and standard laparoscopic-assisted approach) to performing a distal gastrectomy for T1N0-1 gastric cancer in nonoverweight patients (body mass index, ≤ 25 kg/m(2)) performed within a limited study period.

[Robotic hepatobiliary and gastric surgery]

Hepatobiliary surgery is a challenging surgical subspecialty that requires highly specialized training and an adequate level of experience in order to be performed safely. As a result, minimally invasive hepatobiliary surgery has been met with slower acceptance as compared to other subspecialties, with many surgeons in the field still reluctant about the approach. On the other hand, gastric surgery is a very popular field of surgery with an extensive amount of literature especially regarding open and laparoscopic surgery but not much about the robotic approach especially for oncological disease. Recent development of the robotic platform has provided a tool able to overcome many of the limitations of conventional laparoscopic hepatobiliary surgery. Augmented dexterity enabled by the endowristed movements, software filtration of the surgeon's movements, and high-definition three-dimensional vision provided by the stereoscopic camera, allow for steady and careful dissection of the liver hilum structures, as well as prompt and precise endosuturing in cases of intraoperative bleeding. These advantages have fostered many centers to widen the indications for minimally invasive hepatobiliary and gastric surgery, with encouraging initial results. As one of the surgical groups that has performed the largest number of robot-assisted procedures worldwide, we provide a review of the state of the art in minimally invasive robot-assisted hepatobiliary and gastric surgery.The English full-text version of this article is available at SpringerLink (under supplemental).

Short-term outcome of total laparoscopic distal gastrectomy for overweight and obese patients with gastric cancer

BACKGROUND

Laparoscopic distal gastrectomy for gastric cancer has been firmly established in recent decades but still is a difficult procedure, especially for obese patients, as with open surgery. This study aimed to evaluate the perioperative outcome of total laparoscopic distal gastrectomy (TLDG) for early gastric cancer patients with a body mass index (BMI) exceeding 25 kg/m(2) and to consider countermeasures to this.

METHODS

Perioperative outcomes were compared between 42 patients with a BMI exceeding 25 kg/m(2) [overweight or obese group (OWG)] and 174 patients with a BMI lower than 25 kg/m(2) [normal or underweight group (NWG)] who underwent TLDG between September 2010 and December 2012.

RESULTS

The BMI was 26.0 ± 1.4 kg/m(2) in the OWG group and 22.0 ± 2.1 kg/m(2) in the NWG group (P < 0.001). The groups did not differ in terms of age, sex, American Society of Anesthesiologists score, presence of diabetes, number of retrieved lymph nodes, number of metastatic lymph nodes, or metastatic lymph node ratio. The two groups did not differ significantly with respect to the extent of lymph node dissection [OWG: D1 (11.9 %), D1+ (66.7 %), D2 (21.4 %) vs NWG: D1 (5.2 %), D1+ (51.7 %), D2 (43.1 %); P = 0.020] or tumor size (OWG: 25.5 ± 20.2 mm vs NWG: 33.0 ± 17.2 mm; P = 0.037). Differences in operation time (OWG: 212 ± 31 min vs NWG: 200 ± 35 min; P = 0.005) and estimated blood loss (OWG: 15 ± 22 ml vs NWG: 10 ± 34 ml; P = 0.013) seemed to have a minimal impact clinically. Postoperative complications including infectious complications and recovery after surgery did not differ between the two groups.

CONCLUSIONS

For overweight and obese patients, TLDG was managed safely. The procedure was considered to be difficult but sufficiently feasible.

Impact of visceral fat on laparoscopy-assisted distal gastrectomy

BACKGROUND

Obesity is known to be a preoperative risk factor for gastric cancer surgery. However, the influence of obesity on laparoscopy-assisted distal gastrectomy (LADG) remains controversial. In the present study, we evaluated several obesity parameters and investigated the influence of obesity on the surgical outcomes of LADG for gastric cancer.

MATERIALS AND METHODS

Between January 2010 and July 2011, 84 patients who underwent LADG for gastric cancer were enrolled. Visceral fat area (VFA) and subcutaneous fat area (SFA) were measured in cross-sectional CT scan using SlimVision(®) software. Patients were classified into two groups by the degree of BMI or VFA. Surgery time and blood loss were compared between each two groups. Predictive factors for perioperative complications were assessed by univariate and multivariate analyses.

RESULTS

There were no significant differences in surgery time or blood loss between patients with high and low BMIs. In contrast, high VFA patients had significantly longer surgery times (p=0.0047) and higher estimated blood loss (p=0.0034) than low VFA patients. By univariate and multivariate analyses, only a high VFA significantly predicted perioperative complications (p=0.0162, p=0.0288).

CONCLUSIONS

We suggest that VFA is more accurate than BMI in predicting surgery time, blood loss, and perioperative complications associated with LADG for gastric cancer. The visceral fat area could be efficiently assessed before laparoscopic surgery for gastric cancer in obese patients.

The impact of obesity on the use of a totally laparoscopic distal gastrectomy in patients with gastric cancer

PURPOSE

Since a patient's obesity can affect the mortality and morbidity of the surgery, less drastic surgeries may have a major benefit for obese individuals. This study evaluated the feasibility of performing a totally laparoscopic distal gastrectomy, with intracorporeal anastomosis, in obese patients suffering from gastric cancer.

MATERIALS AND METHODS

This was a retrospective analysis of the 138 patients, who underwent a totally laparoscopic distal gastrectomy from April 2005 to March 2009, at the National Kyushu Cancer Center. The body mass index of 20 patients was ≥25, and in 118 patients, it was <25 kg/m(2).

RESULTS

The mean values of body mass index in the 2 groups were 27.3±2.2 and 21.4±2.3. Hypertension was significantly more frequent in the obese patients than in the non-obese patients. The intraoperative blood loss, duration of surgery, post-operative complication rate, post-operative hospital stay, and a number of retrieved lymph nodes were not significantly different between the two groups.

CONCLUSIONS

Intracorporeal anastomosis seemed to have a benefit for obese individuals. Totally laparoscopic gastrectomy is, therefore, considered to be a safe and an effective modality for obese patients.

The impact of abdominal shape index of patients on laparoscopy-assisted distal gastrectomy for early gastric cancer

PURPOSE

The aim of this study was to explore the effects of the abdominal shape index on gastric cancer patients' short-term surgical outcomes of laparoscopy-assisted distal gastrectomy (LADG) in both genders.

METHODS

This retrospective study included 231 consecutive patients with early gastric cancer who underwent LADG with Billroth I anastomosis between 1998 and 2009. The abdominal shape index of patients was calculated using preoperative abdominal computed tomography scans and the Fat Scan software program.

RESULTS

In male patients, the duration of surgery was longer in patients with a body mass index ≥25 kg/m(2) (P = 0.016), with the anterior to posterior diameter ≥200 mm (P < 0.0001), with the transverse diameter (TD) ≥300 mm (P = 0.030), with the waist ≥85 cm (P = 0.039), and with the visceral fat area (VFA) ≥100 cm(2) (P = 0.029). The intraoperative blood loss was higher in the large TD group (P = 0.049), in the high waist group (P = 0.006), and in the large VFA group (P = 0.007). In female patients, the correlations between these surgical outcomes and this abdominal shape index were not found. No significant relationships between each body shape index and the number of lymph nodes retrieved were found in either gender. Postoperative complications were not associated with the fat volume and abdominal shape index.

CONCLUSIONS

Accumulation of fat did not affect short-term surgical outcomes except for the duration of surgery and intraoperative blood loss in male patients.

Minimally invasive surgery for gastric cancer: the future standard of care

Laparoscopy-assisted distal gastrectomy for gastric cancer was first reported by Kitano et al. in 1991. Laparoscopic wedge resection (LWR) and intragastric mucosal resection (IGMR) were quickly adapted for gastric cancer limited to the mucosal layer and having no risk of lymph node metastasis. Following improvements in endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), the use of LWR and IGMR for these indications decreased, and patients with gastric cancer, including those with a risk of lymph node metastases, were more likely to be managed with laparoscopic gastrectomy (LG) with lymph node dissection. Many retrospective comparative trials and randomized-controlled trials (RCT) have confirmed that LG is safe and feasible, and that short-term outcomes are better than those of open gastrectomy (OG) in patients with early gastric cancer (EGC). However, these trials did not include a satisfactory number of patients to establish clinical evidence. Thus, additional multicenter randomized-controlled trials are needed to delineate significantly quantifiable differences between LG and OG. As laparoscopic experience has accumulated, the indications for LG have been broadened to include older and overweight patients and those with advanced gastric cancer. Moreover, advanced techniques, such as laparoscopy-assisted total gastrectomy, laparoscopy-assisted proximal gastrectomy, laparoscopy-assisted pylorus-preserving gastrectomy (PPG), and extended lymph node dissection (D2) have been widely performed.In the near future, sentinel node navigation and robotic surgery will become additional options in minimally invasive surgery (MIS) involving LG. Such developments will improve the quality of life of patients following gastric cancer surgery.

Current status of robot-assisted gastric surgery

In an effort to minimize the limitations of laparoscopy, a robotic surgery system was introduced, but its role for gastric cancer is still unclear. The objective of this article is to assess the current status of robotic surgery for gastric cancer and to predict future prospects. Although the current study was limited by its small number of patients and retrospective nature, robot-assisted gastrectomy with lymphadenectomy for the treatment of gastric cancer is a feasible and safe procedure for experienced laparoscopic surgeons. Most studies have reported satisfactory results for postoperative short-term coutcomes, such as: postoperative oral feeding, gas out, hospital stay and complications, compared with laparoscopic surgery; the difference is a longer operation time. However, robotic surgery showed a shallow learning curve compared with the familarity of conventional open surgery; after the accumulation of several cases, robotic surgery could be expected to result in a similar operation time. Robotic-assisted gastrectomy can expand the indications of minimally invasive surgery to include advanced gastric cancer by improving the ability to perform lymphadenectomy. Moreover, ”total” robotic gastrectomy can be facilitated using a robot-sewing technique and gastric submucosal tumors near the gastroesophageal junction or pylorus can be resected safely by this novel technique. In conclusion, robot-assisted gastrectomy may offer a good alternative to conventional open or laparoscopic surgery for gastric cancer, provided that long-term oncologic outcomes can be confirmed.

Rapid adaptation of robotic gastrectomy for gastric cancer by experienced laparoscopic surgeons

BACKGROUND

Robotic surgery for gastric cancer patients has been increasing because of its many advantages over conventional laparoscopic surgery. Despite the suggestion that robotic surgery may lessen the learning curve for complex laparoscopic procedures, little is known about the learning curve for robotic gastrectomy. This study aimed to assess the learning curve of robotic gastrectomy for patients with cancer by analyzing the operation time.

METHODS

The first 20 consecutive cases of robot-assisted distal gastrectomy with lymphadenectomy for gastric cancer performed by three experienced laparoscopic surgeons' using the da Vinci system were collected and reviewed. A nonlinear least-squares method was developed and used to analyze the learning curves.

RESULTS

Overall, the mean operation time was 247.3 ± 45.7 min, depending on each surgeon's laparoscopic experience and the patient's characteristics. After control was used for confounding factors, the stabilized operation time decreased to 211.8 min. The operation time stabilized at 8.2 cases and was reduced 111.4 min from the first case. A stable operation time was reached in 9.6 cases by surgeon A, in 18.1 cases by surgeon B, and in 6 cases by surgeon C. The stable operation time was 149.2 min for surgeon A, 127.1 min for surgeon B, and 236.8 min for surgeon C, and the reduction in operation time from the first case to stabilization was 233 min for surgeon A, 76.7 min for surgeon B, and 154.6 min for surgeon C.

CONCLUSIONS

Surgeons with sufficient experience in laparoscopic gastrectomy can rapidly overcome the learning curve for robotic gastrectomy. In addition, the surgeon's experience with laparoscopic gastrectomy affects the operation time after stabilization and the reduction in operation time.

The benefits of laparoscopically assisted distal gastrectomy for obese patients

BACKGROUND

In Japan, the number of obese patients with gastric cancer is increasing. This study aimed to evaluate the advantages of laparoscopically assisted distal gastrectomy (LADG) for obese patients relative to those of conventional distal gastrectomy (DG).

METHODS

Between January 2004 and June 2009, a total of 197 consecutive patients with gastric carcinoma underwent curative distal gastrectomy with Billroth 1 reconstruction in the Gunma University Hospital. The patients were assigned to undergo LADG (n = 120) or DG (n = 77) according to the depth of tumor invasion and lymph node status. A body mass (BMI) of 25 kg/m(2) or higher was defined as obesity, and the amounts of blood loss, the operating time, the number of lymph nodes dissected, and the postoperative complications experienced by obese and nonobese patients were compared.

RESULTS

None of the patients in the LADG group required conversion to laparotomy. In the DG group, significantly fewer lymph nodes were retrieved from the obese patients (22.5 ± 3.4) than from the nonobese patients (31.9 ± 2.0; P < 0.05). However, among the obese patients, the number of lymph nodes retrieved did not differ significantly between the LADG and DG groups. In the LADG group, the obese patients had a longer operating time (206.6 ± 6.3 vs. 192.0 ± 3.1 min; P < 0.05) and a greater estimated blood loss (158.2 ± 24.7 vs. 101.9 ± 10.4 ml; P < 0.05) than the nonobese patients. The estimated blood loss correlated the surgical procedures and BMI. No significant difference in postoperative complications was noted between the obese and nonobese groups after each procedure.

CONCLUSIONS

Relative to DG, LADG did not affect the radicality of the procedure for the obese patients, and there is no significant difference in the operating time. The estimated blood loss was significantly less for LADG than for DG. Surgeons should elect to perform LADG for obese patients with gastric cancer.

Robotic gastrectomy for gastric cancer: surgical techniques and clinical merits

BACKGROUND

Robotic gastrectomy in the setting of gastric cancer is reported by some investigators. However, no study has compared robotic surgery with open or laparoscopic surgery for patients with gastric cancer. This study aimed to determine the clinical benefits of robotic gastrectomy over open and laparoscopic gastrectomy for the treatment of gastric cancer.

METHODS

After the introduction of the da Vinci surgical system in November 2007 at the authors' hospital, 18 robotic gastrectomies were performed from 31 December 2007 to 30 June 2008. The prospective data from gastric cancer patients who underwent gastrectomies (16 robotic, 11 laparoscopic, and 12 open) during the same period were retrospectively analyzed.

RESULTS

Sex, age, comorbidity, extent of lymphadenectomy, pT stage, lymph node metastasis, and number of lymph nodes retrieved were similar among the three groups. The estimated blood loss was significantly less in the robotic gastrectomy group than in the open group (p = 0.0312), and the postoperative hospital stay in the robotic group was significantly shorter than in the open and laparoscopic gastrectomy groups (p < 0.001). Postoperative morbidity and time to first flatus were similar in the three groups. There was no open or laparoscopic conversion in the robotic group. No postoperative mortality occurred in any group.

CONCLUSION

Robotic gastrectomy for the treatment of gastric cancer is a feasible and safe procedure in the hands of experienced laparoscopic surgeons. Robotic gastrectomy offers better short-term surgical outcomes than the open and laparoscopic methods. Furthermore, this procedure may be a preferable alternative for the treatment of gastric cancer.

The impact of visceral fat accumulation on laparoscopy-assisted distal gastrectomy for early gastric cancer

BACKGROUND

Laparoscopy-assisted distal gastrectomy (LADG) has been widely accepted for the treatment for early gastric cancer. Obesity is a rapidly growing epidemic, and the number of obese patients with gastric cancer is increasing, but the impact of visceral fat (VF) accumulation on laparoscopic gastric surgery remains unknown. The aim of the present study was to determine the impact of VF accumulation on LADG.

MATERIALS AND METHODS

The medical charts of 30 patients who underwent LADG for early gastric cancer in our hospital between November 2000 and November 2006 were analyzed retrospectively. The patients were divided into two groups on the basis of VF accumulation measured on cross-sectional computed tomography at the level of the umbilicus. Twelve patients had high VF accumulation (> or =100 cm2) and 18 had low VF accumulation (<100 cm2).

RESULTS

Although subcutaneous fat accumulation was not correlated with operation time or operative blood loss, VF accumulation was strongly, and significantly, correlated with both operation time and operative blood loss. The high-VF-accumulation group had a significantly longer operation time and significantly more operative blood loss than the low-VF-accumulation group. There was no significant difference in the rate of postoperative complications or conversion to open laparotomy between the two groups. There were no operative deaths or requirements for blood transfusion in either group.

CONCLUSIONS

VF accumulation was significantly correlated with operative difficulties during LADG. Although LADG was as safe for patients with high VF accumulation as for patients with low VF accumulation, a longer operative time and more operative blood loss were observed in patients with high VF accumulation. VF accumulation appears to be a possible risk factor in LADG and should be considered when making a decision about treating early gastric cancer with LADG.

Laparoscopy-assisted distal gastrectomy for overweight patients in the Asian population

PURPOSE

It is generally considered difficult to operate on overweight patients, who are also at increased risk of postoperative complications. We conducted this study to clarify the technical feasibility and postoperative outcomes of laparoscopy-assisted distal gastrectomy (LADG) for early gastric cancer (EGC) in overweight patients.

METHODS

Between July 2004 and December 2006, 116 patients with preoperatively diagnosed EGC underwent LADG at our department. We classified these patients into two groups based on body mass index (BMI). There were 60 patients in the high-BMI (> or =23 kg/m2) group and 56 in the low-BMI (<23 kg/m2) group. The clinicopathologic features, postoperative outcomes, and operation-related morbidities were compared.

RESULTS

None of the patients needed conversion to laparotomy. There were no notable differences in clinical characteristics or histologic features between the groups. Although the operation time was significantly longer in the high-BMI group, there were no significant differences in postoperative bowel recovery, postoperative hospital stay, or operation-related morbidities.

CONCLUSIONS

Laparoscopy-assisted distal gastrectomy for overweight patients is feasible and safe; however, because of its technical difficulties and the complexities of lymph node dissection, it should be carefully considered, and may only be suitable for early-stage cancers.

The impact of a high body mass index on laparoscopy assisted gastrectomy for gastric cancer

BACKGROUND

Obesity is known to be associated with postoperative morbidity in gastric cancer surgery, but its impact on laparoscopy assisted gastrectomy (LAG) for gastric cancer has rarely been evaluated.

METHODS

The clinical data for 1,485 LAG procedures for gastric cancer in 10 institutions were reviewed. The patients were divided into high body mass index (BMI) (BMI > or = 25 kg/m(2); n = 432) and low BMI (BMI <25 kg/m(2); n = 1,053) groups, and their clinical outcomes were compared.

RESULTS

The mean age and proportion of comorbid patients were higher in the high BMI group than in the low BMI group. Postoperative morbidity and mortality did not differ between the high BMI (15.7% and 0.9%) and low BMI (14% and 0.5%) groups (p = 0.37 and p = 0.29). Only the operation time and the number of retrieved lymph nodes were significantly different between the high BMI (242.5 min and 30.4) and low BMI (223.7 min and 32.6) groups (p < 0.001 and p = 0.005), especially for male patients undergoing surgery by surgeons who have performed 40 or fewer LAGs.

CONCLUSIONS

High BMI itself may not increase operative morbidity after LAG for gastric cancer. However, when a surgeon is relatively inexperienced with LAG, a careful approach is required for male patients with a high BMI.

Predictive factors for surgical complications of laparoscopy-assisted distal gastrectomy for gastric cancer

BACKGROUND

Some studies have found high incidences of intraoperative and postoperative complications for patients with gastric cancer. To determine the predictive factors for the surgical complications of laparoscopic gastric surgery, surgical outcomes were evaluated.

METHODS

Between April 2002 and December 2007, 152 patients with preoperatively diagnosed early gastric cancer who underwent laparoscopy-assisted distal gastrectomy (LADG) were enrolled. Visceral (VFA) and subcutaneous fat areas (SFA) were assessed by Fat Scan software. The predictive factors for surgical complications of LADG were evaluated by univariate and logistic regression analyses.

RESULTS

Of 152 patients, conversion to open surgery due to uncontrollable bleeding was observed in nine male patients, and postoperative complications were detected in seven male and one female patient (four anastomotic leakage, two intraabdominal abscess, one pancreatic fistula, and one lymphorrhea). High body mass index (BMI) and high VFA independently predicted conversion to open surgery and postoperative complications. VFA was significantly higher, operation time was longer, blood loss was greater, and SFA was lower in male than in female patients, whereas no significant difference was observed in BMI between male and female patients.

CONCLUSIONS

High BMI and high VFA can predict technical difficulties during laparoscopic gastric surgery and postoperative complications. Particularly, LADG should be performed cautiously to prevent surgical complications for male patients with high VFA. Predictive impact of VFA should be further determined in a larger set of patients.

Entirely laparoscopic radical gastrectomy for adenocarcinoma: lymph node yield and resection margins

BACKGROUND

Laparoscopic assisted distal gastrectomy for adenocarcinoma has been widely reported from Japan and Korea but there are sparse data for Western patients. This study aimed to describe and compare the perioperative outcomes and pathological staging for consecutive patients who underwent laparoscopic or open gastrectomy by a single surgeon in the UK.

METHODS

During the period from April 2005 to May, 2007, patients with gastric adenocarcinoma were selected for open or laparoscopic resection at the discretion of the surgeon. Gastric resections for gastrointestinal stromal tumour (GIST) or benign disease were excluded. Laparoscopic gastrectomy was performed entirely laparoscopically with intracorporeal anastomosis, followed by specimen retrieval via a suprapubic incision.

RESULTS

There were 21 men and 8 women, median age 75 years (range 45-88 years), with American Anaesthesiology Association scores of 3 or 4 in 19 patients. Gastrectomy was performed laparoscopically in 18 patients (62%; total gastrectomy, 6 patients) or open in 11 patients (total gastrectomy, 7). Five laparoscopic gastrectomies were converted to open procedures, three patients had re-laparoscopy and one patient had subsequent laparotomy. As compared with open gastrectomy, laparoscopic resection had longer operation time and similar length of hospital stay. There was one postoperative mortality in each group. There was similar lymph node retrieval for laparoscopic or open resection [23 (range 10-44) versus 26 (8-95), respectively; p = 0.40], with inadequate lymphadenectomy (<15 nodes) in two laparoscopic cases and one open case. R1 resection was limited to patients with pT3 disease (laparoscopic, 4; open, 2).

CONCLUSIONS

Perioperative outcomes were similar for laparoscopic or open gastrectomy. Lymphadenectomy was adequate in 89% of laparoscopic gastrectomies. pT3 tumours were at risk of noncurative resection, as described in large Western series of open gastrectomy.

Effect of obesity on technical feasibility and postoperative outcomes of laparoscopy-assisted distal gastrectomy--comparison with open distal gastrectomy

OBJECTIVE

The aim of this study was to compare outcomes between laparoscopy-assisted distal gastrectomy (LADG) and open distal gastrectomy (ODG) in obese and non-obese patients.

METHODS

Subjects comprised 248 consecutive patients who underwent distal gastrectomy for gastric cancer between January 1999 and December 2005. Patients with body mass index (BMI) > or = 25 kg/m2 were defined as obese, and patients with BMI < 25 kg/m2 were defined as non-obese. Parameters analyzed included patients characteristics, tumor characteristics, operative details, postoperative outcomes, and prognosis.

RESULTS

For LADG, 35 patients were considered obese, and 106 patients were non-obese. For ODG, 25 patients were considered obese, and 82 patients were non-obese. Mean operative times in each procedure were significantly longer for the obese group than for the non-obese group (ODG: 241.4 min vs. 199.5 min, p < 0.0001; LADG: 279.6 min vs. 255.3 min, p = 0.03). Blood loss was significantly higher for the obese group than for the non-obese group in ODG (300 ml vs. 400 ml, p = 0.024), but no significant differences were observed between obese and non-obese groups for LADG. Incidence of major postoperative complications, number of retrieved lymph nodes, and disease-free survival rates were similar in obese and non-obese groups for each procedure.

CONCLUSIONS

Our analysis revealed that LADG can be safely performed in obese patients, with complication rates and operation outcomes similar to those for non-obese patients.

Obesity Does Not Increase Complications After Anatomic Resection for Non-Small Cell Lung Cancer

BACKGROUND

The effect of obesity on complications after resection for lung cancer is unknown. We hypothesized that obesity is associated with increased complications after anatomic resections for non-small cell lung cancer.

METHODS

A review of our prospective general thoracic database identified 499 consecutive anatomic resections for non-small cell lung cancer from November 2002 to May 2006. Body mass index (BMI) was used to group patients as nonobese (BMI > 18.5 to < 30) and obese (BMI > or = 30). Patient characteristics and oncologic and operative variables were compared between groups. Multivariable logistic regression models were fit with BMI included at every level. Outcomes examined included in-hospital morbidity, mortality, length of stay, and readmission.

RESULTS

Seventy-five percent (372 of 499) were nonobese, and 25% (127 of 499) were obese. Preoperative variables were similar, except for a greater incidence of diabetes mellitus (p < 0.0001) in the obese group. Overall mortality was 1.4% (7 of 499) and was not different between groups (p = 0.85). Thirty-day readmission rates (p = 0.76) and length of stay (p = 0.30) were similar. Obese patients had a higher incidence of acute renal failure (p = 0.001). A complication occurred in 33% (124 of 372) of nonobese and 31% (39 of 127) of obese patients (p = 0.59). Respiratory complications occurred in 22% (81 of 372) of nonobese and 14% (18 of 127) of obese patients (p = 0.06). Significant predictors of any complication include performance status, diffusing capacity, and tumor stage. Significant predictors of respiratory complications include performance status, diffusing capacity, chronic renal insufficiency, prior thoracic surgery, and chest wall resection.

CONCLUSIONS

In contrast to our hypothesis, obesity does not increase the incidence of perioperative complications, mortality, or length of stay after anatomic resection for non-small cell lung cancer.