A Phase-II Clinical Trial of Laparoscopy-Assisted Distal Gastrectomy with D2 Lymph Node Dissection for Gastric Cancer Patients

Objectives This study was conducted to determine whether laparoscopy-assisted distal gastrectomy (LADG) with complete D2 lymph node dissection for gastric cancer is a safe and effective surgical option. Methods During an 8-month period, 64 patients, who were diagnosed preoperatively as having T1-2, N0-1 or M0 gastric cancer, were prospectively enrolled to undergo LADG with D2 lymph node dissection; two surgeons with experience of over 50 cases of laparoscopic gastrectomy performed the procedures. The compliance rate, defined as cases with no more than one missing lymph node station according to the Japanese Research Society of Gastric Cancer (JRSGC) lymph node grouping, for the open gastrectomy with D2 lymph node dissection was 66.0% in a pilot study and was used for calculations of sample size. Compliance rate and other surgical outcomes, including the number of retrieved lymph nodes from each lymph node station, morbidities, mortalities and conversion rate, were analyzed. Results The compliance rate was 67.2% and was similar to that of open distal gastrectomy reported in the pilot study. The mean number of retrieved lymph nodes was 50.1 (range 20–100). The most frequently missed lymph node station was no. 5 (31.2%) followed by no. 3 (25.0%). There were no missed lymph nodes at stations no. 6 and 9. The complication rate was 3.1% (2/66); there were two conversions (3.0%) and no mortalities. Conclusions The current study suggests that LADG with D2 lymph node dissection is oncologically feasible, and phase-III clinical trials will be needed.     

胃癌D3淋巴结清扫术的临床价值

目的探讨D3淋巴结清扫术对进展期胃癌患者的预后、并发症和生活质量的影响。方法对2000年4月至2002年10月收治的132例进展期胃癌患者进行前瞻性研究,随机分为D3组74例,行D3淋巴结清扫术;D2组58例,行D2手术。结果D2组和D3组术后1、2年的生存率无差别,但3至5年的生存率D2组分别为56.9%、46.6%和36.2%,D3组71.6%、62.2%和56.8%,两者有明显差异(P<0.05)。术后并发症发生率D2组和D3组分别为8.6%和13.5%,两组比较无明显差异(P>0.05),但D2组手术时间为(182.0±32.3)min,明显短于D3组的(236.0±23.7)min(P<0.05)。在生活质量评估方面,D2组和D3组患者术后2、4、6个月组间各项特殊症状评分指标差异无显著性意义(P>0.05)。结论进展期胃癌D3淋巴结清除术是安全的,能够显著改善患者的预后且不影响生活质量。     

Comparison of the Invasiveness Between Reduced-Port Laparoscopy-Assisted Distal Gastrectomy and Conventional Laparoscopy-Assisted Distal Gastrectomy

It is unknown whether reduced-port gastrectomy has a less invasive nature than conventional laparoscopy-assisted distal gastrectomy (C-LADG). So we compared 30 cases of dual-port laparoscopy-assisted distal gastrectomy (DP-LADG; using an umbilical port plus a right flank 5-mm port) as a reduced-port gastrectomy with 30 cases of C-LADG alternately performed by a single surgeon. No significant differences were observed in blood loss, intraoperative complications, the number of dissected lymph nodes, postoperative complications, the day of first defecation, analgesic agents required, changes in body temperature, heart rate, white blood cell count, serum albumin level, or lymphocyte count between the 2 groups. The amounts of oral intake in the DP-LADG group were significantly higher on postoperative days 9 and 10. We concluded that the amount of oral intake in the DP-LADG group was superior to that in the C-LADG group; however, no other evidence of DP-LADG being less invasive than C-LADG was obtained.     

远端进展期胃癌腹腔镜辅助与开腹 D2根治术淋巴结清扫的临床对照研究

目的：比较腹腔镜辅助与开腹D2根治术在远端进展期胃癌淋巴结清扫中的效果。方法对2012年1月～2013年10月共44例远端进展期胃癌进行前瞻性研究,根据患者意愿分别行腹腔镜辅助胃癌根治术（腹腔镜组）24例和开腹胃癌根治术（开腹组）20例,比较2组临床情况、各站淋巴结清扫数目及随访结果。结果腹腔镜组2例中转开腹被排除。与开腹组相比,腹腔镜组手术时间长[（312．4±42．8）min vs．（256．2±28．6）min,t＝4．942,P＝0．000];但术后排气早[（3．2±1．3）d vs．（4．6±1．1）d,t＝-3．750,P＝0．000],下床活动早[（3．0±1．2）d vs．（4．2±1．3）d,t＝-3．110,P＝0．004],术后住院时间短[（7．8±3．2）d vs．（14．4±5．6）d,t＝-4．750,P＝0．000]。术中出血量2组差异无显著性[（304．8±112．4）ml vs．（285．6±86．6）ml,t＝0．615,P＝0．247]。2组每例清扫淋巴结数目差异无显著性[（19．4±9．2）枚vs．（20．2±12．0）枚,t＝-0．241,P＝0．652],其中第一站淋巴结2组差异无显著性[（15．4±6．8）枚vs．（16．3±7．3）枚,t＝-0．414,P＝0．431],第二站淋巴结腹腔镜组少于开腹组[（4．8±3．4）枚vs．（7．4±2．8）枚,t＝-2．690,P＝0．008]。随访6～35个月,平均17个月。腹腔镜组3例死亡,3例复发转移带瘤生存;开腹组4例死亡,2例复发转移带瘤生存。结论在进展期胃癌D2根治术中,虽然腹腔镜组第二站淋巴结清扫数目不及开腹组,但从总体而言,腹腔镜辅助手术能够达到与开腹手术相当的淋巴结清扫效果,且具有微创优势。     

The Safety of the Dissection of Lymph Node Stations 5 and 6 in Pylorus-Preserving Gastrectomy

Background  

This study was intended to examine the safety of possibly incomplete dissection of lymph node stations (LNS) 5 and 6 in pylorus-preserving gastrectomy (PPG) for gastric cancer.     

Learning Curve for Total Gastrectomy with D2 Lymph Node Dissection: Cumulative Sum Analysis for Qualified Surgery

Background This study was conducted to evaluate the leaning curve of D2 lymph node dissection for patients with gastric cancer in a high-volume center.Methods The authors prospectively reviewed the data of all patients who underwent total gastrectomy with D2 lymph node dissection during a 4-year period. Retrieved lymph node number was used as a surrogate marker of oncological outcome. The retrieved lymph node number cut-off value required for satisfactory D2 lymph node dissection was defined as >25. Cumulative sum analysis was used to examine the learning curves of individual surgeons at target accuracy rates of 85%, 90%, 92.5%, 95%, and 98%.Results Two junior staff surgeons performed 198 curative-intent total gastrectomies with D2 lymph node dissections during the study period; their success rates exceeded 90%. Operating time decreased with operative experience (Pearson correlation coefficient = −0.515, P < 0.001). The learning period for total gastrectomy with D2 lymph node dissection for these two junior members of staff was calculated as 23–35 cases, presuming a 92.5% success rate.Conclusions The current study suggests that the surgical learning period for D2 lymph node dissection extends to at least 23 cases or 8 months. In clinical trials containing gastric cancer surgery, the learning curve for qualified surgery from the standpoint of oncological outcome should be considered to minimize bias due to surgeon-associated factors.     

腹腔镜胃癌根治术的原则与评价

腹腔镜胃癌根治术自1994年日本Kitano等[1]首次报道以来,由于其相对于传统的胃癌根治术具有明显的微创优势,且能够治疗有淋巴结转移风险的胃癌患者,因而在全世界逐步得到了开展.据日本内镜外科协会调查结果[2]显示,到2003年为止,日本共有7 800例胃癌患者采取腹腔镜胃癌手术,其中主要为早期胃癌.胃癌患者采取腹腔镜手术治疗比例也逐年增多,仅2003年1年,在日本采用腹腔镜胃癌手术就超过了1 700例.腹腔镜早期胃癌根治术经过10余年的发展,技术已逐渐成熟[3],取得了与开腹手术相当的近、远期疗效,已被新版日本胃癌治疗规约[4]接受为ⅠA期胃癌的标准治疗方案之一.1997年Goh等[5]首次将腹腔镜胃癌D2根治术用于治疗进展期胃癌,取得了良好的近期疗效,腹腔镜胃癌D2根治术在技术上的安全性和可行性得到证实,促使了腹腔镜胃癌根治术的手术指征从早期胃癌扩大到较早期的进展期胃癌.然而腹腔镜胃癌D2根治术用于治疗进展期胃癌患者,由于手术技术难度相对较大,国内、外开展单位及报道例数均较少,但近年来报道逐渐增多,并取得了较大进展,是目前胃癌外科临床研究的一大热点问题.     

腹腔镜辅助贲门癌手术淋巴结清扫效果评价

目的评价腹腔镜辅助贲门癌手术淋巴结清扫的效果。方法回顾性分析2004年1月至2009年9月期间我院分别行腹腔镜辅助及开腹贲门癌手术患者的临床资料,比较术后获取的淋巴结数目。结果 39例患者接受腹腔镜辅助贲门癌手术(腹腔镜组),63例患者接受开腹手术(开腹组)。2组患者术前合并症、病理学类型及病理分期差异无统计学意义(P0.05)。腹腔镜组获取淋巴结(16.44±6.25)枚,其中第一站淋巴结(10.56±3.78)枚,转移率为74.4%;第二站淋巴结(3.82±1.82)枚,转移率为46.2%;第三站淋巴结(2.00±1.36)枚,转移率为5.1%。开腹贲门癌手术获取淋巴结(16.38±5.83)枚,其中第一站淋巴结(10.94±3.91)枚,转移率为71.4%;第二站淋巴结(3.71±1.55)枚,转移率为42.9%;第三站淋巴结(1.75±1.06)枚,转移率为3.2%,2组淋巴结清扫数目及转移率比较差异均无统计学意义(P0.05)。结论腹腔镜辅助贲门癌手术淋巴结清扫效果满意,其远期疗效尚在继续观察中。     

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.     

腹腔镜胃癌根治术的现状与前景

胃癌是常见的消化道恶性肿瘤之一,在我国早期胃癌所占比例很小,约90%的病例确诊时已为进展期胃癌。随着内镜、B超、超声内镜等诊疗技术的发展,早期胃癌的诊出率逐渐增多,日本约50%的胃癌为早期胃癌。胃癌的微创治疗包括内镜下胃黏膜切除术、腹腔镜胃腔内黏膜切除术、腹腔镜胃楔形切除术,腹腔镜胃癌根治术也随之得到了较大的发展。1993年Ohgami报道了腹腔镜胃楔形切除术,1994年Ohashi报道了腹腔镜胃腔内黏膜切除术用于治疗无淋巴结转移风险的早期胃癌患者,取得了较好的临床疗效,但由于这两种手术方式均不对胃周淋巴结进行清扫,其应用范围比…     

腹腔镜胃癌D2手术淋巴结清扫原则与技巧

胃癌腹腔镜手术是近年胃癌外科发展的热点,自1991年日本Kitano等[1]率先开展腹腔镜胃癌根治术以来,腹腔镜胃癌手术报道逐年增加,手术适应证亦逐步扩大,由早期胃癌拓展到较早的进展期胃癌,淋巴结清扫范围亦由D1、D1+逐步发展到D2。1997年Goh等[2]首次将腹腔镜胃癌D2手术用于治疗进展期胃癌,此后腹腔镜胃癌D2手术报道逐渐增多     

Japanese D3 Lymph Node Dissection in Low Rectal Cancer with Inferior Mesenteric Lymph Node Metastases

Background

There is currently no consensus on the significance of Japanese D3 lymph node dissection in low rectal cancer with inferior mesenteric lymph node (IMLN) metastasis. This is partly because, despite a number of studies on the subject, cases of IMLN metastasis are relatively rare, and there are few cases of curative resection because of metastasis to other organs. A retrospective study involving a large number of patients was conducted.

Methods

The subjects were 2,743 patients registered in the national registry of the Japanese Society for Cancer of the Colon and Rectum. The data were analyzed for (1) prognostic factors for IMLN metastasis, and (2) outcomes in R0 cases with IMLN metastasis.

Results

In the control group, 67 patients (2.7 %) were considered positive for IMLN metastasis. The outcomes in the 35 R0 cases with IMLN metastasis were 50.8 % for 5-year relapse-free survival (RFS) and 61.9 % for 5-year overall survival (OS), which were each better than for R1+R2 cases (5-year RFS 16.1 %, p = 0.0001; 5-year OS 26.7 %, p = 0.0002). The outcomes for R0 cases (total metastatic lymph nodes ≥7) with IMLN metastasis (5-year RFS 53.9 %, 5-year OS 68.8 %) did not differ significantly from those for IMLN(?) cases (5-year RFS 54.6 %, 5-year OS 57.1 %) (RFS: p = 0.9515, OS: p = 0.4621).

Conclusions

It was confirmed that cases of IMLN metastasis in low rectal cancer tend to have a large total number of metastatic lymph nodes, but if curative resection can be performed, a good prognosis can be expected. These results demonstrate the value of radical Japanese D3 lymph node dissection in low rectal cancer with IMLN metastasis.     

Effect of Age on Surgical Outcomes of Extended Gastrectomy With D2 Lymph Node Dissection in Gastric Carcinoma: Prospective Cohort Study

Background and Purpose  

As a life expectancy increases, the proportion of aged patients diagnosed with gastric cancer has increased over the past decades, but the optimal surgical approach to these patients remains a dilemma because of the presumed risk associated with extended surgery.     

Effect of Obesity on Technical Feasibility and Postoperative Outcomes of Laparoscopy-Assisted Distal Gastrectomy—Comparison with Open Distal Gastrectomy

Objective The aim of this study was to compare outcomes between laparoscopy-assisted distal gastrectomy (LADG) and open distal gastrectomy (ODG) in obese and non-obese patients. Methods Subjects comprised 248 consecutive patients who underwent distal gastrectomy for gastric cancer between January 1999 and December 2005. Patients with body mass index (BMI) ≥ 25 kg/m² were defined as obese, and patients with BMI < 25 kg/m² were defined as non-obese. Parameters analyzed included patients characteristics, tumor characteristics, operative details, postoperative outcomes, and prognosis. Results For LADG, 35 patients were considered obese, and 106 patients were non-obese. For ODG, 25 patients were considered obese, and 82 patients were non-obese. Mean operative times in each procedure were significantly longer for the obese group than for the non-obese group (ODG: 241.4 min vs. 199.5 min, p < 0.0001; LADG: 279.6 min vs. 255.3 min, p = 0.03). Blood loss was significantly higher for the obese group than for the non-obese group in ODG (300 ml vs. 400 ml, p = 0.024), but no significant differences were observed between obese and non-obese groups for LADG. Incidence of major postoperative complications, number of retrieved lymph nodes, and disease-free survival rates were similar in obese and non-obese groups for each procedure. Conclusions Our analysis revealed that LADG can be safely performed in obese patients, with complication rates and operation outcomes similar to those for non-obese patients.     

进展期远端胃癌D2根治术No.12b组淋巴结清扫60例分析

目的探讨进展期远端胃癌行D2根治术时No.12b组淋巴结清扫的必要性及可行性,及No.12b组淋巴结转移与临床病理因素的关系。方法回顾性收集60例进展期远端胃癌患者的病例资料,患者行D2或D2^＋根治术,并均加行No.12b组淋巴结清扫术。分析No.12b组淋巴结转移与临床病理因素的关系。结果全组无手术死亡病例,无严重并发症发生。60例患者中发现12例有No.12b组淋巴结转移,转移率为20.00%。其中BorrmannⅢ、Ⅳ型者No.12b组淋巴结转移率为31.25%（10/32）,淋巴结转移N2～3期者为30.30%（10/33）,肿瘤浸润T3～4期者为29.73%（11/37）,明显高于BorrmannⅠ、Ⅱ型〔7.14%（2/28）〕,N0～1期〔7.41%（2/27）〕及T1～2期者〔4.35%（1/23）〕,P〈0.05;No.12b组淋巴结转移与肿瘤的大小无关（P〉0.05）。结论 No.12b组淋巴结清扫术对于进展期胃远端癌是必要且可行的,其远期效果有待大样本的前瞻性研究进一步证实。