Totally laparoscopic total and subtotal gastrectomy with extended lymph node dissection for early and advanced gastric cancer: early and long-term results of a 100-patient series

Therapeutic potential of flavonoids in gastrointestinal cancer: Focus on signaling pathways and improvement strategies (Review)

Flavonoids are a group of polyphenolic compounds distributed in vegetables, fruits and other plants, which have considerable antioxidant, anti‑tumor and anti‑inflammatory activities. Several types of gastrointestinal (GI) cancer are the most common malignant tumors in the world. A large number of studies have shown that flavonoids have inhibitory effects on cancer, and they are recognized as a class of potential anti‑tumor drugs. Therefore, the present review investigated the molecular mechanisms of flavonoids in the treatment of different types of GI cancer and summarized the drug delivery systems commonly used to improve their bioavailability. First, the classification of flavonoids and the therapeutic effects of various flavonoids on human diseases were briefly introduced. Then, to clarify the mechanism of action of flavonoids on different types of GI cancer in the human body, the metabolic process of flavonoids in the human body and the associated signaling pathways causing five common types of GI cancer were discussed, as well as the corresponding therapeutic targets of flavonoids. Finally, in clinical settings, flavonoids have poor water solubility, low permeability and inferior stability, which lead to low absorption efficiency in vivo. Therefore, the three most widely used drug delivery systems were summarized. Suggestions for improving the bioavailability of flavonoids and the focus of the next stage of research were also put forward.

Early stage gastric adenocarcinoma: clinical and molecular landscapes

Gastric adenocarcinoma, even when diagnosed at an early (localized) disease stage, poses a major health-care burden with cure rates that remain unsatisfactorily low, particularly in Western countries. This lack of progress reflects, among other aspects, the impracticality of early diagnosis, considerable variations in therapeutic approaches that is partly based on regional preferences, and the ingrained heterogeneity of gastric adenocarcinoma cells and their associated tumour microenvironment (TME). Clinical trials have long applied empirical interventions with the assumption that all early stage gastric adenocarcinomas are alike. Despite certain successes, the shortcomings of these approaches can potentially be overcome by targeting the specific molecular subsets of gastric adenocarcinomas identified by genomic and/or multi-omics analyses, including microsatellite instability-high, Epstein-Barr virus-induced, DNA damage repair-deficient, HER2-positive and PD-L1-high subtypes. Future approaches, including the availability of sophisticated vaccines, novel antibody technologies, agents targeting TME components (including fibroblasts, macrophages, cytokines or chemokines, and T cells) and novel immune checkpoint inhibitors, supported by improved tissue-based and blood-based diagnostic assays, seem promising. In this Review, we highlight current knowledge of the molecular and cellular biology of gastric adenocarcinomas, summarize the current approaches to clinical management of the disease, and consider the role of novel management and/or treatment strategies.

Comparing short-term outcomes after totally laparoscopic distal gastrectomy and laparoscopy-assisted distal gastrectomy with Billroth I anastomosis: early experience of a single institution

Purpose

Methods

Results

Conclusion

Laparoscopic versus open distal gastrectomy for locally advanced gastric cancer in middle-low-volume centers in Western countries: a propensity score matching analysis

Background

Gastrectomy with D2 lymphadenectomy is the standard treatment for patients with resectable gastric cancer. Laparoscopic distal gastrectomy (LDG) is routinely performed for early gastric cancer, and its indications are increasing even for locally advanced gastric cancer. The aim of this study is to compare two middle–low-volume centers in Western countries experience on LDG versus open distal gastrectomy (ODG) for locally advanced gastric cancer in terms of surgical and oncological outcomes.

Methods

We reviewed the data of 123 consecutive patients that underwent LDG and ODG with D2 lymphadenectomy between 2009 and 2014. Among them, 91 were eligible for inclusion (46 LDG and 45 ODG). After propensity score matching analysis, using a 1:1 case-control match, 34 patients were stratified for each group.

Results

The mean operative time was significantly longer in the LDG group (257.2 vs. 197.2, p < 0.001). No differences were observed in terms of intraoperative blood loss, average number of lymph nodes removed, and lymph node metastases. The postoperative morbidity was comparable in the two groups. LDG group had a significant faster bowel canalization and soft oral intake (p < 0.001). The 5-year overall and disease-free survival were higher for patients treated by laparoscopy, but the post-hoc subgroups analysis revealed that the advantage of LDG was significant just in N0 and stage IB-II patients, whereas N+ and stage III patient’s survival curves were perfectly superimposable.

Conclusions

LDG for locally advanced gastric cancer seems to be feasible and safe with surgical and long-term oncological outcomes comparable with open surgery, even in medium–low-volume centers.

Esophageal Suspension Method for Hand-Sewn Esophagojejunostomy After Totally Laparoscopic Total Gastrectomy: A Simple, Safe, and Feasible Suturing Technique

Background: Totally laparoscopic total gastrectomy (TLTG) not only is difficult to operate but also has high technical requirements and a long learning curve. Therefore, it has not been widely carried out yet, and esophagojejunostomy is one of its difficulties. Relevant studies have shown that intracorporeal hand-sewn esophagojejunostomy is safe, feasible and low-cost, but it is complicated and time-consuming and requires a high-suture technique. This study introduces a simple, safe and feasible hand-sewn technique. Methods: The clinical data of 32 patients with the esophageal suspension method for hand-sewn esophagojejunostomy (suspension group) after TLTG were collected from February 2018 to June 2019. During the same period, 32 patients with traditional hand-sewn esophagojejunostomy (traditional group) after TLTG were used as the control group. Results: The operative time, anastomosis time, exhaust time and hospitalization time of the suspension group were shorter than those of the traditional group. The intraoperative blood loss in the suspension group was less than that in the traditional group. There were no postoperative complications associated with the suspension group. Conclusion: For those who have some experience in laparoscopic suture technique, the esophageal suspension method for hand-sewn esophagojejunostomy after TLTG is a simple, safe, and feasible suture technique.

Laparoscopic-assisted total gastrectomy for adenocarcinoma in a western country: Safety and oncological issues

Background

Laparoscopic total gastrectomy for adenocarcinoma is a widely diffused operation in eastern countries, but there are only a few reports from western centers. We assessed a single surgeon's experience at a single, nonacademic, community hospital.

Methods

Short-term outcome of patients undergoing laparoscopic total gastrectomy for adenocarcinoma (June 2005-March 2010) was assessed.

Results

Fourteen patients (5 males, 9 females; median age, 66.8 years [interquartile range, 59.7–71.8]) underwent laparoscopic total gastrectomy. The median operative time was 240 min. There were five stage 1 patients, five stage 2, and four stage 3; R0 resection was obtained in all 14 patients, and the median number of lymph nodes retrieved was 38. Mortality and overall morbidity rates were 0% and 35.7%, respectively.

Conclusions

The outcomes of laparoscopic total gastrectomy for adenocarcinoma performed by a well-trained laparoscopic surgeon working in a community hospital are good in terms of safety for the patients and response to the oncological criteria used in open surgery.

Total and Subtotal Laparoscopic Gastrectomy for the Treatment of Advanced Gastric Cancer: Morbidity and Oncological Outcomes

BACKGROUND

A debate is still surrounding the use of laparoscopic surgery for advanced gastric cancer (AGC) related to doubts about the requirements to satisfy oncologic criteria. The aim of this study is to analyze the oncological results, the intraoperative complications, and the short- and medium-term morbidity and mortality in patients with AGC who underwent subtotal laparoscopic gastrectomy (SLG) or total laparoscopic gastrectomy (TLG) with extended lymphadenectomy.

MATERIALS AND METHODS

We reviewed medical records of patients who underwent radical gastrectomy for AGC started laparoscopically with the intent of curative surgery, between July 2007 and October 2015. We recruited 74 patients and studied demographics, American Society of Anesthesiologists (ASA) score, pTNM stage, histologic pattern of the tumor, duration of surgery, conversion rate, estimated blood loss, number of resected lymph nodes, type of gastrointestinal reconstruction, postoperative complication, mortality rate, length of stay, time to canalization and resumption of food intake, and overall and disease-free survival rate.

RESULTS

We performed 74 interventions, with a conversion rate of 14.9% (11/74). Sixty-three were performed totally as laparoscopic: 43 (68.25%) SLGs and 20 (31.75%) TLGs, all with an extended lymphadenectomy (D2 or more). Operative time was 150 ± 34 minutes (range 75-225 minutes), the mean number of resected lymph nodes 21.4 ± 6.2, global morbidity rate 25.39%, rate of reoperation 9.52%, and perioperative mortality at 30 days 0%. We performed an average follow-up of 48.7 months (range 18-60), and we observed 5-year overall and disease-free survival, respectively, of 48.6% and 42.7%.

CONCLUSIONS

LG with extended lymphadenectomy for AGC is a feasible procedure with good results in terms of postoperative course, complications, and mortality. Thanks to the use of extremely precise and safe technologies the extended lymphadenectomy can be performed laparoscopically. The laparoscopic approach, when performed by experienced surgeons, ensures a correct oncological treatment in combination with the benefits of the laparoscopic technique.

Intra-corporeal hand-sewn esophagojejunostomy is a safe and feasible procedure for totally laparoscopic total gastrectomy: short-term outcomes in 100 consecutive patients

BACKGROUND

An optimal method for intracorporeal esophagojejunostomy has not yet been standardized. This study sought to introduce intracorporeal hand-sewn end-to-side esophagojejunostomy after totally laparoscopic total gastrectomy.

METHODS

The author conducted a consecutive series of 100 intracorporeal hand-sewn esophagojejunostomies after totally laparoscopic total gastrectomy for upper third gastric cancer from September 2012 to December 2016.

RESULTS

All patients were successfully operated on without conversion to open- or laparoscope-assisted surgery. The mean reconstruction time was 45 min, and the time until first flatus was 4 days. The time to start a soft diet was 7 days. The length of postoperative hospital stay was 8 days. The overall postoperative morbidity was 8%, including one anastomotic leak, and the mortality was zero. The median follow-up duration was 13 months; no anastomotic strictures were encountered.

CONCLUSIONS

Intracorporeal hand-sewn end-to-side esophagojejunostomy after totally laparoscopic total gastrectomy is a safe and feasible procedure. This method can identify negative margins with intraoperative frozen sections before reconstruction and could be a good option for performing intracorporeal esophagojejunostomy with an advanced endoscopic suture technique.

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

Background and Purpose:

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

Patients and Method:

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

Results:

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

Conclusions:

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

Comparison of laparoscopic versus open gastrectomy for advanced gastric cancer: an updated meta-analysis

BACKGROUND

Laparoscopic gastrectomy (LG) has been used as an alternative to open gastrectomy (OG) to treat early gastric cancer. However, the use of LG for advanced gastric cancer (AGC) has been in debate.

METHODS

Literature retrieval was performed by searching PubMed, EMBASE, and the Cochrane library up to July 2014. Potential studies comparing the surgical effects between LG with OG were evaluated and data were extracted accordingly. Meta-analysis was carried out using RevMan. The pooled risk ratio and weighted mean difference (WMD) with 95 % confidence interval (95 % CI) were calculated.

RESULTS

Overall, 26 studies were included in this meta-analysis. LG had some advantages over OG, including shorter hospitalization (WMD, -3.63, 95 % CI, -4.66 to -2.60; P < 0.01), less blood loss (WMD, -161.37, 95 % CI, -192.55 to -130.18; P < 0.01), faster bowel recovery (WMD, -0.78, 95 % CI, -1.05 to -0.50; P < 0.01), and earlier ambulation (WMD, -0.95, 95 % CI, -1.47 to -0.44; P < 0.01). In terms of surgical and oncological safety, LG could achieve similar lymph nodes (WMD, -0.49, 95 % CI, -1.78 to 0.81; P = 0.46), a lower complication rate [odds ratio (OR), 0.71, 95 % CI, 0.59 to 0.87; P < 0.01], and overall survival (OS) and disease-free survival (DFS) comparable to OG.

CONCLUSIONS

For AGCs, LG appeared comparable with OG in short- and long-term results. Although more time was needed to perform LG, it had some advantages over OG in achieving faster postoperative recovery. Ongoing trials and future studies could help to clarify this controversial issue.

Totally laparoscopic versus laparoscopic-assisted total gastrectomy for upper and middle gastric cancer: a single-unit experience of 253 cases with meta-analysis

BACKGROUND

Laparoscopic-assisted total gastrectomy (LATG) is the most commonly used methods of laparoscopic gastrectomy for upper and middle gastric cancer. However, totally laparoscopic total gastrectomy (TLTG) is unpopular because reconstruction is difficult, especially for the intracorporeal esophagojejunostomy. We adopted TLTG with various types of intracorporeal esophagojejunostomy. In this study, we compared LATG and TLTG to evaluate their outcomes.

METHODS

From March 2006 to September 2015, 253 patients with upper and middle gastric cancer underwent laparoscopic total gastrectomy (LTG), 145 patients underwent LATG, and 108 patients underwent TLTG. The clinicopathological characteristics and postoperative outcomes were retrospectively compared between the two groups. Furthermore, a systematic review and meta-analysis were conducted.

RESULTS

The operation time and estimated blood loss were similar between the groups. There were no significant differences in first flatus, diet initiation, and postoperative hospital stay. The surgical complication rates were 17.2% (25/145) and 13.9% (15/108) in the LATG and TLTG groups, respectively. The meta-analysis also revealed no significant differences in the operation time, estimated blood loss, time to first flatus, length of hospital stay, overall, and anastomosis-related complications among the groups.

CONCLUSIONS

TLTG is a feasible choice for gastric cancer patients, with comparable results to the LATG approach.

Laparoscopic and robot-assisted laparoscopic digestive surgery: Present and future directions

Laparoscopic surgery is applied today worldwide to most digestive procedures. In some of them, such as cholecystectomy, Nissen's fundoplication or obesity surgery, laparoscopy has become the standard in practice. In others, such as colon or gastric resection, the laparoscopic approach is frequently used and its usefulness is unquestionable. More complex procedures, such as esophageal, liver or pancreatic resections are, however, more infrequently performed, due to the high grade of skill necessary. As a result, there is less clinical evidence to support its implementation. In the recent years, robot-assisted laparoscopic surgery has been increasingly applied, again with little evidence for comparison with the conventional laparoscopic approach. This review will focus on the complex digestive procedures as well as those whose use in standard practice could be more controversial. Also novel robot-assisted procedures will be updated.

Laparoscopic gastric cancer surgery: Current evidence and future perspectives

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

Totally laparoscopic D2 radical distal gastrectomy using Billroth II anastomosis: A case report

Here, we present our first case of totally laparoscopic D2 radical distal gastrectomy using Billroth II anastomosis and evaluate its effectiveness in terms of minimal invasiveness, technical feasibility and safety for the resection of early gastric cancer. In the present case, only laparoscopic linear staplers were used for intracorporeal anastomosis. The time taken was 180 min, the anastomotic time was 15 min, the number of staples used was five, and the estimated blood loss was 30 ml. The first flatus was observed at 3 days, and a liquid diet was started at 6 days. The postoperative hospital stay was 8 days. No postoperative complications were noted with our case. In conclusion, totally laparoscopic Billroth II anastomosis using laparoscopic linear staplers for early gastric cancer is considered to be safe and feasible.

Totally intracorporeal delta-shaped B-I anastomosis following laparoscopic distal gastrectomy using the Tri-Staple™ reloads on the manual Ultra handle: a prospective cohort study with historical controls

BACKGROUND

A delta-shaped anastomosis in totally laparoscopic Billroth I gastrectomy could be performed easily and sufficiently using only laparoscopic linear staplers. However, the restricted maneuverability and severe blurring of these staplers along with their limited hemostability induced strain. In this study, we determined the feasibility and safety of performing delta-shaped anastomosis using the Endo GIA™ Reloads with Tri-Staple™ Technology combined with Endo GIA™ Ultra Universal stapler (Tri-Staple) with a particular focus on short-term surgical outcomes.

METHODS

We performed a single-institutional prospective interventional study (UMIN 000008014). The Tri-Staple was prospectively used on 23 consecutive patients who underwent a curative totally laparoscopic Billroth I gastrectomy with delta-shaped anastomosis. These patients were matched with the 19 patients previously treated using the ENDOPATH(®) ETS Articulating Linear Cutters (ETS) on clinical and demographic characteristics.

RESULTS

There were no differences between the groups in anastomosis-related local complications, morbidity, non-anastomosis-related local complications, total systemic complications, and short-term outcomes with the exception of significantly reduced blood loss in the Tri-Staple group (ETS vs. Tri-Staple: 37 [10-306] vs. 15 [5-210] mL, p = 0.02). Intraoperative bleeding from the staple line was significantly reduced in the Tri-Staple group. The postoperative drain indwelling period (ETS vs. Tri-Staple, 6 [4-10] vs. 4 [2-43] days, p = 0.032), fasting period (5 [3-7] vs. 3 [3-24] days, p = 0.022), and hospital stay (14 [10-47] vs. 11 [6-58] days, p = 0.025) were significantly shorter in the Tri-Staple group. There was no mortality in this series. Acceleration assessed as indices of blurring of stapler tip might have a significant adverse influence on staple-line bleeding at stapling sites.

CONCLUSION

Totally laparoscopic Billroth I distal gastrectomy using Tri-Staple was feasible and safe with favorable short-term surgical outcomes. Reduced blurring while stapling may be a novel endpoint which newly developed stapling devices should target.

A prospective randomized clinical trial comparing D2 dissection in laparoscopic and open gastrectomy for gastric cancer

Laparoscopic surgery is an acceptable alternative to open surgery in colorectal cancer treatment. However, in gastric cancer, there is not much scientific evidence. Here, we proposed a prospective randomized clinical trial to evaluate the radicalness and safety of laparoscopic D2 dissection for gastric cancer. From October 2010 to September 2012, 300 patients with gastric cancer were randomized to undergo either laparoscopy-assisted gastrectomy (LAG) or conventional open gastrectomy (OG) with D2 dissection. Clinicopathological parameters, recovery and complications were compared between these two groups. Thirty cases were excluded because of refusing to be involved in the trial, having peritoneal seeding metastasis or LAG conversed to OG, and finally 270 cases were analyzed (128 in LAG and 142 in OG). No significant differences were observed in gender, age, body mass index, stages and types of radical resection [radical proximal gastrectomy (PG + D2), radical distal gastrectomy (DG + D2) and radical total gastrectomy (TG + D2)] (P > 0.05). The number of harvested lymph nodes (HLNs) was similar (29.3 ± 11.8 in LAG vs. 30.1 ± 11.4 in OG, P = 0.574). And in the same type of radical resection, no significant difference was found in the number of HLNs between the two groups (PG + D2, P = 0.770; DG + D2, P = 0.500; TG + D2, P = 0.993). The morbidity of the LAG group (21.8 %) was also comparable to the OG group (19.0 %, P = 0.560). However, the LAG group had significantly less blood loss and faster recovery, and a longer operation time (P < 0.05). Laparoscopic D2 dissection is feasible, safe and capable of fulfilling oncologic criteria for the treatment of gastric cancer.

SAGES TAVAC safety and effectiveness analysis: da Vinci ® Surgical System (Intuitive Surgical, Sunnyvale, CA)

BACKGROUND

The da Vinci(®) Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) is a computer-assisted (robotic) surgical system designed to enable and enhance minimally invasive surgery. The Food and Drug Administration (FDA) has cleared computer-assisted surgical systems for use by trained physicians in an operating room environment for laparoscopic surgical procedures in general, cardiac, colorectal, gynecologic, head and neck, thoracic and urologic surgical procedures. There are substantial numbers of peer-reviewed papers regarding the da Vinci(®) Surgical System, and a thoughtful assessment of evidence framed by clinical opinion is warranted.

METHODS

The SAGES da Vinci(®) TAVAC sub-committee performed a literature review of the da Vinci(®) Surgical System regarding gastrointestinal surgery. Conclusions by the sub-committee were vetted by the SAGES TAVAC Committee and SAGES Executive Board. Following revisions, the document was evaluated by the TAVAC Committee and Executive Board again for final approval.

RESULTS

Several conclusions were drawn based on expert opinion organized by safety, efficacy, and cost for robotic foregut, bariatric, hepatobiliary/pancreatic, colorectal surgery, and single-incision cholecystectomy.

CONCLUSIONS

Gastrointestinal surgery with the da Vinci(®) Surgical System is safe and comparable, but not superior to standard laparoscopic approaches. Although clinically acceptable, its use may be costly for select gastrointestinal procedures. Current data are limited to the da Vinci(®) Surgical System; further analyses are needed.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Current status of minimally invasive surgery for gastric cancer: A literature review to highlight studies limits

BACKGROUND

Gastric cancer represents a great challenge for health care providers and requires a multidisciplinary approach in which surgery plays the main role. Minimally invasive surgery has been progressively developed, first with the advent of laparoscopy and more recently with the spread of robotic surgery, but a number of issues are currently being investigate, including the limitations in performing effective extended lymph node dissections and, in this context, the real advantages of using robotic systems, the possible role for advanced Gastric Cancer, the reproducibility of completely intracorporeal techniques and the oncological results achievable during follow-up.

METHOD

Searches of MEDLINE, Embase and Cochrane Central Register of Controlled Trials were performed to identify articles published until April 2014 which reported outcomes of surgical treatment for gastric cancer and that used minimally invasive surgical technology. Articles that deal with endoscopic technology were excluded.

RESULTS

A total of 362 articles were evaluated. After the review process, data in 115 articles were analyzed.

CONCLUSION

A multicenter study with a large number of patients is now needed to further investigate the safety and efficacy as well as long-term outcomes of robotic surgery, traditional laparoscopy and the open approach.

Robot-assisted surgery for gastric carcinoma: Five years follow-up and beyond: A single western center experience and long-term oncological outcomes

INTRODUCTION

Robot-assisted surgery for the treatment of gastric cancer is considered to be safe and feasible with early post-operative outcomes comparable to open and laparoscopic series. However, data regarding long-term oncological outcomes are lacking. Aim of this study is to evaluate long-term oncological outcomes of a cohort of gastric cancer patients treated surgically with the robot-assisted approach.

MATERIALS AND METHODS

A prospectively collected database of robot-assisted gastrectomies performed for gastric cancer at the 'Misericordia Hospital' between September 2001 and October 2011 was retrospectively analysed. Data regarding surgical procedures, early postoperative course, and long-term follow-up were analysed.

RESULTS

The study included 98 consecutive robot-assisted gastrectomies. Fifty-nine distal gastrectomies, 38 total gastrectomies, and 1 proximal gastrectomy. Open conversion occurred in seven patients (7.1%) due to locally advanced disease. Postoperative morbidity and mortality were 12.2% and 4.1% respectively. Post-operative staging showed 46 patients (46.9%) with stage I disease, 25 patients (25.5%) with stage II, 26 (26.5%) with stage III and 1 (1.02%) with stage IV. The mean follow-up was 46.9 months. Cumulative 5-year overall survival (OS) was 73.3% (95% CI: 62.2-84.4). Five-year survival by stage subgroups was 100% for patients with stage IA, 84.6% for stage IB, 76.9% for stage II, and 21.5% for stage III. The only patient in stage IV of this series died eight months after surgery.

CONCLUSIONS

Robot-assisted gastrectomy for the treatment of gastric cancer is safe and feasible. It provides long-term outcomes comparable to most open and laparoscopic series. Further studies are necessary to better define its indication.

Surgical outcomes of intracorporeal circular-stapled esophagojejunostomy using modified over-and-over suture technique in laparoscopic total gastrectomy

BACKGROUND

Esophagojejunostomy in laparoscopic total gastrectomy (LTG) is a technically demanding procedure. Although several methods have been reported to date, none is considered consistently reliable. We developed a simple method for intracorporeal circular-stapled esophagojejunostomy using a modified over-and-over suture technique. The surgical outcomes of our technique were evaluated in comparison with those of open total gastrectomy (OTG).

METHODS

From April 2012 to August 2014, reconstruction using this method in LTG was performed for 21 consecutive patients with gastric cancer (LTG group). Their surgical outcomes were compared with those of 27 patients with gastric cancer who underwent OTG without splenectomy (OTG group) between January 2011 and April 2014.

RESULTS

Estimated blood loss was significantly lower, and the postoperative hospital stay was significantly shorter in the LTG group than in the OTG group. The operating time and the number of harvested lymph nodes were similar between the two groups. The incidence of overall complications did not differ significantly between the two groups. Anastomotic leakage developed in one of the 21 patients in the LTG group and in two of the 27 patients in the OTG group. Anastomotic stenosis was observed in one patient in the LTG group.

CONCLUSIONS

We consider this method as simple and feasible for most laparoscopic surgeons with basic laparoscopic suturing skills. This method might help LTG to become an accepted standard surgical option for treatment of patients with gastric cancer.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Hand-assisted laparoscopic total gastrectomy with regional lymph node dissection for advanced gastric cancer

BACKGROUND AND OBJECTIVES

Laparoscopic-assisted distal gastrectomy has been applied to the treatment of gastric cancer. However, there have been few reports on the laparoscopic-assisted total gastrectomy for advanced gastric cancer, mainly because of the difficulty of the procedure.

METHODS

Here, we report a series of cases where the hand-assisted laparoscopic total gastrectomies with regional lymph node dissection were performed successfully.

RESULTS

The average operative time was 245 minutes. The mean blood loss was 110 mL. The number of dissected lymph nodes per patient was beyond 15 nodes satisfying a reliable evaluation of nodal status. All resection specimens had no residual tumor at the proximal or distal resection margins. The mean oral feeding was 3.6 days. The mean postoperative length of stay was 8.7 days.

CONCLUSIONS

The hand-assisted laparoscopic D2 total gastrectomy for advanced gastric cancer is both technically feasible and safe.

Minimally invasive surgery for gastric cancer treatment: current status and future perspectives

Minimally invasive surgery, which has been extensively used to treat gastric adenocarcinoma, is now regarded as one of the standard treatments for early gastric cancer, and its suitability for advanced gastric cancer is being investigated. The use of cutting-edge techniques for minimally invasive surgery enables surgeons to deliver various treatment options to minimize a patient's distress and to maintain oncologic safety. Ongoing multicenter prospective studies aim to validate the efficacy of these surgical techniques and to expand the indications of minimally invasive surgery for the treatment of gastric cancer. In this review, we summarize the current status and issues regarding minimally invasive surgery for the treatment of gastric cancer.

Totally laparoscopic total gastrectomy for gastric cancer: literature review and comparison of the procedure of esophagojejunostomy

There has been a recent increase in the use of totally laparoscopic total gastrectomy (TLTG) for gastric cancer. However, there is no scientific evidence to determine which esophagojejunostomy (EJS) technique is the best. In addition, both short- and long-term oncological results of TLTG are inconsistent. We reviewed 25 articles about TLTG for gastric cancer in which at least 10 cases were included. We analyzed the short-term results, relationships between EJS techniques and complications, long-term oncological results, and comparative study results of TLTG. TLTG was performed in a total of 1170 patients. The mortality rate was 0.7%, and the short-term results were satisfactory. Regarding EJS techniques and complications, circular staplers (CSs) methods were significantly associated with leakage (4.7% vs. 1.1%, p < 0.001) and stenosis (8.3% vs. 1.8%, p < 0.001) of the EJS as compared with the linear stapler method. The long-term oncological prognosis was acceptable in patients with early gastric cancers and without metastases to lymph nodes. Although TLTG tended to increase surgical time compared with open total gastrectomy and laparoscopy-assisted total gastrectomy, it reduced intraoperative blood loss and was expected to shorten postoperative hospital stay. TLTG is found to be safer and more feasible than open total gastrectomy and laparoscopy-assisted total gastrectomy. At present, there is no evidence to encourage performing TLTG for patients with advanced gastric cancer from the viewpoint of long-term oncological prognosis. Although the current major EJS techniques are CS and linear stapler methods, in this review, CS methods are significantly associated with leakage and stenosis of the EJS.

Laparoscopic gastric surgery for cancer: Where do we stand?

Gastric cancer poses a significant public health problem, especially in the Far East, due to its high incidence in these areas. Surgical treatment and guidelines have been markedly different in the West, but nowadays this debate is apparently coming to an end. Laparoscopic surgery has been employed in the surgical treatment of gastric cancer for two decades now, but with controversies about the extent of resection and lymphadenectomy. Despite these difficulties, the apparent advantages of the laparoscopic approach helped its implementation in early stage and distal gastric cancer, with an increase on the uptake for distal gastrectomy for more advanced disease and total gastrectomy. Nevertheless, there is no conclusive evidence about the laparoscopic approach yet. In this review article we present and analyse the current status of laparoscopic surgery in the treatment of gastric cancer.

A new intracorporeal Billroth II stapled anastomosis technique in totally laparoscopic distal gastrectomy

BACKGROUND

We introduced a new, safe and simple intracorporeal Billroth II (B-II) gastrojejunostomy technique using laparoscopic linear staplers with totally laparoscopic distal gastrectomy (TLDG) for gastric cancer. We further compared the short-term operative outcomes between intracorporeal B-II gastrojejunostomy with TLDG and extracorporeal B-II gastrojejunostomy with laparoscopy-assisted distal gastrectomy (LADG).

METHODS

From January 01, 2012 to January 31, 2013, a total of 36 patients with gastric cancer underwent TLDG and LADG. Overall, 11 patients underwent intracorporeal B-II gastrojejunostomy with TLDG, and 25 patients underwent a mini-laparotomy incision for extracorporeal B-II anastomosis with LADG. Perioperative parameters, including patient and tumor characteristics, short-term postoperative outcomes, and anastomosis-related complications, were analyzed to compare the two operations.

RESULTS

The time to first flatus, the time on a liquid diet, and the mean postoperative length of hospital stay were significantly different between the groups (P < 0.05). In the TLDG group, the postoperative time to first flatus and the mean postoperative length of hospital stay were significantly shorter than in the LADG group (2.6 ± 0.20 vs. 3.8 ± 0.1 days; 10 ± 1.84 vs. 12.7 ± 3.35 days). However, the operation-related costs were significantly greater for totally laparoscopic distal gastrectomy (P < 0.001). The mean number of staples used in TLDG was six compared with four in LADG.

CONCLUSION

Our new intracorporeal B-II anastomosis method using laparoscopic linear staplers with TLDG was safe, feasible, and minimally invasive compared with extracorporeal B-II gastrojejunostomy with LADG. At the same time, one of its characteristics of our technique is to avoid stricturing of the efferent loop or afferent loop of the jejunum when the entry hole is closed with a stapler.

[Synopsis on clinical practice guideline of gastric cancer in Korea: an evidence-based approach]

Although, gastric cancer is quite common in Korea, the treatment outcome is relatively favorable compared to that of Western countries. However, there is no Korean multidisciplinary guideline for gastric cancer and thus, a guideline adequate for domestic circumstances is required. Experts from related societies developed 22 recommendation statements for the diagnosis (n=9) and treatment (n=13) based on relevant key questions. Evidence levels based on systematic review of literatures were classified as five levels from A to E, and recommendation grades were classified as either strong or weak. The topics of this guideline cover diagnostic modalities (endoscopy, endoscopic ultrasound, radiologic diagnosis), treatment modalities (surgery, therapeutic endoscopy, chemotherapy, radiotherapy) and pathologic evaluation. External review of the guideline was conducted at the finalization phase.

Clinical practice guidelines for gastric cancer in Korea: an evidence-based approach

Although gastric cancer is quite common in Korea, the treatment outcome is relatively favorable compared to those in western countries. However, there are currently no Korean multidisciplinary guidelines for gastric cancer. Experts from related societies developed guidelines de novo to meet Korean circumstances and requirements, including 23 recommendation statements for diagnosis (n=9) and treatment (n=14) based on relevant key questions. The quality of the evidence was rated according to the GRADE evidence evaluation framework: the evidence levels were based on a systematic review of the literature, and the recommendation grades were classified as either strong or weak. The applicability of the guidelines was considered to meet patients' view and preferences in the context of Korea. The topics of the guidelines cover diagnostic modalities (endoscopy, endoscopic ultrasound, and radiologic diagnosis), treatment modalities (surgery, therapeutic endoscopy, chemotherapy, and radiotherapy), and pathologic evaluation. An external review of the guidelines was conducted during the finalization phase.

Advantage of completely laparoscopic gastrectomy with linear stapled reconstruction: a long-term follow-up study

BACKGROUND

Completely laparoscopic gastrectomy with intracorporeal anastomosis was introduced to achieve safer anastomosis and smaller scars. Although several reports have shown the feasibility of linear-stapled anastomosis, there are no studies of a large number of patients assessing the long-term complications and functional outcomes.

METHODS

This retrospective study included 345 patients who had intended to undergo completely laparoscopic distal or total gastrectomy with linear-stapled anastomosis between September 2005 and January 2012. This study evaluated both the short- and long-term complications, as well as the endoscopic findings, changes in body weight and serum albumin.

RESULTS

Completely laparoscopic gastrectomy was successfully achieved in 342 patients (99.1%). Short-term complications occurred in 59 patients (17.3%). Reconstruction-related complications were observed in 19 patients (5.6%). Three patients with anastomotic leakage required reoperation. No patient experienced anastomotic stenosis over a mean follow-up period of 29.6 months. Two patients underwent an emergency operation for an internal hernia after total gastrectomy. Adhesive intestinal obstruction was observed in 5 patients (1.5%), but all were resolved without surgical intervention. Body weight loss at 2 years after distal and total gastrectomy was 7.2% and 13.9%, which were similar to previous reports of open surgery.

CONCLUSIONS

Completely laparoscopic gastrectomy with linear-stapled anastomosis is a feasible choice for gastric cancer patients with some potential long-term advantages such as less anastomotic stenosis and fewer adhesive intestinal obstructions.

Laparoscopic approach to gastrointestinal malignancies: toward the future with caution

After the rapid acceptance of laparoscopy to manage multiple benign diseases arising from gastrointestinal districts, some surgeons started to treat malignancies by the same way. However, if the limits of laparoscopy for benign diseases are mainly represented by technical issues, oncologic outcomes remain the foundation of any procedures to cure malignancies. Cancerous patients represent an important group with peculiar aspects including reduced survival expectancy, worsened quality of life due to surgery itself and adjuvant therapies, and challenging psychological impact. All these issues could, potentially, receive a better management with a laparoscopic surgical approach. In order to confirm such aspects, similarly to testing the newest weapons (surgical or pharmacologic) against cancer, long-term follow-up is always recommendable to assess the real benefits in terms of overall survival, cancer-free survival and quality of life. Furthermore, it seems of crucial importance that surgeons will be correctly trained in specific oncologic principles of surgical oncology as well as in modern miniinvasive technologies. Therefore, laparoscopic treatment of gastrointestinal malignancies requires more caution and deep analysis of published evidences, as compared to those achieved for inflammatory bowel diseases, gastroesophageal reflux disease or diverticular disease. This review tries to examine the evidence available to date for the use of laparoscopy and robotics in malignancies arising from the gastrointestinal district.

Totally laparoscopic gastrectomy for gastric cancer

Totally laparoscopic gastrectomy appears to be a reasonable option for the treatment of gastric malignancy, with early data demonstrating acceptable survival rates and perioperative outcomes.

Background and Objectives:

Recent studies have supported minimally invasive techniques as a viable alternative to open surgery in the treatment of gastric cancer. The goal of this study is to review our institution's experience with totally laparoscopic gastrectomy for the treatment of both early- and advanced-stage gastric cancer.

Methods:

A retrospective study was conducted to examine the short-term outcomes of laparoscopic gastrectomy performed at Monmouth Medical Center between May 2003 and June 2012. We reviewed postoperative complications, surgical margins, number of resected lymph nodes, estimated blood loss, length of stay, narcotic use, and recurrence rate.

Results:

Forty patients were included in the study. There were 21 cases of adenocarcinoma, 15 cases of gastrointestinal stromal tumor, 2 cases of carcinoid, 1 case of small cell neuroendocrine tumor, and 1 case of squamous cell carcinoma. The mean operative time was 220 minutes (range, 67–450 minutes). The median length of stay was 6 days (range, 1–37 days). The mean number of harvested lymph nodes was 11. Early postoperative complications occurred in 7 patients and included anastomotic stricture, wound infection, intra-abdominal abscess, bowel obstruction, and esophageal pneumatosis. There were two deaths. The Kaplan-Meier 5-year overall and recurrence-free survival rate for all cases of adenocarcinoma was 63.2%.

Conclusions:

Totally laparoscopic gastrectomy is a reasonable option for the treatment of gastric malignancy, with early data showing acceptable survival rates and perioperative outcomes. Large-scale randomized trials are still needed to confirm oncologic equivalency to open gastrectomy in patients with advanced disease.

Comparison of short-term clinical outcomes between robotic and laparoscopic gastrectomy for gastric cancer: a meta-analysis of 2495 patients

BACKGROUND

Laparoscopic gastrectomy (LG) is being increasingly used to treat gastric cancer. However, there are still several technical disadvantages limiting its use. Robotic gastrectomy (RG) is an emerging minimally invasive technique that overcomes some of these limitations. This study compares RG with LG in the treatment of gastric cancer by performing a systematic review and meta-analysis of all published literature.

MATERIALS AND METHODS

Comparative studies published between January 1991 and April 2013 in the major databases were systematically searched. Evaluated end points were operative, postoperative, and oncological outcomes. Pooled odds ratios and weighted mean differences with 95% confidence intervals were calculated using either the fixed-effects model or random-effects model.

RESULTS

Nine nonrandomized comparative studies with 2495 patients were included, of which 736 procedures were robotic and 1759 were laparoscopic. RG was associated with a lower intraoperative blood loss and a shorter time to oral intake compared with LG. However, it was associated with a significantly longer operative time and shorter distal resection margin. In addition, there was no significant difference in the number of retrieved lymph nodes, proximal resection margin, rate of conversion to open surgery, overall morbidity, anastomotic leakage, anastomotic stenosis, intestinal obstruction, time to first flatus, length of hospital stay, and perioperative mortality rates between the two groups.

CONCLUSIONS

RG is comparable to LG, with respect to safety, technical feasibility, and oncological effectiveness in the treatment of gastric cancer. However, there is a need for well-designed prospective randomized controlled studies comparing the two procedures with long-term follow-up, to inform future practice.

Minimally invasive surgery for serosa-positive gastric cancer (pT4a) in patients with preoperative diagnosis of cancer without serosal invasion

BACKGROUND

Although surgeons normally use minimally invasive surgery (MIS) for patients with early gastric cancer, in Korea and Japan the procedure is also indicated for serosa-negative tumors. Serosal invasion is regarded to be a potential risk factor for peritoneal dissemination as a result of the effect of pneumoperitoneum and tumor manipulation during the operation. We compared operative outcomes between MIS and conventional open surgery for serosa-involved advanced gastric cancer patients who had a preoperative diagnosis of cancer without serosal invasion.

METHODS

A total of 61 patients (39 patients treated by MIS and 22 by open surgery) treated between 2003 and 2009 who were first diagnosed preoperatively as serosa negative on the basis of computed tomography, endoscopy, and endoscopic ultrasound but then diagnosed as serosa positive upon final pathology were studied. We retrospectively compared recurrence and survival between the two treatment groups.

RESULTS

Clinicopathologic characteristics, clinical stage, extent of surgery, and short-term operative outcome did not differ between the groups. 5-year overall survival (73.5 vs. 67.5 %, p = 0.518, respectively) and disease-free survival (67.8 vs. 54.2 %, p = 0.296, respectively) were comparable between the MIS and open surgery groups. There were recurrences in 12 patients in the MIS group and 11 patients in the open surgery group, with a median follow-up period of 64 months. Recurrence patterns did not differ between the groups; moreover, MIS did not increase peritoneal recurrences compared to open surgery (42.0 vs. 54.5 %, p = 0.537, respectively). In multivariate analyses, the type of surgery was not an independent prognostic factor.

CONCLUSIONS

Similar survival and recurrence patterns were observed in advanced gastric cancer patients preoperatively diagnosed as serosa negative who were treated either by MIS or open surgery. MIS may be safely applied in patients with serosa-positive tumors.

Internal hernia after gastrectomy for cancer with Roux-Y reconstruction

BACKGROUND

The incidence of internal hernia (IH) after gastrectomy for cancer with Roux-Y reconstruction has not been well-defined. This study aimed to define the true incidence of IH after gastrectomy for cancer with Roux-Y reconstruction; to describe the presentation, timing, and management of this complication; and to identify factors associated with IH.

METHODS

Clinical and follow-up information were reviewed for all patients who underwent open or laparoscopic gastrectomy with Roux-Y reconstruction for cancer at a single institution from January 2005 through April 2012.

RESULTS

A total of 298 patients underwent gastrectomy for cancer with Roux-Y reconstruction. At a median follow-up of 22.4 months, we identified 16 patients (5%) who underwent subsequent reoperation for IH. No patient who had closure of mesenteric defects developed IH. IH occurred in 1 of 99 patients after open subtotal gastrectomy (1%), 10 of 165 after open total gastrectomy (6%), 1 of 16 after laparoscopic subtotal gastrectomy (6%), and 4 of 18 after laparoscopic total gastrectomy (22%; P < .03). On univariate analysis, younger age, lower body mass index, no previous abdominal surgery, laparoscopic approach, and total gastrectomy were associated with IH. IH tended to occur early after laparoscopic gastrectomy (median, 7 months) and late after open gastrectomy (median, 24 months).

CONCLUSION

IH after gastrectomy with Roux-Y reconstruction is likely underreported. A high degree of suspicion for IH should be maintained in patients presenting with emesis or abdominal pain after gastrectomy with Roux-Y reconstruction, especially after laparoscopic or total gastrectomy. Closure of mesenteric defects after laparoscopic and total gastrectomy should be considered when technically feasible.

The initial experience of dual port laparoscopy-assisted total gastrectomy as a reduced port surgery for total gastrectomy

Reduced port surgery (RPS), in which fewer ports are used than that in a conventional laparoscopic procedure, is becoming increasingly popular for various surgeries. However, the application of RPS to the field of gastrectomy is still underdeveloped. We started laparoscopy-assisted total gastrectomy through an umbilical port plus another 5 mm port (dual port laparoscopy-assisted total gastrectomy: DP-LATG) as an RPS for laparoscopy-assisted total gastrectomy (LATG). A SILS™ port was inserted into an umbilical incision, while another 5 mm port was inserted at the right flank region. We performed DP-LATG on ten early gastric cancer cases consecutively from May 2011 onwards, with the surgeries all performed by a single surgeon. The results of DP-LATG were compared with the resuls of ten conventional LATGs (C-LATGs) that were performed between March 2010 and April 2011. There were no significant differences in the mean operation time (DP-LATG, 253.0 ± 26.8 min; C-LATG, 235.5 ± 20.6 min; p = 0.119), mean blood loss (33.4 ± 23.7, 39.8 ± 60.4 mL, p = 0.759), and number of lymph nodes dissected (31.6 ± 12.3, 40.9 ± 18.7, p = 0.205). There were no intraoperative complications, there was no need for additional ports, and there were no conversions to open surgery nor postoperative complications in the DP-LATG cases. We successfully and safely performed DP-LATG without incurring any notable differences from C-LATG in terms of operation time, blood loss, and number of lymph nodes dissected.

Laparoscopic-assisted radical gastrectomy for distal gastric cancer

A 48-year-old female patient was diagnosed with a superficial depressed type early gastric cancer (type IIc) of 1.0 cm at the gastric angle as indicated by gastroscopy. Laparoscopic-assisted greater omentum-preserving D2 radical gastrectomy was performed in combination with Billroth I reconstruction under general anesthesia for the distal gastric cancer on April 5, 2013. The postoperative recovery was satisfying without complications. The patient was discharged seven days after surgery.

Transoral extraction of a laparoscopically resected large gastric GIST

Although natural orifice specimen extraction is now widely performed, there have been no reports of transoral extraction following laparoscopic gastric resection. This report describes the first transoral specimen extraction in a patient with a gastrointestinal stromal tumor (GIST) of the lesser curvature of the stomach. The clinical data of a patient with a large gastric GIST were reviewed. Totally laparoscopic resection of the gastric lesser curvature was performed using four trocars. The specimen, put in a retrieval bag, was withdrawn via the transgastric and esophageal route. Reconstruction of the stomach was performed using the intracorporeal technique. The procedure was successfully accomplished without intraoperative and postoperative complications. In conclusion, transoral specimen extraction after laparoscopic gastric resection is a safe and feasible operative procedure for selected patients with a large benign gastric tumor.

Laparoscopy-assisted vs. open total gastrectomy for advanced gastric cancer: long-term outcomes and technical aspects of a case-control study

BACKGROUND AND OBJECTIVES

An increasing number of studies comparing laparoscopy-assisted distal gastrectomy and conventional open distal gastrectomy have been reported; the technical feasibility and clinical efficacy have been confirmed. However, few data are available to compare laparoscopy-assisted total gastrectomy (LATG) and open techniques for the treatment of advanced gastric cancer (AGC). The aim of this study is to compare the oncologic efficacy and long-term outcomes of LATG vs. open total gastrectomy (OTG) for AGC and to provide our experiences regarding these surgical difficulties as well.

METHODS

Using data from a clinical database of all operations performed in our department by a special surgical team, we retrospectively analysed data from 117 cases of LATG and matched OTG performed between January 2004 and December 2010. This analysis was a case-control study in which patients in the two groups were matched according to tumour location, age, gender, BMI and TNM stage via a propensity score matching method. Patient clinical characteristics, lymph node retrieval, early postoperative complications, recurrence and long-term outcomes were compared.

RESULTS

The demographics, preoperative data and characteristics of the tumour were similar in both groups. No significant differences were found in the LATG group compared with the OTG group with regard to the number of retrieved lymph nodes or distance from the proximal margin. Operating time was longer in the LATG group than in the OTG group (292.8 ± 49.5 vs. 242.1 ± 47.4, p < 0.05). Significant differences were found between LATG and OTG with regard to blood loss, postoperative hospitalisation and times of analgesic injection. The early postoperative complication rates in the LATG group were significantly lower than in the OTG group (11.1 vs. 16.3 %, p < 0.05). Operative mortality was zero in both groups. During a median follow-up of 61.2 (range, 6-84) months, the overall 5-year survival rates in the LATG group and OTG group were 49.3 and 46.5 %, respectively; there was no significant difference between the two groups (p = 0.756).

CONCLUSION

Our results suggest that LATG is technically feasible for advanced gastric cancer patients and can yield good short- and long-term oncologic outcomes as compared with conventional OTG.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Stable purse-string suturing using an anterior esophagotomy for reconstruction with a circular stapler during laparoscopic total gastrectomy

INTRODUCTION

During a laparoscopic total gastrectomy, the combined process of purse-string suture placement and anvil insertion of a circular stapler is one of the most difficult steps in the reconstruction. We have developed a stable and reliable technique in which purse-string suture placement and anvil insertion using anterior esophagotomy precede complete transection of the esophagus.

METHODS

The procedure involves tying the distal esophagus, insufflating the esophagus via a nasogastric tube, anterior wall purse-string suture, anterior esophagotomy, posterior wall purse-string suture, anvil insertion, fastening purse-string suture, and transecting the esophagus. The technique has been employed in nine patients since April 2011.

RESULTS

Eight of the nine gastrectomies were for patients with stage IA early gastric cancer and one was for a patient with medically intractable bleeding from multiple polyps. Three were men and six were women. Average BMI was 25.2 ± 5.3 (range, 16.3-33.9). Mean operation time was 276.2 ± 56.3 min (range, 215.0-395.0 min) and the mean duration for anvil insertion was 29.8 ± 7.0 min (range, 23.0-46.0 min). There were no intraoperative or postoperative anastomosis-related complications or mortality.

CONCLUSION

Our method of anvil insertion of a circular stapler can be a good option for safe and reliable esophagojejunostomy during a laparoscopic total gastrectomy.

Esophagojejunal reconstruction after total gastrectomy for gastric cancer using a transorally inserted anvil delivery system

INTRODUCTION

Total gastrectomy (TG) is commonly performed for the treatment of patients with gastric cancer. However, reconstruction of the esophagojejunal (EJ) anastomosis can be technically demanding, with reported anastomotic leak rates in the Western world still approaching 10-15%. We report our experience using the transoral anvil delivery system (OrVil™) for creation of the EJ anastomosis after TG.

METHODS

From 2007 to 2011, 48 consecutive patients with gastric cancer underwent open (n=31) or laparoscopic (n=17) TG. EJ reconstruction was performed with the transoral anvil deliver system (OrVil™) in an end-to-side fashion. Demographic, clinic, and perioperative data were obtained from a prospectively maintained database.

RESULTS

Of the 48 patients, 83% were male. Median age at resection was 64 years. Median body mass index was 27.1 kg/m2. Seventy-nine percent (n=38) of patients had at least one comorbidity. Fifteen patients (31%) had at least one perioperative complication. There was one perioperative death (2%) following a duodenal stump leak. There were four EJ leaks (8%) and two EJ stenoses (independent of leak; 4%). There was one EJ leak (6%) and one EJ stenosis (6%) following a case that was first attempted laparoscopically. There were no deaths as a consequence of an EJ leak.

CONCLUSIONS

The use of the transoral anvil delivery system during EJ reconstruction is a safe and effective option for reconstruction after open or laparoscopic TG with acceptable mortality and morbidity. The anastomotic leak rate appears to be comparable to that of other techniques.

Laparoscopic total gastrectomy in gastric cancer: our experience in 92 cases

INTRODUCTION

Laparoscopic total gastrectomy (LTG) is seldom used for gastric cancer because the complex vascularization and lymphatic drainage makes lymphadenectomy and esophagojejunal anastomosis difficult and requires special skills. Our aim was to demonstrate the feasibility and accuracy of LTG in gastric cancer with D2 lymphadenectomy.

MATERIAL AND METHODS

Eighty-eight LTG and four laparoscopic remnant gastrectomies (LRGs) were performed over >12 years. The median patient age was 64 years, and the male/female ratio was 1.49/1. Eighty-seven patients had a D2 and only five patients had a D1 lymphadenectomy. We propose the retrospective analysis of intra- and perioperative mortality and morbidity.

RESULTS

In only four of 96 cases approached by laparoscopy, a conversion to laparotomy was needed. There were two (2.17%) perioperative deaths in 92 procedures and few complications. Histological data show 79 advanced gastric cancers (AGC), 11 early gastric cancers (EGC), and two gastric diffused lymphomas. The five-year Kaplan-Meier overall survival in patients with EGC and AGC was 100% and 58%, respectively.

CONCLUSIONS

The results demonstrate the feasibility of an oncologically correct minimally invasive total gastrectomy. We would like to promote comparisons among different institutions to achieve better standardization of indications and techniques for a laparoscopic approach to gastric cancer.

Feasibility of laparoscopic gastrectomy for advanced gastric cancer with positive peritoneal cytology

PURPOSE

The role of gastrectomy for patients with positive peritoneal cytology, but a negative macroscopic peritoneal implant (P-/cy+), remains unclear. The aim of this study was to evaluate laparoscopic gastrectomy for P-/cy+ patients.

METHODS

This study reviewed a prospectively maintained gastric cancer database of gastric-cancer patients those underwent surgical resection. P-/cy+ gastric cancer that had invaded the subserosa, or deeper layers, of the stomach wall without distant organ metastases was considered operable in this institution. P-/cy+ patients underwent either open or laparoscopic gastrectomy with D2 lymphadenectomy. The short-term results were examined to assess differences in outcome between the two groups.

RESULTS

Eighteen P-/cy+ patients without distant organ metastases underwent surgery between 2000 and 2010. Laparoscopic gastrectomy was performed in nine patients and open gastrectomy in nine patients. The estimated blood loss was significantly smaller, the resumption of food intake earlier, and the length of postoperative hospital stay shorter in the patients that underwent laparoscopic gastrectomy than in the patients that underwent open gastrectomy. There were no significant differences in the 2-year survival rates between the groups.

CONCLUSION

Laparoscopic gastrectomy for P-/cy+ patients is a minimally invasive and safe oncologic procedure with good short-term results.

Minimally invasive surgery for gastric cancer

Application of minimally invasive techniques to gastric cancer in the West has been curbed by concerns of feasibility and oncologic adequacy. Growing evidence supports improved short-term and equivalent oncologic outcomes in selected patients undergoing laparoscopic surgery for early-stage disease. Laparoscopic resection for advanced gastric cancer remains controversial due to few reliable studies on long-term outcomes. We focus on important studies from Asia and highlight the Western experience with laparoscopic and robotic surgery for gastric carcinoma.