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.     

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.     

Effects of the learning curve on operative time and lymph node harvesting during robotic gastrectomy

Background

Gastric cancer is the fifth most frequent cancer globally. The introduction of minimally invasive surgery for gastric cancer aimed at reducing post-operative morbidity and hospital length of stay. Although the role of laparoscopic gastrectomy has been established, robotic gastric surgery has only recently gained popularity. The purpose of this study was to evaluate, with a multidimensional analysis, the learning curve of a single surgeon with extensive experience in laparoscopic gastrectomy.

Methods

We prospectively collected data from 104 gastric cancer patients who underwent surgery with a robotic approach from June 2015 to June 2019 by a single surgeon. We performed 21 total gastrectomies (TGs) and 83 subtotal gastrectomies (STGs). A D2 lymphadenectomy was performed in all the patients. Proximal and distal resection margins were tumoour-free in all patients. There were no intraoperative complications, and no conversions occurred.

Results

The plateau of the learning curve based on harvesting lymph nodes and operative time was not reached for TG. The learning curve of operative time for STG could be divided into three different phases: an early or learning phase from 1 to 27 cases, an intermediate or proficiency phase from 28 to 48 cases, and a late or mastery phase from 49 to 83 cases. The learning curve for harvesting lymph nodes was achieved after 41 cases in the STG group.

Conclusion

This study shows that robotic gastrectomy is a complex procedure with a significant multiphasic learning curve. Nevertheless, the robotic learning curve seems to be more rapid than that of conventional laparoscopy. Most importantly, our results suggest that the robotic technique can provide oncological adequacy in terms of lymph node harvesting even in the very first phase of the learning curve.     

腹腔镜手术治疗胃间叶源性肿瘤的临床研究

目的:探讨腹腔镜手术治疗胃间叶源性肿瘤的临床应用价值。方法:回顾性分析2008年3月至2010年10月间接受腹腔镜手术的35例胃间叶源性肿瘤病人的临床资料,包括手术方式、手术时间、术中出血量、术后住院时间、并发症、术后病理及随访结果等。结果:所有手术均在腹腔镜下完成,其中使用内镜下线型切割闭合器行腹腔镜胃部分切除术27例,腹腔镜辅助远端胃大部切除术4例,腹腔镜辅助近端胃大部切除术4例。8例手术采用术中胃镜的双镜治疗。无一例中转开腹手术。中位手术时间90(60~160)min,术中平均出血量(42.1±23.6)(10~200)mL,肿瘤平均大小(35.4±13.5)(10~62)mm,肿瘤切缘术中冷冻及术后石蜡病理均为阴性。术后病理胃间质瘤26例、胃神经鞘瘤5例、胃平滑肌瘤2例、胃脉管瘤1例、胃纤维母/肌纤维母细胞瘤1例。术后平均住院时间(6.3±1.3)(4~10)d,无术后并发症。术后中位随访时间22(12~43)个月,所有病人均无肿瘤复发及远处转移。结论:腹腔镜手术切除胃间叶源性肿瘤是安全、微创、有效的,应作为此类肿瘤治疗的首选方法。     

Laparoscopy-assisted distal gastrectomy with laparoscopic sentinel lymph node biopsy after endoscopic mucosal resection for early gastric cancer

Background There has been a trend toward minimally invasive treatment of early gastric cancer. We report the preliminary results of laparoscopy-assisted distal gastrectomy with laparoscopic sentinel lymph node biopsy after endoscopic mucosal resection. Methods Six patients underwent laparoscopy-assisted distal gastrectomy after endoscopic mucosal resection between February 2002 and October 2005 at Mie University Hospital. These patients first underwent laparoscopic sentinel lymph node biopsy and then laparoscopy-assisted distal gastrectomy with lymphadenectomy. Results No patient underwent conversion to open surgery during the operation. None of the patients had any postoperative complications. The mean length of postoperative hospital stay was 11.3 days. Sentinel lymph nodes were identified laparoscopically in five patients. There were 20 sentinel and 85 nonsentinel lymph nodes in the six patients. Postoperatively, tissue sections showed that none of the lymph nodes were metastasized. Immunohistochemistry with D2-40 antibody showed that there were normal lymphatics in the submucosal layer with mucosal defects at the endoscopic mucosal resection site. No patients had any tumor recurrence during followup. Conclusions Laparoscopy-assisted distal gastrectomy after endoscopic mucosal resection was a safe and curative procedure. Endoscopic mucosal resection before sentinel lymph node biopsy was acceptable for early gastric cancer.     

Laparoscopic management for local recurrence of early gastric cancer after endoscopic mucosal resection

Endoscopic mucosal resection (EMR) is a widely accepted technique for early gastric cancer because it is minimally invasive; however, incomplete resection with subsequent cancer recurrence in the remnant remains a difficult problem. Generally, the margins of the local recurrence lesions are unclear, and second EMR is difficult to perform because of scar formation after the first EMR. We performed a laparoscopic treatment on six patients with residual lesions after EMR and reviewed the safety and efficacy of this management. Laparoscopic management consisted of two techniques: laparoscopic wedge resection with a lesion-lifting method and laparoscopic-assisted distal gastrectomy with mini-laparotomy. Cancerous lesions were completely resected with sufficient surgical margins circumferentially. Mean operative time was 171 min, mean estimated blood loss was 16.5 g, time to first walking was 1 day, duration of epidural analgesia was 2.2 days, and mean length of hospital stay was 13.5 days. There were no intra- and postoperative complications, no conversion to open surgery, and no recurrence after surgery. No patients died of gastric cancer during a median follow-up of 60.3 months (range, 38–84). Laparoscopic management for residual lesions of early gastric cancer after EMR is a safe, effective, and minimally invasive procedure by which curative resection can be expected.Part of this article was presented at the Fifth International Gastric Cancer Congress, Rome, Italy, May 2003, and also at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Denver, Colorado, USA, March–April 2004     

Totally Laparoscopic Gastric Resection with Extended Lymphadenectomy for Gastric Adenocarcinoma

Background  Laparoscopic gastric resection with extended lymphadenectomy is being evaluated in North America for the surgical treatment of gastric cancer. The aim of this study is to compare short-term postoperative and oncologic outcomes of laparoscopic and open resection for gastric cancer at a single cancer center. Methods  The study population consisted of patients with gastric adenocarcinoma who underwent a completely abdominal intervention with curative intent. Laparoscopic and open gastric resections were compared. A totally laparoscopic technique was employed with a robotic extended lymphadenectomy in a subset of patients. Results  A total of 78 consecutive patients were evaluated, including 30 laparoscopic and 48 open procedures. An extended lymphadenectomy was performed in 58 patients and was executed robotically in 16 of these. There was no difference in the mean number of lymph nodes retrieved by laparoscopic or open approach (24 ± 8 vs. 26 ± 15, P = .66). Laparoscopic procedures were associated with decreased blood loss (200 vs. 383 mL, P = .0009) and length of stay (7 vs. 10 days, P = .0009), but increased operative time (399 vs. 298 minutes, P < .0001). Conclusion  Completely laparoscopic gastric resection yields similar lymph node numbers compared with open surgery for gastric cancer. It was found to be advantageous in terms of operative blood loss and length of stay. Minimally invasive techniques represent an oncologically adequate alternative for the surgical treatment of gastric adenocarcinoma.     

Laparoscopic approaches to resection of suspected gastric gastrointestinal stromal tumors based on tumor location

Background Surgical resection of gastric gastrointestinal stromal tumor (GIST) should be optimized to achieve a negative pathologic surgical margin while limiting the extent of stomach volume loss. Careful identification of exact gastric tumor location using preoperative computed tomography (CT) scans and gastroscopy should allow for selection of a specific operative approach. Methods This retrospective case series involved 12 patients (7 men and 5 women; mean age, 60.5 years) with suspected gastric GIST undergoing tumor resection at Fletcher Allen Health Care, a university medical center, from January 2005 to August 2006. The main outcome measures were pathologic resection margins, operative time, estimated blood loss (EBL), morbidity, and duration of hospital stay. Results The 12 patients were separated into three groups on the basis of tumor location as follows: type 1 (fundus/greater curvature, n = 5), type 2 (prepyloric/antrum, n = 3), and type 3 (lesser curvature/perigastroesophageal junction, n = 4). Preoperative imaging (CT scan and/or endoscopy) used to identify tumor location accurately predicted the operative approach before surgery for 11 of the12 patients. The surgical approach was selected solely by tumor location as follows: type 1 (laparoscopic partial gastrectomy [LPG]), type 2 (laparoscopic distal gastrectomy [LDG]), and type 3 (laparoscopic transgastric resection [LTG]). Nine patients had a final pathologic diagnosis of GIST. The average tumor size was 4.6 cm, but this did not influence procedure selection. Histologic margins were microscopically negative in all patients. The LPG and LTG approaches had similar outcomes in terms of estimated blood loss (EBL; 80 vs 100 ml) and hospital stay (3.4 vs 3.3 days; p = 0.0198), but LTG had longer operative times (236 vs 180 min). The LDG procedure had longer operative times, greater EBL, and a longer hospital stay. The operative morbidity was 17%, and there was no operative mortality. Conclusion The selection of an operative technique for resection of gastric submucosal tumors can be based on preoperative identification of tumor location, for better definition of both the extent of gastric resection and the technical complexity of the laparoscopic procedure.     

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.     

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Laparoscopy-assisted Billroth I gastrectomy compared with conventional open gastrectomy

BACKGROUND: Although several studies compare surgical results of laparoscopic and open colonic resections, there is no study of laparoscopic gastrectomy compared with open gastrectomy. HYPOTHESIS: When compared with conventional open gastrectomy, laparoscopy-assisted Billroth I gastrectomy is less invasive in patients with early-stage gastric cancer. DESIGN: Retrospective review of operative data, blood analyses, and postoperative clinical course after Billroth I gastrectomy. SETTING: University hospital in Japan. PATIENTS: The study included 102 patients who were treated with Billroth I gastrectomy for early-stage gastric cancer from January 1993 to July 1999: 49 with laparoscopy-assisted gastrectomy and 53 with conventional open gastrectomy. MAIN OUTCOME MEASURES: Demographic features examined were operation time; blood loss; blood cell counts of leukocytes, granulocytes, and lymphocytes; serum levels of C-reactive protein, interleukin 6, total protein, and albumin; body temperature; weight loss; analgesic requirements; time to first flatus; time to liquid diet; length of postoperative hospital stay; complications; proximal margin of the resected stomach; and number of harvested lymph nodes. RESULTS: Significant differences (P<.05) were present between laparoscopy-assisted and conventional open gastrectomy when the following features were compared: blood loss (158 vs 302 mL), leukocyte count on day 1 (9.42 vs 11.14 x 10(9)/L) and day 3 (6.99 vs 8.22 x 10(9)/L), granulocyte count on day 1 (7.28 vs 8.90 x 10(9)/L), C-reactive protein level on day 7 (2.91 vs 5.19 mg/dL), interleukin 6 level on day 3 (4.2 vs 26.0 U/mL), serum albumin level on day 7 (35.6 vs 33.9 g/L), number of times analgesics given (3.3 vs 6.2), time to first flatus (3.9 vs 4.5 days), time to liquid diet (5.0 vs 5.7 days), postoperative hospital stay (17.6 vs 22.5 days), and weight loss on day 14 (5.5% vs 7.1%). There was no significant difference between laparoscopy-assisted and conventional open gastrectomy with regard to operation time (246 vs 228 minutes), proximal margin (6.2 vs 6.0 cm), number of harvested lymph nodes (18.4 vs 22.1), and complication rate (8% vs 21%). CONCLUSIONS: Laparoscopy-assisted Billroth I gastrectomy, when compared with conventional open gastrectomy, has several advantages, including less surgical trauma, less impaired nutrition, less pain, rapid return of gastrointestinal function, and shorter hospital stay, with no decrease in operative curability. When performed by a skilled surgeon, laparoscopy-assisted Billroth I gastrectomy is a safe and useful technique for patients with early-stage gastric cancer.     

Laparoscopic cholecystectomy in patients with a history of gastrectomy

PURPOSE: Previous gastrectomy has been considered a relative contraindication to laparoscopic cholecystectomy (LC). The aim of this study was to evaluate the safety and efficacy of LC in patients with a history of gastrectomy. METHODS: From a database of 1 104 consecutive patients with symptomatic gallstone disease, who underwent LC between April 1992 and January 2007, 51 (4.6%) had undergone previous gastrectomy: for gastric cancer (n = 36) or gastroduodenal ulcer (n = 15). We compared the operative time, blood loss, conversion rate, morbidity rate, diet resumption, and postoperative hospital stay between patients with, and those without, a history of gastrectomy. RESULTS: The incidence of common bile duct stones was significantly higher (33.3% vs 8.6%, P < 0.001) and operative time was significantly longer (111.2 min vs 77.9 min, P < 0.001) in the patients with a history of gastrectomy. There was no significant difference in operative time between the first-half and second-half periods. Conversion to an open cholecystectomy was required in two patients. There was no significant difference between the two groups in blood loss, conversion rate, morbidity rate, diet resumption, or postoperative hospital stay. CONCLUSION: Laparoscopic cholecystectomy is a safe and effective treatment for symptomatic gallstone disease in patients with a history of gastrectomy, although previous gastrectomy is associated with an increased need for adhesiolysis and a longer operative time.     

Totally Laparoscopic Gastrectomy for Gastric Cancer

Background and Objectives:

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

Methods:

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

Results:

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

Conclusions:

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

腹腔镜胃癌手术不应忽视肿瘤治疗的原则

自1994年Kitano报道首例腹腔镜辅助远端胃切除联合淋巴结清扫手术以来,近年在日本和韩国,腹腔镜手术已被广泛应用于淋巴结转移风险低的早期胃癌.腹腔镜胃癌手术的目的在于最大限度地减少手术创伤,提高患者生活质量,但要以保证手术的根治性为前提.随着腹腔镜手术经验的不断积累,目前腹腔镜胃切除术的指征已逐渐从早期胃癌扩大到进展期胃癌.但是由于缺乏长期疗效的循证医学证据支持,腹腔镜手术在进展期胃癌中的运用尚存争议.因此,为保证腹腔镜胃癌手术获得与传统开腹手术相似的临床疗效,必须严格遵循肿瘤治疗的基本原则,诸如合适的病例选择,充分的手术切缘,规范的D2淋巴结清扫及符合无瘤原则等.     

腹腔镜与开腹胃癌根治术治疗早期胃癌的临床对照研究

目的 探讨腹腔镜胃癌根治术在早期胃癌治疗中的临床应用.方法 回顾性分析2004年10月至2009年12月间分别接受腹腔镜胃癌根治术（LAP组）及开腹胃癌根治术（OPEN组）的204例早期胃癌患者的临床资料.LAP组78例,OPEN组126例;比较两组患者手术方式、手术时间、术中失血量、术后肛门排气时间、术后住院天数、并发症、术后病理和随访结果.结果 手术时间LAP组为（202.9±45.6）min,显著低于OPEN组的（219.8±45.2）min（P＜0.05）;术中失血量LAP组为（144.5±146.5）ml,显著低于OPEN组的（245.0±146.4）ml（P＜0.05）.术后第1次肛门排气时间LAP组为（3.1±1.1）d,OPEN组为（4.5±1.6）d（P＜0.05）;术后第1次进食时间LAP组为（5.2±1.9）d,OPEN组为（7.0±3.6）d（P＜0.05）;术后住院天数LAP组为（10.8±1.2）d,OPEN组为（12.4±3.8）d（P＜0.05）.术后短期并发症发生率LAP组10.3%,OPEN组12.7%（P＞0.05）.手术上、下切缘距离肿瘤为LAP组为（4.0±1.9）cm和（3.6±1.7）cm,OPEN组则为（4.2±1.7）cm和（3.5±1.8）cm（p＞0.05）,差异无统计学意义.手术平均清扫淋巴结数LAP组为（13.1±6.5）枚,OPEN组则为（14.5±8.2）枚（P＞0.05）,差异也无统计学意义.术后LAP组中位随访22（2～64）个月,无肿瘤复发和远处转移;OPEN组中位随访24（3～65）个月,1例死于肿瘤腹膜转移.两组患者住院期间的总费用比较,差异无统计学意义（P＞0.05）.结论 腹腔镜胃癌根治术是治疔早期胃癌安全、可行、微创、有效的手术方法.     

Laparoscopic Treatment of Gastric <Emphasis Type="SmallCaps">Gist</Emphasis>: Report of 21 Cases and Literature’s Review

Background Although the feasibility of laparoscopic resection of gastric gastrointestinal stromal tumors (GISTs) has been established, various aspects are debated. This paper describes the problems of minimally invasive resection of gastric GISTs and compares this experience with an extensive literature review. Study Design Between August 2001 and December 2006, 21 consecutive patients undergoing laparoscopic resection of gastric GISTs were enrolled in a prospective study. A literature review of laparoscopic treatment was performed on Pubmed using keywords GIST and surgery. A comparison with authors’ experience with open wedge-segmental resection of GISTs (25 cases from November 1995 to December 2000) was also carried out. Statistical analysis was based on chi-squared test and t Student evaluation. Results Twenty-one patients, mean age 50.1 years (range, 34–68 years), were submitted to laparoscopic wedge- segmental gastric resections. Mean tumor size was 4.5 cm (range, 2.0–8.5 cm). Mean operative time was 151 min (range, 52–310 min), the mean blood loss was 101 mL (range, 10–250 mL), and the mean hospital stay was 4.8 days (range 3–7 days). There were no major operative complications or mortalities. All lesions had negative resection margins. At a mean follow-up of 35 months, all patients were disease-free. Morbidity, mortality, length of stay, and oncologic outcomes were comparable to the open surgery retrospective evaluation (p = not significant). Conclusions As found also in the literature review, the laparoscopic resection is safe and effective in treating gastric GISTs. Given these findings as well as the advantages afforded by laparoscopic surgery, a minimally invasive approach should be the preferred surgical treatment in patients with small- and medium-sized gastric GISTs.     

Thoracoscopic and laparoscopic esophagectomy: initial experience and outcomes

Background: Although surgical resection currently is the preferred treatment for fit patients with resectable esophageal cancers, it is associated with a relatively high risk of morbidity and significant perioperative mortality. Currently, a range of open surgical approaches are used. More recently, minimally invasive approaches have become feasible, with the potential to reduce perioperative morbidity. This study investigated the outcomes from one such approach. Methods: Outcome data were collected prospectively for 36 consecutive patients who underwent a minimally invasive esophagectomy for esophageal cancer. A three-stage approach was used, with all the patients undergoing a thoracoscopic esophageal mobilization, combined with either open or hand-assisted laparoscopic abdominal gastric mobilization, and open cervical anastomosis. An open abdominal approach was used for 15 of the patients and a hand-assisted laparoscopic approach for 21. A total of 34 patients had invasive malignancy, whereas 2 had preinvasive disease. A group of 23 patients (68%) who had invasive malignancies also received neoadjuvant chemotherapy and radiotherapy. Results: The mean operating time ranged from 190 to 360 min (mean, 263 min). The median postoperative hospital stay was 16 days. In-hospital mortality was 5.5% (2/36), and perioperative morbidity was 41%. The perioperative outcomes for patients undergoing an open abdominal approach and those who had hand-assisted laparoscopic surgery were similar. For the patients who underwent a hand-assisted laparoscopic abdominal procedure, the total operating time was shorter (248 vs 281 min), and the blood loss was less (223 vs 440 ml). The median follow-up period was 30 months. The 4-year survival predicted by Kaplan–Meir for the 34 patients with invasive malignancy was 44%. Conclusion: The outcome for esophagectomy using thoracoscopic esophageal mobilization, with or without hand-assisted laparoscopic abdominal surgery, was comparable with data from conventional open surgical approaches. These approaches can be performed with an acceptable level of perioperative morbidity. Further application of these techniques, with close scrutiny of outcome data, is appropriate.     

腹腔镜胃切除手术治疗胃间质瘤

目的：探讨腹腔镜手术治疗胃间质瘤（gastricstromal tumors,GST）的临床应用价值。方法：回顾分析2003年6月至2009年2月间接受腹腔镜手术的36例GST病人的临床资料,包括手术方式、手术时间、术中失血、术后排气时间、术后住院天数、并发症、术后病理及随访资料等。结果：所有GST切除手术均在腹腔镜下完成,其中行腹腔镜胃楔形切除者21例．腹腔镜经胃肿瘤外翻切除术者12例,腹腔镜辅助远端胃切除术者2例,腹腔镜辅助下内镜胃间质瘤圈套套扎术者1例。无一例病人中转开腹手术,手术平均时间为75（30～210）min,术中平均失血60（5-150）mL．肿瘤平均大小3．0（0．5～11．5）cm,肿瘤切缘镜下均为阴性;术后平均排气时间2（1～11）d,手术后平均住院天数8f3。131d。1例病人出现术后胃腔内出血,经保守治疗后1d出出即停止,其余病例无重大术后并发症。术后平均随访25（4～67）个月,所有病人均无肿瘤复发和远处转移。结论：腹腔镜辅助胃切除是治疗GST之安全、可行、做创、有效的手术方法。     

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     

Laparoscopic versus open right hemicolectomy for carcinoma of the colon.

OBJECTIVE: This study aimed to compare the outcomes of laparoscopic resection (LR) with open resection (OR) for right-sided colon cancer. METHODS: During the study period from June 2000 to December 2004, 182 patients (84 men) underwent elective resection for cancer of the right colon. Laparoscopic resection was performed in 77 patients, while 105 patients had open operations. Patients who underwent operations on an emergency basis were excluded. Data on the patients' demographics, operative details, and postoperative complications were collected prospectively. The outcomes of patients with laparoscopic resection were compared with those of patients with open surgery. RESULTS: There was no difference in the age, sex, presence of premorbid medical conditions, and blood loss between the 2 groups. The mean operative time for open resection was 115.4 minutes and that for laparoscopic resection was 165.1 minutes (P<0.001). Among the 77 patients who underwent laparoscopic resection, 7 (9%) required conversion to an open operation. There was no difference in postoperative surgically related complications including wound infection, leakage, intestinal obstruction, postoperative ileus. Nonsurgical-related complications were also similar. The median time to resumption of a normal diet was 3 days and 4 days in the laparoscopic and open groups, respectively. The median hospital stay in patients with laparoscopic resection was significantly shorter than in patients with open surgery (6.0 days vs 7.0 days, P<0.001). The 2-year overall survival rates were 74% in both groups (P=0.904). In the converted to open (LCOR) group, the hospital stay was significantly longer (LR vs OR vs LCOR, 5.5 days vs 7.0 days vs 9.0 days respectively, P<0.001). CONCLUSION: Laparoscopic right hemicolectomy is a safe option for cancers of the right colon. It is associated with a shorter hospital stay and earlier resumption of a normal diet. Mortality and morbidity are similar to that with the open approach. There is no compromise in the survival of patients.