Segmental gastrectomy with radical lymph node dissection for early gastric cancer

AIM: To describe a new surgical technique and evaluate the early results of segmental gastrectomy (SG) with modified D2 lymph node (LN) dissection for early gastric cancer (EGC). METHODS: Fourteen patients with EGC underwent SG with modified D2 dissection from 2006 to 2008. Their operative results and postoperative courses were compared with those of 17 patients who had distal gastrectomy (DG) for EGC during the same period. RESULTS: Operating time, blood loss, and hospital stay were similar between the 2 g...     

腹腔镜早期胃癌根治术的临床研究

目的:探讨腹腔镜胃癌根治术在早期胃癌治疗中的临床应用。方法:回顾性分析2004年10月至2009年12月间79例接受腹腔镜胃癌根治术的早期胃癌患者的临床资料,包括手术方式、手术时间、术中失血、术后排气时间、术后住院天数、并发症、术后病理和随访等。结果:除1例中转开腹手术外,其余78例均在腹腔镜下完成胃切除和淋巴结清扫,其中腹腔镜远端胃切除术74例,近端胃切除术2例,全胃切除术2例;腹腔镜下D1+α式淋巴结清扫34例,D1+β式淋巴结清扫15例,D2式淋巴结清扫29例。手术时间为(202.9±45.6)min,术中失血(144.5±146.5)mL,术后排气时间(2.8±1.0)d,术后住院天数为(11.3±5.6)d,8例(10.1%)患者出现腹腔内出血、吻合口漏、小肠梗阻等,经手术和非手术治疗后痊愈。手术上、下切缘距离肿瘤为(4.0±1.9)cm和(3.6±1.7)cm,手术平均清扫淋巴结(13.1±6.5)枚,其中有3例(3.8%)发现淋巴结转移。术后随访2～64个月,均无肿瘤复发和远处转移。结论:腹腔镜胃癌根治术是治疗早期胃癌安全、可行、微创、有效的手术方法。     

The nutritional advantages of proximal gastrectomy for early gastric cancer.

BACKGROUND/AIMS: Total gastrectomy has generally been performed for the treatment of early gastric cancers involving the upper third of the stomach. However, proximal gastrectomy has also been used for the treatment of cardial early gastric cancer. METHODOLOGY: To compare the nutritional parameters after proximal gastrectomy with the parameters after total gastrectomy, and to also determine the advantages of the postoperative nutritional states, a retrospective analysis was made to evaluate the nutritional status of patients with early gastric cancer who underwent proximal gastrectomy with those undergoing total gastrectomy. Forty-nine patients were studied for one year after surgery; 9 underwent proximal gastrectomy while 40 had a total gastrectomy. RESULTS: Proximal gastrectomy allowed the patient to better maintain both their nutritional parameters and body weight. CONCLUSIONS: Proximal gastrectomy was thus found to be a beneficial modality for early gastric cancer patients regarding terms of the postoperative nutritional status, in comparison to total gastrectomy.     

Gastric emptying after segmental gastrectomy for early cancer in the middle part of the stomach.

BACKGROUND/AIMS: We evaluated the quality of life and gastric emptying in patients who had undergone a segmental gastrectomy to treat early gastric cancer in the middle part of the stomach. METHODOLOGY: Thirty patients were considered in this study. Their mean age was 65.5 years (range: 44-83). All of the patients were free from recurrence of their cancer in the follow-up period. This ranged from 5 to 50 months (mean 30). Patients were interviewed at regular intervals to assess their quality of life and to note particular complaints. The upper gastrointestinal tract was assessed endoscopically. A gastric emptying study was performed at 3, 6, and 12 months after surgery. The meal used in this dual-phase study had solid and liquid phases. For the solid phase, 74 MBq of 99mTc sulfur colloid was injected into an egg, which was then hard-boiled. For the liquid phase, 18.5 MBq of (111)In-diethyltriaminopenta acetic acid (DTPA) were mixed into 150 ml of a commercial, elentary liquid diet. RESULTS: Three months after surgery, the patients' main complaints were gastric stasis (25%), heartburn (8%) and belching (8%). The patients gradually became asymptomatic following surgery. Fifty-nine percent were asymptomatic at the 3-month follow-up, 84% at 6 months, and 92% at 12 months. There was no evidence of reflux esophagitis or gastritis after the 3-month follow-up. One patient developed a complicated duodenal ulcer. Initially, the patients all had prolonged gastric emptying of the dual phase meal, compared to normal individuals. The T1/2 for liquid meal emptying was 87+/-18 min at 3 months, 77+/-20 min at 6 months and 50+/-5 min at 1 year after surgery. The last value is the same as for healthy individuals. Solid meal emptying was still prolonged, with an emptying rate of 36+/-9.7% at 2 hours, one year after surgery. CONCLUSIONS: Segmental gastrectomy patients experienced prolonged gastric emptying in the early post-operative period. This improved in the first year after surgery. The quality of life for patients who underwent segmental gastrectomy has been reasonably good in the follow-up period to date.     

Postoperative evaluation of pylorus-preserving gastrectomy for early gastric cancer

BACKGROUND/AIMS: There have been many reports proposing some advantages of pylorus-preserving gastrectomy for gastric ulcer compared to the conventional distal gastrectomy. However, it is not clear whether similar results will be obtained from the patients with early gastric cancer. METHODOLOGY: Of 50 patients with early gastric cancer, 25 underwent pylorus-preserving gastrectomy under strict criteria and the other 25 underwent distal gastrectomy with Billroth I anastomosis by the same surgeon. The subjects were then interviewed and examined periodically to assess symptoms, food intake, body weight and serum nutritional parameters. Endoscopy and a radioisotope gastric emptying test was performed 1 year after the operation. RESULTS: Many of the patients with pylorus-preserving gastrectomy complained of gastric fullness after meals, resulting in poor food intake; a significant between-group difference was found up to 1 year after the operation. A low incidence of reflux gastritis and slow gastric emptying were confirmed in the patients after pylorus-preserving gastrectomy. CONCLUSIONS: Pylorus-preserving gastrectomy has advantages over distal gastrectomy in terms of the avoidance of dumping syndrome and protection against duodeno-gastric reflux. However, more time was necessary for improved gastric fullness or food intake. Pylorus-preserving gastrectomy should be applied in younger patients with early gastric cancer expecting long survival.     

Postoperative evaluation of function-preserving gastrectomy for early gastric cancer

BACKGROUND/AIMS: We evaluated the efficacy of the following three surgical options in gastrectomy for early gastric cancer; 1) reduction of the extent of gastrectomy, 2) preservation of the vagal nerve, and 3) preservation of the pylorus. METHODOLOGY: The postoperative physical conditions of patients who had undergone 6 kinds of operating methods incorporating elements 1), 2) and 3) were compared. The efficacy of elements 1) and 3) was evaluated by comparison among a 2/3 proximal gastrectomy group (2/3-PG group, n = 5), 4/5 proximal gastrectomy group (4/5-PG group, n = 7), and total gastrectomy group (TG group, n = 12). The efficacy of elements 1), 2) and 3) was also evaluated by comparison among a pylorus-preserving gastrectomy (PPG) group with preservation of the vagal nerve (PPGV group, n = 15), 2/3 distal gastrectomy group with preservation of the vagal nerve (2/3-DGV group, n = 12), and 4/5 distal gastrectomy group without preservation of the vagal nerve (4/5-DG group, n = 15). RESULTS: Body weight loss and the incidence of abdominal symptoms and anemia in the 2/3-PG group, PPGV or 2/3-DGV group were less frequent than in the TG group or 4/5-DG group. The increases in acetaminophen concentration in the 2/3-PG group, PPGV or 2/3-DGV groups, and the changes in blood sugar and insulin levels in the 2/3-PG or PPGV group were modest, while hypergastrinemia in the 2/3-PG group was remarkable. The insulinogenic index was high in the 2/3-DGV group, and the plasma cholecystokinin changes and contraction pattern of the gallbladder resembled their preoperative pattern in the PPGV and 2/3-DGV groups. These results indicated that the patients in the 2/3-PG group owed their benefits to elements 1) and 3), the 2/3-DGV group to elements 1) and 2), and the PPGV group to elements 1), 2) and 3). CONCLUSIONS: Three surgical options in gastrectomy procedures for early gastric cancer, 1) reduction of the extent of gastrectomy, 2) preservation of the vagal nerve, and 3) preservation of the pylorus, were individually confirmed to have benefits for better postoperative quality of life.     

Usefulness of sentinel node biopsy in laparoscopic partial gastrectomy for early gastric cancer

BACKGROUND/AIMS: Five patients having early gastric cancer were treated using laparoscopic partial gastrectomy combined with sentinel lymph node biopsy. METHODOLOGY: Preoperatively, 3.5 mq of Tc-labeled tin colloid was endoscopically injected near the tumor. Under general anesthesia, laparoscopic partial gastrectomy was then performed. Radioisotope (RI)-positive nodes were explored before performing laparoscopic partial gastrectomy. RESULTS: An average of 2.6 sentinel nodes was detected in this way. All patients were found to be free from nodal involvement both histologically and immunohistologically during surgery. Four patients had mucosal cancer and one patient had submucosal cancer, which agreed with the preoperative diagnosis of tumor depth. CONCLUSIONS: Sentinel node biopsy in conjunction with laparoscopy in early gastric cancer surgery may allow confirmation of complete removal of risk nodes in early gastric cancer.     

Anemia after gastrectomy for early gastric cancer: Long-term follow-up observational study

AIM: To identify the incidence and etiology of anemia after gastrectomy in patients with long-term follow-up after gastrectomy for early gastric cancer.METHODS: The medical records of those patients with early gastric adenocarcinoma who underwent curative gastrectomy between January 2006 and October 2007 were reviewed. Patients with anemia in the preoperative workup, cancer recurrence, undergoing systemic chemotherapy, with other medical conditions that can cause anemia, or treated during follow up with red cell transfusions or supplements for anemia were excluded. Anemia was defined by World Health Organization criteria (Hb < 12 g/dL in women and < 13 g/dL in men). Iron deficiency was defined as serum ferritin < 20 μg/dL. Vitamin B₁₂ deficiency was defined as serum vitamin B₁₂ < 200 pg/mL. Iron deficiency anemia was defined as anemia with concomitant iron deficiency. Anemia from vitamin B₁₂ deficiency was defined as megaloblastic anemia (mean cell volume > 100 fL) with vitamin B₁₂ deficiency. The profile of anemia over 48 mo of follow-up was analyzed.RESULTS: One hundred sixty-one patients with gastrectomy for early gastric cancer were analyzed. The incidence of anemia was 24.5% at 3 mo after surgery and increased up to 37.1% at 48 mo after surgery. The incidence of iron deficiency anemia increased during the follow up and became the major cause of anemia at 48 mo after surgery. Anemia of chronic disease and megaloblastic anemia were uncommon. The incidence of anemia in female patients was significantly higher than in male patients at 12 (40.0% vs 22.0%, P = 0.033), 24 (45.0% vs 25.0%, P = 0.023), 36 (55.0% vs 28.0%, P = 0.004), and 48 mo (52.0% vs 31.0%, P = 0.022) after surgery. Patients with total gastrectomy showed significantly higher incidence of anemia than patients with subtotal gastrectomy at 48 mo after surgery (60.7% vs 31.3%, P = 0.008). The incidence of iron deficiency was significantly higher in female patients than in male patients at 6 (35.4% vs 13.3%, P = 0.002), 12 (45.8% vs 16.8%, P < 0.001), 18 (52.1% vs 22.3%, P < 0.001), 24 (60.4% vs 20.9%, P < 0.001), 36 (62.5% vs 29.2%, P < 0.001), and 48 mo (66.7% vs 34.7%, P = 0.001) after surgery.CONCLUSION: Anemia was frequent after gastrectomy for early gastric cancer, with iron deficiency being the major cause. Evaluation for anemia including iron status should be performed after gastrectomy and appropriate iron replacement should be considered.     

Robot-assisted gastrectomy for cancer

Minimally invasive approach for gastric cancer has gained increasing acceptance. Introduction of the da Vinci robotic system has allowed overcoming the technical limitations of standard laparoscopy. To date, several studies have been published reporting the feasibility of robot-assisted gastrectomy (RAG). The aim of this study is to extensively review all the published literature concerning RAG and to assess its value. Since 2003, this systematic review of the literature shows that 10 original studies reporting 199 RAG for cancer have been published worldwide. The authors analyzed operative time, blood loss, conversion rate, lymph nodes retrieval, complications, mortality, length of hospital stay and follow-up through a systematic review. Mean age was 63 years (range: 25-96). Mean operative times were 265 minutes and 334 minutes for total and subtotal gastrectomy respectively. Mean blood loss reported was 113 mL (range: 12-1400). Conversion rate was 2.5%. Average lymph nodes retrieval was 32 (range: 11-83). Twenty-nine complications were reported (14.6%). Mortality rate was 1.5%. Mean length of stay was 10 days (range: 3-175).This review demonstrates that RAG for cancer is not only feasible but also seems to be safe, with low mortality and acceptable morbidity. However, due to the lack of long-term follow-up and the limited number of published studies, it is relatively too early to draw definitive conclusions and/or to recommend the use of RAG for oncologic gastrectomy. Randomized controlled trials with long-term follow up are needed before this promising approach can eventually be generalized.     

Factors influencing the development of small intestinal obstruction following gastrectomy for early gastric cancer

BACKGROUND/AIMS: The factors influencing the development of small intestinal obstruction following gastrectomy for early gastric cancer are controversial. METHODOLOGY: Univariate and multivariate analyses were carried out using data from 136 patients with early gastric cancer who underwent gastrectomy. The mean follow-up interval was 5 years and 11 months. RESULTS: Of these 136 patients, 15(11.0%) presented mechanical obstruction in the small intestine postoperatively. Re-operation for repair of the related ileus was required in 8 patients, 4 of whom had been treated with total gastrectomy, 7 with resection of the greater omentum, and 3 with concomitant resection of other organs. Development of an obstruction was not related to wide resectional procedures such as extended lymph node dissection or combined resection of other organs, but was significantly correlated with total gastrectomy and resection of the greater omentum (p < 0.05). In multivariate logistic regression analysis, total gastrectomy proved to be a significant risk factor related to the development of small intestinal obstruction. CONCLUSIONS: In patients with early gastric cancer, total gastrectomy should not be attempted to prevent postoperative ileus and to ensure a fairly sustained quality of life.     

Laparoscopic gastrectomy for cancer

There are three procedures for the management of early gastric cancer (EGC): laparoscopic wedge resection (LWR), intragastric mucosal resection (IGMR), and laparoscopic gastrectomy. LWR or IGMR can be applied to treat EGC without the risk of lymph node metastasis. However, owing to the recent technical advances in endoscopic mucosal resection for EGC, the use of laparoscopic local resection for these lesions has gradually decreased. On the other hand, laparoscopic gastrectomy with lymph node dissection, such as laparoscopy-assisted distal gastrectomy, is widely accepted for the treatment of EGC with the risk of lymph node metastasis. To establish the acceptability of laparoscopic gastrectomy with D2 lymph node dissection against advanced gastric cancers, safe techniques and new instruments must be developed. The following advantages of laparoscopic surgery for the treatment of gastric cancer have been well demonstrated: clinical course after operation, pulmonary function, immune response. In the future, laparoscopic surgeons have to design and implement education and training systems for standard laparoscopic procedures, evaluate clinical outcomes by multicentric randomized control trial studies, and clarify the oncological aspects of laparoscopic surgery in basic studies.     

Post-operative chemotherapy in non-curative gastrectomy for advanced gastric cancer.

BACKGROUND/AIMS: The definitive effects of post-operative chemotherapy for prolonging survival in patients with non-curative gastrectomy for advanced gastric cancer have not been established. METHODOLOGY: Eighty-three patients with advanced gastric cancer who underwent non-curative gastrectomy were divided into 49 patients with post-operative chemotherapy (chemotherapy group) and 34 patients without post-operative chemotherapy (control group). Chemotherapy regimens were as follows: oral 5-fluorouracil (5-FU) alone (n = 22), intravenous mitomycin (MMC) plus 5-FU (n = 20), intravenous methotrexate (MTX) plus 5-FU (n = 3), intravenous cisplatin plus 5-FU (n = 2), and hepatic arterial infusion of 5-FU plus oral 5-FU (n = 2). No prior chemotherapy or radiation therapy was given. RESULTS: Although the age in the control group (mean: 71.9 years) was significantly older than in the chemotherapy group (mean: 66.1 years), there were no significant differences in the other clinical and pathological background data between the two groups. The 1-year survival rate in the chemotherapy group (71.4%) was significantly higher than in the control group (50.0%). However, the 3-year and 5-year survival rates did not significantly differ in the chemotherapy group versus the control group, 30.6% vs. 32.4% and 24.5% vs. 32.4%, respectively. Although a significant difference did not exist between the two groups, median survival after operation in the chemotherapy group (20.5 months) was longer than that in the control group (16.2 months). Furthermore, median survival of patients with peritoneal dissemination in the chemotherapy group (16.4 months) was significantly longer than that in the control group (7.7 months). CONCLUSIONS: Post-operative chemotherapy may contribute to prolonged survival in patients with non-curable advanced gastric cancer, even when patients had peritoneal dissemination. However, the long-term survival rate was not improved by post-operative chemotherapy. More aggressive chemotherapy may be needed to improve the long-term prognosis for such patients.     

Learning curve of laparoscopy-assisted distal gastrectomy with systemic lymphadenectomy for early gastric cancer

AIM: To evaluate the nature of the "learning curve" for laparoscopy-assisted distal gastrectomy (LADG) with systemic lymphadenectomy for early gastric cancer. METHODS: The data of 90 consecutive patients with early gastric cancer who underwent LADG with systemic lymphadenectomy between April 2003 and November 2004 were reviewed. The 90 patients were divided into 9 sequential groups of 10 cases in each group and the average operative time of these 9 groups were determined. Other learning indicators, such as transfusion requirements, conversion rates to open surgery, postoperative complication, time to first flatus, and postoperative hospital stay, were evaluated. RESULTS: After the first 10 LADGs, the operative time reached its first plateau (230-240 min/operation) and then reached a second plateau (<200 min/operation) for the final 30 cases. Although a significant improvement in the operative time was noted after the first 50 cases, there were no significant differences in transfusion requirements, conversion rates to open surgery, postoperative complications, time to first flatus, or postoperative hospital stay between the groups. CONCLUSION: Based on operative time analysis, this study show that experience of 50 cases of LADG with systemic lymphadenectomy for early gastric cancer is required to achieve optimum proficiency.     

远端胃切除术后残胃早期癌行内镜黏膜下剥离术的研究现状分析

远端胃切除术后残胃发生早期癌行内镜黏膜下剥离术（endoscopic submucosal dissection,ESD）治疗可避免外科手术的巨大创伤及远期并发症,获得理想的生存预后及生活质量。本文综合既往研究发现,远端胃切除术后不同消化道重建方式的内镜手术特点不同,但总体上残胃早期癌ESD难度大,并发症发生率高,并且残胃不同部位病变的ESD手术难度不同,手术用刀的选择及技巧特点各异。对于远端胃切除术后残胃发现早期癌的病例,需在充分评估与筛选后由内镜手术经验丰富的医师进行ESD切除,而术区病变浸润深度的判断以及不同消化道重建方式下ESD手术特点的不同则有待更多的研究与探索。     

腹腔镜下远端胃癌根治术与传统开腹手术治疗早期胃癌的疗效比较

目的比较腹腔镜下远端胃癌根治术与传统开腹手术治疗早期胃癌的临床效果。方法选取该院2013-11~2014-11收治的72例早期胃癌患者,按随机数字表法分为对照组(36例)和观察组(36例)。对照组行传统开腹手术治疗;观察组于腹腔镜下行远端胃癌根治术治疗。统计两组患者手术时间、切口长度、术中出血量、淋巴结清扫数量、术后肛门排气时间、下床活动时间、恢复半流质时间及住院天数,观察两组患者术后并发症发生情况,随访12个月,了解患者术后复发、癌细胞转移及存活情况。结果观察组手术时间、切口长度、术中出血量[(168.8±30.9)min、(6.6±2.3)cm、(131.8±63.4)ml]和术后肛门排气时间、下床活动时间、恢复半流质时间及住院天数[(2.9±1.4)、(2.4±0.9)、(7.4±1.6)及(10.7±3.6)d]均短于或少于对照组(P0.05);观察组患者术后并发症发生率(8.3%)较对照组(27.6%)低,两组比较差异有统计学意义(P0.05)。随访12个月,两组患者均无肿瘤局部复发、癌细胞转移及死亡病例,存活率为100.0%。结论腹腔镜下远端胃癌根治术治疗早期胃癌可获得与开腹手术相同的效果,但其手术时间短,术中出血量少,有利于患者术后尽早恢复,优势更显著。     

Proximal gastrectomy with double-tract reconstruction versus total gastrectomy for proximal early gastric cancer: A systematic review and meta-analysis

Background:The incidence of proximal gastric cancer in the gastric fundus, cardia, and other parts is increasing rapidly. The purpose of this study was to systematically compare the short-term and long-term clinical effects of proximal gastrectomy with double tract reconstruction (PG-DTR) to total gastrectomy (TG) for proximal early gastric cancer (EGC).Methods:A systematic review and meta-analysis was conducted through searching the literature in PubMed, Web of Science, Cochrane Library, EMBASE, CNKI, WAN FANG, and VIP databases. All clinical controlled trials and randomized controlled trials (RCTs) of PG-DTR and PG were included. Simultaneously, the relevant data were extracted, and the software RevMan version 5.1 was used for the meta-analysis.Results:Eight studies with a total of 753 patients were eligible for the meta-analysis. There were no significant differences in the operation time, intraoperative blood loss, postoperative hospital stay, early complications (anastomotic fistula and anastomotic bleeding), late complications (reflux symptoms and anastomotic stenosis), and 5-year survival rate between PG-DTR and TG. However, the levels of partial nutritional indicators (vitamin B12 supplements and vitamin B12 deficiency) were significantly higher in the PG-DTR group than in the TG group.Conclusion:This study showed ample evidence to suggest that PG-DTR improved the postoperative nutritional status without compromising patient safety while providing the same surgical characteristics and postoperative morbidity as TG.     

Anastomotic dehiscence after gastrectomy for cancer. Personal series

BACKGROUND/AIMS: Nowadays the risk of anastomotic dehiscence after gastrectomy still exists. So the aim of this study was to analyze our experience regarding these anastomoses. METHODOLOGY: In our Surgical Unit, which is located in the Department of Surgical Sciences, Organ Transplantation and Advanced Technologies of the University of Catania, from January 1st 1985 to December 31st 2000, 249 patients underwent surgery for gastric cancer. RESULTS: We observed a statistically significant decrease of leaks in the third period of our study. CONCLUSIONS: These data demonstrate a significant decrease of anastomotic leaks with stapler in comparison to manual anastomoses.     

Subtotal gastrectomy for gastric cancer

Although a steady decline in the incidence and mortality rates of gastric carcinoma has been observed in the last century worldwide, the absolute number of new cases/year is increasing because of the aging of the population. So far, surgical resection with curative intent has been the only treatment providing hope for cure; therefore, gastric cancer surgery has become a specialized field in digestive surgery. Gastrectomy with lymph node (LN) dissection for cancer patients remains a challenging procedure which requires skilled, well-trained surgeons who are very familiar with the fast-evolving oncological principles of gastric cancer surgery. As a matter of fact, the extent of gastric resection and LN dissection depends on the size of the disease and gastric cancer surgery has become a patient and “disease-tailored” surgery, ranging from endoscopic resection to laparoscopic assisted gastrectomy and conventional extended multivisceral resections. LN metastases are the most important prognostic factor in patients that undergo curative resection. LN dissection remains the most challenging part of the operation due to the location of LN stations around major retroperitoneal vessels and adjacent organs, which are not routinely included in the resected specimen and need to be preserved in order to avoid dangerous intra- and postoperative complications. Hence, the surgeon is the most important non-TMN prognostic factor in gastric cancer. Subtotal gastrectomy is the treatment of choice for middle and distal-third gastric cancer as it provides similar survival rates and better functional outcome compared to total gastrectomy, especially in early-stage disease with favorable prognosis. Nonetheless, the resection range for middle-third gastric cancer cases and the extent of LN dissection at early stages remains controversial. Due to the necessity of a more extended procedure at advanced stages and the trend for more conservative treatments in early gastric cancer, the indication for conventional subtotal gastrectomy depends on multiple variables. This review aims to clarify and define the actual landmarks of this procedure and the role it plays compared to the whole range of new and old treatment methods.