Right-Side Approach-Duet Totally Laparoscopic Distal Gastrectomy (R-Duet TLDG) Using a Three-Port to Treat Gastric Cancer

Comparison of Reduced Port Gastrectomy and Multiport Gastrectomy in Korea: Ad Hoc Analysis and Nationwide Survey on Gastric Cancer 2019

PURPOSE

This study aimed to evaluate the outcomes and current status of reduced-port laparoscopic distal gastrectomy (RLDG) compared with multiport laparoscopic distal gastrectomy (MLDG) based on a 2019 nationwide survey of surgical gastric cancer treatments by the Korean Gastric Cancer Association (KGCA).

MATERIALS AND METHODS

The study was conducted retrospectively from March to December 2020 using data from the 2019 KGCA nationwide survey database. To compare RLDG and MLDG based on age, sex, body mass index, American Society of Anesthesiologists score, histological type, tumor invasion, and lymph node metastasis, propensity score matching was performed.

RESULTS

Of the 14,076 registered patients with gastric cancer, the five-port approach was the most favored for multiport gastrectomy, accounting for 6,396 (70.9%) cases, followed by the four-port approach, with 1,462 (16.2%) cases. The single-port approach was used in 303 (3.4%) cases, the two-port approach in 95 (1.1%) cases, and the three-port approach in 731 (8.1%) cases. RLDG was performed in 805 patients (6.4%), MLDG was conducted in 4,831 patients (34.3%), and 804 patients were 1:1 matched in each group. The average operation time was shorter in the RLDG (168.2±49.1 min vs. 179.5±61.5 min, P<0.001). No significant difference was found in blood loss (84.8±115.9 cc vs. 75.5±119.6 cc, P=0.152), overall complication rates (11.3% vs. 13.1%, P=0.254), or complications ≥ to grade IIIa (3.2% vs. 4.4%, P=0.240).

CONCLUSIONS

This study revealed that RLDG is a safe and effective surgical option for gastric cancer with the potential to offer shorter operation times without increasing the risk of complications.

Integrating minimally invasive bariatric surgery with lessons from gastric cancer surgery

Laparoscopic procedures in bariatric surgery are evolving to enhance cosmetic outcomes and minimize postoperative complications. This study demonstrates the results of bariatric surgery achieved through the application of surgical techniques derived from gastric cancer surgery. Several surgical techniques from gastric cancer surgery were implemented in bariatric surgery, including: (1) V-shaped liver retraction, (2) Reduced port surgery, (3) Intraoperative endoscopy and (4) Multi-degree-of-freedom articulating device. A single surgeon, with experience in over 1000 gastric cancer surgeries, performed consecutive bariatric surgeries starting from the initial case. The study analyzed short-term results, including operation details, postoperative complications, outcomes of weight loss, and the learning curve. A total 94 consecutive laparoscopic sleeve gastrectomy cases were performed from 2019 to 2022. The mean age of 94 patients was 35.9 ± 9.7 years, with 58 (61.7%) being female. The mean body mass index (BMI) was 40.9 ± 6.2. Type 2 diabetes was prevalent in 46.8% of the patients. On average, 3.3 ± 0.5 trocars were used per surgery. The mean estimated blood loss and hospital stay after surgery were 20.1 ± 36.3 cc and 3.3 ± 0.6 days, respectively. There were no complications reported for postoperative leakage, bleeding, or passage disturbance, and no mortality occurred. At 12 months, the mean percentage total weight loss (%TWL) and excess BMI loss (%EBMIL) were 28.5% and 79.7%, respectively. The mean operation times was 109.5 ± 27.4 min, with a plateau observed at around the 30th case. Bariatric surgery can be effectively performed by a gastric cancer expert surgeon using techniques derived from gastric cancer surgery.

Current Issues in Reduced-Port Gastrectomy: A Comprehensive Review

Reduced-port gastrectomy (RPG) includes all procedures derived from various efforts to minimize surgical invasiveness, with single-incision laparoscopic gastrectomy (SILG) being the ultimate reduced-port technique. However, there are challenges related to its feasibility, oncological validity, training, and education. This review describes the current issues and challenges, as well as the future prospects of RPG for gastric cancer. Gastrectomy, which started as an open surgery, has evolved into a laparoscopic surgery. With the advancements in laparoscopic technology, SILG has been used to minimize surgical scarring. However, owing to the technical difficulties of SILG, cases involving the addition of 1 trocar or needle grasper alongside the multichannel port have also been reported. Additionally, 3-port laparoscopic gastrectomy (3PLG) using only 3 trocars is also being performed. RPG, as a concept, includes a range of approaches such as SILG, 2-port laparoscopic gastrectomy, and 3PLG. These techniques aimed to reduce the number of ports or incisions required for laparoscopic gastrectomy. Despite technical difficulties, RPGs offer numerous advantages, including minimal invasiveness, excellent cosmetic outcomes, and the potential for improved post-operative recovery, such as reduced length of hospital stay and post-operative pain. It could be considered similar to conventional laparoscopic gastrectomy, and may not be oncologically inferior. Ongoing studies, such as the KLASS 12, are required to gain further insights.

Feasibility and Potential of Reduced Port Surgery for Total Gastrectomy With Overlap Esophagojejunal Anastomosis Method

PURPOSE

Reduced port surgery (RPS) for gastric cancer has been frequently reported in distal gastrectomies but rarely in total gastrectomies. This study aimed to determine the feasibility of 3-port totally laparoscopic total gastrectomy (TLTG) with overlapping esophagojejunal (EJ) anastomosis.

MATERIALS AND METHODS

A total of 81 patients who underwent curative TLTG for gastric cancer (36 and 45 patients with 3-port and 5-port TLTG, respectively) were evaluated. All 3-port TLTG procedures were performed with the same method as 5-port TLTG, including EJ anastomosis with the intracorporeal overlap method using a linear stapler, except for the number of ports and assistants. Short-term outcomes, including the number of lymph nodes (LNs) harvested by station and postoperative complications, were analyzed retrospectively.

RESULTS

Clinical characteristics were not significantly different among the groups, except that the 3-port TLTG group was younger and had a lower rate of pulmonary comorbidity. There were no cases of open conversion or additional port placement. All operative details and the number of harvested LNs did not differ between the groups, but the rate of suprapancreatic LN harvest was higher in the 3-port TLTG group. No significant differences were observed in the overall complication rates between the 2 groups.

CONCLUSIONS

Three-port TLTG with overlapping EJ anastomoses using a linear stapler is a feasible RPS procedure for total gastrectomy to treat gastric cancer.

Modern surgical therapy for gastric cancer-Robotics and beyond

The surgical paradigm for gastric cancer has been changed from extended surgery to minimally invasive surgery. Laparoscopic surgery is a practical method for minimally invasive surgery for early gastric cancer, and the indication is expanding to advanced gastric cancer. In recent years, robotic gastrectomy has been highlighted as a breakthrough to overcome the drawbacks of laparoscopic gastrectomy. Here, we discuss the recent updates of modern surgical therapy for gastric cancer-robotics and beyond.

Current Status and Trends of Minimally Invasive Gastrectomy in Korea

Since its introduction in the early 1990s, laparoscopic gastrectomy has been widely accepted for the treatment of gastric cancer worldwide. In the last decade, the Korean Laparoendoscopic Gastrointestinal Surgery Study group performed important clinical trials and exerted various efforts to enhance the quality of scientific knowledge and surgical techniques in the field of gastric cancer surgery. Laparoscopic gastrectomy has shifted to a new era in Korea due to recent advances and innovations in technology. Here, we discuss the recent updates of laparoscopic gastrectomy—namely, reduced-port, single-incision, robotic, image-guided, and oncometabolic surgery.

Evaluation of Reduced Port Laparoscopic Distal Gastrectomy Performed by a Novice Surgeon

Purpose

Reduced port laparoscopic distal gastrectomy (RPLDG) using 3 ports is less invasive than conventional laparoscopic distal gastrectomy (CLDG) using 5 ports. Although RPLDG performed by expert surgeons is safe and feasible, novice surgeons have difficulty performing this procedure. This study evaluated the surgical outcomes and feasibility of RPLDG performed by a novice surgeon.

Materials and Methods

The records of 136 patients who underwent laparoscopic distal gastrectomy for gastric cancer performed by a single novice surgeon between May 2016 and December 2018 were retrospectively reviewed. Among these 136 patients, 52 underwent RPLDG and 84 underwent CLDG. The clinicopathological characteristics, operative outcomes, and short-term postoperative outcomes of the 2 groups were compared.

Results

The percentage of women was significantly higher in the RPLDG group than in the CLDG group (48.1% vs. 31%; P=0.045), but other baseline characteristics did not differ significantly between the groups. Billroth II anastomosis was performed significantly more frequent (90.4% vs. 73.8%, P=0.015) and operation time was significantly shorter (207.1±43.3 min vs. 225.5±44.6 min, P=0.020) in the RPLDG group than in the CLDG group. The time to first flatus, postoperative pain score, length of postoperative hospital stay, and incidence and severity of complications did not differ significantly between the groups. Analysis of the learning curve based on the operation time showed that performing RPLDG on 20-30 patients was required to achieve technical proficiency.

Conclusions

RPLDG is a safe and feasible surgical procedure for the treatment of gastric cancer, even when performed by a novice surgeon.

Long-Term Oncological Outcomes of Reduced Three-Port Laparoscopic Gastrectomy for Early-Stage Gastric Carcinoma: a Retrospective Large-Scale Multi-Institutional Study

Purpose

With advances in surgical techniques, reduced-port laparoscopic surgery is increasingly being performed for the treatment of gastric carcinoma. Many studies have reported satisfactory short-term outcomes after reduced 3-port laparoscopic gastrectomy (LG). The aim of this study was to investigate the long-term oncological outcomes of 3-port LG in patients with gastric carcinoma.

Materials and Methods

We reviewed the medical records of 1,117 patients who underwent LG for gastric carcinoma in three major institutions between 2012 and 2015. The data showed that 460 patients underwent 3-port LG without assistance, and 657 underwent conventional 5-port LG. We compared the overall and disease-free survival rates between the 2 groups.

Results

There were 642 male and 475 female patients with a mean age of 56.1 years. Among them, 1,028 (92.0%) underwent distal gastrectomy and 89 (8.0%) underwent total gastrectomy. In the final pathologic examination, 1,027 patients (91.9%) were stage I, 73 (6.5%) were stage II, and 17 (1.5%) were stage III, and there were no significant difference in the pathologic stage between groups. The 3- and 5-port LG groups showed no significant differences in the 5-year overall survival (94.3% vs. 96.7%, P=0.138) or disease-free survival (94.3% vs. 95.9%, P=0.231). Stratified analyses according to pT and pN stages also showed no significant differences in overall or disease-free survival between the two groups.

Conclusions

Long-term survival after 3- and 5-port LG was comparable in patients with early-stage gastric carcinoma. The 3-port technique requiring limited surgical assistance may be an appropriate surgical option for this patient population.

Comparing the surgical outcomes of dual-port laparoscopic distal gastrectomy and three-port laparoscopic distal gastrectomy for gastric cancer

Purpose

Many studies have demonstrated that single-incision or reduced-port laparoscopic distal gastrectomy is a feasible method compared to conventional laparoscopic distal gastrectomy. Using rigid-type laparoscope and right-side approach, we could perform dual-port laparoscopic distal gastrectomy (DPLDG) for gastric cancer. This study aimed to compare the surgical outcomes of DPLDG to those of 3-port laparoscopic distal gastrectomy (TPLDG).

Methods

From March 2017 to December 2019, this retrospective study included 218 patients with gastric cancer who underwent DPLDG (106 patients) or TPLDG (112 patients) at SMG-SNU Boramae Medical Center. Surgical outcomes were compared between 2 operation methods.

Results

Operation time was similar between DPLDG and TPLDG (158.9 ± 33.4 minutes vs. 154.0 ± 31.1 min, P = 0.787). The number of retrieved lymph nodes was similar between the 2 groups (35.3 ± 14.6 vs. 37.0 ± 13.5, P = 0.415). The complication rate in DPLDG and TPLDG groups was 10.4% and 8.9%, respectively (P = 0.894). The time to first flatus, time to first diet, and postoperative hospital stay were similar between the 2 groups. There were no reoperation or mortality cases. The cost of trocars was 359.9 US dollars (USD) in DPLDG and 291–391.4 USD in TPLDG.

Conclusion

The surgical outcomes of DPLDG and TPLDG did not differ. Regarding fewer incisions, DPLDG can be an alternative option for TPLDG.

D2 Lymph Node Dissections during Reduced-port Robotic Distal Subtotal Gastrectomy and Conventional Laparoscopic Surgery Performed by a Single Surgeon in a High-volume Center: a Propensity Score-matched Analysis

Purpose

Various studies have indicated that reduced-port robotic gastrectomies are safe and feasible for treating patients with early gastric cancer. However, there have not been any comparative studies conducted that have evaluated patients with clinically advanced gastric cancer. Therefore, we aimed to compare the perioperative outcomes of D2 lymph node dissections during reduced-port robotic distal subtotal gastrectomies (RRDGs) and conventional 5-port laparoscopic distal subtotal gastrectomies (CLDGs).

Materials and Methods

We retrospectively evaluated 118 patients with clinically advanced gastric cancer who underwent minimally invasive distal subtotal gastrectomies with D2 lymph node dissections between February 2016 and November 2019. To evaluate the patient data, we performed a 1:1 propensity score matching (PSM) according to age, sex, body mass index, American Society of Anesthesiologists physical status classification score, and clinical T status. The short-term surgical outcomes were also compared between the two groups.

Results

The PSM identified 40 pairs of patients who underwent RRDG or CLDG. The RRDG group experienced a significantly longer operation time than the CLDG group (P<0.001), although the RRDG group had significantly less estimated blood loss (P=0.034). The number of retrieved extraperigastric lymph nodes in the RRDG group was significantly higher than that of the CLDG group (P=0.008). The rate of postoperative complications was not significantly different between the two groups (P=0.115).

Conclusions

D2 lymph node dissections can be safely performed during RRDGs and the perioperative outcomes appear to be comparable to those of conventional laparoscopic surgeries. Further studies are needed to compare long-term survival outcomes.

Surgical Outcomes of Reduced-Port Laparoscopic Gastrectomy Versus Conventional Laparoscopic Gastrectomy for Gastric Cancer: A Propensity-Matched Retrospective Cohort Study

BACKGROUND

The technical feasibility and oncologic efficacy of reduced-port laparoscopic gastrectomy (RPG) for gastric cancer remain unclear.

METHODS

A series of 767 patients with gastric cancer who underwent R0 laparoscopic gastrectomy were retrospectively matched for age, gender, American Society of Anesthesiology score, body mass index, surgeon, lymph node dissection, and pathologic stages by propensity scoring. Finally, data from 274 patients (74 conventional laparoscopic distal gastrectomy [CLDG] cases, 74 reduced-port distal gastrectomy [RPDG] cases, 63 conventional laparoscopic total gastrectomy [CLTG] cases, and 63, reduced-port total gastrectomy [RPTG] cases) were selected for analysis.

RESULTS

Compared with the conventional group, the reduced-port group had significantly longer operation times (RPDG 265 min vs CLDG 239 min; p = 0.001 and RPTG 305 min vs CLTG 285 min; p = 0.012) and reduced blood loss (RPDG 48 ml vs CLDG 68 ml; p = 0.001 and RPTG 75 ml vs CLTG 110 ml; p = 0.026). The number of dissected lymph nodes was significantly higher in the CLDG group than in the RPDG group (38 vs 31; p = 0.002). Cosmetic satisfaction showed significant superiority in the reduced-port group compared with the conventional group. No significant difference was observed in overall survival (OS) (5-year OS: RPDG 100% vs CLDG 96.7%; p = 0.207 and RPTG 91.6% vs CLTG 91.8%; p = 0.615) or relapse-free survival (RFS) (5-year RFS: RPTG 92.3% vs CLTG 92.1%; p = 0.587).

CONCLUSIONS

The study results suggest that RPG for gastric cancer by an experienced surgeon is a feasible and safe technique. The RPG procedure can be presented to patients as one of the effective treatment options.

Three-Port Right-Side Approach-Duet Totally Laparoscopic Distal Gastrectomy for Uncut Roux-en-Y Reconstruction

BACKGROUND

This study presents the initial feasibility of three-port right-side approach-duet totally laparoscopic distal gastrectomy (R-duet TLDG) with uncut Roux-en-Y (R-Y) reconstruction for the treatment of lower- or middle-third gastric cancer.

METHODS

A total of 30 patients who underwent R-duet TLDG with uncut R-Y reconstruction for gastric cancer were enrolled. All patients were treated at the Catholic Medical Center. Reconstructions were performed intracorporeally without special instruments. The clinicopathological characteristics, operative details, postoperative short-term outcomes, and postoperative follow-up endoscopy results were analyzed retrospectively.

RESULTS

All operations were performed by three-port R-duet TLDG. There were no conversions to an open approach, and no additional ports were placed. The mean operating time was 170 minutes, and the mean number of retrieved lymph nodes was 44. Three patients experienced mild postoperative complications, including small bowel ileus and pneumonia. Follow-up endoscopy was carried out at 3 months. No patients had experienced moderate-or-severe food stasis, alkaline gastritis, or bile reflux during the follow-up period. Recanalization of the biliopancreatic limb was not observed.

CONCLUSIONS

R-duet TLDG with uncut R-Y reconstruction could be safely performed as a reduced port surgery without special instruments.