Laparoscopic gastrectomy for remnant gastric cancer: a comprehensive review and case series

Current status of evaluation and treatment of early-stage remnant gastric cancer

Because of early diagnosis and improved prognosis, patients with gastric cancer are now surviving longer and remnant gastric cancer after gastrectomy is becoming more common. Remnant gastric cancer is traditionally considered a malignancy with a dismal outcome. However, recent advances in diagnostic and therapeutic strategies have improved outcomes. In recent years, the development of endoscopic therapy has provided us with new therapeutic ideas. Although with some drawbacks, such as limited working space, gastric fibrosis and staples under the suture line, endoscopic management is still an effective treatment option with potential long-term survival advantage. For gastrectomy patients, endoscopic surveillance should also be recommended, for prompt surveillance and detection in the early remnant gastric cancer. This review aims to provide an overview of remnant gastric cancer, especially focusing on its pathogenesis as well as new advances in the diagnosis and endoscopic treatment of early-stage remnant gastric cancer.

Management challenges and the role of adjuvant chemotherapy in remnant gastric cancer: an analysis of 313 patients from the KEGG multicenter observational study

BACKGROUND

Clinical findings and postoperative follow-up data on remnant gastric cancer (RGC) are limited due to its rarity. Additionally, the preoperative staging, radical surgery, and managing recurrence in RGC present significant clinical challenges.

METHODS

We analyzed the clinicopathological findings, adjuvant chemotherapy, and patterns of postoperative recurrence of 313 consecutive patients who underwent curative surgery for RGC at 17 Japanese institutions. This study investigated the optimal management of RGC and the impact of adjuvant chemotherapy (AC) on recurrence-free survival (RFS).

RESULTS

Pathological stages I, II, and III were observed in 55.9% (N = 175), 24.9% (N = 78), and 19.2% (N = 60) of the patients, respectively. The overall concordance rate between clinical and pathological T staging was 58.3%, with a clinical T4 sensitivity of 41.4% for diagnosing pathological T4. During the median follow-up period of 4.6 years, disease recurrence occurred in 24.3% of patients. Most recurrences (over 80%) occurred within 2.5 years, and 96.1% within 5 years after RGC surgery. Peritoneal recurrence was the most common in patients with advanced RGC, accounting for 14.1% in stage II and 28.3% in stage III. Multivariable regression analysis showed that AC was significantly associated with a longer RFS, with a hazard ratio of 0.45 (95% confidence interval: 0.26-0.76).

CONCLUSIONS

Our study underscores the importance of early detection, accurate preoperative staging, and postoperative surveillance in managing advanced RGC cases. Despite some limitations, our findings indicate that AC may provide survival benefits comparable to those seen in primary gastric cancer.

The safety, feasibility, and oncological outcomes of laparoscopic completion total gastrectomy for remnant gastric cancer: a prospective study with 3-year follow-up (FUGES-004 study)

BACKGROUND

The efficacy of laparoscopic completion total gastrectomy (LCTG) for remnant gastric cancer (RGC) remains controversial.

METHODS

The primary outcome was postoperative morbidity within 30 days after surgery. Secondary outcomes included 3-year disease-free survival (DFS), 3-year overall survival (OS), and recurrence. Inverse probability treatment weighted (IPTW) was used to balance the baseline between LCTG and OCTG.

RESULTS

Final analysis included 46 patients with RGC who underwent LCTG at the FJMUUH between June 2016 and June 2020. The historical control group comprised of 160 patients who underwent open completion total gastrectomy (OCTG) in the six tertiary teaching hospitals from CRGC-01 study. After IPTW, no significant difference was observed between the LCTG and OCTG groups in terms of incidence (LCTG vs. OCTG: 28.0 vs. 35.0%, P =0.379) or severity of complications within 30 days after surgery. Compared with OCTG, LCTG resulted in better short-term outcomes and faster postoperative recovery. However, the textbook outcome rate was comparable between the two groups (45.9 vs. 32.8%, P =0.107). Additionally, the 3-year DFS and 3-year OS of LCTG were comparable to those of OCTG (DFS: log-rank P =0.173; OS: log-rank P =0.319). No significant differences in recurrence type, mean recurrence time, or 3-year cumulative hazard of recurrence were observed between the two groups (all P >0.05). Subgroup analyses and concurrent comparisons demonstrated similar trends.

CONCLUSIONS

This prospective study suggested that LCTG was noninferior to OCTG in both short-term and long-term outcomes. In experienced centers, LCTG may be considered as a viable treatment option for RGC.

Safe and Accurate Laparoscopic Total Gastrectomy for Remnant Gastric Cancer With Severe Adhesions Using Indocyanine Green Fluorescence Imaging: Guidance in Detection of the Accurate Dissection Layer to Avoid Organ Injury

Laparoscopic total gastrectomy (LTG) for remnant gastric cancer (RGC) requires advanced techniques due to severe postoperative adhesions and anatomic changes. We performed LTG in 2 patients with RGC using intraoperative indocyanine green (ICG) fluorescence imaging. Both cases previously underwent distal gastrectomy with Billroth-I reconstruction for gastric cancer and were subsequently diagnosed with early-stage gastric cancer of the remnant stomach. Indocyanine green (2.5 mg/body) was administered intravenously during surgery. The liver and common bile duct were clearly visualized during surgery using near-infrared fluorescence laparoscopy, and the adhesions between the hepatobiliary organs and remnant stomach were safely dissected. Laparoscopic total gastrectomy was successfully performed without complications, and the postoperative course was uneventful in both cases. Intraoperative real-time ICG fluorescence imaging allows clear visualization of the liver and common bile duct and can be useful in LTG for RGC with severe adhesions.

Deep learning model for predicting postoperative survival of patients with gastric cancer

Background

Prognostic prediction for surgical treatment of gastric cancer remains valuable in clinical practice. This study aimed to develop survival models for postoperative gastric cancer patients.

Methods

Eleven thousand seventy-five patients from the Surveillance, Epidemiology, and End Results (SEER) database were included, and 122 patients from the Chinese database were used for external validation. The training cohort was created to create three separate models, including Cox regression, RSF, and DeepSurv, using data from the SEER database split into training and test cohorts with a 7:3 ratio. Test cohort was used to evaluate model performance using c-index, Brier scores, calibration, and the area under the curve (AUC). The new risk stratification based on the best model will be compared with the AJCC stage on the test and Chinese cohorts using decision curve analysis (DCA), the net reclassification index (NRI), and integrated discrimination improvement (IDI).

Results

It was discovered that the DeepSurv model predicted postoperative gastric cancer patients' overall survival (OS) with a c-index of 0.787; the area under the curve reached 0.781, 0.798, 0.868 at 1-, 3- and 5- years, respectively; the Brier score was below 0.25 at different time points; showing an advantage over the Cox and RSF models. The results are also validated in the China cohort. The calibration plots demonstrated good agreement between the DeepSurv model's forecast and actual results. The NRI values (test cohort: 0.399, 0.288, 0.267 for 1-, 3- and 5-year OS prediction; China cohort:0.399, 0.288 for 1- and 3-year OS prediction) and IDI (test cohort: 0.188, 0.169, 0.157 for 1-, 3- and 5-year OS prediction; China cohort: 0.189, 0.169 for 1- and 3-year OS prediction) indicated that the risk score stratification performed significantly better than the AJCC staging alone (P < 0.05). DCA showed that the risk score stratification was clinically useful and had better discriminative ability than the AJCC staging. Finally, an interactive native web-based prediction tool was constructed for the survival prediction of patients with postoperative gastric cancer.

Conclusion

In this study, a high-performance prediction model for the postoperative prognosis of gastric cancer was developed using DeepSurv, which offers essential benefits for risk stratification and prognosis prediction for each patient.

Laparoscopic gastrectomy for remnant gastric cancer: A single-center retrospective study

BACKGROUND

Laparoscopic gastrectomy (LG) for remnant gastric cancer (RGC) remains controversial because of its rarity and heterogeneity of clinical characteristics. Based on our experience, we posited that our established methodology in LG could be applied to the laparoscopic procedure for RGC surgery and introduced LG for RGC at our institution in 2004.

METHODS

This study enrolled 46 patients who underwent LG for RGC between January 2004 and December 2017. Data were obtained through a review of our prospectively maintained database. Laparoscopic total gastrectomy (LTG) was the standard surgical procedure for RGC. Laparoscopic subtotal gastrectomy (LsTG) was performed as an alternative procedure for patients with RGC located near the anastomotic site after primary gastrectomy. The technical and oncological feasibility and safety of LG for RGC were evaluated.

RESULTS

LTG for RGC was performed on 36 patients. LsTG for RGC was performed on 10 patients. All patients completed LG procedure and succeeded R0 resection. Complications of Clavien-Dindo classification grade ≥ IIIa occurred in 4 (8.7%) patients. The retrospective video reviews showed that the time for adhesiotomy around the suprapancreatic area and the lesser curvature of the remnant stomach was significantly shorter in the primary-benign group than in the primary-malignant group. With the median follow-up period of 40 months, the 3-year recurrence-free survival and 3-year overall survival rates were 72.3% and 80.2%, respectively.

CONCLUSION

LG for RGC represents a safe and feasible surgical option with favorable short-term and long-term outcomes in patients with RGC.

The Effect of Surgical Approach on Clinical Outcomes in 535 Patients with Remnant Gastric Cancer

Purpose: This study aimed to evaluate the effect of laparoscopic gastrectomy (LG) and open gastrectomy (OG) on clinical outcomes in patients with remnant gastric cancer (RGC). Materials and Methods: The databases of PubMed, EMBASE, and Cochrane Library were used to search for eligible studies from inception to April 1st, 2023. Hazard ratios (HRs), mean difference (MD), odds ratios (OR), and 95% confidence intervals (CIs) were pooled up to analyze. The Newcastle-Ottawa Scale (NOS) scores were used to evaluate the quality of the included studies. This study was performed with RevMan 5.3 (The Cochrane Collaboration, London, United Kingdom) software. Results: A total of 11 studies involving 535 RGC patients were included in this study. In terms of basic information, we found that the OG group had a higher American Society of Anesthesiologists (ASA) grade (≥2) (OR = 0.24, I2 = 54%, 95% CI = 0.08-0.71, P = .01) than the LG group. In terms of postoperative outcomes, we found that the LG group had longer operative time (MD = 33.95, I2 = 58%, 95% CI = 15.05-52.85, P < .01), shorter postoperative hospital stay (MD = 5.08, I2 = 84%, 95% CI = -9.74 to -0.42, P = .03), shorter length of incision (MD = -7.15, I2 = 94%, 95% CI = -10.99 to -3.31, P < .01), earlier food intake (MD = -3.09, I2 = 76%, 95% CI = -4.84 to -1.35, P < .01), and earlier time to first flatus (MD = -0.84, I2 = 0%, 95% CI = -1.09 to -0.59, P < .01). We found that there was no statistically significant difference in overall survival (HR = 0.96, I2 = 0%, 95% CI = 0.48-1.93, P = .92) between the LG group and the OG group. Conclusion: LG for RGC patients had longer surgical time, shorter postoperative hospital stay, shorter length of incision, earlier food intake, and earlier time to first flatus.

Appraisal of gastric stump carcinoma and current state of affairs

Gastric stump carcinoma, also known as remnant gastric carcinoma, is a malignancy arising in the remnant stomach following gastrectomy for a benign or malignant condition. Enterogastric reflux and preexisting risk factors in a patient with gastric cancer are the major contributors to the development of gastric stump carcinoma. The occurrence of gastric stump carcinoma is time-dependent and seen earlier in patients operated on for malignant rather than benign diseases. The tumor location is predominantly at the anastomotic site towards the stomach. However, it can occur anywhere in the remnant stomach. The pattern of lymph node involvement and the type of surgery required is distinctly different compared to primary gastric cancer. Gastric stump carcinoma is traditionally considered a malignancy with a dismal outcome. However, recent advances in diagnostic and therapeutic strategies have improved outcomes. Recent advances in molecular profiling of gastric stump carcinoma have identified distinct molecular subtypes, thereby providing novel therapeutic targets. Also, reports of gastric stump carcinoma following pancreatoduodenectomy and bariatric surgery highlight the need for more research to standardize the diagnosis, staging, and treatment of these tumors. The present review aims to provide an overview of gastric stump carcinoma highlighting the differences in clinicopathological profile and management compared to primary gastric carcinoma.

Comparison of Minimally Invasive Surgery with Open Surgery for Remnant Gastric Cancer: A Multi-institutional Cohort Study

BACKGROUND

Despite growing evidence of the effectiveness of minimally invasive surgery (MIS) for primary gastric cancer, MIS for remnant gastric cancer (RGC) remains controversial due to the rarity of the disease. This study aimed to evaluate the surgical and oncological outcomes of MIS for radical resection of RGC.

PATIENTS AND METHODS

Patients with RGC who underwent surgery between 2005 and 2020 at 17 institutions were included, and a propensity score matching analysis was performed to compare the short- and long-term outcomes of MIS with open surgery.

RESULTS

A total of 327 patients were included in this study and 186 patients were analyzed after matching. The risk ratios for overall and severe complications were 0.76 [95% confidence interval (CI): 0.45, 1.27] and 0.65 (95% CI: 0.32, 1.29), respectively. The MIS group had significantly less blood loss [mean difference (MD), -409 mL; 95% CI: -538, -281] and a shorter hospital stay (MD, -6.5 days; 95% CI: -13.1, 0.1) than the open surgery group. The median follow-up duration of this cohort was 4.6 years, and the 3-year overall survival were 77.9% and 76.2% in the MIS and open surgery groups, respectively [hazard ratio (HR), 0.78; 95% CI: 0.45, 1.36]. The 3-year relapse-free survival were 71.9% and 62.2% in the MIS and open surgery groups, respectively (HR, 0.71; 95% CI: 0.44, 1.16).

CONCLUSIONS

MIS for RGC showed favorable short- and long-term outcomes compared to open surgery. MIS is a promising option for radical surgery for RGC.

Robotic total gastrectomy for carcinoma in the remnant stomach: a comparison with laparoscopic total gastrectomy

Background

Total gastrectomy for carcinoma in the remnant stomach (CRS) remains a technically demanding procedure. Whether robotic surgery is superior, equal, or inferior to laparoscopic surgery in patients with CRS is unclear. This study was designed to compare the efficacy and safety of robotic total gastrectomy (RTG) and laparoscopic total gastrectomy (LTG) for the treatment of CRS.

Methods

In this cohort study, we retrospectively analysed the data from patients who underwent RTG or LTG for CRS at Southwest Hospital (Chongqing, China) between May 2006 and October 2019. The surgical outcomes, post-operative complications, and survival outcomes between the two groups were compared.

Results

Compared with LTG, RTG was associated with similar effective operation time (272.0 vs 297.9 min, P = 0.170), higher total costs (105,967.2 vs 81,629.5 RMB, P < 0.001), and less estimated blood loss (229.2 vs 288.8 mL, P = 0.031). No significant differences were found between the robotic and laparoscopic groups in terms of conversion rate, time to first flatus, time to first soft diet, post-operative hospital stay, post-operative complications, R0 resection rate, and number of retrieved lymph nodes (all P > 0.05). The 3-year disease-free survival and 3-year overall survival rates were comparable between the two groups (65.5% vs 57.5%, P = 0.918; 69.0% vs 60.0%, P = 0.850, respectively).

Conclusions

RTG is a safe and feasible procedure for the treatment of CRS and could serve as an optimal treatment for CRS.

Laparoscopic Completion Total Gastrectomy for Remnant Gastric Cancer

Background: Remnant gastric cancer (RGC) is increasing due to past use of subtotal gastrectomy to treat benign diseases, improvements in the detection of gastric cancer, and increased survival rates after gastrectomy for gastric cancer. Laparoscopic access provides the advantages and benefits of minimally invasive surgery. However, laparoscopic completion total gastrectomy (LCTG) for RGC is technically demanding, even for experienced surgeons. Because of its rarity and heterogeneity, no standard surgical strategy has been established and few surgeons will develop technical expertise to carry out this procedure. Aim: To describe our standard technique, giving surgeons a head start in LCTG and report the early experience with this stepwise approach. Materials and Methods: We detail all the steps involved in the procedure, including trocar placement and surgical description. Results: Between 2009 and 2019, a total of 8 patients with past history of RGC were operated with this technique. All patients had been previously operated by open method, 7 due to peptic ulcer disease and 1 due to gastric cancer. Their mean age at the time of the first surgery was 38.9 years (range 25-56 years) and the mean interval between the first and the second gastrectomy was 32.1 years (range 13.6-49). Billroth II was the previous reconstruction in all cases. A 5-trocar technique was used followed by total gastrectomy with side-to-side stapled intracorporeal esophagojejunostomy anastomosis and Roux-en-Y reconstruction. The mean operation time was 272 minutes (range 180-330) and median blood loss was 247 mL (range 50-500). There was no conversion and no major intraoperative complication. Major postoperative complications occurred in 3 patients. Conclusion: Completion total gastrectomy for RGC is a morbid procedure and laparoscopic access is technically feasible, hopefully carrying the benefits of faster recovery, reduced postoperative pain, and wound complications. By standardizing the approach, the learning curve may be shortened and better results achieved.

Laparoscopic Completion Total Gastrectomy as a Standardized Procedure for Gastric Stump Cancer: A Case Control Study

Objective

Complete gastrectomy for gastric stump cancer (GSC) can be challenging due to severe adhesions; therefore, advanced techniques are required when being performed by laparoscopic surgery. This study aimed to evaluate the clinical outcomes of laparoscopic completion total gastrectomy (LCTG) for the treatment of GSC.

Methods

Patient records from January 2010 to October 2018 were retrospectively evaluated. The patients were classified into 2 groups depending on whether they underwent open or laparoscopic gastrectomy. We compared patient characteristics; operative, clinical, and pathological data between the groups.

Results

Twenty open and 17 LCTGs were performed. Laparoscopic gastrectomy resulted in a significantly longer operation time (230 versus 182.5 min; P = 0.026), lower blood loss (14 versus 105 mL; P &lt; 0.001), and shorter period to the first flatus passage (2 versus 3 days; P &lt; 0.001) than open gastrectomy. No significant differences in the number of retrieved lymph nodes, duration of hospital stay, complication rate, and postoperative analgesic usage between the 2 groups were observed. No patients required conversion to open surgery in the laparoscopic-treatment group. Pathologic findings revealed that the laparoscopic group had a smaller tumor size (not pathologic T category) and fewer metastatic lymph nodes than the open group, leading to an earlier distribution of the pathologic stage in the laparoscopic group.

Conclusions

LCTG for the treatment of GSC was safely conducted with fewer complications and mortalities than previously reported results. Advanced technologies and sophistication of laparoscopic skills may further yield minimal invasiveness with better short-term outcome.

Safety and feasibility of laparoscopic gastrectomy for remnant gastric cancer compared with open gastrectomy: Single-center experience

The usefulness, safety and oncological validity of laparoscopic gastrectomy (LG) for remnant gastric cancer (RGC) have not been widely reported.A total of 38 patients who underwent gastrectomy for RGC were enrolled at Wakayama Medical University Hospital between April 2008 and December 2018. All consecutive patients were included in this retrospective study; the patients were divided into the open gastrectomy group and the laparoscopic group according to the sequential nature of their operation. Fifteen patients underwent open gastrectomy for RGC (OGR) between April 2008 and December 2013, and 23 patients underwent LG for RGC (LGR) after 2014.In the OGR group, all initial operations were performed by open surgery, whereas in the LGR group, 11 patients (47%) initially underwent laparoscopic surgery and 12 patients (53%) initially underwent open surgery (P = .002), 3 patients of which (25%) converted to open gastrectomy. There was no significant difference in the number of lymph node dissections or in operative time between the 2 groups, but blood loss was significantly lower in the LGR group than that in the OGR group (P = .002). Furthermore, although there was no difference between the 2 groups in C-reactive protein value on postoperative day 1, C-reactive protein value on postoperative day 3 was significantly lower in the LGR group than in the OGR group (P = .012). There were no differences in postoperative complications or long-term outcomes, including recurrence-free survival and overall survival.LGy is suitable in cases in which the initial surgery is performed by laparoscopic surgery. Even if the initial surgery is open surgery, it is oncologically equivalent to open gastrectomy and can be performed safely with less blood loss.

Laparoscopic approach to early gastric cancer in a patient with a prior history of open right hepatectomy: a case report

Background

Laparoscopic gastrectomy is regarded a standard treatment procedure for early gastric cancer and is widely used in clinical practice. However, the feasibility of laparoscopic gastrectomy for patients with a prior history of open surgery, especially in the case of a complicated operation, remains unclear. Here, we report a laparoscopic gastrectomy case with a prior history of right hepatectomy.

Case presentation

A 70-year-old man was diagnosed with early gastric cancers preceding a right hepatectomy for a solitary hepatocellular carcinoma at risk of rupture. An additional gastrectomy, after non-curative endoscopic submucosal dissection, was planned after the hepatectomy. Extensive adhesions were found around the liver. Rigid adherence of the duodenum to the adjacent hepatoduodenal ligament had formed. In addition, identification of the hepatic artery was difficult due to stiffening of the mesentery. Peeling off the adhesions from the ventral side of the duodenum revealed the supra-pyloric vessels and enabled us to transect the duodenum safely. Further, exposing the proper hepatic artery via the dorsal side of the mesentery and subsequent supra-pancreatic dissection on the outermost layer allowed effective identification of the right gastric artery. The postoperative course was uneventful.

Conclusions

We successfully performed total laparoscopic distal gastrectomy on a patient with a prior history of major hepatectomy.

Current controversies in treating remnant gastric cancer: Are minimally invasive approaches feasible?

The incidence of remnant gastric cancer (RGC) is still increasing. Minimally invasive approaches including endoscopic resection, laparoscopic and robotic approaches, and function-preserving gastrectomy have been utilized as curative treatment methods for primary gastric cancer. However, adhesions and anatomical alterations due to previous gastrectomy make the use of minimally invasive approaches complicated and difficult for RGC. Application of these approaches for the treatment of RGC is still controversial. Endoscopic submucosal dissection is a favorable alternative therapy for the resection of early gastric cancer that occurs in the remnant stomach and can prevent unnecessary complications. The majority of retrospective studies have shown that endoscopic submucosal dissection is an effective and oncologically safe treatment modality for RGC. Subtotal gastrectomy could serve as a function-preserving gastrectomy for patients with early RGC and improve postoperative late-phase function. However, there are only two studies that demonstrate the feasibility and oncological efficacy of subtotal gastrectomy for RGC. The non-randomized controlled trials showed that compared to open gastrectomy, laparoscopic gastrectomy for RGC led to better short-term outcomes and similar oncologic results. Because of the rarity of RGC, future multicenter studies are required to determine the indications of minimally invasive treatment for RGC.

Laparoscopic completion gastrectomy in elderly patients with remnant gastric cancer: a case series

Background

Open completion gastrectomy (OCG) has been selected to treat remnant gastric cancer (RGC) due to severe adhesions and difficulty recognizing anatomical orientation after primary gastrectomy. In general, elderly individuals’ physiological reserves gradually decrease. Moreover, elderly patients (EPs) often have multiple complicating factors (i.e., frailty and comorbidities), leading to more postoperative complications after abdominal surgery. Recently, several trials revealed the advantages of laparoscopic surgery for EPs with gastric cancer in early recovery. However, there are limited studies investigating the use of laparoscopic completion gastrectomy (LCG) for RGC in EPs. This study aims to assess the efficacy of LCG in EPs aged ≥ 70 years. We compared the short- and long-term outcomes of LCG with those of OCG.

Case presentation

Twenty-one EPs who underwent completion gastrectomy for RGC between 2007 and 2017 were enrolled and classified into two groups according to the surgical approach, namely the LCG (n = 6) and OCG (n = 15) groups. We adopted the G8 geriatric screening tool to comprehensively evaluate the EPs’ physical, mental, and social functions. Patient characteristics, clinicopathological characteristics, surgical outcomes, and survival were retrospectively reviewed and compared between groups.

Results

There was no significant difference in the preoperative modified G8, indicating that the EPs’ backgrounds between the groups were comparable. Of note, blood loss during surgery was significantly reduced in the LCG group [median (range); LCG, 50 ml (20.0–65.0); OCG, 465 ml (264.5–714.0); p = 0.002]. The median number of retrieved lymph nodes in the LCG and OCG groups were 7 (range 4–10) versus 3 (range 1–6), respectively. There were no statistically significant differences in postoperative hospitalization, intake of solid food, and Clavien–Dindo grade ≥ II postoperative complications. In patients with a history of gastrectomy for gastric cancer in the LCG group, operative time tended to be longer in patients who underwent D2 lymph node dissection as primary surgery.

Conclusions

LCG was comparable to OCG for the treatment of RGC in EPs with significantly reduced blood loss. While LCG should be selected with caution in patients who have undergone D2 lymph node dissection as primary surgery, it could be considered as a surgical procedure in EPs with RGC.

Is Laparoscopic Approach Also Safe for the Treatment of Remnant Gastric Cancer?

The most important advantages of laparoscopic gastrectomy are the minimal invasiveness, including less postoperative pain, shorter recovery, and minimal complications. A laparoscopic distal gastrectomy is accepted widely as a standard treatment for gastric cancer. On the other hand, a laparoscopic total gastrectomy has not been popularized as a distal gastrectomy because of the complexity of a lymph node dissection and the diversity of reconstruction. In terms of laparoscopic surgery for a remnant gastrectomy, there are three key points, which are critical for safe operation: adequate lymph node dissection, meticulous adhesiolysis, and reconstruction. After radical surgery for gastric cancer, the intra-abdominal condition is greatly changed. In addition, the lymphatic anatomy around the stomach is broken and surgeons should be aware of a newly developed lymphatic system to perform adequate node dissection. An esophago-jejunal reconstruction is at risk of leakage. Until evidence that is more concrete can be obtained, experienced surgeons should consider the laparoscopic approach.

Short-term clinical outcomes of laparoscopic gastrectomy for remnant gastric cancer: A single-institution experience and systematic review of the literature

AIM

Application of laparoscopic approaches for the treatment of remnant gastric cancers (RGC) is still controversial. Therefore, in the present study, the safety and effectiveness of laparoscopic gastrectomy (LG) for RGC was investigated.

METHODS

A total of 27 patients who underwent gastrectomy for RGC from June 2008 to September 2017 were enrolled in this study. A comprehensive review of the literature on LG for RGC published before December 2017 using the PubMed database was carried out.

RESULTS

Laparoscopic gastrectomy was carried out in seven patients, and open gastrectomy (OG) was done in the remaining 20 patients. LG was associated with significantly less intraoperative blood loss (70 ± 71 vs. 1066 ± 1428 g; P < 0.001), significantly more retrieved lymph nodes (22 ± 13 vs. 12 ± 9; P = 0.03), a relatively lower postoperative complication rate, and a relatively shorter postoperative hospital stay than OG. A comprehensive review of the literature showed that LG for RGC was more likely to correlate with longer operative time, less blood loss, lower postoperative complication rate, shorter postoperative hospital stay, and more retrieved lymph nodes than OG.

CONCLUSION

The clinical outcome of our patients with RGC and the literature indicated that a laparoscopic approach contributed to faster recovery after surgery than an open approach without sacrificing its radicality and was a safe and secure treatment option for RGC.

Transverse colon stenosis following laparoscopic total gastrectomy for gastric remnant carcinoma

Laparoscopic surgery for remnant gastric cancer has been reported in a limited number of cases, and data on post-operative complications are lacking. A 58-year-old male was admitted with remnant gastric cancer. He had undergone open subtotal gastrectomy 9 years ago for gastric cancer. Laparoscopic total gastrectomy was performed, and he was discharged on the 10^th day uneventfully. The patient had complained of nausea and vomiting in the 2^nd post-operative month. He clinically and radiologically diagnosed as ileus and required open emergency surgery. There was a transverse colon stenosis near the splenic flexure. Hartmann's procedure was done, and he was discharged on day 17. We have limited knowledge about colonic complications after laparoscopic gastric surgery. The development of stenosis in the transverse colon is one of these complications that should be kept in mind. As far as we know, such a complication has never been reported before.

Laparoscopic total gastrectomy for remnant gastric cancer: A single-institution experience

INTRODUCTION

The incidence of remnant gastric cancer is increasing because of past use of subtotal gastrectomy to treat peptic ulcer and increased survival rates after radical gastrectomy for gastric cancer. The feasibility and advantages of laparoscopic total gastrectomy (LTG) for remnant gastric cancer remain unclear. Therefore, we aimed to investigate the safety, feasibility, and clinical short-term outcomes of LTG for remnant gastric cancer.

METHODS

Patients who underwent completion total gastrectomy for remnant gastric cancer between April 2007 and October 2017 were divided into two groups: the open total gastrectomy (OTG) group and the LTG group. Clinicopathological data and short-term outcomes were analyzed.

RESULTS

A total of 31 remnant gastrectomies (23 OTG, 8 LTG) were performed. Blood loss was significantly lower in the LTG group than in the OTG group (135.5 vs 568.3 mL, P = 0.013). However, there was no significant difference in the operation time, days to food intake, or length of hospital stay between the two groups. Additionally, there was no significant difference in the postoperative complications, number of retrieved lymph nodes, or pathological findings. Two LTG patients (25.0%) required conversion to open surgery. There was no mortality in either group.

CONCLUSIONS

LTG for remnant gastric cancer can be a safe treatment option and may have an advantage of less blood loss than OTG.

Laparoscopic gastrectomy for remnant gastric cancer: Risk factors associated with conversion and a systematic analysis of literature

BACKGROUND

In traditional opinion, history of abdominal surgery was the relative contraindication for Laparoscopic gastrectomy (LG) with high rate of conversion to Open gastrectomy (OG).Use of LG for treatment of remnant gastric cancer (RGC) has been documented in some case studies and controlled clinical trials. However, whether LG is superior, equal or inferior to OG in these patients is not clear.

METHODS

English language articles published between January 2005 and January 2016 were searched in MEDLINE, Embase and the Cochrane Database of Systematic Reviews. Main outcome measures were: conversion of LG to OG, operative time, intraoperative blood loss, tumor size, positive proximal resection margin, lymph node dissection, disease stage, post-operative resumption of oral intake, postoperative hospital stay, complications, mortality and follow-up findings. Published clinical data which was in the situation of conversion to OG was collected, and the factors associated with conversion to open surgery were examined.

RESULTS

Five non-randomized controlled trials and seven LG case studies were included in the systematic review. Meta-analysis of the data could not be performed due to high variation and heterogeneity in study design, study population, LG technique, and outcome measures among the included studies. Systematic analysis of the included studies showed that LG was associated with significantly shorter mean operative time, early resumption of oral intake, and shorter hospital stay, as compared to that with OG. No significant difference in complications was observed between the two groups.

CONCLUSION

LG in the hands of experienced surgeons is relative feasibility and safety for RGC. Previous surgical anastomosis, previous open surgery and surgical experience were associated with conversion to OG. However, these findings should be validated with robust prospective comparative studies.

Ubiquitin-Conjugating Enzyme E2T is an Independent Prognostic Factor and Promotes Gastric Cancer Progression

Ubiquitin-conjugating enzyme E2T (UBE2T) is a member of the E2 family that mediates the ubiquitin-proteasome system and regulates gene expression. It is a major oncogene in several cancers such as lung cancer and breast cancer, while the potential functions of UBE2T in gastric cancer (GC) remains largely unknown. Here, we identified the roles of UBE2T in GC progression and its potential to act as a prognostic marker of GC. Our data demonstrated that UBE2T was significantly upregulated in gastric cancer tissues, and the high expression of UBE2T was significantly correlated with poor differentiation, high T classification, and poor prognosis. In vitro experiments indicated that UBE2T promoted cell proliferation and inhibited cell cycle arrest. In addition, we observed that UBE2T modulated cell mobility by inducing epithelial-mesenchymal transition. Collectively, these findings suggest that UBE2T plays an important role in the tumorigenesis of gastric cancer and could act as a potential independent prognostic factor for cancer therapy.

A Case of Laparoscopic Resection for Carcinoma of the Gastric Remnant following Proximal Gastrectomy Reconstructed with Jejunal Interposition

A 72-year-old Japanese man had a history of proximal gastrectomy for early gastric cancer located in the upper third of the stomach in 2007. Our usual treatment strategy for early gastric cancer in the upper third of the stomach in 2007 was open proximal gastrectomy reconstructing by jejunal interposition with a 10 cm single loop. Upper gastrointestinal fiberscopy for annual follow-up revealed a type 0-IIc-shaped tumor with ulcer scar, 4.0 cm in size, located in the gastric remnant near the jejunogastrostomy. A clinical diagnosis of cancer of the gastric remnant, clinical T1b(SM)N0M0, Stage IA, following the proximal gastrectomy was made and a laparoscopic approach was selected because of the cancer's early stage. Remnant total gastrectomy with D1 plus lymphadenectomy was carried out with five ports by a pneumoperitoneal method. Complete resection of the reconstructed jejunum was undergone along with the jejunal mesentery. Reconstruction by the Roux-en-Y method via the antecolic route was selected. Total operative time was 395 min and blood loss was 40 mL. Our patient was the first successful case of resection for carcinoma of the gastric remnant following proximal gastrectomy reconstructed with jejunal interposition in a laparoscopic approach.

Current status in remnant gastric cancer after distal gastrectomy

Remnant gastric cancer (RGC) and gastric stump cancer after distal gastrectomy (DG) are recognized as the same clinical entity. In this review, the current knowledges as well as the non-settled issues of RGC are presented. Duodenogastric reflux and denervation of the gastric mucosa are considered as the two main factors responsible for the development of RGC after benign disease. On the other hand, some precancerous circumstances which already have existed at the time of initial surgery, such as atrophic gastritis and intestinal metaplasia, are the main factors associated with RGC after gastric cancer. Although eradication of Helicobacter pylori (H. pylori) in remnant stomach is promising, it is still uncertain whether it can reduce the risk of carcinogenesis. Periodic endoscopic surveillance after DG was reported useful in detecting RGC at an early stage, which offers a chance to undergo minimally invasive endoscopic treatment or laparoscopic surgery and leads to an improved prognosis in RGC patients. Future challenges may be expected to elucidate the benefit of eradication of H. pylori in the remnant stomach if it could reduce the risk for RGC, to build an optimal endoscopic surveillance strategy after DG by stratifying the risk for development of RGC, and to develop a specific staging system for RGC for the standardization of the treatment by prospecting the prognosis.