Port-Site Recurrence After Laparoscopy-Assisted Gastrectomy: Report of the First Case

Port-Site Metastasis After Laparoscopic Gastrectomy Extending to the Thigh: A Case Report

Port-site metastasis (PSM) is rare following laparoscopic gastrectomy for gastric cancer. Previous reports focused on localized lesions treated with excision; contrastingly, case reports describing extensive invasion into the lower extremity skeletal muscles causing deterioration in activities of daily living are nonexistent. A 55-year-old male underwent a laparoscopic distal gastrectomy for gastric cancer. The pathological findings revealed a stage IIIA tumor. Two years later, skin hardening was observed on the left upper abdominal wall. Computed tomography displayed a 13-cm-long, flat tumor along the skeletal muscle around the left upper 12 mm port site and right hydronephrosis. The patient was diagnosed with PSM and retroperitoneal recurrence. Despite chemotherapy, three years postoperatively, PSM widely spread from the left upper abdomen to the left thigh, eventually inducing opioid-resistant leg pain and subsequent walking difficulties. Palliative radiotherapy could not improve these symptoms. The patient died three years and five months postoperatively. Extensively invasive PSM can induce refractory cancer pain and physical disorders. Therefore, early detection and palliative resection of PSM may help maintain the quality of life of patients with gastric cancer.

Solitary port-site metastasis 42 months after laparoscopic distal gastrectomy for gastric cancer

We report a case of solitary port-site recurrence after laparoscopy-assisted distal gastrectomy for advanced gastric cancer. A 66-year-old man had previously undergone laparoscopy-assisted gastrectomy with regional lymph-node dissection for advanced gastric cancer, which was a poorly differentiated adenocarcinoma invading the subserosal layer with lymphatic infiltration and no lymph-node metastases. He experienced dull pain in the left upper quadrant of the abdomen 42 months after the surgery. On physical examination, erythematous induration of the skin around the scar of the port insertion was observed in the left upper quadrant of the abdomen. Abdominal ultrasonography and contrast-enhanced computed tomography revealed a subcutaneous lesion with a well-defined mass measuring 3.0 cm in diameter located in the left upper quadrant of the abdomen. A skin biopsy revealed a metastatic adenocarcinoma from gastric cancer. Since there was no evidence of further metastatic lesions in other organs, the patient underwent surgical resection of the metastatic tumor arising at the port site. The abdominal wall tumor was resected with a leaf-skin incision and an adequate safety margin, and the inferior border of the tumor reached the muscular layer, which was resected with the tumor. Pathological examination confirmed the diagnosis of a poorly differentiated adenocarcinoma in the subcutaneous tissue with invasion of the muscle layer at the port site. The postoperative course was uneventful; chemotherapy using oxaliplatin plus S-1 was administered, and the patient was in good health with no evidence of the disease for 3 months postoperatively. Although port-site metastasis after laparoscopic gastrectomy for gastric cancer is a rare recurrence form, we should be aware of this issue, and further studies and assessments of additional cases are needed to establish a treatment strategy.

Metachronous port site, muscular and subcutaneous metastases from a gastric adenocarcinoma: a case report and review of articles

Background

Port site metastasis (PSM) after curative gastrectomy for gastric cancer and muscular metastasis from gastric cancer are rare manifestations. Similarly, subcutaneous metastasis from gastric cancer is rare, and muscular and subcutaneous metastases are associated with poor prognosis. We report a case of long-term survival in a patient who underwent curative resection of gastric cancer and repeated recurrence of port site, muscular and subcutaneous metastases from gastric cancer, treated by resection.

Case presentation

A 75-year-old man was diagnosed with gastric cancer and referred to our department. Upper endoscopy demonstrated a 5-cm circumferential ulcerated lesion at the cardia. Biopsy findings showed a poorly differentiated tubular adenocarcinoma. He underwent laparoscopic total gastrectomy with lymph node dissection, and pathologic examination revealed a moderately differentiated tubular adenocarcinoma stage T4aN1M0 and IIIA according to the UICC (Union for International Cancer Control) classification. He refused adjuvant chemotherapy and was only carefully observed. Twenty-three months after the primary gastrectomy, computed tomography (CT) revealed an irregular mass near the port site wounds. Then the patient underwent mass resection, and the pathological diagnosis was consistent with metastatic adenocarcinoma, located in the subcutaneous tissue at the port site wounds. Thirteen months after the second surgery, CT revealed an enhanced mass in the abdominal wall. Positron emission tomography (PET) CT showed an elevated uptake in the rectus abdominis muscle and a standardized uptake value (SUV) of 3.1. The patient underwent another mass resection, and the pathological diagnosis was consistent with metastatic adenocarcinoma in the rectus abdominis muscle. Thirty-five months after the third surgery, CT revealed a mass in the left gluteal subcutaneous region. Furthermore, PET-CT revealed a 35-mm mass with an elevated SUV of 9.6. Another mass resection procedure was performed, and the pathological diagnosis was consistent with metastatic adenocarcinoma in the subcutaneous tissue. Since tumor cells were present at the resection margin, additional radiation therapy was performed. The patient has survived 78 months after primary gastrectomy.

Conclusion

The prognosis of muscular and subcutaneous metastases from gastric cancer is poor. However, if the metastatic tumor is solitary, surgical excision could be a feasible treatment option and might prolong survival.

Long-Term Results and Current Problems in Laparoscopic Gastrectomy: Single-Center Experience

Introduction: The study aims to evaluate the long-term results of patients who underwent laparoscopic gastrectomy for gastric cancer in Ankara University Medical Faculty, Surgical Oncology Clinic, within 5 years. Materials and Methods: We retrospectively reviewed the data of patients who underwent laparoscopic gastrectomy for gastric cancer at the Surgical Oncology Clinic of Ankara University Medical Faculty between January 2014 and September 2019. One hundred forty-six patients were included in the study. Results: Fifty-one (34.9%) of the patients were female; 95 (65.1%) were male. The mean ± standard deviation and median (minimum-maximum) values of the patients were 60.92 ± 14.13 and 64.00 (22.00-93.00), respectively (Table 1). Eighty-seven (59.6%) cases were located in the antrum, 29 (19.9%) were in the cardia region, and 30 (20.5%) were in the corpus region. Overall, 106 (72.6%) of 146 patients were alive, while 40 (27.4%) were ex. The mean survival was 21.8 months (0-69). Postoperative mortality was seen in 9 patients (6.2%) and our disease-free survival rate was 70.5%. Recurrence occurred in 14 (9.6%) of all patients. [Table: see text] Conclusion: In conclusion, although laparoscopic gastrectomy is a reliable and feasible method for gastric cancer, the standardization of laparoscopic surgery is required in clinics.

Surgical Treatment of Port-Site Metastases After Laparoscopic Radical Resection of Gastrointestinal Tumors

Aim: This study was performed to investigate the feasibility of surgical treatment of port-site metastasis after laparoscopic radical resection of gastrointestinal tumors. Patients and Methods: We retrospectively analyzed the clinical data and follow-up data of 8 patients with port-site metastases after gastrointestinal cancer resection in our hospital from January 2014 to January 2018. Results: Six of port-site metastases occurred within 6 months after gastrointestinal tumor resection, one of port-site metastases occurred in 10 months after the operation, and one of port-site metastases occurred in 30 months after the operation. Any metastasis to the abdominal cavity or distant metastasis was ruled out before the surgical treatment of the port-site metastases, and all patients recovered well after the extended operation. No incisional infection or incisional hernia occurred. By December 2019, 4 patients had died (they had survived for 12, 13, 18, and 24 months, respectively) and 5 patients had survived. The follow-up duration ranged from 19 to 28 months. Conclusions: Surgical resection of port-site metastases is not difficult because of their superficial location. Surgical treatment can improve the prognosis of patients without abdominal metastasis or distant metastasis/recurrence.

Long-term oncologic outcomes of a randomized controlled trial comparing laparoscopic versus open gastrectomy with D2 lymph node dissection for advanced gastric cancer

BACKGROUND

Laparoscopy-assisted gastrectomy is a feasible and safe procedure for treating advanced gastric cancer in terms of short-term outcomes. However, concern about long-term oncologic outcomes has limited the adoption of laparoscopy-assisted gastrectomy for advanced gastric cancer.

METHODS

We launched a prospective randomized controlled trial comparing laparoscopic and open gastrectomy with D2 lymph node dissection for locally advanced gastric cancer to evaluate long-term oncologic feasibility. The 5-year overall survival, disease-free survival, and tumor recurrences have been determined on an intention-to-treat basis.

RESULTS

Between January 2010 and June 2012, a total of 328 patients with preoperative clinical stage T_2-4aN_0-3M₀ gastric cancer were enrolled in the trial. We excluded 6 patients with unresected tumor, and the remaining 322 patients were randomized to the laparoscopic group (162 patients) or the open group (160 patients) for radical surgery. One patient in laparoscopy-assisted gastrectomy and 4 patients in open gastrectomy were lost to follow-up immediately after discharge, leaving 317 patients (161 in laparoscopy-assisted gastrectomy and 156 in open gastrectomy) eligible for long-term analysis. The 5-year overall survival rate was 49.0% in the laparoscopic group and 50.7% in the open group, and the 5-year disease-free survival rate was 47.2% and 49.6% in the 2 groups, respectively. Kaplan-Meier curves for overall survival and disease-free survival showed no differences between the 2 groups. There was no difference in the 5-year tumor recurrence rate between the 2 procedures.

CONCLUSION

Laparoscopy-assisted gastrectomy can provide comparable long-term survival without an increase in recurrence and metastasis in treating advanced gastric cancer.

Feasibility and Safety of Totally Laparoscopic Radical Gastrectomy for Advanced Gastric Cancer: Comparison with Early Gastric Cancer

Purpose

Totally laparoscopic gastrectomy (TLG) for advanced gastric cancer (AGC) is a technically and oncologically challenging procedure for surgeons. This study aimed to compare the oncologic feasibility and technical safety of TLG for AGC versus early gastric cancer (EGC).

Materials and Methods

Between 2011 and 2016, 535 patients (EGC, 375; AGC, 160) underwent curative TLG for gastric cancer. Clinicopathologic characteristics and surgical outcomes of both patient groups were analyzed and compared.

Results

Patients with AGC required a longer operation time and experienced more intraoperative blood loss than those with EGC did. However, patients from both the AGC and EGC groups demonstrated similar short-term surgical outcomes such as postoperative morbidity (14.4% vs. 13.3%, P=0.626), mortality (0% vs. 0.5%, P=0.879), time-to-first oral intake (2.7 days for both groups, P=0.830), and postoperative hospital stay (10.2 days vs. 10.1 days, P=0.886). D2 lymph node dissection could be achieved in the AGC group (95%), with an adequate number of lymph nodes being dissected (36.0±14.9). In the AGC group, the 3-year overall and disease-free survival rates were 80.5% and 73.7%, respectively.

Conclusions

TLG is as safe and effective for AGC as it is for EGC.

Preoperative gastric lavage in gastric cancer patients undergoing surgical, endoscopic or minimally invasive treatment: An oncological measure preventing peritoneal spillage of intragastric cancer cells and development of related metastases

In addition to classical metastatic pathways, recently gastric cancer was described having an alternative route called "endoluminal exfoliation". Provisional analyses demonstrated, in fact, this kind of shedding is associated with several clinico-pathological features indicative of aggressive behavior and resulted to be an independent prognostic factor entailing poor prognosis. Compared with non-sowing counterparts, in fact, patients affected with exfoliating early and advanced gastric carcinomas met with shorter overall survival, disease free survival, progression free survival and time to tumor progression. In spite of these interesting results, however, the clinico-pathological and oncological significance of this unconventional metastatic route is still to be clarified. Such an investigation is further urged by the increasing widespread employment of minimally invasive treatments for gastric cancer which include a wide spectrum of intragastric interventions and maneuvers. Indeed, endoscopic mucosal resection, endoscopic submucosal dissection, endoscopic full-thickness resection, intragastric laparoscopic surgery and hybrid procedures all take place inside of the stomach. However, iatrogenic perforations can occur during execution of these treatments leading to spillage of malignant cells from gastric to the peritoneal cavity or trocar insertion sites. Furthermore, many other gastric conditions and interventions can collide with endogastric presence of floating cancer cells: spontaneous ulceration or perforation, laparotomy surgery, gastrointestinal occlusion, diverticula. Viability, migration and intraluminal transportability of the intragastric floating cancer cells represents another original and intriguing topic. All these considerations led us to entertain the hypothesis that removing the exfoliated cancer cells from the gastric lumen could save patients from the dreaded potential risk of spillage. Performing gastric lavage before starting any kind of tumor intervention could be the most appropriate procedure to adopt with prophylactic intent. Should our speculation prove to be clinically significant, preoperative gastric lavage should be pointed out as a simple but cogent method useful for preventing oncological mishaps such as spillage of gastric cancer cells and development of related recurrences or metastases.

Risk factors for recurrence of gastric cancer after curative laparoscopic gastrectomy

INTRODUCTION

Curative laparoscopic gastrectomy (LG) is associated with good outcomes when performed for early gastric cancers. The aim of this study was to identify risk factors for recurrence after LG.

METHODS

212 patients with gastric cancer who underwent gastrectomy were enrolled (LG: 143, open gastrectomy, OG: 69). Univariate analysis was used to assess overall (OS) and disease-free survival (DFS) in LG and OG group. Multivariate analysis was used to assess risk factors for recurrence after LG.

RESULTS

In LG, six cases of recurrence were observed (liver: 2, peritoneum: 4). Neither lymph node nor port-site recurrences were evident after LG. The 5-year DFS after LG was 91.4%. Based on univariate analysis of 5-year DFS, three negative prognostic factors-lymph node metastasis, lymphatic invasion, and venous invasion-were identified. The independent risk factor for recurrence of LG was lymph node metastasis. LG and OG showed no significant differences in 5-year DFS among Stage IA, IB, IIA, and IIB groups. Independent risk factors for recurrence after LG or OG were tumor invasion≥muscularis mucosa and lymph node metastasis.

CONCLUSIONS

DFS following LG is comparable to that following OG. Lymph node metastasis is an independent risk factor for gastric cancer recurrence after LG. J. Med. Invest. 64: 79-84, February, 2017.

Is All Advanced Gastric Cancer Suitable for Laparoscopy-Assisted Gastrectomy With Extended Lymphadenectomy? A Case-Control Study Using a Propensity Score Method

BACKGROUND

The oncologic outcomes of laparoscopy-assisted gastrectomy (LAG) for the treatment of patients with local advanced gastric cancer (AGC) have not been evaluated. This study aimed to validate the oncologic efficacy of LAG for AGC.

METHODS

The data from 539 patients who underwent LAG and 539 patients treated with open gastrectomy (OG) were selected using the propensity score-matching method from a database prospectively constructed between 2005 and 2011. The therapeutic value of lymph node (LN) dissection and the long-term surgical outcomes of these matched groups were compared.

RESULTS

The groups were well balanced after the propensity score matched. The LAG and OG groups did not differ significantly in terms of clinicopathologic characteristics. The number of dissected LNs at stations 11 and 12a were significantly higher in the LAG group. However, the therapeutic index at each LN station did not differ significantly between the two groups. Although the overall survival curve at each stage did not differ significantly (P > 0.05), the survival rate increased overall for patients with pT4aN3bM0 in the OG group (P < 0.05). The stratified analysis showed that overall survival was inferior for LAG surgeons with fewer than 40 completed cases. The survival results for surgeons who had performed more than 40 cases were similar to the results from open surgery.

CONCLUSIONS

Although LAG yields comparable oncologic outcomes for local AGC, patients with pT4aN3bM0 gastric cancer may not be suitable for laparoscopic surgery, especially for surgeons with limited experience.

Long-Term Survival Following Port-Site Metastasectomy in a Patient with Laparoscopic Gastrectomy for Gastric Cancer: A Case Report

A 78-year-old man underwent laparoscopy-assisted total gastrectomy for gastric cancer (pT3N0M0). Multiple port sites were used, including a 10 mm port for a videoscope at the umbilical point and three other working ports. During the six-month follow-up evaluation, a 2 cm enhancing mass confined to the muscle layer was found 12 mm from the right lower quadrant port site, suggesting a metastatic or desmoid tumor. Follow-up computed tomography imaging two months later showed that the mass had increased in size to 3.5 cm. We confirmed that there was no intra-abdominal metastasis by diagnostic laparoscopy and then performed a wide resection of the recurrent mass. The histologic findings revealed poorly differentiated adenocarcinoma, suggesting a metastatic mass from the stomach cancer. The postoperative course was uneventful, and the patient completed adjuvant chemotherapy with TS-1 (tegafur, gimeracil, and oteracil potassium). There was no evidence of tumor recurrence during the 50-month follow-up period.

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.

Long-term outcomes of laparoscopic gastrectomy for gastric cancer

BACKGROUND

Laparoscopic gastrectomy (LG) has been established as a procedure for the treatment of gastric cancer. However, there have been few reports on the long-term outcomes of LG for gastric cancer. The aim of this study is to investigate the long-term outcomes of LG for gastric cancer.

METHODS

A total of 278 consecutive patients who underwent LG in our unit between January 1999 and December 2006 were included in this study. Survival, recurrence, and late gastrointestinal complications were analyzed.

RESULTS

The median follow-up period was 73.7 mo (6-165 mo). Distal gastrectomy was performed in 229 patients, total gastrectomy in 23 patients, proximal gastrectomy in 15 patients, and pylorus-preserving gastrectomy in 11 patients. Five-year overall and disease-specific survival rates were 91% and 99% for stage IA, 75% and 91% for stage IB, 72% and 88% for stage II, and 40% and 50% for stage III, respectively. Recurrences were detected in 15 (5.4%) patients, including 5 distant lymph node, 5 peritoneal, 4 hematogenous, and 1 locoregional recurrences. Bowel obstruction occurred in 4 (1.4%) patients, and gallstones developed in 37 (15%) patients.

CONCLUSIONS

This follow-up investigation suggested that LG for gastric cancer is a feasible procedure from the standpoint of long-term oncological outcome and postoperative complications.

Patterns, timing and risk factors of recurrence of gastric cancer after laparoscopic gastrectomy: reliable results following long-term follow-up

BACKGROUND

To clarify the patterns, timing and risk factors of recurrence of gastric cancer after laparoscopic gastrectomy.

METHODS

From January 1999 to March 2012, 577 patients underwent laparoscopic or laparoscopy-assisted gastrectomy for curative resection of gastric cancer. Recurrence patterns were classified as locoregional, hematogenous, peritoneal, distant lymph node and mixed. Recurrence patterns and time to recurrence were retrospectively examined and risk factors for recurrence were analyzed.

RESULTS

Recurrence occurred in 28 (4.9%) cases with patterns as follows: locoregional in 2 patients (7.1%), hematogenous in seven (25.0%), peritoneal in nine (32.1%), distant lymph node in four (14.3%), and mixed in 6 (21.4%). There was no recurrence pattern peculiar to laparoscopic surgery. Recurrence occurred at one site in 21 patients (78.6%), two in 4 patients (14.3%), and three in 2 patients (7.1%). The median time to recurrence was 384 days (range 83-1497 days). Recurrence was detected within a year in 13 cases (46.4%), within two years in 21 (75%), and within three years in 25 (89.3%). Univariate analysis revealed tumor location, tumor size, type of operation, tumor depth, and lymph node classification as risk factors for recurrence. Multivariate analysis indicated tumor depth and lymph node classification as risk factors of recurrence.

CONCLUSIONS

Patterns, timing and risk factors of recurrence of gastric cancer after laparoscopic gastrectomy are similar to those after open gastrectomy, with no peculiarities specific to laparoscopic gastrectomy. Thus, as long as laparoscopic gastrectomy is performed according to the present inclusion criteria, follow-up can be similarly performed as for open gastrectomy.

Systematic review of laparoscopy-assisted versus open gastrectomy for advanced gastric cancer

OBJECTIVE

The study compared laparoscopy-assisted gastrectomy (LAG) with open gastrectomy (OG) in the management of advanced gastric cancer (AGC).

METHODS

Literature search was performed in the Medline, Embase, and Cochrane Library databases to identify control studies that compared LAG and OG for AGC. A meta-analysis was conducted to examine the surgical safety and oncologic adequacy, using the random-effect model.

RESULTS

Seven eligible studies including 815 patients were analyzed. LAG was associated with less blood loss, less use of analgesics, shorter time of flatus and periods of hospital stay, but longer time of operation. The incidence of most complications was similar between the two groups. However, LAG was associated with a lower rate of pulmonary infection (odds ratio (OR) 0.19; 95% confidence interval (CI) 0.05 to 0.68; P<0.05). No significant differences were noted in terms of the number of harvested lymph nodes (weighted mean difference (WMD) 1.165; 95% CI -2.000 to 4.311; P>0.05), overall mortality (OR 0.65; 95% CI 0.39 to 1.10; P>0.05), cancer-related mortality (OR 0.64; 95% CI 0.32 to 1.25; P>0.05), or recurrence (OR 0.62; 95% CI 0.33 to 1.16; P>0.05).

CONCLUSIONS

LAG could be performed safely for AGC with adequate lymphadenectomy and has several short-term advantages compared with conventional OG. No differences were found in long-term outcomes. However, these results should be validated in large randomized controlled studies (RCTs) with sufficient follow-up.

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.

A propensity score-matched case-control comparative study of laparoscopic and open extended (D2) lymph node dissection for distal gastric carcinoma

BACKGROUND

Technical proficiency at laparoscopic D2 lymph node dissection (LND) is essential for extending the use of laparoscopic surgery beyond the treatment of early gastric cancer (EGC). The aim of this study was to evaluate the technical and oncological feasibility of laparoscopic distal gastrectomy (LDG) with D2 LND for distal gastric cancer.

METHODS

Of 922 patients who underwent open or LDG with D2 LND for gastric carcinoma, 133 treated by LDG and 133 treated by open distal gastrectomy (ODG) were selected using the propensity score matching method. The short-term surgical outcomes and long-term survivals of these matched groups were compared.

RESULTS

The two study groups were well matched with respect to age, sex, body mass index, comorbidity, ASA score, abdominal operation history, and tumor stage. The LDG group had a significantly longer mean operating time (227 vs. 161 min, p < 0.001) but showed significantly less intraoperative blood loss (149 vs. 189 ml, p = 0.007). Total numbers of collected lymph nodes were similar in the two groups. Postoperatively, no significant intergroup differences were found for hospital stay, morbidity, or mortality. Furthermore, overall survivals were similar in the two groups (p = 0.621). Multivariate analysis showed that male gender, age ≥70 years, and intraoperative blood loss of ≥200 ml were independent risk factors of postoperative morbidity.

CONCLUSIONS

Laparoscopic D2 LND for distal gastric cancer is technically safe and feasible compared with ODG. A prospective randomized trial is warranted to evaluate long-term oncological outcomes in advanced gastric carcinoma.

Clinical experience of 528 laparoscopic gastrectomies on gastric cancer in a single institution

BACKGROUND

Laparoscopic gastrectomy (LG) for locally advanced gastric cancer (AGC) as well as early gastric cancer (EGC) has gradually gained popularity. However, long-term experiences of LG for AGC as well as EGC rarely have been reported.

METHODS

A total of 528 patients with gastric cancer were enrolled in the study, and clinical experiences of LG were evaluated.

RESULTS

The study included 332 men and 196 women. The mean age was 61.3 ± 11.8 years. Of the 528 patients, 432 underwent distal gastrectomy, 87 had a total gastrectomy, and 9 had a proximal gastrectomy. There were 198 T1a, 139 T1b, 63 T2, 83 T3, and 45 T4a lesions. In 127 patients, lymph node metastasis was observed, and the rate of it was 1.5% in T1a, 12.2% in T1b, 34.9% in T2, 59.0% in T3, and 80.0% in T4a. The median follow-up period was 24 months (range, 1-83 months). The 5-year survival and disease-free survival rates according to the stage of tumor were 99.3% and 97.8% in stage I, 95.4% and 89.7% in stage II, and 44.4% and 31.3% in stage III, respectively. Operation related morbidities occurred in 45 patients, and there were 2 mortalities. Tumors recurred in 36 patients consisting of 2 in T1a, 2 T1b, 2 T2, 12 T3, and 18 T4a. Carcinomatosis peritonei was observed most commonly.

CONCLUSION

In our experience, oncologic results and the safety of LG for EGC and serosa-negative AGC were acceptable. This treatment may be considered as an alternative operative approach.

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.

Diagnosis of a trocar site mass as omental herniation after laparoscopic gastrectomy

A trocar site hernia is a rare complication. We report a patient who had an abdominal wall mass at a previous trocar site after laparoscopic distal gastrectomy. It was diagnosed as omental herniation and fat necrosis. We conclude that patients with trocar site masses exhibiting fat density on a computed tomography scan could be followed up without surgery, and that fascial defects located at 10-mm or larger trocar sites should be closed whenever possible to prevent hernia formation.

Laparoscopic gastrectomy for patients with advanced gastric cancer produces oncologic outcomes similar to those for open resection

BACKGROUND

Laparoscopic gastrectomy has gained acceptance as treatment for early gastric cancer. However, its role for advanced gastric cancer remains unclear. This study aimed to compare the oncologic outcomes between laparoscopic and open gastrectomy in the management of advanced gastric cancer for patients receiving adjuvant chemoradiotherapy.

METHODS

This study reviewed consecutive patients treated with gastric cancer resection and adjuvant chemoradiation (45 Gy/25 with 5-fluorouracil [FU]-based chemotherapy), at a quaternary care comprehensive cancer center between 1 Jan 2000 and 30 Nov 2009. Of 203 patients, 21 were treated with laparoscopic gastrectomy. These patients were compared with patients who had open surgery and evaluated for overall survival, relapse-free survival, and site of first disease recurrence.

RESULTS

The 21 patients in the laparoscopic group had a median age of 61.3 years (range, 28.2-76.6 years) and a median follow-up period of 21.3 months (range, 6.7-50.4 months). The majority of the patients (71%) were men. Most of these patients had tumor node metastasis (TNM) v6 stage 2 (33%) or 3 (52%) disease as classified by the American Joint Committee on Cancer (AJCC) and the Union for International Cancer Control (UICC). The demographic characteristics of the laparoscopic and open groups were similar. The incidence of recurrence was 38.1% (8/21) in the laparoscopic group and 36.8% (67/182) in the open group. In the laparoscopic group, the site of first recurrence was distant in three patients, peritoneal in four patients, and mixed in one patient (locoregional and distant). The recurrence patterns did not differ significantly between the laparoscopic and open surgery groups. In the open group, recurrence was distant in 26 patients, peritoneal in 12 patients, and locoregional in 15 patients. At presentation, 14 patients showed a mixed pattern. The 3-year relapse-free survival rate was 58% (range, 50-66%), and the difference between the two groups by Gray's test was not significant (P = 0.32). The 3-year overall survival rate was 65.9% (range, 58-73%) and did not differ significantly between the two groups in the univariate (P = 0.92) or multivariate (P = 0.54) analysis.

CONCLUSION

The study findings suggest that laparoscopic gastrectomy is an oncologically safe procedure for advanced gastric cancer with outcomes similar to those for open resection.

Auxiliary partial orthotopic liver transplantation for adult onset type II citrullinemia

Adult-onset type II citrullinemia (CTLN2) is a disorder caused by an inborn error of metabolism affecting the liver. CTLN2 is an autosomal recessive disorder characterized by recurrent encephalopathy with hyperammonemia due to highly elevated plasma levels of citrulline and ammonia, caused by a deficiency of argininosuccinate synthetase in the liver. A small number of patients have undergone liver transplantation with favorable results. In Korea, the limitations of the deceased donor pool have made living donor liver transplantation a common alternative treatment option. We report the case of a patient with type II citrullinemia who was treated successfully with auxiliary partial orthotopic liver transplantation (APOLT) from a living donor. This is the first description of an APOLT for a patient with adult onset type II citrullinemia in Korea.

Gasless laparoscopy-assisted distal gastrectomy for early gastric cancer: analysis of initial results

BACKGROUND

Laproscopic surgery is widely used in treating gastrointestinal disease. This study investigated the clinical result, short-term outcomes, and cost analysis of the newly developed gasless laparoscopy-assisted distal gastrectomy (GLADG) and compared it with conventional open distal gastrectomy (ODG).

METHODS

Seventy-five patients underwent distal gastrectomy with radical lymph node dissection for early gastric cancer from December 2005 to January 2008. Thirty-one patients underwent GLADG and 44 underwent ODG. Postoperative pain, morphine use, disease-free and overall survival, and surgical and hospital costs were measured postoperatively and compared between the two groups.

RESULTS

Patients in the two groups were comparable by age, sex, body mass index, tumor size, tumor location, cancer staging, and operative time. The GLADG group had early start of oral intake and shorter postoperative hospital stay (P < .05). There was less morphine use from postoperative day 1 to 4 in the GLADG group than in the ODG group (P < .05), and body temperature from postoperative day 1 to 2 was lower in the GLADG than in the ODG group (P < .05). Cost analysis showed that operation cost (100,242 ± 5385 versus 36,455 ± 1419) and equipment cost (65,909 ± 5385 versus 2122 ± 1419) was higher in the GLADG group, but its total hospital cost (193,552 ± 12,715 versus 206,676 ± 41,920) was lower than in the ODG group (P < .05). The 2-year disease-free and overall survival rates were not different between the two groups.

CONCLUSIONS

GLADG is feasible for early gastric cancer. It is advantageous because of less pain, less postoperative inflammatory response, less blood loss, and shorter total hospital stay while achieving the same oncologic results as ODG.

A case-control study of laparoscopy-assisted and open distal gastrectomy for advanced gastric cancer

BACKGROUND

The application of laparoscopy-assisted gastric surgery has been increasing rapidly for the treatment of early gastric cancer. However, there were few reports of laparoscopic surgery in the management of advanced gastric cancer (AGC), especially with T3 depth of invasion. The aim of this study was to compare the technical feasibility and oncologic efficacy of laparoscopy-assisted distal gastrectomy (LADG) versus open distal gastrectomy (ODG) for advanced gastric cancer.

METHODS

A retrospective case-control study was performed comparing LADG and ODG for AGC. Thirty-five consecutive patients with AGC undergoing LADG between August 2005 and December 2007 were enrolled and these patients were compared with 35 AGC patients undergoing ODG during the same period.

RESULTS

Forty-two (60.0%) patients were T3 in terms of depth of invasion. Tumor location and histology were similar between the two groups. Operation time was significantly longer in the LADG group than in the ODG group. Estimated blood loss was significantly less in the LADG group. Hospital length of stay after LADG was significantly shorter than in the open group. Postoperative pain was significantly lower for laparoscopic patients. There were no significant differences in postoperative early and late complication and in the number of lymph nodes retrieved between the two groups, and the cumulative survival of the two groups was similar.

CONCLUSION

Our data indicate that LADG for AGC, mostly with T3 depth of invasion, yields good oncologic outcomes including the similar early and late complication and the cumulative survival between the two groups after 50 months of follow-up. To be accepted as a choice treatment for advanced distal gastric cancer, well-designed prospective trial to assess long-term outcomes is necessary.

Laparoscopy-assisted total gastrectomy for advanced gastric cancer with carcinomatous ascites after S1 plus cisplatin chemotherapy: a case report

A 29-year-old man with a type 4 tumor, in the lower third of the stomach, and carcinomatous ascites was diagnosed by aspiration cytology of the ascitic fluid. Curative resection was considered impossible, and S1 (120 mg/d) and cisplatin (90 mg/d) were given for 21 days in 1 course. The cancer lesion showed marked remission (partial response), and the ascites completely disappeared after the fourth course. Twenty-five days after completion of the S1 treatment, laparoscopy-assisted total gastrectomy was performed. Histopathological examination showed no remnant cancer cells in the resected specimen and no lymph node metastases. The tumor was replaced with fibrosis having a granulomatous change. The patient's postoperative course was uneventful. The patient was continued with S1 monotherapy after surgery, and no signs of recurrence or metastases have been seen on any examination 12 months after the surgery.

Risk of recurrence after laparoscopy-assisted radical gastrectomy for gastric cancer performed by a single surgeon

BACKGROUND

The risk of recurrence after laparoscopy-assisted radical gastrectomy (LAG) was investigated.

MATERIALS AND METHODS

Clinical data of 398 consecutive patients who underwent radical gastrectomy with R0 resection for gastric cancer at Gyeongsang National University Hospital between January 2005 and December 2007 were reviewed retrospectively.

RESULTS

Of the patients, 65.4% (n = 261) and 34.6% (n = 138) underwent LAG and open radical gastrectomy (OG), respectively. Of the LAG cases, 73.2% (n = 192), 10.7% (n = 28), 12.6% (n = 33), and 3.1% (n = 8) had stage I, II, III, and IV gastric cancer, respectively. All patients were followed up for a mean of 36.8 ± 13.7 months, and 14.6% (n = 58) had recurrence during the follow-up period. Univariate analysis revealed that tumor size, tumor-node-metastasis (TNM) stage, method of approach (LAG versus OG), and operation type were associated significantly with recurrence. Multivariate analysis revealed that only high TNM stage was significantly associated with recurrence (P = 0.00). While patients who underwent OG had higher incidence of recurrence than patients who underwent LAG, OG was not significantly associated with recurrence on multivariate analysis (P = 0.06).

CONCLUSIONS

LAG and OG did not differ significantly in terms of recurrence, even when used in advanced gastric cancer cases. Multivariate analysis revealed that high TNM stage was significantly associated with recurrence. Thus, LAG appears to be a safe and feasible procedure that has the potential to be an alternative to open surgery, even for advanced gastric cancer.

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.

Recurrence following laparoscopy-assisted gastrectomy for gastric cancer: a multicenter retrospective analysis of 1,417 patients

BACKGROUND

The risk of recurrence and recurrence patterns after laparoscopy-assisted gastrectomy for gastric cancer remain unclear. The objective of this study is to assess recurrence and its timing, patterns, and risk factors following laparoscopy-assisted gastrectomy from multicenter data.

METHODS

A retrospective multicenter study was performed using data from 1,485 patients who had undergone laparoscopy-assisted gastrectomy for gastric cancer at ten institutions from 1998 to 2005. Recurrence and its timing and patterns were reviewed. Univariate and multivariate analyses were performed to identify risk factors for recurrence.

RESULTS

Excluding 68 patients (9 postoperative mortalities, 1 synchronous distant metastasis, 2 nonadenocarcinomas, and 56 losses to follow-up), 50 of 1,417 patients (3.5%) had recurrences. Incidence of recurrence was 1.6% (19/1186) in early gastric cancer and 13.4% (31/231) in advanced gastric cancer. Recurrence occurred in 34 of 50 patients (68.0%) within 2 years of surgery, and in 45 of 50 patients (90.0%) within 3 years. The recurrence pattern was hematogenous in 17 patients (34.0%), peritoneal in 11 (22.0%), locoregional in 10 (20.0%), distant lymph nodes in 2 (4.0%), and mixed in 10 (20.0%). Advanced T-classification and lymph node metastases were risk factors for recurrence.

CONCLUSIONS

Laparoscopy-assisted gastrectomy showed satisfactory long-term oncologic outcomes similar to those of open surgery. The study provides additional evidence suggesting that laparoscopy-assisted gastrectomy is a good alternative to open gastrectomy in patients with gastric cancer of relatively early stage, although results of a randomized controlled trial and more long-term follow-up are needed to provide conclusive evidence.

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.

Laparoscopy-assisted distal gastrectomy with D2 lymphadenectomy for T2b advanced gastric cancers: three years' experience

BACKGROUND

The application of laparoscopy-assisted distal gastrectomy (LADG) with advanced gastric cancer (AGC) is a controversial. The purpose of this study was to assess the possibility of using LADG application to AGC.

METHODS

Of 160 patients who underwent LADG with D2 lymphadenectomy between April 2004 and March 2007, 26 patients with stage pT2b were selected and compared to 25 patients of the same stage who underwent open distal gastrectomy (ODG) within same period. The comparison was based on the clinicopathologic characteristics, surgical outcome, and follow-up results.

RESULTS

There was no significant difference between LADG and ODG groups in most operation results including complication rates (15.4% vs. 16.0%, P = 1.000) except for less average loss of blood (160.0 ml vs. 215.0 ml, P = 0.012) and longer average operating time (255.0 min vs. 190.0 min, P < 0.001) in LADG. Three-year overall survival rates (88.2% vs. 77.2%; P = 0.246) and disease-free survival rates (71.4% vs. 53.4%; P = 0.757) were not significantly different in LADG and ODG groups.

CONCLUSIONS

The early results of current study suggest that LADG for AGC is technically safe and oncologically feasible. Therefore, LADG should be considered as a curative treatment for AGC not exposed to serosa.

Robot-assisted laparoscopic gastrectomy with D2 dissection for adenocarcinoma: initial experience with 17 patients

Robot-assisted gastrectomy has been practised so far in very few centres in the world. The aims of this study were to assess the feasibility of robot-assisted gastrectomy for adenocarcinoma with D2 lymph nodal dissection and to analyze our preliminary results. Between January 2006 and August 2008, as many as 17 patients (11 females, 6 males) underwent laparoscopic robot-assisted surgery for non-metastatic adenocarcinoma of the stomach by a 3-armed da Vinci(®) Robotic Surgical System. The mean age of patients was 65.9 years. This series included eight patients with early gastric cancer (EGC) and nine with advanced gastric cancer (AGC). A 4/5 laparoscopic subtotal gastrectomy (LSG) with D2 nodal clearance was the procedure of choice for 16 distal cancers. Laparoscopic total gastrectomy (LTG) with D2 lymphadenectomy was performed for one AGC of the middle third of the stomach. No intraoperative complication was registered. Conversion to laparotomy was required in two patients with distal cancer. The mean operating time (excluding converted patients) was 352 min (348 for LSG). Morbidity consisted in one pancreatic leak that healed conservatively. One death occurred postoperatively for haemorragic stroke. On average, 25.5 ± 4 lymph nodes were collected (range 10-40). The resection margin was 6.4 ± 0.6 cm (range 4.2-8), and the margin was tumour free in all the specimens. The mean hospital stay of totally laparoscopic subtotal gastrectomy was 10 ± 1.2 days (range 8-13). The mean follow-up was 14 months (range 1-29) and three patients with AGC showed recurrence after LSG and died of disease. Robotics in gastrectomy for cancer is a feasible and safe procedure, yielding adequate D2 nodal clearance with respect of oncologic principles. Robotic techniques can represent a remarkable tool to improve laparoscopic surgeon's ability and precision in small surgical fields, i.e. during D2 dissection. This study demonstrated the feasibility of robot-assisted gastrectomy for cancer although further studies are required to validate our preliminary results, especially as far as patients' benefits are concerned.

Outcomes and survival after laparoscopic gastrectomy for adenocarcinoma. Analysis on 65 patients operated on by conventional or robot-assisted minimal access procedures

AIMS

Despite laparoscopic surgery for gastric cancer has gained worldwide acceptance, long term results and survival are seldom reported. This study was designed to assess long term outcomes after laparoscopic gastrectomy with D2 dissection. The short term results of conventional and robot-assisted minimally invasive procedures were also examined.

PATIENTS AND METHODS

The charts of 65 patients who underwent laparoscopic surgery for non-metastatic adenocarcinoma were reviewed retrospectively. This series included 35 patients with early gastric cancer (EGC) and 30 with advanced gastric cancer (AGC). A 4/5 laparoscopic subtotal gastrectomy (LSG) with D2 nodal clearance was the procedure of choice for distal cancers. Laparoscopic total gastrectomy (LTG) with modified D1 lymphadenectomy was performed for mid-proximal EGC.

RESULTS

Sixty gastrectomies were carried out laparoscopically, 56 LSG and 4 LTG. Conversion to laparotomy was required in 5 patients with distal cancer. No intraoperative complication was registered. Morbidity included 2 duodenal leaks that healed conservatively. Two postoperative deaths were registered. An average number 31.3+/-8.8 lymph nodes were collected. The mean hospital stay was 10 days (range 7-24). The mean follow up was 30 months (range 2-86) and the cumulative overall 5 year survival rate was 78%. Survival at 5 years for EGC was 94% and survival at 4 years for AGC was 53% (57% for non-converted patients).

CONCLUSIONS

Laparoscopic gastrectomy for cancer represents a valid alternative to open surgery with minimal morbidity and acceptable long term survival. Considering the risk of preoperative under diagnoses a D2 lymphadenectomy is suggested also for EGC. This study validated the effectiveness of minimally invasive technique in the management of gastric cancer.