1
|
Park DJ, Han SU, Hyung WJ, Hwang SH, Hur H, Yang HK, Lee HJ, Kim HI, Kong SH, Kim YW, Lee HH, Kim BS, Park YK, Lee YJ, Ahn SH, Lee I, Suh YS, Park JH, Ahn S, Park YS, Kim HH. Effect of Laparoscopic Proximal Gastrectomy With Double-Tract Reconstruction vs Total Gastrectomy on Hemoglobin Level and Vitamin B12 Supplementation in Upper-Third Early Gastric Cancer: A Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2256004. [PMID: 36790808 PMCID: PMC9932836 DOI: 10.1001/jamanetworkopen.2022.56004] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Abstract
IMPORTANCE Patients undergoing proximal gastrectomy (PG) with double-tract reconstruction (DTR) have been reported to have an incidence of reflux esophagitis that is as low as that observed after total gastrectomy (TG). It is unclear whether PG has an advantage over TG for the treatment of patients with upper early gastric cancer (GC). OBJECTIVE To evaluate the effect of laparoscopic PG with DTR (LPG-DTR) vs laparoscopic TG (LTG) on levels of hemoglobin and vitamin B12 supplementation required among patients with clinically early GC in the upper third of the stomach (upper-third early GC). DESIGN, SETTING, AND PARTICIPANTS This multicenter open-label superiority randomized clinical trial was conducted at 10 institutions in Korea. A total of 138 patients with upper-third cT1N0M0 GC were enrolled between October 27, 2016, and September 9, 2018. Follow-up ended on December 3, 2020. INTERVENTIONS Patients were randomized to undergo either LPG-DTR or LTG. MAIN OUTCOMES AND MEASURES The primary co-end points were change in hemoglobin level and cumulative amount of vitamin B12 supplementation at 2 years after LPG-DTR or LTG. The secondary end points included morbidity, postoperative reflux esophagitis, quality of life, overall survival, and disease-free survival. Quality of life outcomes were assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ) 30-item core questionnaire (C30) and the EORTC QLQ stomach cancer-specific questionnaire at 3 months, 12 months, and 24 months. RESULTS Among 138 patients (mean [SD] age, 60.0 [10.9] years; 87 men [63.0%]; all of Asian race and Korean ethnicity), 68 (mean [SD] age, 56.7 [10.4] years; 39 men [57.4%]) were randomized to receive LPG-DTR and 69 (mean [SD] age, 61.3 [11.3] years; 48 men [69.6%]) were randomized to receive LTG. The mean (SD) changes in hemoglobin levels from baseline to month 24 were -5.6% (7.4%) in the LPG-DTR group and -6.9% (8.3%) in the LTG group, for an estimated difference of -1.3% (95% CI, -4.0% to 1.4%; P = .35). The mean (SD) cumulative amount of vitamin B12 supplementation was 0.4 (1.3) mg in the LPG-DTR group and 2.5 (3.0) mg in the LTG group, for an estimated difference of 2.1 mg (95% CI, 1.3-2.9 mg; P < .001). The late complication rates in the LPG-DTR and LTG groups were 17.6% and 10.1%, respectively (P = .31). The incidence of reflux esophagitis was not different between the LPG-DTR and LTG groups (2.9% vs 2.9%; P = .99). Compared with the LTG group, the LPG-DTR group had better physical functioning scores (85.2 [15.6] vs 79.9 [19.3]; P = .03) and social functioning scores (89.5 [17.9] vs 82.4 [19.4]; P = .03) on the EORTC QLQ-C30. Two-year overall survival (98.5% vs 100%; P = .33) and disease-free survival (98.5% vs 97.1%; P = .54) did not significantly differ between the LPG-DTR vs LTG groups. CONCLUSIONS AND RELEVANCE In this study, patients with upper-third early GC who received LPG-DTR required less vitamin B12 supplementation than those who received LTG, with no increase in complication rates and no difference in overall and disease-free survival rates. There was no difference in change in hemoglobin level between groups. In addition, the LPG-DTR group had better physical and social functioning than the LTG group. These findings suggest that LPG-DTR may be as safe as LTG and may be a function-preserving procedure for the treatment of patients with upper-third early GC. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02892643.
Collapse
Affiliation(s)
- Do Joong Park
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Sang-Uk Han
- Department of Surgery, Ajou University Hospital, Suwon, Gyenggi, Republic of Korea
| | - Woo Jin Hyung
- Department of Surgery, Yonsei University Severance Hospital, Seoul, Republic of Korea
| | - Sun-Hwi Hwang
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Gyeongsangnam-do, Republic of Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Gyeongsangnam-do, Republic of Korea
| | - Hoon Hur
- Department of Surgery, Ajou University Hospital, Suwon, Gyenggi, Republic of Korea
| | - Han-Kwang Yang
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyuk-Joon Lee
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyoung-Il Kim
- Department of Surgery, Yonsei University Severance Hospital, Seoul, Republic of Korea
| | - Seong-Ho Kong
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young Woo Kim
- Center for Gastric Center, National Cancer Center, Goyang, Gyeonggi, Republic of Korea
| | - Han Hong Lee
- Department of Surgery, Catholic University of Seoul St Mary’s Hospital, Seoul, Republic of Korea
| | - Beom Su Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young-Kyu Park
- Department of Surgery, Chonnam National University College of Medicine, Hwasun, Republic of Korea
| | - Young-Joon Lee
- Department of Surgery, Gyeongsang National University School of Medicine, Jinju, Republic of Korea
| | - Sang-Hoon Ahn
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Inseob Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yun-Suhk Suh
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Ji-Ho Park
- Department of Surgery, Gyeongsang National University School of Medicine, Jinju, Republic of Korea
| | - Soyeon Ahn
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Young Suk Park
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Hyung-Ho Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| |
Collapse
|
2
|
Kim TH, Kim IH, Kang SJ, Choi M, Kim BH, Eom BW, Kim BJ, Min BH, Choi CI, Shin CM, Tae CH, Gong CS, Kim DJ, Cho AEH, Gong EJ, Song GJ, Im HS, Ahn HS, Lim H, Kim HD, Kim JJ, Yu JI, Lee JW, Park JY, Kim JH, Song KD, Jung M, Jung MR, Son SY, Park SH, Kim SJ, Lee SH, Kim TY, Bae WK, Koom WS, Jee Y, Kim YM, Kwak Y, Park YS, Han HS, Nam SY, Kong SH. Korean Practice Guidelines for Gastric Cancer 2022: An Evidence-based, Multidisciplinary Approach. J Gastric Cancer 2023; 23:3-106. [PMID: 36750993 PMCID: PMC9911619 DOI: 10.5230/jgc.2023.23.e11] [Citation(s) in RCA: 70] [Impact Index Per Article: 70.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 01/22/2023] [Accepted: 01/25/2023] [Indexed: 02/09/2023] Open
Abstract
Gastric cancer is one of the most common cancers in Korea and the world. Since 2004, this is the 4th gastric cancer guideline published in Korea which is the revised version of previous evidence-based approach in 2018. Current guideline is a collaborative work of the interdisciplinary working group including experts in the field of gastric surgery, gastroenterology, endoscopy, medical oncology, abdominal radiology, pathology, nuclear medicine, radiation oncology and guideline development methodology. Total of 33 key questions were updated or proposed after a collaborative review by the working group and 40 statements were developed according to the systematic review using the MEDLINE, Embase, Cochrane Library and KoreaMed database. The level of evidence and the grading of recommendations were categorized according to the Grading of Recommendations, Assessment, Development and Evaluation proposition. Evidence level, benefit, harm, and clinical applicability was considered as the significant factors for recommendation. The working group reviewed recommendations and discussed for consensus. In the earlier part, general consideration discusses screening, diagnosis and staging of endoscopy, pathology, radiology, and nuclear medicine. Flowchart is depicted with statements which is supported by meta-analysis and references. Since clinical trial and systematic review was not suitable for postoperative oncologic and nutritional follow-up, working group agreed to conduct a nationwide survey investigating the clinical practice of all tertiary or general hospitals in Korea. The purpose of this survey was to provide baseline information on follow up. Herein we present a multidisciplinary-evidence based gastric cancer guideline.
Collapse
Affiliation(s)
- Tae-Han Kim
- Department of Surgery, Gyeongsang National University Changwon Hospital, Changwon, Korea
| | - In-Ho Kim
- Division of Medical Oncology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seung Joo Kang
- Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam Center Seoul, Seoul, Korea
| | - Miyoung Choi
- National Evidence-based Healthcare Collaborating Agency (NECA), Seoul, Korea
| | - Baek-Hui Kim
- Department of Pathology, Korea University Guro Hospital, Seoul, Korea
| | - Bang Wool Eom
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Bum Jun Kim
- Division of Hematology-Oncology, Department of Internal Medicine, Hallym University Medical Center, Hallym University College of Medicine, Anyang, Korea
| | - Byung-Hoon Min
- Department of Medicine, Samsung Medical Center, Seoul, Korea
| | - Chang In Choi
- Department of Surgery, Pusan National University Hospital, Pusan, Korea
| | - Cheol Min Shin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seungnam, Korea
| | - Chung Hyun Tae
- Department of Internal Medicine, Ewha Woman’s University College of Medicine, Seoul, Korea
| | - Chung sik Gong
- Division of Gastrointestinal Surgery, Department of Surgery, Asan Medical Center and University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Jin Kim
- Department of Surgery, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | | | - Eun Jeong Gong
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Geum Jong Song
- Department of Surgery, Soonchunhyang University, Cheonan, Korea
| | - Hyeon-Su Im
- Department of Hematology and Oncology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Hye Seong Ahn
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Hyun Lim
- Department of Gastroenterology, Hallym University Sacred Heart Hospital, University of Hallym College of Medicine, Anyang, Korea
| | - Hyung-Don Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae-Joon Kim
- Division of Hematology-Oncology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jeong Il Yu
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, Korea
| | - Jeong Won Lee
- Department of Nuclear Medicine, Catholic Kwandong University, College of Medicine, Incheon, Korea
| | - Ji Yeon Park
- Department of Surgery, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jwa Hoon Kim
- Division of Oncology, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Kyoung Doo Song
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University, Seoul, Korea
| | - Minkyu Jung
- Division of Medical Oncology, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
| | - Mi Ran Jung
- Department of Surgery, Chonnam National University Medical School, Gwangju, Korea
| | - Sang-Yong Son
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Shin-Hoo Park
- Department of Surgery, Korea University Anam Hospital, Seoul, Korea
| | - Soo Jin Kim
- Department of Radiology, National Cancer Center, Goyang, Korea
| | - Sung Hak Lee
- Department of Hospital Pathology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Tae-Yong Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Woo Kyun Bae
- Division of Hematology-Oncology, Department of Internal Medicine, Chonnam National University Medical School and Hwasun Hospital, Hwasun, Korea
| | - Woong Sub Koom
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Yeseob Jee
- Department of Surgery, Dankook University Hospital, Cheonan, Korea
| | - Yoo Min Kim
- Department of Surgery, Severance Hospital, Seoul, Korea
| | - Yoonjin Kwak
- Department of Pathology, Seoul National University Hospital, Seoul, Korea
| | - Young Suk Park
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hye Sook Han
- Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea.
| | - Su Youn Nam
- Department of Internal Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea.
| | - Seong-Ho Kong
- Department of Surgery, Seoul National University Hospital and Seoul National University College of Medicine Cancer Research Institute, Seoul, Korea.
| | | |
Collapse
|
3
|
Park DJ, Park YS, Ahn SH, Kim HH. [Laparoscopic Proximal Gastrectomy as a Surgical Treatment for Upper Third Early Gastric Cancer]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2018; 70:134-140. [PMID: 28934829 DOI: 10.4166/kjg.2017.70.3.134] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Recently, the incidence of upper third gastric cancer has increased, and with it the number of endoscopic submucosal dissection (ESD) procedures performed has been increasing. However, if ESD is not indicated or non-curable, surgical treatment may be necessary. In the case of lower third gastric cancer, it is possible to preserve the upper part of the stomach; however, in the case of upper third gastric cancer, total gastrectomy is still the standard treatment option, regardless of the stage. This is due to the complications associated with upper third gastric cancer, such as gastroesophageal reflux after proximal gastrectomy rather than oncologic problems. Recently, the introduction of the double tract reconstruction method after proximal gastrectomy has become one of the surgical treatment methods for upper third early gastric cancer. However, since there has not been a prospective comparative study evaluating its efficacy, the ongoing multicenter prospective randomized controlled trial (KLASS-05) comparing laparoscopic proximal gastrectomy with double tract reconstruction and laparoscopic total gastrectomy is expected to be important for determining the future of treatment of upper third early gastric cancer.
Collapse
Affiliation(s)
- Do Joong Park
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.,Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Young Suk Park
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sang Hoon Ahn
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hyung Ho Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.,Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| |
Collapse
|
4
|
Kubota K, Suzuki A, Fujikawa A, Watanabe T, Sekido Y, Shiozaki H, Taketa T, Shimada G, Ohigashi S, Sakurai S, Kishida A. Modified esophagogastrostomy in laparoscopy-assisted proximal gastrectomy: A reverse-Tornado anastomosis. Asian J Endosc Surg 2017; 10:12-16. [PMID: 27766753 DOI: 10.1111/ases.12335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Revised: 07/30/2016] [Accepted: 08/15/2016] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The aim of this study was to introduce and examine a modified mechanical end-to-side esophagogastrostomy method ("reverse-Tornado" anastomosis) in laparoscopy-assisted proximal gastrectomy. METHODS Five patients with gastric cancer who underwent laparoscopy-assisted proximal gastrectomy were analyzed retrospectively. Esophagogastrostomy in the anterior wall was performed in three patients, and esophagogastrostomy in the posterior wall was performed in two patients. Clinicopathological features, operative outcomes (operative time, operative blood loss), and postoperative outcomes (complications, postoperative hospital stay, reflux esophagitis) were evaluated. RESULTS Operative time was normal (278 min). There was no marked operative blood loss, postoperative complications, prolonged hospital stay, or reflux esophagitis. CONCLUSION Esophagogastrostomy was completed in a normal time with reverse-Tornado anastomosis. This method can be safe and can enable good postoperative quality of life.
Collapse
Affiliation(s)
- Keisuke Kubota
- Department of Gastroenterological Surgery, St. Luke's International Hospital, Tokyo, Japan
| | - Akihiro Suzuki
- Department of Gastroenterological Surgery, St. Luke's International Hospital, Tokyo, Japan
| | - Aoi Fujikawa
- Department of Gastroenterological Surgery, St. Luke's International Hospital, Tokyo, Japan
| | - Takayuki Watanabe
- Department of Gastroenterological Surgery, St. Luke's International Hospital, Tokyo, Japan
| | - Yuki Sekido
- Department of Gastroenterological Surgery, St. Luke's International Hospital, Tokyo, Japan
| | - Hironori Shiozaki
- Department of Gastroenterological Surgery, St. Luke's International Hospital, Tokyo, Japan
| | - Takashi Taketa
- Department of Gastroenterological Surgery, St. Luke's International Hospital, Tokyo, Japan
| | - Gen Shimada
- Department of Gastroenterological Surgery, St. Luke's International Hospital, Tokyo, Japan
| | - Seiji Ohigashi
- Department of Gastroenterological Surgery, St. Luke's International Hospital, Tokyo, Japan
| | - Shintaro Sakurai
- Department of Gastroenterological Surgery, St. Luke's International Hospital, Tokyo, Japan
| | - Akihiro Kishida
- Department of Gastroenterological Surgery, St. Luke's International Hospital, Tokyo, Japan
| |
Collapse
|
5
|
Lee CM, Park DW, Jung DH, Jang YJ, Kim JH, Park S, Park SH. Single-Port Laparoscopic Proximal Gastrectomy with Double Tract Reconstruction for Early Gastric Cancer: Report of a Case. J Gastric Cancer 2016; 16:200-206. [PMID: 27752399 PMCID: PMC5065951 DOI: 10.5230/jgc.2016.16.3.200] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 07/06/2016] [Accepted: 07/06/2016] [Indexed: 12/19/2022] Open
Abstract
In Korea, proximal gastrectomy has recently attracted attention as a better choice of function-preserving surgery for proximal early gastric cancer than total gastrectomy. Of the various strategies to overcome reflux symptoms from remnant stomach, double tract reconstruction not only reduces the incidence of anastomosis-related complications, but is also sufficiently reproducible as a laparoscopic procedure. Catching up with the recent rise of single-port laparoscopic surgeries, we performed a pure single-port laparoscopic proximal gastrectomy with DTR. This procedure was designed by merging the function-preserving concept of proximal gastrectomy with single-port laparoscopic total gastrectomy.
Collapse
Affiliation(s)
- Chang Min Lee
- Department of Surgery, Korea University Medical Center, Korea University College of Medicine, Seoul, Korea
| | - Da Won Park
- Department of Surgery, Korea University Medical Center, Korea University College of Medicine, Seoul, Korea
| | - Do Hyun Jung
- Department of Surgery, Korea University Medical Center, Korea University College of Medicine, Seoul, Korea
| | - You Jin Jang
- Department of Surgery, Korea University Medical Center, Korea University College of Medicine, Seoul, Korea
| | - Jong-Han Kim
- Department of Surgery, Korea University Medical Center, Korea University College of Medicine, Seoul, Korea
| | - Sungsoo Park
- Department of Surgery, Korea University Medical Center, Korea University College of Medicine, Seoul, Korea
| | - Seong-Heum Park
- Department of Surgery, Korea University Medical Center, Korea University College of Medicine, Seoul, Korea
| |
Collapse
|
6
|
Jung DH, Ahn SH, Park DJ, Kim HH. Proximal Gastrectomy for Gastric Cancer. J Gastric Cancer 2015; 15:77-86. [PMID: 26161281 PMCID: PMC4496445 DOI: 10.5230/jgc.2015.15.2.77] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 05/26/2015] [Accepted: 05/26/2015] [Indexed: 12/19/2022] Open
Abstract
Laparoscopic proximal gastrectomy (LPG) is theoretically a superior choice of minimally-invasive surgery and function-preserving surgery for the treatment of proximal early gastric cancer (EGC) over procedures such as laparoscopic total gastrectomy (LTG), open total gastrectomy (OTG) and open proximal gastrectomy (OPG). However, LPG and OPG are not popular surgical options due to three main concerns: the first, oncological safety; the second, functional benefits; and the third, anastomosis-related late complications (reflux symptoms and anastomotic stricture). Numerous recent studies have concluded that OPG and LPG present similar oncological safety profiles and improved functional benefits when compared with OTG and LTG. While OPG with modified esophagogastrostomy does not provide satisfactory results, OPG with modified esophagojejunostomy showed similar rates of anastomosis-related late complications when compared to OTG. At this stage, no standard reconstruction method post-LPG exists in the clinical setting. We recently showed that LPG with double tract reconstruction (DTR) is a superior choice over LTG for proximal EGC in terms of maintaining body weight and preventing anemia. However, as there is no definitive evidence in favor of LPG with DTR, a randomized clinical trial comparing LPG with DTR to LTG was recommended. This trial, the Korean Laparoscopic Gastrointestinal Surgery Study-05 (NCT01433861), is expected to assist surgeons in choice of surgical approach and strategy for patients with proximal EGC.
Collapse
Affiliation(s)
- Do Hyun Jung
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Sang-Hoon Ahn
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Do Joong Park
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hyung-Ho Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| |
Collapse
|
7
|
Nakamura M, Yamaue H. Reconstruction after proximal gastrectomy for gastric cancer in the upper third of the stomach: a review of the literature published from 2000 to 2014. Surg Today 2015; 46:517-27. [PMID: 25987497 DOI: 10.1007/s00595-015-1185-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 04/28/2015] [Indexed: 12/14/2022]
Abstract
Proximal gastrectomy (PG) is occasionally performed to preserve the physiological function of the remnant stomach with the aim of maintaining a gastric reservoir for patients with early gastric cancer in the upper third of the stomach. Many reconstructive procedures after PG have been reported, including esophagogastrostomy (EG), jejunal interposition, jejunal pouch interposition, and double tract. However, no general agreement exists regarding the optimal reconstructive procedure. This article reviews the current reconstructive procedures available for PG. We examined the surgical outcomes, postoperative complications, endoscopic findings, and quality of life (QOL) according to the reconstructive procedures. We found no significant difference in anastomotic leakage and anastomotic stricture among the procedures. The frequency of reflux esophagitis was higher with simple EG compared with the other reconstructive procedures. Some additional procedures, such as fundoplication, the use of a narrow gastric conduit, and placement of a gastric tube in the lower mediastinum on EG, could decrease the frequency of reflux esophagitis and reflux symptoms. These additional procedures may improve the QOL; however, the previous studies were small and could not adequately compare the reconstructive procedures. Prospective randomized controlled trials that involve a longer trial period and more institutions are needed to clarify the optimal reconstructive procedures after PG.
Collapse
Affiliation(s)
- Masaki Nakamura
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan.
| |
Collapse
|
8
|
A modified technique for esophagojejunostomy or esophagogastrostomy after laparoscopic gastrectomy. Surg Laparosc Endosc Percutan Tech 2014; 23:e109-15. [PMID: 23752017 DOI: 10.1097/sle.0b013e31828e3939] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Reconstruction of the digestive tract involving esophageal anastomosis after laparoscopic gastrectomy is a surgically difficult procedure. In this study, a newly developed transoral pretilted circular anvil, a "the oral to the abdomen" method, was proven to be effective. METHOD A total of 34 consecutive patients underwent esophageal anastomosis using the OrVil in our hospital from July 2009 to February 2011. The esophagus was transected and a small hole was then made in the esophageal stump through which the nasogastric tube of the OrVil was passed to insert the anvil into the abdominal cavity. After fixation with a stapler and a glove at the jejunal loop or the remnant stomach, the abdominal cavity was entered through the minilaparotomy. Pneumoperitoneum and airtightness were reestablished after the glove edge was turned over to seal off the protector. Eventually, intracorporeal esophagojejunostomy or esophagogastrostomy was accomplished under the guidance of laparoscopy. RESULTS There were 34 patients in the study: 1 with Zollinger-Ellison syndrome, 7 with stromal tumors in cardia, 23 with adenocarcinoma in the stomach, and 3 with cardia adenocarcinoma involving the lower esophagus. The surgical margins for all tumor patients were negative for tumor cells. The mean operative time was 175.0 minutes (90 to 240 min) and the mean intraoperative blood loss was 195.6 mL (50 to 800 mL). The 34 patients underwent successful laparoscopic surgeries with no open conversions. For 32 patients, there were no technological complications in the transoral insertion of the anvil to the esophageal stump. There were no anastomotic leaks after the surgery. CONCLUSIONS The use of the OrVil device, a "the oral to the abdomen" method, changes the direction of the anvil insertion and significantly decreases both difficulty and duration of the laparoscopic surgery. More importantly, if the mass is at a higher position, this approach can achieve a higher surgical margin compared with the hand-sewn purse-string suture technique, thus avoiding the need to undergo a thoracotomy (Supplemental Digital Content 1, http://links.lww.com/SLE/A83).
Collapse
|
9
|
Takeuchi H, Oyama T, Kamiya S, Nakamura R, Takahashi T, Wada N, Saikawa Y, Kitagawa Y. Laparoscopy-assisted proximal gastrectomy with sentinel node mapping for early gastric cancer. World J Surg 2012; 35:2463-71. [PMID: 21882026 DOI: 10.1007/s00268-011-1223-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Laparoscopy-assisted proximal gastrectomy (LAPG) remains a relatively uncommon procedure because of certain technical issues, such as curability, safety, and retention of postoperative patients' quality of life. The aim of the present study was to evaluate the feasibility of a newly developed LAPG procedure for early-stage proximal gastric cancer. METHODS We enrolled 37 consecutive patients who were preoperatively diagnosed with cT1N0M0 primary gastric cancer in the upper third of the stomach with the primary tumor diameter less than 4 cm. Laparoscopy-assisted proximal gastrectomy with sentinel node (SN) mapping and esophagogastric anastomosis with a circular stapler and transoral placement of the anvil was attempted. RESULTS The LAPG procedure was completed in 36 patients. It was converted to laparoscopy-assisted total gastrectomy in one patient because one SN detected intraoperatively was positive for metastasis by intraoperative pathological diagnosis. There were no severe postoperative complications in any patient. Only one patient (3%) complained of mild reflux symptoms immediately after operation, which were graded endoscopically as B by the Los Angeles Classification of gastroesophageal reflux disease; however, the symptoms were controlled well by a proton-pump inhibitor. Sentinel nodes were detected successfully in 37 (100%) of our patients. The mean number of dissected lymph nodes and identified SNs per case was 29.7 and 5.8, respectively. The sensitivity of prediction of nodal metastasis (including isolated tumor cells) and diagnostic accuracy based on SN status were 100% (3/3) and 100% (37/37), respectively. All patients have been free from recurrence for a median follow-up period of 26 months. CONCLUSIONS This study reveals that our novel LAPG approach is curative and represents a feasible minimally invasive surgical procedure with minimal morbidity and postoperative reflux esophagitis in patients with upper-third early-stage gastric cancer.
Collapse
Affiliation(s)
- Hiroya Takeuchi
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | | | | | | | | | | | | | | |
Collapse
|
10
|
An JY, Cheong JH, Hyung WJ, Noh SH. Recent evolution of surgical treatment for gastric cancer in Korea. J Gastric Cancer 2011; 11:1-6. [PMID: 22076195 PMCID: PMC3204480 DOI: 10.5230/jgc.2011.11.1.1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Accepted: 03/10/2011] [Indexed: 12/11/2022] Open
Abstract
Gastric cancer is the most common malignancy and the incidence is steadily increasing in Korea. The principal treatment modality for gastric cancer is surgical extirpation of tumor along with draining lymph nodes. Gastrectomy with D2 lymph node dissection has been well established as a standard of surgery and improved the survival of gastric cancer patients. Recently, technological advances are drastically reshaping the landscape of surgical treatment of gastric cancer. One of the most notable trends is that minimal access surgery becomes dominating the treatment of early stage diseases. For advanced diseases, the standard access surgery is considered a reference treatment. Although there is a pilot study underway to evaluate the feasibility of the application of minimal access surgery to advanced gastric cancer (AGC), the evidence for oncological safety is not yet provided sufficiently. Based on the recent randomized controlled trials, the extent of surgery for AGC has re-defined as para-aortic lymph node dissection dose not add any survival benefit while increasing surgery-related morbidities. In addition, it is now accepted as a standard operation omitting unnecessary procedures such as splenectomy and/or distal pancreatectomy for prophylactic lymph node dissection. Conceptual and technical innovation has contributed to decreasing morbidity and mortality without impairing oncological safety. All these recent advances in the field of gastric cancer surgery would be concluded in maximizing therapeutic index for gastric cancer while improving quality of life.
Collapse
Affiliation(s)
- Ji Yeong An
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | | | | | | |
Collapse
|