Laparoscopic and open gastric resections for malignant lesions: A prospective comparative study

Background Whereas laparoscopy for benign diseases provides clear advantages over traditional surgery, the benefits of laparoscopic gastric resection for malignant diseases are less clear. The objectives of this study were to compare prospectively the clinical outcomes between completely laparoscopic and open total and partial gastrectomies for malignant diseases and to assess whether laparoscopic gastrectomies obtain adequate margins and follow oncologic principles.Methods Between April 1995 and March 2004, a prospective comparative study was performed comparing eight patients who underwent laparoscopic total gastrectomy with 11 patients who underwent open total gastrectomy, and 16 patients who underwent laparoscopic partial gastrectomy with 17 who patients underwent open partial gastrectomy. Stage, extent of lymphadenectomy, and long-term follow-up were examined. The intraoperative and postoperative details of the two groups were compared.Results The laparoscopic group patients had fewer intraoperative complications while the operative time was similar to that of the open group. Both ambulation and hospital stay were significantly shorter in the laparoscopic groups than in the open groups. The short-term morbidity was lower in the laparoscopic groups and there were no cases of death, whereas one case of postoperative death occurred after an open total gastrectomy. There was no need to convert to open surgery. The number of lymph nodes obtained in the laparoscopic and open procedures was not significantly different. In addition, all resected margins were tumor free in the laparoscopic group, whereas tumor involvement was presented in the margin of one specimen in the open group.Conclusions The totally laparoscopic approach to total and partial gastrectomies had good results and was proven to be a feasible and safe procedure. In addition, the laparoscopic procedures are superior to open surgeries in terms of faster postoperative recovery, shorter hospital stay, and better cosmetic outcomes. A totally laparoscopic approach for early and advanced gastric cancer can obtain adequate margins and follow oncologic principles.     

Comparison of laparoscopic and open gastrectomy for malignant disease

This study compares the outcome of a series of totally laparoscopic cases with that of matched open controls for the treatment of malignant gastric disease. Laparoscopic techniques can follow oncologic principles and obtain adequate margins. Short-term follow-up evaluation shows no difference in survival rates between the two approaches. BACKGROUND: Few studies have examined a totally laparoscopic approach to gastrectomy for malignancy. This is the first study to compare the outcome of a series of totally laparoscopic cases with matched open surgeries for gastric cancer. METHODS: A retrospective case-matched study was performed comparing open and laparoscopic partial gastrectomies for cancer. A total of 25 cases (12 laparoscopic and 13 open) were matched for age and indication for surgery. Stage, extent of lymphadenectomy, and survival at 18 months were examined. The intraoperative and postoperative details were compared. RESULTS: The stages ranged from I to IV, with no statistical difference between the two groups. All resected margins in the laparoscopic group were free of tumor. The extent of lymphadenectomy did not differ. Follow-up assessment at 18 months showed no difference in survival. CONCLUSIONS: Laparoscopic gastrectomy for malignancy is a viable alternative to open surgery. Laparoscopic techniques can obtain adequate margins and follow oncologic principles. Short-term follow-up evaluation shows no difference in survival rates between the two approaches.     

Full robot-assisted gastrectomy: surgical technique and preliminary experience from a single center

The treatment of gastric cancer requires a multidisciplinary approach in which surgery plays the main role. The diffusion of minimally invasive surgery for gastric cancer treatment is limited by the complexity of performing an extended lymphadenectomy. This surgical step can be facilitated through the use of a robot-assisted system. To date, there are few published articles discussing a full robotic approach that precisely show the different surgical steps. The aim of this study is to describe our experience, surgical techniques and the short-term results of a consecutive series of full robotic gastrectomies using the Da Vinci Surgical System. From November 2011 to January 2015, 17 patients with gastric cancer underwent curative resection by robotic approach for locally advanced tumors. In summary, there were 15 total gastrectomies with a Roux-en-Y esophagojejunostomy, one total gastrectomy with transverse colectomy and one sub-total gastrectomy. Resection margins were negative in all cases. Conversions occurred in two patients. Robot-assisted gastrectomy with extended lymphadenectomy is a safe technique and successfully allows an adequate lymph node harvest and optimal R0-resection rates with low postoperative morbidity. The learning curve appears to be shorter than in laparoscopic surgery. Further follow-up and randomized clinical trials are required to confirm the role of a robotic approach in gastric cancer surgery.     

Laparoscopic assisted distal gastrectomy for early gastric cancer: Five years' experience

BACKGROUND: Laparoscopic assisted gastrectomy is being reported increasingly as the treatment of choice for early gastric cancer. However, no reports concerning the prognosis of patients who have undergone laparoscopic assisted distal gastrectomy (LADG) for early gastric cancer or data comparing the results to those obtained after open gastric surgery are yet available. METHODS: A retrospective study was performed comparing laparoscopic assisted and open distal gastrectomies for early gastric cancer. Eighty-nine patients who underwent LADG were compared to 60 who underwent conventional open distal gastrectomy (DG) in terms of pathologic findings, operative outcome, complications, and survival. RESULTS: There were no significant differences between LADG and DG in operation time (209 vs 200 minutes), complication rate (9% vs 18%), and 5-year survival rate (98% vs 95%). There were differences between LADG and DG with regard to blood loss (237 vs 412 mL), number of lymph nodes (19 vs 25), postoperative stay (17 vs 25 days), and the duration of epidural analgesia (2 vs 4 days) ( P < .05 each). CONCLUSIONS: For properly selected patients, LADG can be a curative and minimally invasive treatment for early gastric cancer.     

Radical surgical treatment of gastric cancer. Personal experience

After surgical therapy the survival outcome of gastric cancer is still poor. Early diagnosis and radical surgery are the two most important means to improve the prognosis. Radical surgery must include all lymph nodes embryologically related to stomach. The aim of this study was to verify whether an aggressive surgical strategy can increase postoperative survival rate. In the period 1990-1994 eighty two patients with gastric cancer were operated on. The M:F ratio was 1.6:1 and the mean age was 65.3 years (range 23-89). Palliative operations (6 gastroenterostomy) were performed in 7.3% of cases. In the other patients, 36 total gastrectomies (43.9%), 8 total gastrectomies extended to spleen, pancreas and colon (9.7%), 32 distal subtotal gastrectomies (39.1%) were performed. Gastric exeresis was always associated with lymph node dissection extended to level I and II (R2). In some cases level III and IV lymphadenectomy (R3) was performed according to Maruyama-Mishima technique. There were no intraoperative deaths. The operative mortality was 13.6% for total gastrectomies and 3.1% for subtotal gastrectomies. Postoperative complications occurred in 15.9% of total gastrectomies (3 anastomotic fistula, 2 wound infection, 1 subphrenic abscess, 1 melena) and in 3.1% of subtotal gastrectomies (1 sepsis). Stage III and IV cancers represented 74.4% of all cases (stage IIIA 19.6%, IIIB 21.9%, IV 32.9%). Metastatic lymph node involvement (N2+) affected 53.1% of T3 and 88.2% of T4 cancers. The mean survival rate of patients subjected to gastroenterostomy was 6 months. The 2-year survival for total gastrectomies was 42%, for subtotal gastrectomies 28.1%. In our experience, wide removal of lymph nodes and total or extended gastrectomies were performed without any increase of mortality and morbidity. In advanced stages, a wider exeresis increased survival and prevented local recurrence.     

腹腔镜根治手术在胃癌中应用的现状与争议

我国胃癌治疗效果仍不容乐观,我中心近年来由于规范的手术质量控制,胃癌尤其进展期Ⅲ期胃癌的治疗效果得到很大提高。全球多中心大样本的临床研究已明确了腹腔镜胃癌根治术治疗早期胃癌的安全性和有效性,中国和日本先后将腹腔镜手术确定为临床I期远端胃癌的推荐术式。腹腔镜根治手术治疗进展期胃癌,手术难度大、学习曲线长。目前,中国、日本和韩国等开展了多项临床研究评价腹腔镜根治手术治疗进展期胃癌的可行性、有效性,有望证实其长期疗效。随着手术技术进步、手术步骤优化、手术操作进一步熟练,腹腔镜根治手术治疗胃癌的适应证将不断扩大。腹腔镜手术可完成常规的淋巴结清扫,有经验的中心甚至可完成扩大清扫及脉络化清扫。进展期胃癌根治手术网膜囊切除存有争议,掌握技术,腹腔镜下网膜囊切除安全、可行,本文总结分享了我中心腹腔镜下胃癌根治网膜囊切除的经验。随着腹腔镜手术技术和设备的发展,以及经验的积累,腹腔镜手术在保证其安全性的前提下,完全可达到与开腹手术相当的根治程度。对于腹腔镜根治手术存在的争议,需开展相应的临床研究,以期进一步阐明腹腔镜根治手术在胃癌治疗中的优劣。     

达芬奇人工智能手术系统辅助胃癌手术

目的 探讨达芬奇人工智能手术系统应用于胃癌手术的安全性和可行性.方法 总结2010年3、4月复旦大学附属中山医院普通外科完成的9例人工智能辅助胃癌手术的方法及临床效果.结果 9例患者行全胃切除5例,远端胃切除2例,近端胃切除1例,胃楔形切除1例.手术均顺利完成,无中转开放手术或普通腹腔镜手术者.手术时间150-440 min,出血量10～100 ml.D1清扫2例,清扫淋巴结数分别为19和24枚;D2清扫7例,清扫淋巴结数28-38枚.术后发生胃漏1例,保守治疗后痊愈：无其他并发症发生.结论 达芬奇人工智能手术系统辅助胃癌手术在临床上安全可行.     

Laparoscopic gastric resection for benign and malignant conditions: lessons learned from 35 consecutive cases

INTRODUCTION: Despite significant advances in laparoscopy, gastric surgery is still generally carried out by conventional open techniques. The aim of the study was to report the short- and medium-term outcomes of gastric surgery when carried out laparoscopically for a variety of benign and malignant conditions. METHODS: A retrospective review was carried out for all patients who underwent a laparoscopic gastric resection between January 2000 and September 2006. Follow up was carried out at the private consulting rooms and by telephone interview. RESULTS: Thirty-five consecutive laparoscopic gastric resection were carried out in 31 patients for a variety of benign lesions, six early gastric cancer and 13 adenocarcinomas. The totally intracorporeal laparoscopic procedures included four total, eight distal and 21 partial gastrectomies. There were two open conversions (6%). There was one in-hospital mortality (3%) and one non-fatal anastomotic leak. Median operative duration and length of stay were 75, 205 and 252 min and 5, 6.5 and 8 days for laparoscopic partial, distal and total gastrectomy, respectively. After malignant resections, there were six recurrences; however, 15 patients remained disease-free at up to 60 months follow up. CONCLUSION: Laparoscopic gastric resection is feasible with good short- and medium-term results and may be an appropriate treatment option in selected cases.     

淋巴清扫在胃癌治疗中的意义

目的　探讨淋巴结清扫术在胃癌手术中的价值。　方法　回顾性分析 485例胃癌切除病例 ,按淋巴结清扫范围分为广泛淋巴清扫组及非广泛淋巴清扫组 ,比较两组间的 5年生存率 ,并用Cox比例风险模型分析影响胃癌手术预后的因素。　结果　总体 5年生存率为 3 7.8% ,行广泛淋巴清扫术、非广泛淋巴清扫术后 5年生存率分别为 43 .3 %和16.4% (P <0 .0 0 1)。多元分析表明淋巴清扫程度是影响预后的一个重要因素。　结论　广泛淋巴清扫术可以提高胃癌手术的 5年生存率 ,因而对胃癌应努力开展广泛性淋巴清扫术。     

Stomach cancer: a study of 117 consecutive resected cases and results of R2-R3 gastrectomy

In a consecutive series of 175 patients with gastric carcinoma, 66.8% underwent gastric resection: 74 total gastrectomies with R3 lymphadenectomy and 43 distal subtotal gastrectomies with R2 lymphadenectomy were performed. 73% (86 cases) of resective procedures proved to be "absolute curative" according to Japanese criteria (JRSGC). Nodal involvement was present in 62 out of 117 resected patients (52.9%): 29.9% N1, 9.4% N2, 13.6% N3; a significant relationship (p = 0.012) between depth of invasion of the gastric wall and lymph node metastases was revealed. The hospital mortality after R2-R3 gastrectomy was 4.2%, major surgical complications occurred in 6.8% of cases. The actuarial 5-year survival after curative resection was 59%. The results suggest that extended lymphadenectomy (R2-R3 gastrectomy) is justified in the surgical treatment of gastric cancer; this procedure can be safely performed and permits "absolute curative" resections in a remarkable percentage of cases.     

Safety and application of laparoscopic gastrectomy for benign gastric disease and gastric cancer

INTRODUCTION

Laparoscopic gastrectomy is rapidly expanding despite reservations by some surgeons regarding its safety and radicality. The aim of this study was to evaluate patients undergoing laparoscopic gastrectomy for both benign and malignant disease with particular emphasis on technical feasibility, safety, effectiveness and complications.

PATIENTS AND METHODS

Review of prospectively collected data of patients who underwent laparoscopic gastrectomy from May 2005 to September 2009 under the care of one consultant surgeon.

RESULTS

A total of 61 laparoscopic gastrectomies were performed (35 men and 26 women) with a median age of 68 years (range, 41–90 years). There were 39 distal gastrectomies (19 adenocarcinoma, 6 gastrointestinal stromal tumour [GIST], 4 benign gastric outlet obstruction, 4 high-grade dysplasia in gastric adenomas, 4 non-healing ulcers, 2 gastric antral vascular ectasia [GAVE]); 15 sub-total gastrectomies (13 adenocarcinomas, 2 GIST); and 7 total gastrectomies (5 adenocarcinomas, 1 GIST, 1 carcinoid). Median follow-up was for 48 months (range, 1–72 months). There was one death, two major and six minor complications. All patients with complications made a satisfactory recovery.

CONCLUSIONS

Laparoscopic gastrectomy is associated with a low mortality (1.75%) and major morbidity (3.50%). Although technically demanding, especially when a D2 lymphadenectomy is performed, our results have shown that tailored laparoscopic resection based on tumour characteristics with either D1 or D2 lymphadenectomy results in good surgical and oncological outcomes.     

Laparoscopically assisted total or distal gastrectomy with lymph node dissection for early gastric cancer

BACKGROUND: A secure lymphadenectomy in a laparoscopically assisted gastrectomy performed for gastric cancer is required because of the high prevalence of lymph node metastasis. A surgical technique for laparoscopic gastrectomy with lymph node dissection and reconstruction using a conventional circular stapler is reported. METHODS: Forty-nine laparoscopically assisted gastrectomies with lymphadenectomy (47 distal and two total gastrectomies) were performed using devices for retraction of the stomach and laparoscopic ligation of arteries, which were developed to ensure secure dissection of lymph nodes. Reconstruction by Billroth I or intestinal interposition using a conventional circular stapler was performed through a small incision through which the specimen was removed. When submucosal invasion was suspected (n = 16), the lymph nodes along with the common hepatic artery were also dissected through the same incision. RESULTS: The operations were performed without serious complication. None was converted to laparotomy, and there were no deaths. Metastatic lymph nodes were seen in perigastric nodes and nodes along the left gastric artery in five cases. In five of the 49 patients the macroscopic diagnosis of depth of invasion was underestimated. CONCLUSION: A technique of laparoscopic gastrectomy with lymph node dissection for early invasive gastric cancer is described. A definitive answer concerning the appropriate level of lymph node dissection and the role of laparoscopic gastrectomy in the treatment of more advanced gastric cancer remains to be defined.     

Long-term outcomes after laparoscopy-assisted gastrectomy for advanced gastric cancer: a large-scale multicenter retrospective study

Background

Recently, the number of laparoscopic procedures for gastric cancer has increased rapidly. Laparoscopic surgery is reported to have many advantages over open gastrectomy with oncologic safety in early gastric cancer. However, there were few reports on long-term outcomes of laparoscopy-assisted gastrectomy (LAG) for advanced gastric cancer (AGC). The aim of this study was to investigate long-term survival outcomes after LAG for AGC.

Methods

The data of 1,485 patients who underwent LAG between April 1998 and December 2005 by ten surgeons at ten hospitals were collected retrospectively. Among them, 239 patients who were diagnosed with AGC on final pathologic examination were enrolled in the present study to investigate long-term clinical outcomes.

Results

The ratio of male to female patients was 151:88 and the mean age was 57.1?years. One hundred ninety-three subtotal gastrectomies, 41 total gastrectomies, and 5 proximal gastrectomies were performed. D1?+?α, D1?+?β, and D2 lymph node dissections were performed for 14, 62, and 163 cases, respectively. The median follow-up period was 55.4?months. The overall 5-year survival rate of the 239 AGC patients was 78.8% and the disease-specific 5-year survival rate was 85.6%. The 5-year survival rates of the TNM staging system’s (7th ed.) stages were 90.5% (stage Ib, n?=?86), 86.4% (stage IIa, n?=?53), 78.3% (stage IIb, n?=?44), 52.8% (stage IIIa, n?=?24), 52.9% (stage IIIb, n?=?24), and 37.5% (stage IIIc, n?=?8) (p?Conclusion The long-term survival outcome rates of LAG for AGC in the present study were comparable to those previously reported for open gastrectomy. Based on the present results, a well-designed phase III trial comparing LAG and open gastrectomy for AGC will be needed to affirm the validity of LAG for AGC.     

Total and subtotal laparoscopic gastrectomy for adenocarcinoma

BACKGROUND: Laparoscopic gastrectomies are currently performed in many centers, but compliance with oncologic requirements still represents a subject open to debate. The aim of this work was to compare the short-term and oncologic outcomes after laparoscopic and open surgery in gastric adenocarcinoma. METHODS: From June 2000 through June 2005, 147 patients in our institution underwent gastrectomy by open or mininvasive approach for adenocarcinoma. The laparoscopy group included 48 patients, 29 with early gastric cancer (EGC) and 19 with antral advanced gastric cancer (AGC). The short-term results and oncologic data were compared to those obtained in 99 patients who underwent open surgery. Survival in the laparoscopy group was analyzed. RESULTS: In the laparoscopy group no intraoperative complications were observed, and conversion was needed in only one patient with a large advanced tumor. Overall, 32 lymph nodes were collected by D2 dissection, 30 for EGC, 34 for advanced cancers. The resection margin was 6.7 cm (range: 4-8 cm). The mean operating time was 240 min (range: 150-360 min), with a blood loss of 150 ml on average (range: 70-250 ml). Morbidity included two duodenal leaks that healed without reoperation; after enclosing or reinforcing the staple line, no further leaking was noted. There was one death from massive bleeding in a cirrhotic patient. Ambulation and oral feeding started significantly earlier than in open surgery. The mean hospital stay was 10 days (range: 7-24 days), significantly shorter than the stay of 18 days after open surgery (p < 0.05). All patients treated laparoscopically were alive without recurrence at the end of this study. CONCLUSIONS: Short-term results with laparoscopic gastrectomy were better than with open surgery in this study. Oncologic radicality was a major concern, but in the authors' experience the extent of lymphadenectomy was the same as in open surgery. This study suggests that laparoscopic gastrectomy in malignancies is a reliable tool and oncologic requirements can be warranted.     

Completely laparoscopic versus open gastrectomy for early and advanced gastric cancer: a matched cohort study

Introduction

The application of laparoscopic gastric surgery has rapidly increased for the treatment of early gastric cancer. However, laparoscopic gastrectomy for advanced tumor remains controversial, particularly in terms of oncologic outcomes. This study was designed to compare 3-year survival of laparoscopic versus open curative gastrectomy in early and advanced gastric cancer.

Methods

This was a retrospective matched cohort study. We included patients between 2003 and 2010 with an R0 resection. A totally laparoscopic technique was used and D2 lymph node dissection was practiced routinely. We performed an intracorporeal hand-sewn esophagojejunostomy in all laparoscopic total gastrectomy cases. We matched all laparoscopic cases 1:1 with open cases according to TNM AJCC seventh edition. We used Mann–Whitney or t test and Chi-square test to compare both groups. Kaplan–Meier analysis with log-rank test was performed to compare survival.

Results

We included 31 open and 31 laparoscopic cases (mean age 63?±?14?years; 66% males). Both groups were identical in type of gastrectomy (71% total and 29% subtotal). There were no statistical difference between laparoscopic and open groups in age, sex, N category, tumor location and size, histological differentiation, and T category (48% T1, 13% T2, 16% T3, and 23% T4 in both groups), with 48% early and 52% advanced tumors. The median number of resected lymph nodes was similar: 35 (23–53) for laparoscopic and 39 (23–45) for open cases (P?=?0.81). The median follow-up was 50?months. The overall 3-year survival was 82% for laparoscopic surgery and 87% for the open surgery group (P?=?0.56). There were no difference in 3-year survival for the laparoscopic versus the open surgery groups for advanced tumors (74 vs. 75%, P?=?0.88), N+?tumors (73 vs. 73%, P?=?0.99) and for the different AJCC stages (stage 1: 94 vs. 100%, stage 2: 89 vs. 82%, and stage 3: 50 vs. 50%, P?=?0.32, 0.83, and 0.98 respectively).

Conclusions

In this preliminary report, with 52% of advanced tumor, the 3-year overall and stage-by-stage survival was comparable for laparoscopic and open curative gastrectomy.     

腹腔镜下胃癌全胃切除术79例的体会

目的 探讨腹腔镜下胃癌行全胃切除术的可行性及效果.方法 对2004年6月至2006年12月共行腹腔镜下根治性全胃切除术79例,其中行D1及D1+淋巴结清扫12例,D2/D2+淋巴结清扫67例.肿瘤位于胃近端者19例,位于胃体者41例,皮革胃2例,位于胃窦并浸润至胃小弯中上部者17例进行分析.结果 79例中77例成功进行腹腔镜手术,2例中转开腹,中转率为2.5%.平均手术时间(275.8±20.8) min,平均出血量(163.3±48.6) ml,平均每例清扫淋巴结(34.7±12.2) 枚,肿瘤近残端(3.8±1.2) cm,远残端(6.9±2.8) cm.术后肛门排气时间(3.6±0.9) d,下床活动时间(2.5±0.4) d.无术后死亡,无吻合口漏,术后发生并发症7例均经内科治疗痊愈.术后随访9～39个月,平均25.6个月,15例患者因肿瘤复发死亡,余64例仍生存.结论 腹腔镜下全胃切除联合胃癌标准根治术是安全可行的,能达到开腹手术的淋巴结清扫范围,且具有创伤小、出血少、恢复快、并发症率低等优点.     

腹腔镜与开腹进展期胃癌全胃切除术远期疗效的meta分析

目的:系统评价腹腔镜与开腹进展期胃癌全胃切除术的远期疗效。方法:以进展期胃癌、腹腔镜、开腹、生存率、Total gastrectomy、Advanced gastric cancer、Survival rate为检索词,检索发表于PubMed、Embase、Web of Science等英文数据库,以及万方医学网数据库、中国知网(CNKI)等中文数据库的文献,提取有关腹腔镜与开腹进展期胃癌全胃切除术进行对比研究的文献,检索时间为2013~2019年。对提取的文献按预设标准进行筛选并进行质量评价,提取两组患者远期生存与复发情况,采用RevMan 5.3软件进行meta分析。结果:共检索14篇文献,其中2篇因存在数据缺失未能入选,共纳入12篇、共计2674例患者,其中腹腔镜组970例,开腹组1704例。meta结果显示,腹腔镜组与开腹组5年总体生存率(OR=1.12,95%CI:0.91~1.36,P=0.29),3年无病生存率(OR=0.84,95%CI:0.55~1.30,P=0.44),5年无病生存率(OR=1.14,95%CI:0.91~1.41,P=0.25),复发率(OR=0.48,95%CI:0.19~1.24,P=0.13),差异均无统计学意义。结论:腹腔镜进展期胃癌全胃切除术可达到与开腹手术相当的远期疗效。     

The role of superextended lymphadenectomy (D4) in gastric cancer

AIM: The outcome of surgery in gastric cancer differs in Japan and Western countries and the extension of lymphadenectomy may play a crucial role in survival. In Japan the choice of performing extended (D2) and superextended (D4) lymphadenectomies is based on retrospective studies, and a prospective randomized study comparing D2 and D4 is still in course. In Western countries the randomized trials comparing D1 and D2 could not provide definite indications, D2 is not yet performed as a routine procedure and D4 is accepted only by few surgeons. We report our experience and discuss indications and results. METHODS: Since January 2000 through December 2002 we performed 27 superextended lymphadenectomies for the radical treatment of advanced gastric cancer. Early gastric cancers and patients over 80 years of age received conventional D2 gastrectomies. Selection of patients for D4 was made after laparotomy, when intraoperative peritoneal lavage cytology could rule out the presence of malignant cells, while D2 was done in case of peritoneal micrometastases. RESULTS: Every patients had 39.5 nodes removed on average (range 17-94), and micrometastases in tier 16 were found in 7 cases (26%). Early post-operative surgical morbidity was 18% (5 patients) and mortality was 3.7% (1 patient). As much as 30% of patients complained of diarrhea as a late complication. The follow up could demonstrate a 3 year overall actuarial survival of 76%. Actuarial survival was 100% for N- and 70% for N+. A remarkable data was that 4 out of 5 patients who died from recurrence in the follow-up, were N4+. Actuarial survival at 3 years for N4+ patients was 34%, and the difference in survival between N4+ and other N+ was statistically significant (p<0.05). CONCLUSIONS: Superextended lymphadenectomy in gastric cancer is feasible with postoperative morbidity and mortality rates not exceeding the rates of other lymphadenectomies. Actuarial survival at 3 years with D4 was better than in previous personal experience with D2, although the patients who underwent D4 were selected by intraperitoneal lavage cytology, while D2 patients had not been selected. The prognosis for N4- patients was better than for N4+ with micrometastases in tier 16. The presence of N4 micrometastases worsens the prognosis, but it is still uncertain whether D4 does improve survival: it is undoubtedly a new means of more accurate staging in gastric cancer surgery. The newer TNM classification regards the number of nodes removed as an indicator of radicality. Every surgeon should consider that superextended lymphadenectomies could comply with R0 radicality, and perform it within the ranges of low morbidity and mortality, until randomized trials with definitive results are available.     

Laparoscopic gastrectomy for gastric cancer: early experience among the elderly

Background The data are scarce on the outcome for elderly patients presenting with resectable gastric cancer in the West who have been treated with minimally invasive surgery. This report presents the authors’ early experience with totally laparoscopic gastric resections for cancer in elderly patients. Methods A total of 20 patients underwent laparoscopic gastrectomy procedures: 14 distal, 5 subtotal, and 1 total gastrectomy. The male-to-female ratio was 15 to 5. The ages ranged from 75 to 88 years (mean, 80 years). Results All cases were managed laparoscopically with R0 resection. Four patients needed high-dependency unit care postoperatively. There were no perioperative deaths. The median time required for the procedure was 212 min, and time to diet was 4 days. The hospital stay was 8 days. Four patients experienced significant complications, with two patients requiring reoperation. The pathology was adenocarcinoma for 17 patients and high-grade dysplasia for 3 patients. Conclusion: Among elderly patients for whom conventional gastric surgery carries a high morbidity and mortality risk, minimal access surgery may offer equivalent oncologic integrity but with superior safety and economy. The primary aim is to remove the tumor with at least a D1 lymphadenectomy. Presented in part at the Association of Endoscopic Surgeons of Great Britain and Ireland, Hull, November 2002, and at the 18th World Congress of Digestive Surgery in Hong Kong, December 2002     

Early international results of laparoscopic gastrectomies

Background: The first totally laparoscopic Billroth II gastrectomy was performed in 1992. To date, laparoscopic gastrectomy has been performed by a small number of surgeons around the world and the laparoscopic approach has been extended to Billroth I and total gastrectomy. The aim of this study is to review the state of laparoscopically performed gastrectomies in the international scene. Methods: Questionnaires were prepared and sent to every surgeon in the world known by the authors or their contacts to have performed a laparoscopic gastrectomy. A questionnaire survey was started in July 1994 and completed by November 1994. Data collected included age, sex, type of gastric resection, technique of reconstruction after resection, average duration of surgery, time to liquid and solid intake, postoperative hospital stay, complications, and opinions of the surgeons. Results: Sixteen surgeons contributed to this study. A total number of 118 cases of laparoscopic gastrectomies, comprising Billroth I (11), Billroth II (87), vagotomy and antrectomy (10), and total gastrectomy (10) had been performed. The indications were gastric and/or duodenal ulcers and benign and malignant gastric tumors. Conclusions: Laparoscopic gastrectomy was found to be superior to the open technique by 10 of 16 surgeons because of faster recovery, less pain, and better cosmesis. The procedure was an expensive and long operation according to four. Two surgeons were uncertain of any benefit because of limited experience. Received: 7 August 1996/Accepted: 28 October 1996