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 gastrectomy for patients with a history of upper abdominal surgery: results of a matched-pair analysis

Purpose

The safety and feasibility of laparoscopic gastrectomy (LG) for patients who have undergone previous upper abdominal surgery (PUAS) remain unclear. A matched-pair analysis was conducted to compare the short-term outcomes of LG between patients with gastric cancer who had undergone PUAS and those who had not.

Methods

A matched-pair analysis was performed to compare the short-term outcomes of LG between 22 patients who had undergone PUAS and 66 who had not (control group). To compare the outcome to that of open gastrectomy (OG) following PUAS, a total of 143 consecutive OG patients treated during the same study period were also reviewed.

Results

Cholecystectomy was the most common type of PUAS, followed by gastrectomy. There were no significant differences between the groups in terms of the length of the operation, blood loss, and the number of retrieved lymph nodes or the rate of conversion to open surgery. The postoperative morbidity in the PUAS group (3/22, 13.6 %) was comparable to that of the control group (7/66, 10.6 %, P = 0.6981). There was no mortality within 30 days in either group. When compared to OG following PUAS (n = 23), LG was performed with significantly less blood loss with an equivalent postoperative outcome.

Conclusions

LG following PUAS is considered to be a safe and feasible surgical modality. PUAS should therefore not be regarded as a contraindication for LG.     

Laparoscopic Versus Open Reversal of a Hartmann Procedure: A Single-Center Study

Purpose

Re-anastomosis after a Hartmann procedure is associated with a higher morbidity and mortality than other elective colorectal operations. The goal of this comparative study was to evaluate whether laparoscopic reversal is a justified operative approach, although the initial operation is most often an emergency laparotomy.

Methods

A retrospective analysis was conducted on data collected on all 70 patients who underwent laparoscopic and open reversal of a Hartmann procedure at the Department of Surgery, University of Schleswig–Holstein, Campus Lübeck, between January 1999 and December 2011. Together with general demographic data, the analysis included the indication for the initial Hartmann procedure, time to reversal, intraoperative findings, the choice of operative method, operating time, postoperative pain control, return of normal bowel function, length of hospital stay, and peri- and postoperative morbidity and mortality.

Results

In most patients, the Hartmann procedure was performed after a perforated sigmoid diverticulitis. We were not able to find any statistically significant differences with respect to gender, body mass index (BMI) and American Society of Anesthesiologists classification between the laparoscopic group (LG) (N = 24 patients) and the open group (OG) (N = 46). In the LG, patients were significantly younger (p = 0.019). The median operating time was 210 min (75–245) in the LG, which was significantly longer than in the OG (166 min; 66–230). The statistical analysis of the duration of postoperative analgesic therapy (LG 7 days [6–10]; OG 12 days [6–30] ), return to normal diet (LG 3 days [2–6]; OG 4 days [2–10] ), return of normal bowel function (LG 3 days [2–4]; OG 4 days [2–9] ) and length of hospital stay (LOS) (LG 10 days [8–13]; OG 15 days [8–163]) detected significant differences in advantage for the LG. Unplanned return to theatre during index admission was only necessary in the OG (N = 7, 15.2 %). With a median follow-up of 8 months (range 1–20), we observed a comparable number of minor complications in both groups but a significantly higher number of major complications in the OG (N = 27, 58.7 %) (p = 0.001). Conversion occurred in three cases (12.5 %). There was no mortality in either of the two groups.

Conclusions

This study was able to demonstrate the feasibility of the laparoscopic approach. In terms of postoperative results it should be seen as equivalent to the open procedure. However, the laparoscopic approach requires profound surgical expertise. The indication should be made after a careful risk/benefit analysis for each individual patient.     

Laparoscopic versus open surgery for obese patients with rectal cancer: a retrospective cohort study

Purpose

To evaluate the advantages of laparoscopic surgery for rectal cancer in obese patients.

Methods

We collected clinical data from consecutive patients who underwent anterior resection for rectal cancer between 2008 and 2015 to compare the surgical outcomes of a laparoscopic surgery group (LG) with those of an open surgery group (OG) stratified by obesity. Obesity was defined as a body mass index ≥25.

Results

A total of 268 patients were analyzed, with 157 in the LG (44 obese and 113 non-obese) and 111 in the OG (25 obese and 86 non-obese). The rates of complications between the LG and the OG were 18.5 vs. 11.6 % (p = 0.18) for the non-obese patients and 18.2 vs. 20.0 % (p = 1.0) for the obese patients, respectively, without a significant difference. Operative time was longer in the LG than in the OG, but the difference between the non-obese and obese patients was not significant, being 266 vs. 189 min (p < 0.0001) and 260 vs. 254 min (p = 0.96), respectively. Blood loss was much lower in the LG for both obese and non-obese patients, being 10 vs. 435 mL (p < 0.0001) and 10 vs. 275 mL (p < 0.0001), respectively.

Conclusion

There were no significant differences between LG and OG in operative time or complications for obese patients with rectal cancer, and blood loss was much lower in the LG. Thus, laparoscopic surgery is a safe and minimally invasive approach for obese patients with rectal cancer.

     

Morbidity and mortality after laparoscopic gastrectomy for advanced gastric cancer: results of a phase II clinical trial

Background

Very few reports are available on laparoscopic gastrectomy (LG) for advanced gastric cancer (AGC) patients. We therefore conducted a prospective phase II clinical trial to address the feasibility of LG in AGC. Morbidity and mortality were evaluated.

Methods

The eligibility criteria were as follows: 20–80 years of age, cT2N0–cT4aN2, American Society of Anesthesiologists score of 3 or less, and no other malignancy. A total of 204 patients were enrolled onto this study. Of these, 16 were excluded because far-advanced stages of disease were identified after laparoscopic exploration, and 31 were excluded because early gastric cancer was diagnosed postoperatively. All patients underwent a D2 lymphadenectomy. Morbidity was stratified according to the Clavien–Dindo classification.

Results

Conversion to open surgery occurred in 11 patients (7.0 %). The mean hospital stay was 6.3 days for distal gastrectomy and 8.5 days for total gastrectomy. The mean number of collected lymph nodes was 52.7 for distal gastrectomy and 63.8 for total gastrectomy. The rates of local and systemic complications of grade II or more were 8.3 and 3.2 %. One patient died of operative complications. In multivariate analysis, old age (>70 years) was an independent risk factor for complications, and old age and Billroth I anastomosis were predictable risk factors for local complications.

Conclusions

LG with D2 lymphadenectomy was safe and technically feasible for the treatment of AGC, with acceptable rate of morbidity and mortality. ClinicalTrial.gov Registration: NCT01441336.     

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.     

Safety of laparoscopic radical gastrectomy in gastric cancer patients with liver cirrhosis

Background

Laparoscopic gastrectomy (LG) in gastric cancer patients with liver cirrhosis (LC) has rarely been reported. In this study, we aimed to elucidate the feasibility of LG compared with that of open gastrectomy (OG) for LC patients.

Methods

Of the 75 LC patients who underwent radical gastrectomy for gastric cancer between April 2005 and March 2014, 36 patients who underwent LG were compared with 39 patients who underwent OG. Comparisons were based on clinicopathologic characteristics, surgical outcomes, and long-term survival rates.

Results

Comparison of LG and OG revealed no significant differences in the clinicopathologic characteristics. Five patients in the LG group and eight in the OG group showed a Child–Turcotte–Pugh score (CTPs) over A. In surgical outcomes, we observed shorter operation times (191.4?±?63.9 vs. 225.9?±?77.1 min, p?=?0.039), reduced estimated blood loss (175.5?±?214.1 vs. 396.9?±?514.8 ml, p?=?0.021), and shorter hospital stays (10.4?±?4.6 vs. 13.7?±?5.8 days, p?=?0.008) in LG than OG. Regarding postoperative morbidity, 7 (19.4%) and 10 (25.6%) complications were observed in the LG and OG groups, respectively. There was no difference in complications between the two groups regardless of the CTPs. One patient with a CTPs of C succumbed to hepatic failure following LG. Long-term survival and overall and recurrence-free survival rates did not differ between the two groups.

Conclusions

Even in cases with CTPs B, LG with lymph node dissection for gastric cancer patient was safer and acceptable than OG was. Therefore, LG can be considered an alternative surgical approach in gastric cancer with LC.

     

Minimally invasive surgical approach for the treatment of gastroparesis

Background

Gastroparesis is a chronic disorder resulting in decreased quality of life. The gastric electrical stimulator (GES) is an alternative to gastrectomy in patients with medically refractory gastroparesis. The aim of this study was to analyze the outcomes of patients treated with the gastric stimulator versus patients treated with laparoscopic subtotal or total gastrectomy.

Methods

A retrospective chart review was performed of all patients who had surgical treatment of gastroparesis from January 2003 to January 2012. Postoperative outcomes were analyzed and symptoms were assessed with the Gastroparesis Cardinal Symptom Index (GCSI).

Results

There were 103 patients: 72 patients (26 male/46 female) with a GES, implanted either with laparoscopy (n = 20) or mini-incision (n = 52), and 31 patients (9 male/22 female) who underwent laparoscopic subtotal (n = 27), total (n = 1), or completion gastrectomy (n = 3). Thirty-day morbidity rate (8.3 % vs. 23 %, p = 0.06) and in-hospital mortality rate (2.7 % vs. 3 %, p = 1.00) were similar for GES and gastrectomy. There were 19 failures (26 %) in the group of GES patients; of these, 13 patients were switched to a subtotal gastrectomy for persistent symptoms (morbidity rate 7.7 %, mortality 0). In total, 57 % of patients were treated with GES while only 43 % had final treatment with gastrectomy. Of the GES group, 63 % rated their symptoms as improved versus 87 % in the primary gastrectomy group (p = 0.02). The patients who were switched from GES to secondary laparoscopic gastrectomy had 100 % symptom improvement. The median total GCSI score did not show a difference between the procedures (p = 0.12).

Conclusion

The gastric electrical stimulator is an effective treatment for medically refractory gastroparesis. Laparoscopic subtotal gastrectomy should also be considered as one of the primary surgical treatments for gastroparesis given the significantly higher rate of symptomatic improvement with acceptable morbidity and comparable mortality. Furthermore, the gastric stimulator patients who have no improvement of symptoms can be successfully treated by laparoscopic subtotal gastrectomy.     

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.     

Morbidity and Mortality Associated with Gastrectomy for Gastric Cancer

Background

Surgery alone is often inadequate for advanced-stage gastric cancer. Surgical complications may delay adjuvant therapy. Understanding these complications is needed for multidisciplinary planning.

Material and Methods

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried for patients who underwent gastrectomy for malignancy (ICD-9 code 151.x) from 2005 to 2010. Thirty-day mortality and morbidity were evaluated.

Results

Overall, 2,580 patients underwent gastrectomy for malignancy, divided as total gastrectomy 999 (38.7 %) and partial gastrectomy 1,581 (61.3 %). Overall, serious morbidity occurred in 23.6 %, and the 30-day mortality was 4.1 %. Patients receiving a total gastrectomy were younger and healthier than those receiving a partial gastrectomy for the following measured criteria: age, diabetes, chronic obstructive pulmonary disease and hypertension. Serious morbidity and mortality were significantly higher in the total gastrectomy group than the partial gastrectomy group (29.3 vs. 19.9 %, p < 0.001; and 5.4 vs. 3.4 %, p < 0.015, respectively). The inclusion of additional procedures increased the risk of mortality for the following: splenectomy (odds ratio [OR] 2.8; p < 0.001), pancreatectomy (OR 3.5; p = 0.001), colectomy (OR 3.6; p < 0.001), enterectomy (OR 2.7; p = 0.030), esophagectomy (OR 3.5; p = 0.035). Abdominal lymphadenectomy was not associated with increased morbidity (OR 1.1; p = 0.41); rather, it was associated with decreased mortality (OR 0.468; p = 0.028).

Conclusions

Gastrectomy for cancer as currently practiced carries significant morbidity and mortality. Inclusion of additional major procedures increases these risks. The addition of lymphadenectomy was not associated with increased morbidity or mortality. Strategies are needed to optimize surgical outcomes to ensure delivery of multimodality therapy for advanced-stage disease.     

Clinical significance of medial approach for suprapancreatic lymph node dissection during laparoscopic gastric cancer surgery

Objective

Suprapancreatic lymph node dissection is critical for gastric cancer surgery. Beginning in 2010, a medial approach was adopted for suprapancreatic lymph node dissection during laparoscopic gastrectomy for distal gastric cancer in our institution. The aim of this study was to compare surgical outcomes of the medial approach and conventional approach in laparoscopic gastric surgery.

Methods

Between January 2007 and December 2012, a total of 100 patients with clinical T1 or T2 tumors underwent laparoscopic distal gastrectomy involving suprapancreatic lymph node dissection by the medial approach (n = 44) and conventional approach (n = 56) with curative intent. The comparison was based on clinicopathological characteristics and surgical outcome.

Results

The laparoscopic procedure was not converted to laparotomy in any patient. The patients’ demographics and tumor characteristics did not show any statistically significant difference, except for tumor location. In the conventional approach group, the tumors were at a higher position (p = 0.037) and more frequently received Roux-en-Y reconstruction (p < 0.001). Intracorporeal anastomosis was significantly more common in the medial approach group (p < 0.001). Compared with the conventional approach, the medial approach was associated with significantly less operative blood loss (p < 0.001), more retrieved suprapancreatic lymph nodes (p = 0.019), and a shorter hospital stay (p = 0.018). The rates of complications were comparable between the two groups.

Conclusion

This study suggests that the medial approach to suprapancreatic lymph node dissection seems to be convenient and useful in laparoscopic gastric cancer surgery.     

Fifteen-year experience in managing obturator hernia: from open to laparoscopic approach

Purpose

Obturator hernia is a rare disease and preoperative diagnosis is always difficult. There are increasing reports employing laparoscopic approach in the recent literature. Our aim was to review and compare the open and laparoscopic approach in repairing obturator hernia.

Methods

All patients with obturator hernia from 1997 to 2011 were recruited. Patient’s demographics, presentation, operative details, morbidity, and mortality were retrospectively collected and reviewed.

Results

There were 36 patients during the 15-year period. All of them were elderly ladies (median 83). Nineteen underwent open surgery while 16 received laparoscopic surgery. Both age and ASA were comparable. The median operative time was 68 and 65 min for laparoscopic and open group, respectively (p = 0.690). The median hospital stay was significantly longer in the open group (19 vs 5 days, p = 0.007). There were less major complications (p = 0.004) and mortality (p = 0.049) in the laparoscopic group. Two recurrences were reported in the laparoscopic group, although statistically not significant (p = 0.202).

Conclusions

Laparoscopic repair can achieve a shorter hospital stay and has lesser major complications and mortality in selected patients.     

Laparoscopic total gastrectomy versus open total gastrectomy for cancer: a systematic review and meta-analysis

Background

The possible advantages of laparoscopic (assisted) total gastrectomy (LTG) versus open total gastrectomy (OTG) have not been reviewed systematically. The aim of this study was to systematically review the short-term outcomes of LTG versus OTG in the treatment of gastric cancer.

Methods

A systematic search of PubMed, Cochrane, CINAHL, and Embase was conducted. All original studies comparing LTG with OTG were included for critical appraisal. Data describing short-term outcomes were pooled and analyzed.

Results

A total of eight original studies that compared LTG (n = 314) with OTG (n = 384) in patients with gastric cancer fulfilled quality criteria and were selected for review and meta-analysis. LTG compared with OTG was associated with a significant reduction of intraoperative blood loss (weighted mean difference = 227.6 ml; 95 % CI 144.3–310.9; p < 0.001), a reduced risk of postoperative complications (risk ratio = 0.51; 95 % CI 0.33–0.77), and shorter hospital stay (weighted mean difference 4.0 = days; 95 % CI 1.4–6.5; p < 0.001). These benefits were at the cost of longer operative time (weighted mean difference = 55.5 min; 95 % CI 24.8–86.2; p < 0.001). In-hospital mortality rates were comparable for LTG (0.9 %) and OTG (1.8 %) (risk ratio = 0.68; 95 % CI 0.20–2.36).

Conclusion

LTG shows better short term outcomes compared with OTG in eligible patients with gastric cancer. Future studies should evaluate 30- and 60-day mortality, radicality of resection, and long-term follow-up in LTG versus OTG, preferably in randomized trials.     

Outcome of Tumor-Specific Mesorectal Excision for Rectal Cancer: The Impact of Laparoscopic Resection

Objective

The study aimed to compare the outcomes of laparoscopic and open resection for rectal cancer in 1,063 consecutive cases in a single center.

Methods

We performed an analysis of 11 years of experience in rectal cancer surgery and compared the outcome of laparoscopic and open surgery. Multivariate and subgroup analysis was performed to look at the effect of the level of tumor and stage of disease on short-term outcomes like conversion rate, anastomotic leak rate, length of stay, complication rate, 30-day mortality, and long-term outcomes like local recurrence and survival.

Results

A total of 1,063 patients underwent rectal resection with 470 (44.2 %) patients undergoing the laparoscopic approach. Groups were comparable in terms of age, sex, or co-morbidities, and the operating time was longer in the laparoscopic group (210 vs. 150 min; p value < 0.001). A conversion rate of 6.8 % was noted, with an anastomotic leak rate of 3.87 % in the open group and 2.97 % in the laparoscopic group. The laparoscopic group had a lower blood loss (100 vs. 350 ml; p < 0.001), lower complication rates, and shorter length of stay (6 vs. 9 days). The local recurrence rate was comparable, and the laparoscopic approach had better overall and cancer-specific survival, even after adjusting for stages. The laparoscopic approach was an independent factor associated with better overall and cancer-specific survival on multivariate analysis.

Conclusion

We confirmed the oncological safety of laparoscopic rectal cancer surgery. Laparoscopic surgery also showed superiority in the short-term and long-term outcomes of rectal cancer.     

Advantages of totally laparoscopic distal gastrectomy over laparoscopically assisted distal gastrectomy for gastric cancer

Background

Laparoscopic gastrectomy for gastric cancer has become common due to improvement of the surgical techniques and devices for laparoscopic surgery. Although laparoscopically assisted distal gastrectomy (LADG) has several advantages over open distal gastrectomy, little has been reported about the safety and feasibility of totally laparoscopic distal gastrectomy (TLDG).

Methods

Between October 2005 and June 2007, 80 laparoscopic distal gastrectomies with regional lymphadenectomies were performed for patients with gastric cancer. After 24 patients underwent LADG and 56 patients underwent TLDG, the clinical data were compared between the two groups.

Results

The groups were comparable in terms of age, gender, body mass index (BMI), tumor location, tumor size, macroscopic type, depth of invasion, histologic type, lymph node metastasis, and length of proximal margin. However, when only the patients with gastric cancer in the middle third of the stomach were compared between the two groups, the length of the proximal margin was significantly longer in the TLDG group (p < 0.05). The mean blood loss was significantly less in the TLDG group (p < 0.05). The patients in the TLDG group recovered earlier and thus had a significantly shorter postoperative hospital stay. Furthermore, the C-reactive protein level on postoperative day 7 was lower in the TLDG group than in the LADG group (p < 0.05). There was no significant difference in the postoperative complications between the two groups.

Conclusion

This study demonstrated that TLDG has several advantages over LADG including smaller wounds, less invasiveness, and better feasibility of a secure ablation. The TLDG procedure yields safe anastomosis independently of the patient’s constitution or the location of the cancer. Therefore, TLDG is considered to be a useful technique for patients with gastric cancer.     

Laparoscopic Versus Open Surgery for Stage I Rectal Cancer: Long-term Oncologic Outcomes

Background

Laparoscopic resection is increasingly being performed for rectal cancer. However, few data are available to compare long-term outcomes after open versus laparoscopic surgery for early-stage rectal cancer.

Methods

Included in this retrospective study were 160 patients who underwent surgery for stage I rectal cancer between 2001 and 2008. Perioperative outcomes, overall survival (OS), and disease-free survival (DFS) were compared for open versus laparoscopic surgery.

Results

Altogether, 85 patients were treated using open surgery and 80 with laparoscopic surgery. Postoperative mortality (0 vs. 1.3 %; p = 1.00), morbidity (31.3 vs. 25.0 %; p = 0.38), and harvested lymph nodes (22.5 vs. 20.0; p = 0.84) were similar for the two groups. However, operating time was longer (183.8 vs. 221.0 min; p = 0.008), volume of intraoperative bleeding was less (200.0 vs. 150.0 ml; p = 0.03), time to first bowel movement was shorter (3.54 vs. 2.44 days; p < 0.001), rate of superficial surgical-site infection was lower (7.5 vs. 0 %; p = 0.03), and postoperative hospital stay was shorter (11.0 vs. 8.0 days; p < 0.001) in the laparoscopy group than in the open surgery group. At 5 years, there was no difference in OS (98.6 vs. 97.1 %; p = 0.41) or DFS (98.2 vs. 96.4 %; p = 0.30) between the open and laparoscopy groups.

Conclusions

Long-term outcomes of laparoscopic surgery for stage I rectal cancer were comparable to those of open surgery. Laparoscopic surgery, however, produced more favourable short-term outcomes than open surgery.     

Laparoscopic left hemihepatectomy a consideration for acceptance as standard of care

Introduction

Since the inception of laparoscopic liver surgery, the left-lateral sectionectomy has become the standard of care for resection of lesions located in segments II and III. However, few centers employee laparoscopic left hemihepatectomy on a routine basis. This study evaluated the safety and efficacy of the laparoscopic left hemihepatectomy as a standard of care.

Methods

An international database of 1,620 laparoscopic liver resections was established and outcomes analyzed comparing the laparoscopic left lateral sectionectomy (L lat) to laparoscopic left hemihepatectomy (LH). All data are presented as mean ± standard deviation.

Results

A total of 222 laparoscopic L lat and 82 LH were identified. The L lat group compared with LH group had a higher incidence of cirrhosis (27 vs. 21 %; p = 0.003) and cancer (48 vs. 35 %; p = 0.043). Tumors were larger in the LH group (7.09 ± 4.2 vs. 4.89 ± 3.1 cm; p = 0.001). Operating time for LH was longer than L lat (3.9 ± 2.3 vs. 2.9 ± 1.4 h; p < 0.001). Operative blood loss was higher in LH (306 vs. 198 cc; p = 0.003). Patient morbidity (20 vs. 18 %; p = 0.765) was equivalent with a longer length of stay (7.1 ± 5.1 vs. 2.5 ± 2.3 days; p < 0.001) for LH. Patient mortality and tumor recurrence were equivalent.

Conclusions

Laparoscopic left hemihepatectomy is a more technically challenging and often time-consuming procedure than a left-lateral sectionectomy. This international multi-institutional confirmed that intraoperative blood loss, complications, and conversions are more than acceptable for laparoscopic left hemihepatectomy in expert hands. Postoperative morbidity and mortality rates together with adequate surgical margins and long-term recurrence are not compromised by the laparoscopic approach.     

Gastrectomy in Advanced Gastric Cancer Effectively Palliates Symptoms and May Improve Survival in Select Patients

Background

The role of gastrectomy in the face of incurable gastric cancer is evolving. We sought to evaluate our experience with incomplete (i.e., R2) gastrectomy in advanced gastric cancer.

Methods

We reviewed 210 locally advanced or metastatic gastric cancers (1992–2008). Patient characteristics and outcomes were compared between three groups: gastrectomy (N?=?99), exploration without resection (N?=?66), and no surgery (N?=?45).

Results

Clinicopathologic characteristics were similar between groups. Symptoms successfully resolved after gastrectomy in 48 % with a complication rate of 32 % and mortality of 6 %. Overall median survival for all patients was 6.2 months: 10.0 months after gastrectomy, 4.1 months after exploration without resection, and 5.3 months for no surgery (p?<?0.001). Perioperative complications were the only predictor of symptom resolution following resection (OR?=?0.175). Resolution of symptoms (p?<?0.001, Hazards Ratio (HR)?=?0.09) and preoperative nausea/vomiting (p?=?0.017, HR?=?0.55) improved survival, while linitis plastica (p?=?0.035, HR?=?4.05) and spindle cell morphology (p?=?0.011, HR?=?1.98) were predictors of poor survival in patients undergoing resection.

Conclusions

Gastrectomy in the setting of advanced gastric cancer may be useful in up to half of patients with an acceptable perioperative mortality rate. Symptom resolution offers a potential survival advantage but is dependent upon a complication-free course, so should only be considered selectively.