Robot Versus Laparoscopic Gastrectomy for Cancer by an Experienced Surgeon: Comparisons of Surgery, Complications, and Surgical Stress

Background

No previous robotic studies present an equivalent surgical quality comparison in an experienced setting for gastric cancer. In addition, a reliable postoperative complication assessment is needed to accurately evaluate surgical outcomes.

Methods

After 20 cases of robotic-assisted gastrectomy (RAG), a total of 121 consecutive gastric cancer patients underwent gastrectomy (38 RAG vs 83 laparoscopic-assisted gastrectomy [LAG]) from February 2009 to November 2010 at the Department of Surgery, Korea University Anam Hospital, Seoul, Korea. The Clavien-Dindo (C-D) classification was used to classify surgical complications. The granulocyte-to-lymphocyte (G:L) ratio was analyzed to evaluate surgical stress.

Results

The baseline characteristics, with the exception of age, were similar. The mean total operation time for RAG (234.4 ± 48.0 min) was not significantly different than that for LAG (220.0 ± 60.6 min; P = 0.198). However, in obese patients, fewer lymph nodes were harvested by RAG (23.4 ± 7.0) than by LAG (32.2 ± 12.5, P = 0.006). Overall C-D complications were more common for RAG (47.3 vs 38.5 %), but the difference was not significant (P = 0.361). The mean hospital stay was similar for the 2 groups. Surgical stress as estimated by the G:L ratio was comparable between the 2 groups.

Conclusions

RAG performed by an experienced surgeon resulted in similar postoperative outcomes and complications to those of LAG. Assessment of operation time, C-D complication grade, and G:L ratio revealed that RAG is a practical and feasible alternative to LAG, with the possible exception of obese patients.     

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.     

Hand-assisted laparoscopic versus laparoscopy-assisted D2 radical gastrectomy: a prospective study

Backgroud

The feasibility and safety of Hand-assisted laparoscopic D2 radical gastrectomy (HALG) have been seldom reported, also, benefits and outcomes are not defined.

Methods

We performed a comprehensive and in-depth comparative analysis of the general information, the intraoperative data and postoperative data in the Group HALG and the Group laparoscopy-assisted D2 radical gastrectomy (LAG).

Results

The general data of HALG and LAG were no differences (P > 0.05); the blood loss and unexpected injury were similar(P > 0.05); the operative time, the incision length, the number of lymph nodes recovered, the rate of procedure conversion, the amount of postoperative complications, and the length of postoperative hospital stay of Group HALG were prior to that of Group LAG(P < 0.05); there were no differences for the pain score after day 2, the recovery time of intestinal function, the rate of reoperation, the 30-day hospital and readmission rate(P > 0.05); and there were significant linear correlations between the length of postoperative hospital stay and the operative time for both groups(P = 0.00).

Conclusion

Compared with LAG, HALG had similar features of being minimally invasive and radical in treating gastric cancers, and HALG was safer than LAG.     

Robotic gastrectomy versus laparoscopic gastrectomy for gastric cancer: comparison of surgical performance and short-term outcomes

Purpose

This study was designed to compare robot-assisted gastrectomy with laparoscopy-assisted gastrectomy in surgical performance and short-term clinical outcomes for gastric cancer and evaluate the safety and feasibility of robotic surgery.

Methods

A retrospective database of patients who underwent robotic or laparoscopic gastrectomy for gastric cancer between March 2010 and May 2013 was examined. After screening, 514 patients who underwent gastrectomy for gastric cancer were enrolled in this study: 120 robotic and 394 laparoscopic surgery. Patient demographics, surgical performance, and short-term clinical outcomes were examined.

Results

All operations were performed successfully. The clinicopathologic characteristics were similar between the two groups. Compared with the laparoscopic group, the robotic group had less intraoperative blood loss (118.3 ± 55.8 vs. 137.6 ± 61.6 ml, P < 0.001), more lymph nodes dissection (34.6 ± 10.9 vs. 32.7 ± 11.2, P = 0.013), and longer operation time (234.8 ± 42.4 vs. 221.3 ± 44.8 min, P = 0.003). The survival rates were 90.2 % at 1 year, 78.1 % at 2 years, and 67.8 % at 3 years in the RAG group compared with 87.3 % at 1 year, 77.1 % at 2 years, and 69.9 % at 3 years in the LAG group. The difference in overall survival rate between the two groups was not statistically significant (P = 0.812). In view of lymph node involvement, the 3-year survival rates for patients with negative nodal metastasis were 84.4 % in the RAG group versus 82.6 % in the LAG group (P = 0.972) and 57.5 % in the RAG group versus 60.3 % in the LADG group (P = 0.653) for those with positive nodal metastasis.

Conclusions

Comparing well with laparoscopic gastrectomy, robot-assisted gastrectomy is a feasible and safe surgical procedure with clear operation field, precise dissection, minimal trauma, and fast recovery. Longer follow-up time and randomized, clinical trials are needed to evaluate the clinical benefits and long-term oncological outcomes of this new technology.     

Proper preparation to reduce endoscopic reexamination due to food residue after distal gastrectomy for gastric cancer

Background

Reducing food residue by proper preparation methods before endoscopy after distal gastrectomy can increase the quality of examination and decrease patient discomfort. We evaluated the risk factors for food residue and proper methods of preparation for endoscopy after distal gastrectomy.

Methods

Follow-up endoscopy with questionnaires was performed on 1,001 patients who underwent distal gastrectomy at Asan Medical Center between December 2010 and July 2011.

Results

Endoscopic examination failed in 94 patients (9.4 %) as a result of large amounts of food residue. Rates of failure were significantly higher in patients who ate a regular diet rather than a soft diet at last dinner before examination (13.9 vs. 6.1 %, p = 0.050), and in those who ate lunch rather than not eating lunch on the day before examination (14.6 vs. 7.7 %, p = 0.020). Multivariate analysis showed that the rate of failed examination was lower in patients who had a history of abdominal surgery (p = 0.011), those who ate a soft (p < 0.001) or liquid (p = 0.003) diet as a last meal rather than a regular diet, those who underwent Billroth I rather than Billroth II reconstruction (p = 0.035), patients with longer fasting time (p = 0.009), and those with a longer gastrectomy-to-endoscopy time interval (p < 0.001).

Conclusions

Patients who undergo follow-up endoscopy after surgery should fast more than 18 h and ingest a soft or liquid diet on the day before examination.     

The impact of a high body mass index on laparoscopy assisted gastrectomy for gastric cancer

Background

Obesity is known to be associated with postoperative morbidity in gastric cancer surgery, but its impact on laparoscopy assisted gastrectomy (LAG) for gastric cancer has rarely been evaluated.

Methods

The clinical data for 1,485 LAG procedures for gastric cancer in 10 institutions were reviewed. The patients were divided into high body mass index (BMI) (BMI ≥ 25 kg/m²; n = 432) and low BMI (BMI <25 kg/m²; n = 1,053) groups, and their clinical outcomes were compared.

Results

The mean age and proportion of comorbid patients were higher in the high BMI group than in the low BMI group. Postoperative morbidity and mortality did not differ between the high BMI (15.7% and 0.9%) and low BMI (14% and 0.5%) groups (p = 0.37 and p = 0.29). Only the operation time and the number of retrieved lymph nodes were significantly different between the high BMI (242.5 min and 30.4) and low BMI (223.7 min and 32.6) groups (p < 0.001 and p = 0.005), especially for male patients undergoing surgery by surgeons who have performed 40 or fewer LAGs.

Conclusions

High BMI itself may not increase operative morbidity after LAG for gastric cancer. However, when a surgeon is relatively inexperienced with LAG, a careful approach is required for male patients with a high BMI.     

Survival outcome of laparoscopic gastrectomy for clinical early (cT1) gastric cancer

Purposes

Laparoscopy-assisted gastrectomy (LAG) for clinical early (cT1) gastric cancer (EGC) is superior to open gastrectomy in terms of the short-term outcome; however, long-term survival outcome remains elusive.

Methods

Four hundred and ninety-one cT1 EGC patients who underwent LAG between 1998 and 2010 were registered to evaluate the survival outcome, including 237 patients who were observed for at least 5 years (long-term, L group), while 221 patients who were observed for at least 2–5 years (intermediate term, I group).

Results

There were 17 deaths, including 7 patients who developed recurrence (5 in pT1 and 2 in pT4a). Two fatal cases with pStage IIB were uniquely T1N3b. Six out of the 7 recurrences occurred within 2 years after surgery. The 237 patients in the L group included 6 of the recurrent deaths (2.5 %), while the 221 patients in the I group included 1 recurrent death (0.9 %). Recurrent sites of pathological T1 cases were the liver (n = 2), lung (n = 1), ovary (n = 1), and bone (n = 1), and no peritoneal or local recurrence was found.

Conclusions

Collectively, the survival outcome of EGC by LAG was excellent and LAG was acceptable as a therapeutic procedure for EGC.     

Laparoscopy-assisted gastrectomy versus open gastrectomy for resectable gastric cancer: an update meta-analysis based on randomized controlled trials

Background

We carry out a meta-analysis to evaluate the effectiveness and safety of laparoscopy-assisted gastrectomy (LAG) versus open gastrectomy for resectable gastric cancer.

Methods

We searched EMBASE, the Cochrane Library, PubMed, Science Citation Index (SCI), Chinese biomedicine literature database to identify randomized controlled trials (RCTs) from their inception to April 2012. Meta-analyses were performed using RevMan 5.0 software. It was in line with the preferred reporting items for systematic reviews and meta-analyses statement. The quality of evidence was assessed by GRADEpro 3.6.

Results

Eight RCTs totaling 784 patients were analyzed. Compared with open gastrectomy group, no significant differences were found in postoperative mortality (OR = 1.49; 95 % CI 0.29–7.79), anastomotic leakage (OR = 1.02; 95 % CI 0.24–4.27) , overall mean number of harvested lymph nodes [weighed mean difference (MD) = ?3.17; 95 % CI ?6.39 to 0.05]; the overall postoperative complication morbidity (OR = 0.54; 95 % CI 0.36–0.82), estimated blood loss (MD = ?107.23; 95 % CI ?148.56 to ?65.89,) frequency of analgesic administration (MD = ?1.69; 95 % CI ?2.18 to ?1.21, P < 0.00001), incidence of pulmonary complications (OR = 0.43, 95 % CI 0.20–0.93, P = 0.03) were significantly less in LAG group; LAG had shorter time to start first flatus (MD = ?0.23; 95 % CI ?0.41 to ?0.05) and decreased hospital stay (MD = ?1.72; 95 % CI ?3.40 to 0.04), but, LAG still had longer operation time (MD = 76.70; 95 % CI 51.54–101.87).

Conclusions

On the basis of this meta-analysis we conclude that although LAG was still a time-consuming and technically dependent procedure, it has the advantage of better short-term outcome. Long term survival data from other studies are urgently needed to estimate the survival benefit of this technique.     

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.     

Prognostic Significance of Non-curative Gastrectomy for Incurable Gastric Carcinoma

Background

To date, there is no convincing evidence regarding the benefits of non-curative gastrectomy for gastric carcinoma. In the present study, we reviewed the outcomes of patients who underwent surgery for incurable gastric carcinoma and evaluated the prognostic significance of non-curative gastrectomy.

Methods

Between 2004 and 2011, a total of 197 patients undergoing elective surgery for incurable gastric carcinoma were divided into the gastric resection and non-resection groups. Patient survival was compared between the two groups, and the prognostic significance of non-curative gastrectomy was investigated using multivariate analysis.

Results

Overall, 162 (82.2 %) patients underwent non-curative gastrectomy with morbidity and mortality of 21.0 and 1.2 %, respectively. The median survival of patients undergoing non-curative gastrectomy was significantly longer than that of patients without gastrectomy (12.4 vs. 7.1 months, p = 0.003). Patients who received postoperative chemotherapy also showed significantly better survival than those without chemotherapy (13.2 vs. 4.3 months, p < 0.001). Multivariate analysis revealed that non-curative gastrectomy was an independent prognostic factor (hazard ratio 0.61, 95 % CI 0.40–0.93, p = 0.023) after adjusting for postoperative chemotherapy and other clinical factors. Median survival in patients receiving non-curative gastrectomy combined with postoperative chemotherapy was 13.9 months, which was significantly longer than gastrectomy alone (5.4 months), chemotherapy alone (9.6 months), and no treatment (3.2 months) (p < 0.001).

Conclusion

Primary tumor resection and postoperative chemotherapy are the most important prognostic factors for incurable gastric carcinoma. The survival benefits of non-curative gastrectomy need to be confirmed in a large-scale, randomized trial.     

Systematic Review and Meta-analysis of Laparoscopic Versus Open Distal Gastrectomy

Background

Laparoscopic distal gastrectomy has been increasingly utilized in the treatment of gastric adenocarcinoma. This study aims to compare the morbidity/mortality and postoperative outcomes of laparoscopic-assisted versus open distal gastrectomy since 2000.

Methods

A comprehensive search of MEDLINE and EMBASE was conducted including studies published between 2000 and present.

Results

Seventeen studies with a total of 7,109 distal gastrectomies (3,496 lap vs 3,613 open) were included. Across all studies, postoperative morbidity rates for laparoscopic gastrectomy were lower than that of open [median (range) 10 (0–36)?% vs 17 (0–43)?%]. Meta-analysis of postoperative morbidity rates in prospective studies only yielded pooled odds ratio of 0.52 (95 % CI 0.33–0.81) (P?=?0.004). In-hospital mortality rates were comparable between the two (range: laparoscopic 0–3.3 vs open 0–6.7 %). The long-term oncological outcomes of resection were difficult to analyze given variable reporting but appeared similar between the two. Meta-analysis of prospective studies showed that laparoscopic-assisted distal gastrectomy was associated with significantly shorter hospital length of stay [standard mean difference (SMD)?=??0.78 (95 % CI?=??1.0 to ?0.56)], comparable intraoperative bleeding [SMD?=?0.64 (95 % CI?=??1.3–0.0430) P?=?0.066] and longer operative time compared to open gastrectomy [1.9 (95 % CI 0.05–3.8) P?=?0.045, with P?<?0.001].

Conclusion

This study supports the use of laparoscopic-assisted distal gastrectomy for treatment of gastric adenocarcinoma with evidence of comparable, if not better, short-term postoperative parameters when compared to open distal gastrectomy. The long-term oncological outcomes appear similar but may require more evaluation.     

Metallic Stent Placement in Patients with Recurrent Malignant Obstruction in the Surgically Altered Stomach

Purpose

The purpose of this study was to assess the technical feasibility and clinical effectiveness of expandable metallic stent placement in 196 patients with recurrent malignant obstruction in their surgically altered stomach.

Methods

The 196 patients were treated using five different types of gastric surgery performed for gastric cancer: total gastrectomy (type 1) in 73 patients; distal gastrectomy with gastroduodenostomy (type 2) in 39 patients; distal gastrectomy with a Roux-en-Y gastrojejunostomy (type 3) in 21 patients; distal gastrectomy with a gastrojejunostomy (type 4) in 49 patients; and palliative gastrojejunostomy for unresectable gastric cancer (type 5) in 14 patients. The technical and clinical success rates, complications, dysphagia score, and influence of chemotherapy were evaluated and the complications compared between the two stent types. The overall survival and stent patency were calculated using the Kaplan–Meier method.

Results

Stent placement was technically successful in 192 of 196 patients (97.9 %), with 184 of the 192 patients (95.8 %) showing symptomatic improvement. The mean dysphagia score improved from 3.24 ± 0.64 to 1.48 ± 0.82 (p < 0.001). The complication rate was 25 %. The incidence of stent migration was significantly higher in fully covered stents and in patients who underwent chemotherapy (p < 0.001 and p = 0.005, respectively). Chemotherapy was significantly associated with an increase of survival (p < 0.001). The median survival and stent patency were 131 and 90 days, respectively.

Conclusion

Placement of expandable metallic stents in patients with recurrent cancer after a surgically altered stomach is technically feasible and clinically effective. Chemotherapy was associated with increased stent migration and prolonged survival.     

Laparoscopy-Assisted vs. Open Total Gastrectomy for Advanced Gastric Cancer: Long-Term Outcomes and Technical Aspects of a Case–Control Study

Background and Objectives

An increasing number of studies comparing laparoscopy-assisted distal gastrectomy and conventional open distal gastrectomy have been reported; the technical feasibility and clinical efficacy have been confirmed. However, few data are available to compare laparoscopy-assisted total gastrectomy (LATG) and open techniques for the treatment of advanced gastric cancer (AGC). The aim of this study is to compare the oncologic efficacy and long-term outcomes of LATG vs. open total gastrectomy (OTG) for AGC and to provide our experiences regarding these surgical difficulties as well.

Methods

Using data from a clinical database of all operations performed in our department by a special surgical team, we retrospectively analysed data from 117 cases of LATG and matched OTG performed between January 2004 and December 2010. This analysis was a case–control study in which patients in the two groups were matched according to tumour location, age, gender, BMI and TNM stage via a propensity score matching method. Patient clinical characteristics, lymph node retrieval, early postoperative complications, recurrence and long-term outcomes were compared.

Results

The demographics, preoperative data and characteristics of the tumour were similar in both groups. No significant differences were found in the LATG group compared with the OTG group with regard to the number of retrieved lymph nodes or distance from the proximal margin. Operating time was longer in the LATG group than in the OTG group (292.8?±?49.5 vs. 242.1?±?47.4, p?<?0.05). Significant differences were found between LATG and OTG with regard to blood loss, postoperative hospitalisation and times of analgesic injection. The early postoperative complication rates in the LATG group were significantly lower than in the OTG group (11.1 vs. 16.3 %, p?<?0.05). Operative mortality was zero in both groups. During a median follow-up of 61.2 (range, 6–84)?months, the overall 5-year survival rates in the LATG group and OTG group were 49.3 and 46.5 %, respectively; there was no significant difference between the two groups (p?=?0.756).

Conclusion

Our results suggest that LATG is technically feasible for advanced gastric cancer patients and can yield good short- and long-term oncologic outcomes as compared with conventional OTG.     

Surgical outcomes in the newly introduced phase of intracorporeal anastomosis following laparoscopic distal gastrectomy is safe and feasible compared with established procedures of extracorporeal anastomosis

Background

Totally laparoscopic distal gastrectomy (TLDG) with intracorporeal anastomosis has been introduced to achieve safer anastomosis with good vision, and a small wound. However, little is known about the surgical outcomes of newly introduced TLDG compared with established procedures of laparoscopy-assisted gastrectomy (LADG) with extracorporeal anastomosis.

Methods

This retrospective study included 114 patients who underwent laparoscopic distal gastrectomy (LDG) between January 2010 and September 2012. The patients were classified into two groups according to the approach of reconstruction (LADG group: n = 74; TLDG group: n = 40). The parameters analyzed included patients, operation details, and operative outcomes.

Results

No complication was observed in the TLDG group. Surgical outcomes of the TLDG group, such as mean operation time, estimated blood loss, and rate of conversion to laparotomy were not inferior to the LADG group. Furthermore, postoperative hospital stay of the TLDG group was significantly shorter than the LADG group (p < 0.05).

Conclusion

Surgical outcomes in the newly introduced phase of TLDG were safe as well as feasible compared with established LADG. TLDG has several advantages over LADG, such as shorter post-hospital stay, no incidence of operative complication, adequate working space, and small wound size. Although prospective, randomized control studies are warranted, we submit that TLDG can be used as a standard procedure for LDG.     

Short-term outcomes of laparoscopic-assisted distal gastrectomy for gastric cancer during a surgeon’s learning curve period

Background

Laparoscopy-assisted distal gastrectomy (LADG) is gaining wider acceptance for treating early gastric cancer (EGC). However, many gastric surgeons are still reluctant to perform LADG, mainly because this procedure entails a considerable learning curve. We aimed to evaluate the technical feasibility and short-term outcomes of performing LADG by a single experienced gastric surgeon who initially had no experience with laparoscopic surgery as compared with open distal gastrectomy (ODG).

Methods

Between January 2006 and December 2007, 177 patients with preoperatively diagnosed EGC located at the middle or lower third of the stomach were enrolled; 102 patients underwent LADG, 4 patients had open conversion, and 71 patients underwent conventional ODG. The operative and early postoperative outcomes from a prospective database were compared between the two groups.

Results

The clinicopathological characteristics were similar between the two groups. No operation-related deaths occurred. Although operation time was significantly longer for LADG than for ODG, time to first flatus was shorter and, consequently, postoperative hospital stay was significantly shorter in the LADG group. There was no significant difference in the overall complication rates between the two groups. On comparing the early (n = 50) and late groups (n = 52) of LADG patients, operation time and postoperative hospital stay were shorter and number of retrieved lymph nodes was greater in the late group (p < 0.05). Major and minor complications were markedly reduced in the late group (p < 0.05).

Conclusions

Although LADG was more time consuming than ODG, it was a feasible, safe procedure that accomplished the oncological requirements. Postoperative morbidity of LADG was similar to that of ODG, and LADG led to faster postoperative recovery. However, LADG should be performed carefully to prevent unexpected complications, especially during the early learning period.     

Progression from laparoscopic-assisted to totally laparoscopic distal gastrectomy: comparison of circular stapler (i-DST) and linear stapler (BBT) for intracorporeal anastomosis

Background

Billroth I (B-I) gastroduodenostomy is an anastomotic procedure that is widely performed after gastric resection for distal gastric cancer. A circular stapler often is used for B-I gastroduodenostomy in open and laparoscopic-assisted distal gastrectomy. Recently, totally laparoscopic distal gastrectomy (TLDG) has been considered less invasive than laparoscopic-assisted gastrectomy, and many institutions performing laparoscopic-assisted distal gastrectomy are trying to progress to TLDG without markedly changing the anastomosis method. The purpose of this report is to introduce the technical details of new methods of intracorporeal gastroduodenostomy using either a circular or linear stapler and to evaluate their technical feasibility and safety.

Methods

Seventeen patients who underwent TLDG with the intracorporeal double-stapling technique using a circular stapler (n = 7) or the book-binding technique (BBT) using a linear stapler (n = 10) between February 2010 and April 2011 were enrolled in the study. Clinicopathological data, surgical data, and postoperative outcomes were analyzed.

Results

There were no intraoperative complications or conversions to open surgery in any of the 17 patients. The usual postoperative complications following gastroduodenostomy, such as anastomotic leakage and stenosis, were not observed. Anastomosis took significantly longer to complete with DST (64 ± 24 min) than with BBT (34 ± 7 min), but more stapler cartridges were needed with BBT than with DST.

Conclusions

TLDG using a circular or linear stapler is feasible and safe to perform. DST will enable institutions performing laparoscopic-assisted distal gastrectomy with circular staplers to progress to TLDG without problems, and this progression may be more economical because fewer stapler cartridges are used during surgery. However, if an institution has already been performing δ anastomosis in TLDG but has been experiencing certain issues with δ anastomosis, converting from δ anastomosis to BBT should be beneficial.     

Comparison of Billroth I and Roux-en-Y Reconstruction after Distal Gastrectomy for Gastric Cancer: One-year Postoperative Effects Assessed by a Multi-institutional RCT

Purpose

This randomized, controlled trial evaluated the clinical efficacy of Billroth I (BI) and Roux-en-Y (RY) reconstruction at 1 year after distal gastrectomy for gastric cancer.

Methods

The primary end point was the amount of body weight lost at 1 postoperative year, and secondary end points included other items related to nutritional status such as serum albumin and lymphocyte count, as well as endoscopic examination findings of the remnant stomach and esophagus. Of the 332 patients enrolled, 163 were assigned to the BI group and 169 were randomized to the RY group.

Results

The loss in body weight 1 year after surgery did not differ significantly between the BI and RY groups (9.1 % and 9.7 %, respectively, p = 0.39). There were no significant differences in other aspects of nutritional status between the 2 groups. Endoscopic examination 1 year after gastrectomy showed reflux esophagitis in 26 patients (17 %) in the BI group versus 10 patients (6 %) in the RY group (p = 0.0037), while remnant gastritis was observed in 71 patients (46 %) in the BI group versus 44 patients (28 %) in the RY group (p = 0.0013); differences were significant for both conditions. Multivariable analysis showed that the only reconstruction was the independently associated factor with the incidence of reflux esophagitis.

Conclusions

RY reconstruction was not superior to BI in terms of body weight change or other aspects of nutritional status at 1 year after surgery, although RY more effectively prevented reflux esophagitis and remnant gastritis after distal gastrectomy.     

Meta-Analysis of Efficacy and Safety of Fast-Track Surgery in Gastrectomy for Gastric Cancer

Background

Fast-track surgery (FTS) is a promising program for surgical patients and has been applied to several surgical diseases. FTS is much superior to conventional perioperative care. Our aim was to evaluate and compare the safety and efficacy of FTS and conventional perioperative care for patients undergoing gastrectomy using a systematic review.

Methods

We searched the literature in PubMed, SCOPUS, and EMBASE up to November 2013. No language restriction was applied. Weighted mean differences (WMDs) and odds ratios (ORs) with their 95 % confidence intervals (CIs) were used for analysis by a fixed or a random effects model according to the heterogeneity assumption.

Results

In the present meta-analysis, we included five randomized controlled trials and one controlled clinical trial from five studies. Compared with conventional care, FTS shortened the duration of flatus (WMD ?21.08; 95 % CI ?27.46 to ?14.71, z = 6.48, p < 0.00001 in the open surgery group; WMD ?8.20; 95 % CI ?12.87 to ?3.53, z = 3.44, p = 0.0006 in the laparoscopic surgery group), accelerated the decrease in C-reactive protein (WMD ?15.56; 95 % CI 21.28 to 9.83, z = 5.33, p < 0.00001), shortened the postoperative stay (WMD ?2.00; 95 % CI ?2.69 to ?1.30, z = 5.64, p < 0.00001), and reduced hospitalization costs (WMD ?447.72; 95 % CI ?615.92 to ?279.51, z = 5.22, p < 0.00001). FTS made no significant difference in operation times (p = 0.93), intraoperative blood loss (p = 0.79), or postoperative complications (p = 0.07).

Conclusions

Based on current evidence, the FTS protocol was feasible for gastric cancer patients who underwent gastrectomy (distal subtotal gastrectomy, proximal subtotal gastrectomy, or radical total gastrectomy) via open or laparoscopic surgery. Larger studies are needed to validate our findings.     

Accurate,safe, and rapid method of intraoperative tumor identification for totally laparoscopic distal gastrectomy: injection of mixed fluid of sodium hyaluronate and patent blue

Background

In totally laparoscopic distal gastrectomy, determining the resection line with safe proximal margins is often difficult, particularly for tumors located in a relatively upper area. This is because, in contrast to open surgery, identifying lesions by palpating or opening the stomach is essentially impossible. This study introduces a useful method of tumor identification that is accurate, safe, and rapid.

Methods

On the operation day, after inducing general anesthesia, a mixture of sodium hyaluronate and patent blue is injected into the submucosal layer of the proximal margin. When resecting stomach, all marker spots should be on the resected side. In all cases, the proximal margin is examined histologically by using frozen sections during the operation.

Results

From October 2009 to September 2011, a prospective study that evaluated this method was performed. A total of 34 patients who underwent totally laparoscopic distal gastrectomy were enrolled in this study. Approximately 5 min was required to complete the procedure. Proximal margins were negative in all cases, and the mean ± standard deviation length of the proximal margin was 23.5 ± 12.8 mm. No side effects, such as allergy, were encountered.

Conclusions

As a method of tumor identification for totally laparoscopic distal gastrectomy, this procedure appears accurate, safe, and rapid.     

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.