Laparoscopic pyloroplasty is a safe and effective first-line surgical therapy for refractory gastroparesis

Introduction

Surgical options for symptomatic delayed gastric emptying include gastric stimulator implantation, subtotal gastrectomy, and pyloroplasty. Pyloroplasty has been shown to improve gastric emptying yet is seldom described as a primary treatment for gastroparesis. We present a single-institution experience of laparoscopic Heineke–Mikulicz pyloroplasty (LP) as treatment for gastroparesis.

Methods and Procedures

A prospective foregut surgery database was queried for LP over a 5-year period. Charts were reviewed for indications, complications, symptom score, and outcomes. Gastroparesis was defined by (1) abnormal gastric emptying study, (2) endoscopic visualization of retained food after prolonged NPO status, or (3) clinical symptoms suspicious of vagal nerve injury following complex re-operative foregut surgery. Results were analyzed using a paired T test and single-factor ANOVA.

Results

One hundred and seventy-seven LP patients were identified and reviewed. One hundred and five had a concurrent fundoplication for objective reflux. There were no intraoperative complications or conversions to laparotomy. Overall morbidity rate was 6.8 % with four return to OR and two confirmed leaks (1.1 % leak rate). Average length of stay was 3.5 days, and readmission rate was 7 %. Eighty-six percent had improvement in GES with normalization in 77 %. Gastric emptying half-time decreased from 175 ± 94 to 91 ± 45 min. Nineteen patients (10.7 %) had subsequent surgical interventions: gastric stimulator implantation (12), feeding jejunostomy and/or gastrostomy tube (6), or subtotal gastrectomy (4). Symptom severity scores for nausea, vomiting, bloating, abdominal pain, and early satiety decreased significantly at 3 months.

Conclusion

Laparoscopic pyloroplasty improves or normalizes gastric emptying in nearly 90 % of gastroparesis patients with very low morbidity. It significantly improves symptoms of nausea, vomiting, bloating, and abdominal pain. Some patients may go on to another surgical treatment for GP, but it remains a safe and less invasive alternative to a subtotal gastrectomy in these clinically challenging patients.

     

Long-Term Effects of Gastric Stimulation on Gastric Electrical Physiology

Introduction

This study evaluates the modeling of gastric electrophysiology tracings during long-term gastric electrical stimulation for gastroparesis. We hypothesized that serosal electrogastrogram may change over time representing gastric remodeling from gastric stimulation.

Patients

Sixty-five patients with gastroparesis underwent placement of gastric stimulator for refractory symptoms. Mean age at initial stimulator placement was 44 years (range, 8–76), current mean age was 49, and the majority of the subjects were female (n?=?51, 78 %). Only a minority had diabetes-induced gastroparesis (n?=?16, 25 %); the remainder were either idiopathic or postsurgical.

Methods

At the time of stimulator placement, electrogastrogram was performed after the gastric leads were placed but before stimulation was begun. Patients underwent continuous stimulation until pacer batteries depleted. At the time of replacement, before the new pacemaker was attached, electrogastrogram was again performed.

Results

After a mean of 3.9 years of stimulation therapy, the mean of baseline frequency before stimulation therapy was 5.06 cycles/min and declined to 3.66 after replacement (p?=?0.0000002). The mean amplitude was 0.33 mV before stimulation therapy and decreased to 0.31 mV (p?=?0.73). The frequency/amplitude ratio was 38.4 before stimulation therapy and decreased to 21.9 (p?=?0.001).

Conclusion

Long-term gastric electrical stimulation causes improvement in basal unstimulated gastric frequency to near normal.     

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.     

Laparoscopic Gastric Electrical Stimulation for Medically Refractory Diabetic and Idiopathic Gastroparesis

Background

Gastric electrical stimulator (GES) implantation is effective in certain patients with gastroparesis; however, laparotomy is often employed for placement. The aim of this study is to review outcomes of patients who underwent laparoscopic GES therapy for diabetic and idiopathic gastroparesis at a large referral center.

Methods

Patients who underwent GES (Enterra Therapy System; Medtronic, Minneapolis, MN) implantation with subsequent interrogation and programming between March 2001 and November 2011 were analyzed.

Results

A total of 113 patients underwent GES placement or revision during the study period. One hundred eleven patients underwent primary GES at our institution, while two patients underwent GES generator revision at our institution. Primary operations were completed laparoscopically in 110 of 111 cases, with one conversion to laparotomy due to severe adhesions. At a mean follow-up of 27 months (1–113), symptom improvement was achieved in 91 patients (80 %) and was similar for both the diabetic and idiopathic subgroups. Need for supplemental nutrition (enteral and/or parental) decreased in both groups.

Conclusions

GES placement is feasible using a laparoscopic approach. Medical refractory gastroparesis in the diabetic and idiopathic groups had significant symptom improvement with no difference between the two groups. Need for supplemental nutrition is decreased following GES.     

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.     

Outcome After Curative Surgery for Gastric Cancer Patients with Type 2 Diabetes

Background

Bariatric surgery has been adapted to the management of morbid obesity, leading to not only loss of body weight but also improvement of type 2 diabetes mellitus (DM). The goal of our study was to evaluate the effect of gastrectomy in gastric cancer patients with type 2 DM.

Methods

From 1989 to 2011, a total of 69 gastric cancer patients receiving curative surgery were enrolled in this study. They were diagnosed with type 2 DM preoperatively and all are alive without tumor recurrence. The clinical characteristics were compared between groups with improved or unimproved DM, and groups were also analyzed based on the extent of gastrectomy and different reconstruction methods.

Results

Of the 69 patients, 58 received subtotal gastrectomy and 11 received total gastrectomy. The frequency of DM improvement was significantly higher after total gastrectomy than subtotal gastrectomy (81.8 vs. 36.2 %; p = 0.007). Patients with DM duration of less than 5 years tended to experience DM improvement after surgery more frequently than patients with DM duration of more than 5 years (p = 0.028). Roux-en-Y esophagojejunostomy (R-Ye) led to a higher rate of DM improvement than did R-Y gastrojejunostomy (R-Yg), especially in patients with DM duration more than 5 years. Among patients receiving duodenal bypass after gastrectomy, R-Ye was associated with a higher frequency of DM improvement than R-Yg and B-II.

Conclusions

The extent of gastrectomy rather than the reconstruction method played an important role in DM improvement after curative surgery for gastric cancer.     

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.     

Vitamin E Deficiency Begins within 6 Months after Gastrectomy for Gastric Cancer

Background

To clarify factors related to vitamin E malabsorption after gastric surgery, we evaluated serum vitamin E levels in patients who had undergone gastrectomy for gastric cancer.

Methods

We studied 39 patients (26 men, 13 women; mean age, 61.7 years) who underwent gastrectomy for early gastric cancer. Surgical procedures included 24 subtotal gastrectomies and 15 total gastrectomies. We measured serum levels of vitamin E before and 3, 6, 9, and 12 months after gastrectomy. A level of less than 0.75 mg/dl was defined as a low vitamin E level.

Results

Serum vitamin E levels decreased to less than 0.75 mg/dl in 6 (15.4 %) of the 39 patients within 6 months after gastrectomy and in 7 (17.9 %) of the 39 patients within 1 year after gastrectomy. The proportion of patients with a low serum vitamin E level was significantly higher in the total gastrectomy group (p = 0.002). A low vitamin E level was significantly associated with a low total cholesterol level. Total cholesterol levels in low vitamin E levels patients were lower than normal vitamin E levels patients. None of the patients with a low vitamin E level had neuropathy.

Conclusions

The type of operation performed (total vs. subtotal gastrectomy) may be the major cause of vitamin E malabsorption after gastrectomy for gastric cancer. Vitamin E deficiency probably begins within 6 months after gastrectomy for gastric cancer.     

National outcomes and uptake of laparoscopic gastrectomy for cancer in England

Background

Gastrectomy remains the mainstay of curative treatment for gastric cancer, yet it is associated with significant postoperative mortality. The laparoscopic approach has been introduced in an attempt to improve surgical outcomes. This study examines the uptake of laparoscopic gastrectomy in England and quantifies postoperative mortality and morbidity following gastrectomy for cancer.

Methods

A population-based study of a national administrative database was undertaken. Patients undergoing gastrectomy for cancer in any National Health Services hospital in England between April 2000 and March 2010 were included. The main outcome measures were mortality, morbidity and length of stay.

Results

A total of 10,713 patients underwent gastrectomy, of which 10,233 (95.5 %) underwent open gastrectomy (OG), and 480 (4.5 %) underwent laparoscopic gastrectomy (LG). There was no significant difference in 30-day in-hospital mortality between OG and LG (5.6 % vs. 4.8 %; p = 0.461). Medical complications occurred in 2,311 (22.6 %) and 120 (25 %) patients from OG and LG groups respectively (p = 0.217). Patients in the LG groups had a shorter hospital stay than OG with median (interquartile range) of 11 (8–17) versus 14 (11–19) days respectively (p < 0.001). Readmission and reoperation rates were 10.2 versus 12.1 % (p = 0.175) and 4 versus 4.6 % (p = 0.523) for OG and LG respectively.

Conclusions

LG is increasingly being performed in England. Postoperative morbidity and mortality of LG is similar to that of OG, but it is associated with a shorter hospital stay. Data from randomised controlled trials evaluating long term survival and patients’ reported outcomes are essential before the final judgement on the value of LG in the management of gastric cancer.     

Laparoscopic gastrointestinal anastomoses using knotless barbed sutures are safe and reproducible: a single-center experience with 201 patients

Background

Intestinal anastomosis is a complex procedure during laparoscopy, mainly due to the difficulties knotting the sutures. Unidirectional barbed sutures have been proposed to simplify wall and mesentery closure, but the results for intestinal anastomosis are not clear. This study aimed to establish the feasibility and the safety of laparoscopic intestinal anastomosis using barbed suture.

Methods

Between June 2011 and May 2012, 15-cm-long unidirectional absorbable barbed sutures (V-Loc; Covidien, Mansfield, MA, USA) were used for all laparoscopic intestinal anastomoses: one suture for closure of intestinal openings after mechanical anastomoses and two sutures for hand-sewn anastomoses.

Results

Over a 1-year period, 201 consecutive patients required 220 laparoscopic anastomoses for gastrojejunostomy (n = 177; 172 during Roux-en-Y gastric bypass and 5 after gastrectomy), ileocolostomy (n = 15), colocolostomy (n = 1), esophagojejunostomy (n = 5), and jejunojejunostomy (n = 22; 4 after small bowel resection and 18 during gastric bypass or gastrectomy). Senior and training surgeons performed 209 closures of intestinal openings and 11 hand-sewn anastomoses. There was no conversion to usual sutures. One fistula occurred in an esophagojejunostomy and was managed conservatively. One self-limited anastomotic bleeding occurred, and no anastomotic stenosis occurred during 6 months of follow-up evaluation.

Conclusions

The use of knotless barbed suture for laparoscopic intestinal anastomosis is safe and reproducible.     

Surgical Outcomes After Gastric Electric Stimulator Placement for Refractory Gastroparesis

Background

Gastric electric stimulation (GES) is used for refractory gastroparesis symptoms. Although symptomatic improvement has been reported with GES, few studies describe the need for additional surgery after placement. Our goal was to evaluate the outcomes of a large series of GES at a single institution.

Methods

A retrospective review was performed for patients undergoing Enterra GES (Medtronic, Inc.) placement for refractory gastroparesis from October 2000 to October 2011. The main outcome measures were the need/indications for additional procedures and symptom improvement.

Results

A total of 266 patients had a GES implanted; 233 had complete records and were included in the analysis. Fifty-eight percent (n?=?135) required an additional procedure after GES placement. Nutrition access (45 patients requiring 77 procedures) and subcutaneous pocket issues (n?=?21) were the most common indications for subsequent procedures. Twelve percent (n?=?29) had the GES explanted, mainly for continued gastroparetic symptoms (n?=?11), mechanical issues (n?=?9), or infection (n?=?4). Ninety patients had subsequent hospitalizations, mainly for gastroparetic flares. Mortality during the follow-up period was 2.1 %. BMI was predictive of additional surgical procedure: when overweight, the risk of pocket revision increased 4.45 times (OR?=?4.452). Of 74 most recent patients with prospective long-term outcome data, 70 % reported improved symptoms of pain, bloating, and nausea.

Conclusions

Although most patients reported symptomatic improvement after GES implantation, there is often a need for additional surgical procedures as well as associated complications after GES placement. Additional procedures were most frequent for surgical nutrition and subcutaneous pocket issues; pocket revisions were more frequent in obese patients. From our results, we amended our practice to add a jejunostomy tube in malnourished patients and suture the stimulator to the subcutaneous pocket fascia. Further studies will determine if these changes reduce the rate of complications and additional procedures after GES placement.     

Noncurative Gastrectomy for Gastric Adenocarcinoma Should only be Performed in Highly Selected Patients

Background

The benefit of surgical resection in patients with incurable gastric adenocarcinoma is controversial.

Methods

A total of 289 patients who presented with advanced or metastatic gastric cancer from 1995 to 2010 were retrospectively reviewed.

Results

Ten patients (3.5 %) required emergent surgery at presentation and were excluded from further analyses. Patients who underwent nonemergent surgery at presentation (n = 110, 38.1 %) received either gastric resection (group A, n = 46, 42 %) or surgery without resection (group B, n = 64, 58 %). Procedures in group A included distal gastrectomy (n = 25, 54 %), total gastrectomy (n = 17, 37 %), and proximal/esophagogastrectomy (n = 4, 9 %). Procedures in group B included laparoscopy (n = 17, 27 %), open exploration (n = 25, 39 %), gastrostomy and/or jejunostomy tube (n = 12, 19 %), and gastrojejunostomy (n = 10, 16 %). Group A required a stay in the intensive care unit or additional invasive procedure significantly more often than group B (15 vs. 2 %, p = 0.009). Four patients in group A (8.7 %) and three patients in group B (4.7 %) died within 30 days of surgery (p = 0.45). When the 110 patients who underwent nonemergent surgery (groups A and B) were compared to nonoperatively managed patients (group C, n = 169, 58 %), median overall survival did not significantly differ (8.6 vs. 9.2 vs. 7.7 months; p > 0.05). Three patients in group B (4.7 %) and three in group C (1.8 %) ultimately required an operation for their primary tumor.

Conclusions

Patients with gastric adenocarcinoma who present with advanced or metastatic disease not amenable to curative resection infrequently require emergent surgery. Noncurative resection is associated with significant perioperative morbidity and mortality as well as limited overall survival, and should therefore be performed judiciously.     

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.     

Pre-operative gastric emptying time correlates with clinical response to gastric electrical stimulation in the treatment of gastroparesis

BackgroundGastric electrical stimulation (GES) may be of benefit in cases of gastroparesis that fail to respond to standard medical therapy. Response to this treatment is varied and prediction of clinical improvement is difficult.MethodsThis was a retrospective review and symptom questionnaire survey for all patients who underwent GES insertion in a single institution from November 2008 until May 2010 using the gastroparesis cardinal symptom index (GCSI).Results14 out of 17 patients who had GES insertion responded to telephone or postal questionnaire. Mean pre-operative gastric emptying time was 151 min (median 146 min, range 18–318). Median follow up was 14 months (range 7–25 months). The mean reduction in GCSI score after GES insertion was 51% (13.4 vs 6.4, Z = 0.0013). Percentage reduction in GCSI correlated with pre-operative solid gastric emptying time (p = 0.0086). Two patients who responded to questionnaire required device removal, one due to a gastric perforation and the other for discomfort related to the implant and a poor clinical response.ConclusionsGES significantly improves symptoms of gastroparesis on the GCSI score. Not all patients respond equally to GES, and response may be predicted by pre-operative solid gastric emptying times.     

Do Perioperative Blood Transfusions Influence Prognosis of Gastric Cancer Patients? Analysis of 927 Patients and Interactions with Splenectomy

Background

This study was to assess the influence of perioperative blood transfusions on the prognosis of patients undergoing a potentially curative resection for gastric cancer and to investigate the interaction between transfusions and splenectomy.

Materials and Methods

Between January 1990 and December 2005, 927 patients from 6 Italian tertiary referral centers underwent curative resections for gastric cancer. Clinical and pathologic variables were prospectively collected. The influence of perioperative blood transfusions on survival were evaluated by univariate and multivariate analysis. Moreover, the influence of splenectomy both in transfused and nontransfused patients undergoing total gastrectomy was also evaluated.

Results

The overall 5-year survival was 54.6%. The 5-year survival rate in transfused patients (n = 327) was 50.6% compared with 56.6% in nontransfused patients (n = 600) (P = .094). In the subgroup of patients who underwent total gastrectomy with spleen preservation (n = 209), 5-year survival rate was 46% and 51.4% in transfused and nontransfused patients, respectively (P = .418); those who underwent total gastrectomy with splenectomy (n = 199) presented a 5-year survival rate of 45% in transfused group compared with 39.1% in nontransfused patients (P = .571).

Conclusions

Our study indicates a slightly, but not significantly, negative effect of allogeneic blood transfusion on prognosis of gastric cancer patients. In the subgroup of patients who underwent total gastrectomy, splenectomy seems to invert this mild effect, with a positive influence on overall survival.     

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.     

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.     

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.     

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.     

Symptomatic gallstones after sleeve gastrectomy

Background

Cholelithiasis is a common complication after bariatric surgery. Pure restrictive procedures such as sleeve gastrectomy and gastric banding theoretically should result in less gallstone formation because the food continues to follow the normal gastrointestinal transit, maintaining the enteric–endocrine reflex intact. To the authors’ knowledge, the literature has no studies that analyze the incidence of gallstone formation after sleeve gastrectomy. This study aimed to compare the rates of symptomatic gallstones between laparoscopic Roux-en-Y gastric bypass (RYGBP) and sleeve gastrectomy (SG).

Methods

A retrospective chart review of patients who underwent laparoscopic RYGBP and SG between 2004 and 2006 was performed. The patients with previous cholecystectomy, known gallstones with or without concomitant cholecystectomy, and previous weight-reduction operations were excluded from the analysis. The outcome measures were the numbers of patients who had experienced symptomatic and complicated gallstones. Using Cox regression analysis, comparisons was made between the patients with laparoscopic RYGBP (group A) and those with laparoscopic SG (group B).

Results

Groups A excluded 174 (26%) of 670 patients, and group B excluded 27 (34.2%) of 79 patients. The patients in group A had a significantly higher preoperative body mass index (BMI) than those in group B. Additionally, more group A than group B patients had a BMI exceeding 45 and more than a 25% loss of original weight. No significant difference in the development of symptomatic (8.7% vs. 3.8%; p = 0.296) or complicated (1.8% vs. 1.9%; p = 0.956) gallstones was noted between the two groups

Conclusions

There was no significant difference in symptomatic or complicated gallstone disease between the patients treated with laparoscopic SG and those treated with laparoscopic RYGBP. Routine prophylactic cholecystectomy should not be recommended for weight reduction during laparoscopic SG.