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

Background

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

Methods

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

Results

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

Conclusions

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

Robotic spleen-preserving total gastrectomy for gastric cancer: comparison with conventional laparoscopic procedure

Background

Robotic systems recently have been introduced to overcome technical limitations of conventional laparoscopic surgery, especially for complex procedures. Laparoscopic spleen-preserving total gastrectomy with D2 lymph node (LN) dissection (LTGD2) is one of the most complicated procedures. We hypothesized that robotic LN dissection would be more thorough and accurate. We compared robotic spleen-preserving total gastrectomy with D2 LN dissection (RTGD2) with LTGD2 to investigate the impact of robotics.

Methods

Clinicopathologic characteristics and short-term and long-term outcomes of RTGD2 (n = 51) versus LTGD2 (n = 58) in gastric adenocarcinoma patients were extracted from a prospectively designed database and analyzed retrospectively.

Results

There was no difference of patients’ characteristics between groups. Mean operation time of RTGD2 was longer than LTGD2 (p < 0.001), and no differences in tumor histology, size, location, and TNM stage were seen. Total retrieved LNs from RTGD2 was similar to LTGD2 (mean 47.2 vs. 42.8, respectively), as were retrieved LNs at splenic hilum (1.3 vs. 0.8). However, mean numbers of retrieved LNs along the splenic artery from RTGD2 was higher than LTGD2 (2.3 vs. 1.0, respectively; p = 0.013), as was also the case at the splenic hilum and artery (3.6 vs. 1.9, p = 0.014). Postoperative complication (16 vs. 22 %, p = 0.374) and overall and disease-free survival between the two groups were not significantly different (p = 0.767 and p = 0.666, respectively).

Conclusions

Robotic spleen-preserving total gastrectomy with D2 LN dissection is feasible. Operation time and retrieved total LNs and splenic hilar LNs in the robotic procedure are acceptable.     

Oncologic Outcomes of Laparoscopy-Assisted Distal Gastrectomy for Gastric Cancer

Background

In both advanced and early gastric cancer with preoperatively suspected lymph node metastasis, extended lymph node dissection is needed to achieve R0. Since extended lymph node dissection is difficult to perform laparoscopically, few reports have reported long-term outcomes in large numbers of patients. The purpose of this study was to investigate oncologic outcomes after laparoscopy-assisted distal gastrectomy (LADG) with extended lymph node dissection.

Methods

Between April 2004 and March 2010, LADG with extended lymph node dissection was performed at our hospital for 880 patients diagnosed with T1N0-1 or T2N0 (N is classified by Japanese topographic classification) gastric cancer in the lower or middle body of the stomach. D2 lymph node dissection was performed for stage IB (T1N1, T2N0) cancers. Modified D2 lymph node dissection was performed for stage IA (T1N0). Overall survival (OS), disease-free survival (DFS), and form of tumor recurrence at 4 years were investigated retrospectively.

Results

Median follow-up was 42 months. The 4-year OS was 98.2 % for all patients. By stage, OS/DFS were 99.0/99.0 % in stage IA patients, 95.9/95.9 % in stage IB, 92.6/92.0 % in stage IIA, and 90.0/92.9 % in stage IIB. A total of 11 patients died, including 4 deaths from recurrence (liver metastasis, n = 1; peritoneal dissemination, n = 2; distant lymph node and bone metastases, n = 1). There is 1 patient is alive with recurrence (liver). Mean time until recurrence was 14 months.

Conclusions

Oncologic outcomes were good in patients with T1N0-1 and T2N0 gastric cancer who underwent LADG with extended lymph node dissection. This approach appears effective for treating T1N0-1 and T2N0 gastric cancer.     

Optimal surgical management for esophagogastric junction carcinoma

Objectives

Esophagogastric junction carcinoma incidence is increasing worldwide. However, surgical strategies for this cancer remain controversial. This study aimed to clarify the optimal surgical strategy for esophagogastric junction carcinoma.

Methods

We retrospectively reviewed a database of 68 consecutive patients with esophagogastric junction carcinoma [Japanese classification of gastric carcinoma (Nishi’s definition): adenocarcinoma, N = 53; squamous cell carcinoma, N = 15] who underwent curative surgical resection at Keio University Hospital between January 2000 and September 2008.

Results

In both adenocarcinoma and squamous cell carcinoma, most lymph node metastases were located in the lesser curvature area. Mediastinal lymph node metastasis was observed in 4 patients (7.5 %) with adenocarcinoma and 7 patients (46.7 %) with squamous cell carcinoma. No patient presented with lymph node metastases in the pyloric region. The therapeutic value of extended lymph node dissection was 0, except for lymph node station numbers 1, 2, 3, 4sa, 7, and 110. Extended lymph node dissection in the lesser curvature area showed a high therapeutic value. The para-aortic lymph node was the most frequent nodal recurrence site. All patients with tumor centers located below the esophagogastric junction (N = 37) did not develop mediastinal lymph node metastasis or recurrence.

Conclusions

Proximal gastrectomy through a transhiatal approach may be the optimal surgical strategy for esophagogastric carcinoma. Mediastinal lymph node dissection through a thoracic approach seems unnecessary, particularly when the tumor center is located below the esophagogastric junction. To confirm the necessity of para-aortic nodal dissection, further studies are required.     

Feasibility of the trans-umbilical route compared with the trans-oral route in gastric upper body endoscopic submucosal dissection: a porcine model

Background

Total gastrectomy is performed for early gastric cancer in the upper body of the stomach because of the high complication rate of endoscopic submucosal dissection (ESD). The aims of the present animal study in pigs were to verify: (1) the feasibility of the trans-umbilical route compared with the trans-oral route in gastric upper body ESD; (2) the non-inferiority of single port laparoscopic lymph node dissection (LLND) compared with multiport LLND; and (3) the safety of 2-basin LLND (upper greater and lesser curvature).

Methods

We separated the pigs (~40 kg each) into two groups: conventional and experimental (n = 5 per group). We performed ESD in the fundus and upper body anterior wall (UBAW) via the trans-oral route and multiport LLND in the conventional group, and via the trans-umbilical route and single port LLND in the experimental group.

Results

The completion rates, tissue weights, and specimen diameters of both routes showed no statistical differences in either the fundus or the UBAW. The operative time was shorter with the trans-umbilical route than with the trans-oral route in both areas (p < 0.05). In LLND, there were no differences in surgical outcomes between the multiport and single port groups. Intraoperative perforation was seen in the trans-oral route group (n = 1). Delayed perforation was observed in 30 % of the ESD sites.

Conclusions

The trans-umbilical route is feasible and has lower complication rates than the trans-oral route in gastric upper body ESD. Additionally, single port LLND is not inferior to multiport LLND, and one-side-basin dissection is safer than two-side.     

Simultaneous Indocyanine Green and 99mTc-Antimony Sulfur Colloid-Guided Laparoscopic Sentinel Basin Dissection for Gastric Cancer

Background

There are few reports on a dual dye and isotope approach using laparoscopy in gastric cancer sentinel node mapping. The aim of this study is to evaluate the feasibility of laparoscopic sentinel basin dissection for gastric cancer using simultaneous indocyanine green (ICG) and ^99mTc-antimony sulfur colloid (ASC) injections.

Methods

Sixty-eight patients were enrolled who had been diagnosed with cT1–T2 and cN0 stage gastric cancers. They underwent laparoscopic sentinel basin dissection between June 2005 and May 2008. ICG and ^99mTc-tin colloid (separate injections in the first phase, n = 16) or ICG and ^99mTc-ASC (simultaneous injections in the second phase, n = 52) were injected into the submucosa endoscopically. After performing the sentinel basin dissection, laparoscopy-assisted gastrectomy with curative lymphadenectomy was done. Green-stained or radioactive sentinel nodes (SNs) were analyzed by hematoxylin and eosin staining and by immunohistochemistry for cytokeratin.

Results

SNs were identified in 62 of the 68 patients (91.2%; mean 3.3 per patient). Eighteen patients had lymph node metastases. The sensitivity and specificity were, respectively, 72.2 and 100% using the dye method and 83.3 and 100% by the isotope method. However, the dual dye/isotope procedure improved both sensitivity and specificity to 100%. Patients receiving this protocol had significantly more SNs than those receiving separate ICG and ^99mTc-tin colloid injections (3.3 vs. 1.9, P = 0.008).

Conclusion

Simultaneous ICG and ^99mTc-ASC-guided laparoscopic sentinel basin dissection is an effective tool for gastric cancer SN mapping, giving a high detection rate and excellent sensitivity.     

Additional surgery for non-curative resection after endoscopic submucosal dissection for gastric cancer: a retrospective analysis of 200 cases

Purpose

Endoscopic submucosal dissection is recommended for early gastric cancer with a low risk of lymph node metastasis. When the pathological findings do not meet the curative criteria; then, an additional gastrectomy with lymph node dissection is recommended. However, most cases have neither lymph node metastasis nor a local residual tumor during an additional surgery.

Methods

This was a single-institutional retrospective cohort study, analyzing 200 patients who underwent an additional gastrectomy after non-curative endoscopic submucosal dissection from January 2005 to October 2015. We reviewed the patients’ clinicopathological data and evaluated the predictors for the presence of a residual tumor.

Results

Histopathology revealed lymph node metastasis in 15 patients (7.5 %) and a local residual tumor in 23 (11.5 %). A multivariable analysis revealed macroscopic findings (flat/elevated type) (p = 0.011, odds ratio = 4.63), lymphatic invasion (p < 0.0001, odds ratio = 14.2), and vascular invasion (p = 0.04, odds ratio = 4.00) to be predictors for lymph node metastasis. A positive vertical margin (p = 0.0027, odds ratio = 3.26) and horizontal margin (p = 0.0008, odds ratio = 5.74) were predictors for a local residual tumor. All cases with lymph node metastasis had lymphovascular invasion with at least one other non-curative factor.

Conclusions

The risk of a residual tumor can, therefore, be estimated based on the histopathology of endoscopic submucosal dissection samples. Lymphovascular invasion appears to be a pivotal predictor of lymph node metastasis.

     

Quilting Prevents Seroma Formation Following Breast Cancer Surgery: Closing the Dead Space by Quilting Prevents Seroma Following Axillary Lymph Node Dissection and Mastectomy

Background

Seroma is a frequent problem after mastectomy (ME) and axillary lymph node dissection (ALND). Seroma is associated with pain, discomfort, impaired mobilisation and repeated aspirations, often resulting in a surgical site infection (SSI). It has already been demonstrated that minimizing dead space through fixation of the skin flaps to the underlying muscles (quilting) lowers the incidence of seroma. The aim of this study was to evaluate the effect of quilting on the incidence of seroma, and SSI.

Methods

Two consecutive groups with a total of 176 patients following ME and/or ALND were retrospectively compared. Endpoints were the incidence of seroma, and number and volume of aspirations and SSIs. Analysed risk factors were age, ME, lymph node dissection, neoadjuvant therapy, body mass index (BMI) and hypertension.

Results

The quilted group (n = 89) scored significantly better on all endpoints compared with the conventional group (n = 87). The incidence of seroma decreased from 80.5 % to 22.5 % (p < 0.01), the mean number of aspirations from 4.86 to 2.40 (p = 0.015), the volume of aspirations from 1660 ml to 611 ml (p = 0.05) and the SSIs from 31.0 % to 11.2 % (p < 0.01). Increasing age and lymph node dissection were found to be risk factors for seroma; quilting was a protective factor.

Conclusion

Quilting is an effective method for preventing seroma and its complications.     

Is There Any Role of Additional Retropancreatic Lymph Node Dissection on D2 Gastrectomy for Advanced Gastric Cancer?

Background

Extended lymph node dissection beyond D2 in resectable gastric cancer has not shown any survival benefits. However, whether the retropancreatic (No. 13) lymph node should be dissected still remains controversial. The purpose of this study was to evaluate the effects of additional No. 13 lymph node dissection on D2 gastrectomy for gastric cancer in terms of overall survival.

Methods

From May 2001 to December 2006, 528 patients underwent curative resection for the middle- or lower-third advanced gastric cancer at the National Cancer Center, Korea. The patients were grouped according to whether a No. 13 lymphadenectomy was performed (13D+/13D?). Clinicopathological characteristics and treatment-related factors were compared between the two groups. The overall survival was analyzed using the Cox proportional hazard model.

Results

The incidence of No. 13 lymph node metastasis was 6.7 %. There was no significant difference in morbidity or mortality between the 13D+ and 13D? groups. In clinical stages I/II, No. 13 lymph node dissection did not affect overall survival. However, it was an independent prognostic factor in patients with clinical stages III/IV gastric cancer (hazard ratio (HR), 0.55; P = 0.022).

Conclusions

Additional retropancreatic lymph node dissection beyond a D2 gastrectomy might be favorable for survival in patients with clinical stage III/IV middle- or lower-third gastric cancer.     

Minimally Invasive Inguinal Lymph Node Dissection (MILND) for Melanoma: Experience from Two Academic Centers

Background and Aim

Regional lymph nodes are the most frequent site of spread of metastatic melanoma. Operative intervention remains the only potential for cure, but the reported morbidity rate associated with inguinal lymphadenectomy is approximately 50 %. Minimally invasive lymph node dissection (MILND) is an alternative approach to traditional, open inguinal lymph node dissection (OILND). The aim of this study is to evaluate our early experience with MILND and compare this with our OILND experience.

Methods

We conducted a prospective study of 13 MILND cases performed for melanoma from 2010 to 2012 at two tertiary academic centers. We compared our outcomes with retrospective data collected on 28 OILND cases performed at the same institutions, by the same surgeons, between 2002 and 2011. Patient characteristics, operative outcomes, and 30-day morbidity were evaluated.

Results

Patient characteristics were similar in the two cohorts with no statistically significant differences in patient age, gender, body mass index, or smoking status. MILND required longer operative time (245 vs 138 min, p = 0.0003). The wound dehiscence rate (0 vs 14 %, p = 0.07), hospital readmission rate (7 vs 21 %, p = 0.25), and hospital length of stay (1 vs 2 days, p = 0.01) were all lower in the MILND group. The lymph node count was significantly higher (11 vs 8, p = 0.03) for MILND compared with OILND.

Conclusions

MILND for melanoma is a novel alternative to OILND, and our preliminary data suggest that MILND provides an equivalent lymphadenectomy while minimizing the severity of postoperative complications. Further research will need to be conducted to determine if the oncologic outcomes are similar.     

Laparoscopic total gastrectomy for remnant gastric cancer: feasibility study

Background

The benefits and feasibility of laparoscopic surgery for remnant gastric cancer are still unclear. The purpose of this study was to describe the detailed procedure and to evaluate the clinical short-term outcomes of laparoscopic total gastrectomy (LTG) compared with open total gastrectomy (OTG) for remnant gastric cancer (RGC).

Methods

Of 1,247 consecutive patients who underwent gastrectomy for gastric cancer in our department at Kyushu University Hospital from January 1996 to May 2012, 22 patients who underwent successful curative resection of RGC with precise nodal dissection were enrolled in this study. Twelve patients underwent LTG and the remaining ten patients underwent OTG. We analyzed the clinical short-term outcomes of LTG and compared the results between LTG and OTG groups to evaluate the safety and feasibility of LTG.

Results

Twelve patients with RGC successfully underwent LTG without open conversion and morbidity. The mean operation time of LTG, 362.3 ± 68.4 min, was significantly longer than that of OTG (p = 0.0176), but the mean blood loss of LTG, 65.8 ± 62 g, was smaller than that of OTG (p < 0.01). The mean postoperative times to resumption of water and food intake were significantly shorter in the LTG group than in the OTG group (p < 0.01). The overall 3-year survival rate was comparable between the LTG and OTG groups (77.8 vs. 100 %; p = 0.9406).

Conclusions

This study shows that LTG is a feasible and reliable procedure for the treatment of RGC in terms of short-term outcomes.     

Laparoscopic resection of paraaortic or paracaval lesions: feasibility and outcome

Background

Laparoscopic retroperitoneal lymph node dissection of paraaortic and paracaval lymph nodes is used to stage nonseminomatous germ cell tumors. Primary tumors can arise from the retroperitoneum, and tumors from nonurologic malignancy also may metastasize to retroperitoneal lymph nodes. This study aimed to describe the authors’ experience with laparoscopic resection of these lesions.

Methods

A consecutive series of patients between January 2007 and June 2011 with paraaortic, aortocaval, or paracaval tumors with a maximum diameter smaller than 10 cm and confined to the abdomen were considered for laparoscopic resection. Data were collected on size and pathology of the lesions, anesthesia time, postoperative stay, and postoperative morbidity and mortality.

Results

In this study, 25 patients with a median age of 49 years were assessed for laparoscopic resection. Eight patients were considered unsuitable for a laparoscopic approach because of tumor location (n = 5), previous retroperitoneal surgery (n = 1), stoma (n = 1), or lesion not clearly visible on computed tomography (n = 1). Of the 17 patients undergoing laparoscopic resection, 1 was found to have diffuse peritoneal disease at laparoscopy, whereas another was converted to an open procedure due to bleeding. All the laparoscopic patients had an R0 resection. The median hospital stay was significantly shorter in the laparoscopic group (2 days) than in the open group (6 days) (P = 0.009). One patient in the laparoscopic group with a functioning paraganglioma and advanced cardiac disease died on postoperative day 7.

Conclusion

Laparoscopic paraaortic and paracaval surgery for primary and recurrent tumors of the retroperitoneum is feasible, with clear resection margin rates similar to that observed for open surgery.     

Gastrectomy with Extended Lymphadenectomy: a North American Perspective

Purpose

Despite evidence of oncologic benefits from extended (D2) lymphadenectomy in gastric cancer from many East Asian studies, there is persistent debate over its use in the West, mainly due to perceived high rates of morbidity and mortality. This study evaluates the safety and efficacy of D2 dissection in a high-volume North American center.

Methods

A prospectively entered database of all patients undergoing gastrectomy for cancer at a North American referral center from 2005 to 2016 was reviewed. Wedge resections, thoracoabdominal approach, emergency surgery, palliative operations, and non-adenocarcinoma cases were excluded.

Results

Of 366 non-bariatric gastrectomies over this period, 175 met the inclusion criteria. Median age was 73 years and 69% were male. One hundred forty-one patients (80%) underwent D2 dissection, the rest having D1. There was no difference in postoperative complications (D1 = 44%: D2 = 42%), anastomotic leaks (D1 = 6%: D2 = 5%), and same-admission or 30-day mortality (D1 = 6%: D2 = 2%). D2 dissection was associated with higher pathological stage (72% > stage 1 vs 38% > stage 1; p < 0.05) and median lymph node yield (30 vs 14; p < 0.05), with no difference in complete resection (R0) rate (D1 = 98% vs D2 = 92%). Laparoscopic approach was employed in 34% (45/141) of D2 cases, resulting in shorter median length of stay (6 days vs 9; p < 0.05) and equivalent oncologic outcomes compared to open D2.

Conclusion

This study supports the use of D2 lymphadenectomy, by either open or laparoscopic approach, in high-volume North American centers as a safe and effective oncologic procedure for gastric cancer, with equivalent complication rates and superior lymph node yield to traditional D1 dissection.

     

Poor Prognosis of Advanced Gastric Cancer with Metastatic Suprapancreatic Lymph Nodes

Background

Whether gastrectomy with D2 lymphadenectomy improves survival of patients with advanced gastric cancer (AGC) remains controversial. Few studies have described the pathological features of AGC with metastatic suprapancreatic lymph nodes (LN), which are the target of D2 lymphadenectomy. This study therefore aims to clarify the prognosis and clinical pathological features including the number and location of metastatic LN in AGC with metastatic suprapancreatic LN.

Methods

406 patients with AGC, who underwent gastrectomy with D2 lymphadenectomy from 1982 to 2007 at Oita University, were reviewed retrospectively with regard to presence or absence of metastatic suprapancreatic LN. The pathological factors associated with AGC with metastatic suprapancreatic LN were examined by univariate and multivariate analysis.

Results

Of 362 patients with AGC, 78 had suprapancreatic LN metastasis (21.5 %), differing significantly in terms of presence of vascular invasion and having a larger number of metastatic perigastric LN in comparison with only metastatic perigastric LN on univariate analysis. According to multivariate analysis, they were associated with presence of vascular invasion and a large number of total metastatic LN (more than two; N2≤). The overall 5-year survival rate of the AGC with perigastric LN metastasis (station 1–7) group was 37.9 % and of the AGC with suprapancreatic LN metastasis group was 12.8 %. There were significant differences in each group (P < 0.05).

Conclusions

Patients with AGC with metastatic suprapancreatic LN had a large number of total metastatic LN and poor prognosis, suggesting that it may be a systemic disease.     

Feasibility of laparoscopy-assisted gastrectomy for patients with chronic obstructive pulmonary disease

Background

Laparoscopy-assisted gastrectomy (LG) is an established treatment for early gastric cancer. However, carbon dioxide pneumoperitoneum during laparoscopic surgery can adversely affect the pulmonary function of patients with chronic obstructive pulmonary disease (COPD). This retrospective cohort study was performed to assess the feasibility of LG for patients with COPD.

Methods

Among 1,053 patients who underwent radical gastrectomy with lymph node dissection between 1999 and 2011 at the authors’ hospital, 220 patients with COPD were studied retrospectively. The clinical outcomes for the patients with COPD who underwent LG (LG group) were compared with those of COPD patients who underwent open gastrectomy (OG group), as well as those of patients with no operative risk and normal pulmonary function who underwent LG (NOR group). Postoperative pulmonary complications (PPCs) were defined as pneumonia, atelectasis, pneumothorax, prolonged mechanical ventilation (>24 h), and adult respiratory distress syndrome within 30 days after operation.

Results

Pulmonary function variables were similar in the LG and OG groups. The findings showed PPCs to be slightly but not significantly less frequent in the LG group (1.7 %) than in the OG group (6.3 %) (p = 0.09). No difference in PPCs was found between the LG group and the NOR group (p > 0.99). For patients with COPD, advanced stage (stage 2 or 3 vs stage 1) was significantly associated with PPCs (p = 0.03), but was not an independent risk factor for PPCs (p = 0.12).

Conclusion

The LG procedure is tolerated in patients with gastric cancer who have mild or moderate COPD, similar to OG.     

Laparoscopic versus open D2 gastrectomy for advanced gastric cancer: a retrospective cohort study

Background

The oncologic safety and feasibility of laparoscopic D2 gastrectomy for advanced gastric cancer are still uncertain. The aim of this study is to compare our results for laparoscopic D2 gastrectomy with those for open D2 gastrectomy.

Methods

Between 1998 and 2008, a total of 336 patients with clinical T2, T3, or T4 tumors underwent laparoscopic (n = 186) or open (n = 150) gastrectomy involving D2 lymph node dissection with curative intent. To produce this study population, 123 patients in the open group who matched those of the laparoscopic group with regard to age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) score, tumor location, and clinical tumor stage were retrospectively selected. The short- and long-term outcomes of these patients were examined.

Results

Laparoscopic D2 gastrectomy was associated with significantly less operative blood loss and shorter hospital stay, but longer operative time, compared with open D2 gastrectomy. The mortality and morbidity rates of the laparoscopic group were comparable to those of the open group (1.1 % vs. 0, P = 0.519, and 24.2 % vs. 28.5 %, P = 0.402). The 5-year disease-free and overall survival rates were 65.8 and 68.1 % in the laparoscopic group and 62.0 and 63.7 % in the open group (P = 0.737 and P = 0.968). There were no differences in the patterns of recurrence between the two groups.

Conclusions

This study suggests that laparoscopic D2 gastrectomy provides reasonable oncologic outcomes with acceptable morbidity and low mortality rates. Although operation time is currently long, this approach is associated with several advantages of laparoscopic surgery, including quick recovery of bowel function and short hospital stay. Laparoscopic D2 gastrectomy may offer a favorable alternative to open D2 gastrectomy for patients with advanced gastric cancer.     

Robotic-assisted lateral lymph node dissection for lower rectal cancer: short-term outcomes in 50 consecutive patients

Background

The goal of this study was to evaluate the short-term outcomes of robotic-assisted lateral lymph node dissection for patients with advanced lower rectal cancer.

Methods

Between 2012 and 2013, 50 consecutive patients underwent robotic-assisted lateral lymph node dissection for rectal cancer in Shizuoka Cancer Center Hospital. Perioperative outcomes including operative time, operative blood loss, length of stay, postoperative complications, and histopathological data were collected prospectively.

Results

Median patient age was 62 years (range 36–74 years). Operative procedures included low anterior resections (n = 27), intersphincteric resections (n = 16), and abdominoperineal resections (n = 7). Bilateral lymph node dissection was performed in 44 patients. The median operative time was 476 min (range 320–683 min), and the median time required for lateral lymph node dissection was 165 min (range 85–257 min). The median blood loss was 27 mL (range 5–690 mL). There were no cases of open surgery or laparoscopic conversion. The median duration of postoperative hospital stay was 8 days (range 6–13 days). Clavien–Dindo classification Grade III–IV complications occurred in only one patient (2.0 %). There were no cases of anastomotic leak. There was no perioperative mortality. The median number of harvested lateral lymph nodes was 19 (range 5–47).

Conclusions

Robotic-assisted lateral lymph node dissection is a safe, feasible, and useful approach for patients with advanced lower rectal cancer.

     

A Multi-institutional Analysis of Open Versus Minimally-Invasive Surgery for Gastric Adenocarcinoma: Results of the US Gastric Cancer Collaborative

Background

Surgical experience with minimally invasive surgery (MIS) has increased; however, published reports on MIS resection of gastric adenocarcinoma are limited.

Methods

Between 2000 and 2012, 880 patients who underwent surgical resection of gastric adenocarcinoma were identified from a multi-institutional database. Clinicopathological characteristics, operative details, and outcomes were stratified by operative approach (open vs. MIS) and analyzed.

Results

Overall, 70 (8 %) patients had a MIS approach. Patients who underwent a MIS resection were more likely to have a smaller tumor (open 4.5 cm vs. MIS 3.0 cm, p?p?p?=?0.03) and median lymph node yield was good in both groups (open 17 vs. MIS 14, p?=?0.10). MIS had a similar incidence of complications (open 33.1 % vs. MIS 20 %, p?=?0.07) and a similar length of stay (open 9 days vs. MIS 7 days, p?=?0.13) compared with open surgery. In the propensity-matched analysis, median recurrence-free and overall were not impacted by operative approach.

Conclusion

An MIS approach to gastric cancer was associated with adequate lymph node retrieval, a high incidence of R0 resection, and comparable long-term oncological outcomes versus open gastrectomy.     

Surgical Outcomes of Gastrectomy for Elderly Patients with Gastric Cancer

Background

This study was designed to determine the surgical outcomes of gastric cancer in elderly patients. This information can help establish appropriate treatment for these patients.

Methods

A total of 1,193 patients with gastric cancer who underwent gastrectomy between 1995 and 2010 were enrolled in this retrospective study. The clinicopathologic features of 104 elderly patients (aged ≥80 years) were compared with those of 1,089 nonelderly patients.

Results

(1) Tumors located in the lower-third of the stomach, differentiated cancer, and surgery with limited lymph node dissection were more common in elderly patients. However, there was no difference in the proportion of laparoscopic gastrectomy between elderly and nonelderly patients. (2) Although surgical complication rates were similar in the two groups, the operative mortality rate was higher in elderly patients (1.9 %) than in nonelderly patients (0.7 %). (3) Elderly patients had a significantly poorer overall survival rate, whereas the disease-specific survival rates of the two groups were similar. Limited lymph node dissection did not influence the disease-specific survival rate of elderly patients. (4) The median life expectancy of elderly gastric cancer survivors was 9.8 years in patients aged 80–84 years and 6.0 years in those ≥85 years. The patients with limited lymph node dissection had slightly better prognosis.

Conclusions

The treatment results in elderly patients were comparable to those in nonelderly patients. These findings suggest that R0 resection with at least limited lymph node dissection according to Japanese guidelines should be considered, even for elderly patients.     

Transvaginal specimen extraction versus conventional minilaparotomy after laparoscopic anterior resection for colorectal cancer: mid-term results of a case-matched study

Background

Although the vagina is considered a viable route during laparoscopic surgery, a number of concerns have led to a need to demonstrate the safety of a transvaginal approach in colorectal surgery. However, the data for transvaginal access in left-sided colorectal cancer are extremely limited, and no study has compared the clinical outcomes with a conventional laparoscopic procedure.

Objective

We compared the clinical outcomes of totally laparoscopic anterior resection with transvaginal specimen extraction (TVSE) with those of the conventional laparoscopic approach with minilaparotomy (LAP) for anastomosis construction and specimen retrieval in left-sided colorectal cancer.

Methods

Fifty-eight patients underwent TVSE between October 2006 and July 2011 and were matched by age, surgery date, tumor location, and tumor stage with patients who underwent conventional LAP for left-sided colorectal cancer.

Results

Operative time was significantly longer in the TVSE group (149.3 ± 39.8 vs. 131.9 ± 41.4 min; p = 0.023). Patients in the TVSE group experienced less pain (pain score 4.9 ± 1.6 vs. 5.8 ± 1.9; p = 0.008), shorter time to passage of flatus (2.2 ± 1.1 vs. 2.7 ± 1.2 days; p = 0.026), and higher satisfaction with the cosmetic results (cosmetic score 8.0 ± 1.4 vs. 6.3 ± 1.5; p = 0.001). More endolinear staplers for rectal transection were used in the LAP group (1.2 ± 0.5 vs. 1.1 ± 0.2; p = 0.021). Overall morbidities were similar in both groups; however, three wound infections only occurred in the LAP group. After a median follow-up of 34.4 (range 11–60) months, no transvaginal access-site recurrence occurred. The 3-year disease-free survival was similar between groups (91.5 vs. 90.8 %; p = 0.746).

Conclusions

Transvaginal access after totally laparoscopic anterior resection is safe and feasible for left-sided colorectal cancer in selected patients with better short-term outcomes.