Morbidity and mortality of laparoscopy-assisted gastrectomy with extraperigastric lymph node dissection for gastric cancer

The effect and clinical significance of using nathanson liver retractor on liver function tests in laparoscopic gastric cancer surgery

ABSTRACT Aim: There are very few studies in the literature investigating the changes caused by the Nathanson retractors in liver function tests (LFT) after LG and its clinical significance. The present study investigated the changes made by the Nathanson retractor used during LG on LFT and its clinical significance. Material and Method: The data of 236 patients, who underwent radical gastrectomy for primary gastric cancer at Surgical Oncology Unit in the period between January 2015 and January 2020 were retrospective studied. The patients were divided into two groups: laparoscopic gastrectomy (LG; 136 cases) and open gastrectomy (OG; 106 cases). Patients who have undergone cholecystectomy, with primary or secondary liver tumors, with chronic hepatic disease, who have preoperative high ALT, AST and bilirubin values were excluded from the study. LFT were measured preoperatively and postoperative day 1 (LFT1), LFT3, LFT5 and LFT7. LFT: ALT, AST and Total bilirubin (BIL). Results: ALT1, ALT3, ALT5, ALT7 ALT values and AST1, AST3, AST5 AST values of the patients in the LG group were found to be significantly higher (P <0.001). Mean total bilirubin values of the groups were similar (P >0.05). In order to evaluate how the increase in LFT due to the use of the Nathanson retractors reflected on the patients' clinic, we divided the patients who underwent LG into two groups based on ALT increase in ALT1: Normal and Elevated. The in-hospital mortality rates (P = 0.080) and oral nutrition time (P = 0.913) of the groups were similar. No liver infarction developed in any of the groups. The duration of stay in the ICU was significantly longer in individuals with elevated LFT (P = 0.019). Conclusion: Although the use of the Nathanson retractor during LG causes an increase in liver function tests, this does not cause major clinical problems in patients. Key Words: Gastrectomy; gastric cancer; laparoscopy; liver enzymes; liver dysfunciton

The Impact of the COVID-19 Pandemic on Gastric Cancer Surgery: A Single-Center Study

Introduction: Coronavirus disease 2019 (COVID-19) was declared to be a global pandemic by the World Health Organization on March 11, 2020. The impact on gastric cancer (GC) surgery is unknown. Various reports have shown data indicating that cancer patients with COVID-19 have high morbidity and mortality rates. The choice of surgical procedures and perioperative management of the patients with malignancy has become even more impor¬tant in the COVID-19 pandemic. In this study, we aimed to evaluate the effects of the COVID-19 pandemic on the preopartive, intraoperative, and postoperative findings of patients operated for gastric cancer in our clinic. Materials and Methods: We defined the ‘COVID-19’ period as occurring between 12-03-2020 and 31-08-2020. All the enrolled patients were divided into two groups, pre-COVID-19 group (Pre-CG; 64 cases) and COVID-19 group (CG; 39 cases). A total of 103 patients with gastric cancer were included in this study. Patient characteristics, preoperative, intraoperative, and postoperative clinicopathological findings were compared between groups. Results: The waiting times before admission increased in CG (Pre-CG [6.73±2.85] vs CG [20.61±5.16] ; p<0.001). After admission, the waiting time before surgery was longer in CG (Pre-CG [5.06±3.06] vs CG [6.89±3.32] ; p=0.006). No significant difference was detected between the groups in terms of operation time, surgical procedure, combine organ resection, intraoperative blood transfusion requirment (p values, respectively; p=0.108; p=0.951; p=0.204; p=0.597). Postoperative complications were oesophagojejunostomy leak (3/1) , atelectasis (2/2), duodenal leak (2/2), ileus (3/0), pleural effusion (2/2), and others (1/1), and there was no statistically significant difference between the two groups (p = 0.333). There was no significant difference between the two groups in terms of hospital stay (p = 0.086) and ICU stay (p = 0.989). Conclusion: In this study, it was seen that the COVID-19 pandemic did not affect morbidity and mortality in gastric cancer surgery, but it prolonged admission waiting and operation waiting times. Since there is very little data in the literature regarding the effect of COVID-19 on gastric cancer surgery, our study will guide future studies on this subject. Keywords: COVID-19, Impact, Gastric Cancer, Pandemics, Surgery

Evaluation of Peroperative and Oncological Results in Laparoscopic Surgery of Gastric Cancer in Elderly Patients: Single-Center Study

Introduction: Laparoscopic treatment of gastric cancer in elderly patients is still controversial. The aim of this retrospective study is to evaluate the safety and feasibility of laparoscopic gastrectomy in elderly gastric cancer patients based on the long- and short-term results of laparoscopic surgery. Materials and Methods: The data of 163 patients who underwent laparoscopic gastrectomy for gastric cancer. Patients were categorized into two groups by age based on World Health Organization (WHO) criteria: elderly (≥65 years, 80 cases) and nonelderly (<65 years, 83 cases). Patient characteristics and clinicopathological findings, surgical findings, short- and long-term results were compared between the two groups. Results: The patients in the study group were in the age range of 22-87 years and 80 (49%) patients were found out to be 65 years old or older. When all complications were categorized according to Clavien-Dindo (C-D) classification, >3 serious complication rates were similar between groups (P = .421). Although the length of hospital stay and the need for intensive care were higher in the elderly group, the difference was not significant (P = .066; P = .072). There was no significant difference between the two in terms of in-hospital mortality (P = .364). No statistically significant differences were found in the rates of overall survival (nonelderly group; 61.17 ± 3.34, 95% confidence interval [CI]: 54.61-67.74 versus elderly group; 56.48 ± 3.80, 95% CI: 49.03-63.93; P = .176) and disease-specific survival (nonelderly group; 64.24 ± 3.15, 95% CI: 58.06-70.40 versus elderly group; 61.93 ± 3.57, 95% CI: 54.93-68.93; P = .363) between the age groups. Conclusion: In conclusion, although laparoscopic gastrectomy is a feasible and safe method in elderly gastric cancer patients, further randomized prospective studies are needed.

The safety and feasibility of laparoscopic gastrectomy for gastric cancer in very elderly patients: short-and long-term outcomes

PURPOSE

It remains unclear whether laparoscopic gastrectomy (LG) for gastric cancer is a suitable treatment for very elderly (VE) patients. We aimed to assess the safety and feasibility of LG for gastric cancer in VE patients.

METHODS

We reviewed 226 consecutive patients who underwent LG between January 2010 and December 2016. We compared VE patients (age ≥ 80, n = 38) with non-elderly patients (age ≤ 79, n = 188).

RESULTS

An ASA-PS score ≥ 2 was more common in VE group (86.8 vs. 48.9%; P < 0.01). There were no significant differences in the operating time, blood loss, postoperative hospital stay, or postoperative morbidity between the groups. The 3-year survival rate and 3-year disease-specific survival rate were lower in the VE group (53.7 vs. 85.6%; P < 0.0001, 78.5 vs. 92.4%; P = 0.0116). A univariate analysis showed that PS scores ≥ 2, Charlson comorbidity index ≥ 4, and pN stage were independent predictors of decreased overall survival rates in the VE group. A multivariate analysis showed total gastrectomy, a Charlson comorbidity index ≥ 4, and the pN stage to be independent predictors in the VE group.

CONCLUSION

LG for gastric cancer is, thus, considered to be safe for patients aged 80 years or older. Total gastrectomy, a Charlson comorbidity index ≥ 4, and the pN stage were independent risk factors for a poor prognosis in these patients.

Serum C-reactive protein level on first postoperative day can predict occurrence of postoperative pancreatic fistula after laparoscopic gastrectomy

Purpose : Postoperative pancreatic fistula (POPF) is a serious complication after gastrectomy for gastric cancer. The purpose of this study is to identify the risk factor of POPF and evaluate C-reactive protein on postoperative day 1 (POD1) as the predictor for POPF after laparoscopic gastrectomy (LG). Methods : Between May 2013 and September 2016, 226 patients who underwent LG for gastric cancer were investigated. Patients were divided into 2 groups; POPF group (n = 17) and control group (n = 209). Clinicopathological factors were compared between 2 groups. Results : In POPF group, there are more male patients (p = 0.003) compared with control group. Preoperative factors, such as age, BMI, and prevalence of previous operation and comorbidity showed no significant difference between 2 groups. Regarding tumor factors and perioperative data such as blood loss and operative time, there were also no significant difference between 2 groups. POPF group showed longer postoperative hospital stay, and higher serum CRP level on POD1 (p < 0.0001). Multivariate analysis revealed that high CRP level on POD1 ( ≥ 3mg/dl) was independent risk factor of POPF. Conclusions : High serum CRP level on POD1 can predict the occurrence of POPF. J. Med. Invest. 66 : 285-288, August, 2019.

Serum level of C-reactive protein on postoperative day 3 is a predictive indicator of postoperative pancreatic fistula after laparoscopic gastrectomy for gastric cancer

INTRODUCTION

Postoperative pancreatic fistula (POPF) is a serious complication after gastrectomy for gastric cancer. It is vitally important to detect signs of POPF in the early postoperative period and perform adequate management to avoid patient death. The aim of this study was to investigate the predictive indicators of POPF after laparoscopic gastrectomy for gastric cancer.

METHODS

The current study included 197 patients who were pathologically diagnosed with adenocarcinoma and underwent laparoscopic gastrectomy between January 2010 and December 2014 in our hospital.

RESULT

Nine patients (5.6%) developed POPF of grade III or higher according to the Clavien-Dindo classification. There was no statistical difference between POPF and various clinicopathological indicators, including age, gender, BMI, extent of lymph node dissection, and operative procedure. With respect to postoperative laboratory data, however, the serum level of C-reactive protein on postoperative day 3 was significantly related to the development of POPF. Receiver-operating characteristic analysis indicated that optimal cut-off value of the serum level of C-reactive protein on postoperative day 3 was 17.0 mg/dL, with a sensitivity of 74.0, specificity of 88.0, positive predictive value of 0.14, and negative predictive value of 0.99.

CONCLUSION

An elevated C-reactive protein level on postoperative day 3 can help physicians predict the likelihood of POPF and facilitate decision making regarding prompt clinical evaluation and therapeutic approaches for POPF.

Impact of obesity on short- and long-term outcomes of laparoscopy assisted distal gastrectomy for gastric cancer

BACKGROUND

Laparoscopy assisted distal gastrectomy (LADG) for gastric cancer has been rapidly adopted for the treatment of both early and advanced gastric cancers which need lymph node dissection, but remains difficult procedure, especially in patients with obesity. We evaluated the impact of obesity on short- and long-term outcomes of LADG for gastric cancer.

METHODS

We retrospectively investigated 243 patients who underwent LADG for gastric cancer between January 2007 and December 2014. The patients were classified based on their body mass index (BMI) into the Obese (BMI ≥ 25) and Non-Obese (BMI < 25) Groups. Patient characteristics, clinicopathologic and operative findings, and short- and long-term outcomes were investigated and compared between the groups.

RESULTS

The groups did not differ in age, sex, American Society of Anesthesiologists score, the presence of comorbidities, or pathologic stage. Operative time (265 ± 46.6 vs. 244 ± 55.6 min; P = 0.007) and estimated blood loss (113 ± 101.4 vs. 66.5 ± 95.2 ml; P = 0.007) were greater in the Obese Group. Fewer lymph nodes were retrieved in the Obese Group (38 ± 23.7 vs. 47.5 ± 24.3; P = 0.004). No differences were evident in postoperative complication rate (20% vs. 17%; P = 0.688) or the duration of postoperative hospital stay (9 ± 8.5 vs. 9 ± 5.1 days; P = 0.283) between the two groups. In the Obese Group, the 5-year overall survival rate was significantly lower than in the Non-Obese Group (67.6% vs. 90.3%; P = 0.036). Furthermore, 5-year disease-specific survival was significantly lower in the Obese Group than in the Non-Obese Group (72.7% vs. 94.9%; P = 0.015).

CONCLUSIONS

LADG in patients with obesity could be performed as safe as in patients without obesity, with comparable postoperative results. But obesity may be a poor prognostic factor in gastric cancer.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Use of a clinical pathway in laparoscopic gastrectomy for gastric cancer

AIM: To evaluate the implementation of a clinical pathway and identify clinical factors affecting the clinical pathway for laparoscopic gastrectomy.

METHODS: A standardized clinical pathway for gastric cancer (GC) patients was developed in 2001 by the GC surgery team at the Asan Medical Center. We reviewed the collected data of 4800 consecutive patients treated using the clinical pathway following laparoscopic gastrectomy with lymph node dissection for GC involving intracorporeal and extracorporeal anastomosis. The patients were treated between August 2004 and October 2013 in a single institution. To evaluate the rate of completion and risk factors affecting dropout from the clinical pathway, we used a multivariate logistic regression analysis.

RESULTS: The overall completion rate of the clinical pathway for laparoscopic gastrectomy was 84.1% (n = 4038). In the comparison between groups of intracorporeal anastomosis and extracorporeal anastomosis patients, the completion rates were 83.88% (n = 1740) and 84.36% (n = 2071), respectively, showing no statistically significant difference. The main reasons for dropping out were postoperative complications (n = 463, 9.7%) and the need for patient observation (n = 299, 6.2%). Among the discharged patients treated using the clinical pathway, the number of patients who were readmitted within 30 d due to postoperative complications was 54 (1.1%). In a multivariate analysis, the intraoperative events (OR = 2.558) were the most predictable risk factors for dropping out of the clinical pathway. Additionally, being male (OR = 1.459), advanced age (OR = 1.727), total gastrectomy (OR = 2.444), combined operation (OR = 1.731), and ASA score (OR = 1.889) were significant risk factors affecting the dropout rate from the clinical pathway.

CONCLUSION: Laparoscopic gastrectomy appears to be a good indication for the application of a clinical pathway. For successful application, patients with risk factors should be managed carefully.

A scoring system to predict the risk of postoperative complications after laparoscopic gastrectomy for gastric cancer based on a large-scale retrospective study

To investigate the risk factors for postoperative complications following laparoscopic gastrectomy (LG) for gastric cancer and to use the risk factors to develop a predictive scoring system.Few studies have been designed to develop scoring systems to predict complications after LG for gastric cancer.We analyzed records of 2170 patients who underwent a LG for gastric cancer. A logistic regression model was used to identify the determinant variables and develop a predictive score.There were 2170 patients, of whom 299 (13.8%) developed overall complications and 78 (3.6%) developed major complications. A multivariate analysis showed the following adverse risk factors for overall complications: age ≥65 years, body mass index (BMI) ≥ 28 kg/m, tumor with pyloric obstruction, tumor with bleeding, and intraoperative blood loss ≥75 mL; age ≥65 years, a Charlson comorbidity score ≥3, tumor with bleeding and intraoperative blood loss ≥75 mL were identified as independent risk factors for major complications. Based on these factors, the authors developed the following predictive score: low risk (no risk factors), intermediate risk (1 risk factor), and high risk (≥2 risk factors). The overall complication rates were 8.3%, 15.6%, and 29.9% for the low-, intermediate-, and high-risk categories, respectively (P < 0.001); the major complication rates in the 3 respective groups were 1.2%, 4.7%, and 10.0% (P < 0.001).This simple scoring system could accurately predict the risk of postoperative complications after LG for gastric cancer. The score might be helpful in the selection of risk-adapted interventions to improve surgical safety.

Laparoscopic double-tract proximal gastrectomy for proximal early gastric cancer

BACKGROUND

Proximal gastrectomy is not routinely performed because it is associated with increased reflux symptoms and anastomotic strictures. The purpose of this study is to describe a novel method of laparoscopic proximal gastrectomy (LPG) with double-tract reconstruction (DTR) for proximal early gastric cancer (EGC), and to evaluate the technical feasibility, safety, and short-term surgical outcomes, especially reflux symptoms, after LPG.

METHODS

Retrospective review of the prospective cohort data of 43 patients who presented to a single tertiary hospital from June 2009 through April 2012 and underwent LPG with DTR for proximal EGC. The data of this prospective cohort were analyzed, and the reflux symptoms, clinicopathologic characteristics, surgical outcomes, postoperative morbidities and mortalities, and follow-up findings were analyzed.

RESULTS

The mean surgical time was 180.7 min; mean estimated blood loss, 120.4 mL; mean length of the proximal resection margin, 4.13 cm; mean number of retrieved lymph nodes, 41.2; and mean postoperative hospital stay, 7.1 days. Early complication rate was 11.6 % (n = 5); major complication (grade higher than Clavien-Dindo IIIa) occurred in 1 patient (2.3 %). Late complication rate was 11.6 % (n = 5): 2 patients had esophagojejunostomy stenosis, which was successfully treated with fluoroscopic balloon dilatations; 1, chylous ascites; and 2 had Visick grade II reflux symptoms (4.6 %), managed by medication during the mean follow-up period of 21.6 months.

CONCLUSION

DTR after LPG is a feasible, simple, and novel reconstruction method with excellent postoperative outcomes in terms of preventing reflux symptoms. Its clinical applicability must be validated by prospective randomized trials.

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.

"Fast track" rehabilitation after gastric cancer resection: experience with 80 consecutive cases

Background

To evaluate the safety, efficacy and outcomes of fast-track rehabilitation applied to gastric cancer proximal, distal and total gastrectomy.

Methods

Eighty consecutive patients undergoing gastric cancer resection performed by a single surgeon, received perioperative multimodal rehabilitation. Demographic and operative data, gastrointestinal function, postoperative hospital stays, surgical and general complications and mortality were assessed prospectively.

Results

Of the 80 patients (mean age 56.3 years), 10 (12.5%) received proximal subtotal gastrectomy (Billroth I), 38 (47.5%) received distal (Billroth II), and 32 (40%) received total gastrectomy (Roux-en-Y). Mean operative time was 104.9 minutes and intraoperative blood loss was 281.9 ml. Time to first flatus was 2.8 ± 0.5 postoperative days. Patients were discharged at a mean of 5.3 ± 2.2 postoperative days; 30-day readmission rate was 3.8%. In-hospital mortality was 0%; general and surgical complications were both 5%.

Conclusions

Fast-track multimodal rehabilitation is feasible and safe in patients undergoing gastric cancer resection and may reduce time to first flatus and postoperative hospital stays.

Role of 3DCT in laparoscopic total gastrectomy with spleen-preserving splenic lymph node dissection

AIM: To investigate whether computed tomography with 3D imaging (3DCT) can reduce the risks associated with laparoscopic surgery.

METHODS: We performed a retrospective case-control study evaluating the efficacy of preoperative 3DCT of the splenic vascular anatomy on surgical outcomes in patients undergoing laparoscopic spleen-preserving splenic hilar lymph node (LN) dissection for upper- or middle-third gastric cancer. The clinical records of 312 patients with upper- or middle-third gastric cancer who underwent laparoscopic total gastrectomy with spleen-preserving splenic lymph node dissection in our hospital from January 2010 to June 2013 were collected, and the patients were divided into two groups (group 3DCT vs group NO-3DCT) depending on whether they underwent 3DCT or not. Clinicopathologic characteristics, operative and postoperative measures, the number of retrieved LNs, and complications were compared between these two groups. Patients were further compared regarding operative and postoperative measures, the number of retrieved LNs, and complications when subdivided by body mass index ( ≥ 23 and < 23 kg/m²) and the number of operations performed by their surgeon (≤ 40 vs > 40).

RESULTS: The mean numbers of retrieved splenic hilar LNs were similar in patients in group 3DCT and group NO-3DCT (2.85 ± 2.33 vs 2.48 ± 2.18, P > 0.05). The operation time and blood loss at the splenic hilum were lower in the patients in group 3DCT (P < 0.05 each). The postoperative recovery time and complication rates were similar between the two groups (P > 0.05 each). Subgroup analysis showed that the operation time at the splenic hilum in patients with a BMI ≥ 23 kg/m² was significantly shorter in patients in group 3DCT than in group NO-3DCT (20.27 ± 5.84 min vs 26.17 ± 11.01 min, P = 0.003). In patients with a BMI < 23 kg/m², the overall operation time (171.8 ± 26.32 min vs 188.09 ± 52.63 min, P = 0.028), operation time at the splenic hilum (19.39 ± 5.46 min vs 23.74 ± 9.56 min, P = 0.001), and blood loss at the splenic hilum (13.27 ± 4.96 mL vs 17.98 ± 8.12 mL, P = 0.000) were significantly lower in patients in group 3DCT than in group NO-3DCT. After 40 operations, the operation time (18.63 ± 4.40 min vs 23.85 ± 7.92 min, P = 0.000) and blood loss (13.10 ± 4.17 mL vs 15.10 ± 4.42 mL, P = 0.005) at the splenic hilum were significantly lower in patients who underwent 3DCT, but there were no significant between-group differences prior to 40 operations.

CONCLUSION: 3DCT is critical for surgical guidance to reduce the risks of splenic LN dissection. This method may be important in safely facilitating laparoscopic spleen-preserving splenic LN dissection.

Comparison of short- and long-term outcomes of laparoscopic-assisted total gastrectomy and open total gastrectomy in gastric cancer patients

BACKGROUND

Laparoscopy-assisted total gastrectomy (LATG) has been used more frequently despite the associated technical difficulty and concerns over oncological safety. This study was undertaken to compare the short- and long-term surgical outcomes following either LATG or open total gastrectomy (OTG) for gastric cancer.

METHODS

A total of 120 LATG and 228 OTG were retrospectively matched with respect to sex, age (±5 years), and pathological tumor-node-metastasis stage for comparison of the clinical outcomes.

RESULTS

The total complication rate among 120 LATG and 228 OTG was 18.3 % (22/120) and 16.2 % (37/228), respectively. The most common complication after LATG was anastomotic-related complication (6.7 %); five anastomotic leakages (4.2 %) and three anastomotic strictures were reported (2.5 %). That after OTG was wound complication (3.5 %), including seroma or infection. Matched patients analysis: Time to first gas passing and time to the resumption of a soft diet were significantly shorter in the LATG group than in the OTG group. The postoperative hospital stay of LATG was shorter in the LATG group (9.3 ± 4.2 days) than in the OTG group (11.7 ± 7.3 days; p = 0.057). Among matched patients, there was no significant difference between complication rate (24 vs. 32 %; p = 0.504) or leakage rate (6 vs. 4 %). During median follow-up of 50 (range, 10-92) months, there was no significant difference in the disease-free survival rate between the matched groups, respectively (94.5 vs. 87.1 %: p = 0.148). As for patients with TNM stage I gastric cancer, the disease-free survival rate (100 vs. 90.9 %; p = 0.5) and the cumulative survival rate (91.5 vs. 95.2 %; p = 0.618) did not differ significantly between the LATG and OTG groups.

CONCLUSIONS

LATG for gastric cancer has the advantage over an OTG in terms of better short-term outcomes and similar long-term outcome. LATG is an acceptable alternative to OTG for the treatment of gastric cancer.

Postoperative outcomes and complications after laparoscopy-assisted pylorus-preserving gastrectomy for early gastric cancer

OBJECTIVE

Laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) was introduced as a function-preserving and minimally invasive operation for early gastric cancer (EGC) in Japan. This study investigated the postoperative outcomes, complications, and associated risk factors of the procedure.

METHODS

From January 2005 to December 2009, 307 patients with EGC diagnosed before surgery underwent LAPPG. The postoperative outcomes and complications were assessed in this study. Postoperative complications were classified according to the Clavien-Dindo classification of surgical complications, and risk factors related to complications were analyzed.

RESULTS

The mean operation time for LAPPG was 229.4 ± 47.5 minutes and estimated blood loss was 49.1 ± 62.0 mL. The mean total number of dissected lymph nodes was 31.6 ± 10.4, with nodal involvement observed in 25 patients (8.5%). The preoperative diagnostic accuracy of EGC was 93.2%. Complications developed in 53 patients (17.3%), and major complications, classified as grades greater than Clavien-Dindo classification IIIa, were observed in 4 patients (1.3%). The most frequent complication was gastric stasis, occurring in 19 patients (6.2%). Body mass index (BMI) and surgical experience of LAPPG were identified as significant risk factors of postoperative complications. Body mass index was related to severity of the complications. The patients' serum total protein and albumin did not change significantly after surgery.

CONCLUSIONS

Laparoscopy-assisted pylorus-preserving gastrectomy is a safe operation with excellent postoperative outcomes in terms of minimized major complications based on the Clavien-Dindo classification in patients with EGC in the middle third of the stomach. To prevent postoperative complications, surgeons need to ensure an extra leaning period for LAPPG, and LAPPG should be performed cautiously in patients with high BMI.

Laparoscopy-assisted distal gastrectomy for gastric cancer after liver transplantation

A case report described a 72-year-old man with a history of a deceased-donor liver transplantation (due to hepatitis B-associated end-stage liver cirrhosis) performed in 1994. The patient was diagnosed with renal cell carcinoma and pulmonary metastasis in 1997 and was successfully treated with radiofrequency ablation and thoracoscopic superior segmentectomy. There was no evidence of newly diagnosed metastatic lesions or recurrence until the 19th post-operative month. Gastric cancer was identified by endoscopy during a routine follow-up examination; the pre-pyloric antral lesion measured 1.5 cm in size and was histologically well-differentiated and confined to the submucosal layers on endoscopic ultrasound. Laparoscopic gastrectomy and lymph node dissection (D1 + β) was successfully performed in March 2009, and the patient was discharged on the 5th post-operative day without complications. This suggests that laparoscopic surgery is one of the feasible methods for resection of gastric cancer in liver transplant patients.

Laparoscopic gastric surgery in an enhanced recovery programme

BACKGROUND

Laparoscopy is associated with less pain and organ dysfunction than open surgery. Improved perioperative care (enhanced recovery programmes, fast-track methodology) has also led to reduced morbidity and a shorter hospital stay. The effects of a combination of laparoscopic resection and accelerated recovery have not been examined previously in the context of gastric surgery.

METHODS

This was a prospective study of 32 consecutive patients undergoing laparoscopic gastric resection combined with an enhanced recovery protocol (early oral intake, no drains or nasogastric tubes, no epidural analgesia, use of a urinary catheter for less than 24 h and planned discharge 72 h after surgery). Outcomes included length of hospital stay, intraoperative and postoperative complications, readmission rate and 30-day mortality.

RESULTS

Operative procedures were elective distal or subtotal gastrectomy (22 patients) and total gastrectomy (10). Median length of hospital stay was 4 (range 2-30) days. There were two major complications: postoperative bleeding requiring reoperation and pulmonary embolism. Two patients required readmission, one for a wound abscess and one for treatment of a urinary tract infection. There were no deaths within 30 days.

CONCLUSION

Minimally invasive gastrectomy with enhanced postoperative recovery results in a short hospital stay and low morbidity rate.

Long-term oncologic outcomes from laparoscopic gastrectomy for gastric cancer: a single-center experience of 601 consecutive resections

BACKGROUND

Laparoscopic gastrectomy (LG) is becoming increasingly popular for management of early gastric cancer (EGC). Although short-term efficacy is proven, reports on long-term effectiveness are still infrequent.

STUDY DESIGN

All patients with a diagnosis of gastric cancer undergoing LG from the beginning of our laparoscopic experience were included in the analysis. At our unit, LG is indicated for all cancers up to preoperative stage T2N1.

RESULTS

Six-hundred and one laparoscopic resections were included in the analysis. There were 392 men and 209 women. Mean age was 64.2 +/- 10.9 years. Distal gastrectomy was performed in 305 patients, pylorus-preserving gastrectomy in 148, segmental gastrectomy in 42, proximal gastrectomy in 53, total gastrectomy in 27, and wedge resection in 26. Histological staging revealed that 478 patients had stage IA disease, 47 had stage IB, 44 had stage IIA, 19 had stage IIB, 8 had stage IIIA, 3 had stage IIIB, and 2 had stage IIIC. Morbidity and mortality rates were 17.6% and 0.3%, respectively. Median follow-up was 35.9 months (range 3 to 113 months). Cancer recurrence occurred in 15 patients and metachronous gastric remnant cancer was detected in 6 patients. The 5-year overall and disease-free survival rates were 94.2% and 89.9%, respectively, for stage IA tumors, 87.4% and 82.7% for stage IB, 80.8% and 70.7% for stage IIA, and 69.6% and 63.1% for stage IIB.

CONCLUSIONS

In our experience, long-term oncological outcomes from LG for EGC are acceptable. Wherever expertise permits, LG should be considered as the primary treatment in patients with EGC.

Long-term outcomes after laparoscopy-assisted gastrectomy for advanced gastric cancer: analysis of consecutive 106 experiences

BACKGROUND AND OBJECTIVES

The purpose of this retrospective study is to suggest the possibility of laparoscopy-assisted gastrectomy (LAG) for advanced gastric cancer (AGC) through long-term outcomes.

METHODS

Of 283 patients with gastric cancer who underwent LAG with extraperigastric (D2) lymphadenectomy between January 2004 and February 2009, 106 were pathologically confirmed with AGC and analyzed.

RESULTS

There were 75 men and 31 women, with a mean age of 61.4 +/- 11.7 years. There were 32 total gastrectomies and 74 distal gastrectomies with D2 lymphadenectomy. The mean tumor size was 4.8 +/- 2.6 cm. The mean numbers of retrieved and metastatic lymph nodes were 34.3 +/- 15.3 and 5.4 +/- 8.7, respectively. There was no lymph node metastasis in 44 patients (41.5%), and there were 35 grade T2a, 51 T2b, and 20 T3 lesions. There were 10 operation-related morbidities (9.4%) and one postoperative death (0.9%) from hepatic failure. The overall and disease-free survival rates were 81.4% and 72.4%, respectively. Tumors recurred in 17 patients (16.0%) during the follow-up periods (median 21.5 months; range 2-60).

CONCLUSIONS

LAG for AGC might be considered as a minimally invasive treatment in selected cases, but further study comparing it with open gastrectomy will be needed.

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.

Risk factors for operative complications in elderly patients during laparoscopy-assisted gastrectomy

BACKGROUND

We evaluated the feasibility of laparoscopy-assisted gastrectomy in elderly patients with gastric cancer.

STUDY DESIGN

We performed a retrospective analysis of 632 patients who underwent laparoscopy-assisted gastrectomy from May 2003 to December 2007 at Seoul National University Bundang Hospital. Postoperative complication rates were compared between patients older and younger than 70 years of age.

RESULTS

Of the 632 patients, 515 (81.5%) were younger than 70 years and 117 (18.5%) were aged 70 years or older. Significant differences in the prevalence of cardiovascular disease and hypertension were observed in patients older than 70 years (p < 0.05). Although the overall complication rates of the patients younger and older than 70 years were 12.6% and 17.9%, respectively, there was no statistically significant difference between groups (p=0.12). Multiple logistic regression analysis revealed that comorbidities with hypertension or with liver cirrhosis were the only variables that correlated independently with postoperative complications.

CONCLUSIONS

Complications after laparoscopy-assisted gastrectomy for patients older than 70 years of age with gastric cancer were similar to those of younger patients. But a careful approach is required when patients older than 70 years of age have hypertension or liver cirrhosis.

Previous laparotomy is not a contraindication to laparoscopy-assisted gastrectomy for early gastric cancer

BACKGROUND

Laparoscopic procedures have generally been considered to be contraindicated in patients with a history of laparotomy because of a high risk of enteric injury during the procedure. Laparoscopy-assisted gastrectomy (LAG) has been used increasingly in the treatment of early gastric cancer, but its indication for patients with a history of laparotomy remains unclear. The aim of the present study was to estimate whether LAG is contraindicated for the patient with a history of laparotomy (PSURG).

METHODS

From January 2003 to March 2006, 139 patients with early gastric cancer underwent LAG with curative intent in our institute. Fifty were PSURG patients, and the remaining 89 patients underwent LAG without any history of laparotomy (NSURG). Operative and early postoperative outcomes were compared between the groups.

RESULTS

Appendectomy and gynecological surgery were the predominant procedures performed in the PSURG group prior to undergoing LAG, involving 28 patients (56.0%) and 16 patients (32.0%), respectively. Detachment of adhesion above the umbilicus was required in 25 PSURG patients (50.0%). There was no significant difference in operative and postoperative results between the two groups, although 1 PSURG patient developed symptoms of bowel injury on the first postoperative day, probably caused during the laparoscopic procedure for dissection of a jejuno-jejunal adhesion.

CONCLUSIONS

There was no difference in outcome following LAG between the PSURG and NSURG groups in the present study. The PSURG patient is not contraindicated for LAG assuming careful attention is given for all operative procedures, including port insertion and dissection of intra-abdominal adhesions.

Risk factors associated with complication following laparoscopy-assisted gastrectomy for gastric cancer: a large-scale korean multicenter study

BACKGROUND

The aim of this multicenter retrospective study was to establish background data for future randomized clinical trial comparing open and laparoscopy-assisted gastrectomies (LAGs). We sought to evaluate the technical feasibility of LAG by determining the morbidity and mortality and identifying corresponding predictive factors.

PATIENTS AND METHODS

A retrospective multicenter study was carried out in Korea on 1,485 patients in who, LAG had been attempted for gastric cancer under the care of ten surgeons, at ten institutions, during the period spanning May 1998 to December 2005. Patient characteristics, operative outcomes, and postoperative morbidities and mortalities were analyzed.

RESULTS

Overall morbidity and mortality rates were 14.0% and 0.6%, respectively. Complications included: wound problem (4.2%, n = 62), intraluminal bleeding (1.3%, n = 20), intra-abdominal abscess or fluid collection (1.3%, n = 19), anastomotic leakage (1.3%, n = 18), and intra-abdominal bleeding (1.3%, n = 18). By using multivariate analysis we found that the two most important risk factors associated with postoperative complications were presence of comorbidity in the patient and lack of experience on the part of the surgeon.

CONCLUSION

LAG is a technically feasible, safe, and effective method for treating patients with gastric cancer. Extra caution in patients with comorbidities, and dedication to improving surgical proficiency in LAG, may decrease the risk of complications. Through this study, we have established the inclusion criteria for LAG. For our multicenter, prospective, randomized trials (NCT00452751), potential patients should have an American Society of Anesthesiology (ASA) score of less than 3, and surgeons performing the procedures should have experience with more than 50 cases of LAG.

Complications with laparoscopically assisted gastrectomy: multivariate analysis of 300 consecutive cases

BACKGROUND

Complications associated with laparoscopically assisted gastrectomy (LAG) are not significantly different from those associated with open gastrectomy. However, additional risks related to abdominal access, pneumoperitoneum, and special electrosurgical instruments result in an increased incidence of complications with LAG. This study analyzed the causes and risk factors linked to postoperative morbidity.

METHODS

A retrospective review analyzed the data of 300 patients who underwent consecutive LAG for gastric cancer in our department from May 2003 to October 2006. Among the 300 patients, total gastrectomy was performed for 42 patients, distal gastrectomy for 258 patients, and proximal gastrectomy for 3 patients. The clinical and operative data obtained included body mass index, medical comorbidities, history of previous abdominal surgery, operative time, type of surgery, extent of lymph node dissection according to the Japanese Guideline, number of retrieved lymph nodes and lymph node metastases, additional operative procedure, depth of tumor invasion, and disease stage. The outcome data consisted of mortality, major morbidities, and postoperative hospital stay. The 300 cases were divided into two periods: 50 cases in the first period and 250 cases in the second period.

RESULTS

Postoperative complications developed in 61 cases (20.3%), wound infection in 21 cases (7%), intraabdominal abscess in 3 cases (1%), bleeding in 12 cases (4%), stenosis in 13 cases (4.3%), leakage in 3 cases (1%), acute pancreatitis in 2 cases (0.7%), pulmonary complication in 4 cases (1.3%), renal complication in 4 cases (1.3%), and cardiac complication in 2 cases (0.7%). The 30-day mortality rate was 0.7% (n=2). Univariate analysis proved that gender, operative period, comorbidity, and operative times were important risk factors. Multivariate analysis proved that cormobidity and operative period were important risk factors.

CONCLUSION

The data suggest that LAG can be performed with acceptable perioperative complication rates. The surgeon's experience and careful patient selection determined optimal patient outcomes.

Surgical complications and the risk factors of laparoscopy-assisted distal gastrectomy in early gastric cancer

BACKGROUND

Information on surgical complications of laparoscopy-assisted distal gastrectomy (LADG) and their risk factors is limited in the literature despite increasing popularity of this procedure. This study was performed to identify the surgical complications and their associated risk factors of LADG in early gastric cancer.

METHODS

LADG was performed in 347 gastric cancer patients from January 2002 to December 2006 at the Korean National Cancer Center by four surgeons with ample experience of open gastric surgery before LADG. LADG indications for cases of gastric cancer at our institution are preoperatively diagnosed cT1N0 or cT1N1, except in cases with an absolute indication for endoscopic resection. Lymph node dissection of more than D1 + beta was performed in all patients. Intraoperative and postoperative complications were reviewed and their risk factors were retrospectively analyzed by prospective database information.

RESULTS

Forty complications occurred in 34 patients (9.8%), but there was no mortality. Intraoperative complications occurred in nine patients (2.6%), and open conversion was performed in eight (2.3%) of these patients. Early and late postoperative complications occurred in 21 (6.1%) and 10 (2.9%) patients, respectively. The most serious complication was vascular injury resulting in bleeding or organ ischemia, which occurred in seven patients. Degree of lymph node dissection and surgical inexperience were found to be risk factors of surgical complication (P = .023, odds ratio 2.832, 95% confidence interval 1.155-6.946 vs. P = .028, odds ratio 2.975, 95% confidence interval 1.127-7.854).

CONCLUSIONS

Lymph node dissection during LADG should be performed cautiously to prevent surgical complications like vascular injuries, especially during the surgeon's early learning period.