Laparoscopy-Assisted Distal Gastrectomy for Gastric Cancer

Objective  The purpose of this study was to evaluate the safety and value of laparoscopy-assisted distal gastrectomy (LADG) for early stage gastric cancer (stages IA, IB, and II). Materials and Methods  We retrospectively assessed 101 cases treated by LADG and compared to 49 contemporaneous cases treated by open distal gastrectomy (DG) between 2001 and 2006. Clinical variables, such as tumor diameter, operation time, blood loss, number of lymph nodes dissected, and length of stay were investigated. Results  Tumor size (mm) was significantly smaller in the LADG group (p < 0.0001). Although operation time (min) in the two groups was similar (278 ± 57 vs. 268 ± 55), mean blood loss was significantly higher in the DG group (139 ± 181 vs. 460 ± 301, p < 0.0001). Fewer lymph nodes were harvested in the LADG group (27 ± 14 vs. 34 ± 19, p = 0.012). Hospital stay was longer in the DG group (13.3 ± 8.5 vs. 16.7 ± 10.5, p = 0.034). There was no mortality in either group. Postoperative surgical complications occurred in six (6%) of the LADG and four (8%) of the DG. Conclusions  The authors conclude that laparoscopy-assisted distal gastrectomy is a safe and useful operation for early-stage gastric cancers. If patients are selected properly, laparoscopy-assisted distal gastrectomy can be a curative and minimally invasive treatment for gastric cancer. Presented at The Forty-Eighth Annual Meeting of The Society for Surgery of the Alimentary Tract, Washington DC, May 19–24, 2007.     

Effects of Mosapride Citrate on Patients after Vagal Nerve Preserving Distal Gastrectomy Reconstructed by Interposition of a Jejunal J Pouch with a Jejunal Conduit for Early Gastric Cancer

Background Vagal nerve–preserving distal gastrectomy reconstructed by interposition of a jejunal J pouch with a jejunal conduit (hereinafter called DGP) is a function-preserving operation for early gastric cancer. However, some patients after DGP have suffered from postprandial stasis in the substitute stomach, and postprandial stasis leads to abdominal symptoms. To clarify the significance of mosapride citrate (MS) for prevention of food stasis in the substitute stomach for patients after DGP, we studied the effects of MS before and after administration of MS. Materials and Methods In a total of 18 patients (10 men, 8 women; aged 34 to 70 years, average 63.1 years) during 5 years after DGP for early gastric cancer (Billroth I, D1 + α lymph node dissection, curability A), the relationship between their postoperative quality of life (QOL) and emptying function of the substitute stomach (EFS) was compared using a radioisotope method before MS therapy and after MS therapy at an oral dose of 15 mg/day for 3 months. Results (1) Interview. After MS therapy patients evidently had more appetite and ate more, with a slightly increase in body weight (0.5 ∼ 2 kg) compared with patients before MS therapy. Before and after MS therapy no patients had early dumping symptoms, and after MS therapy all patients clearly had fewer symptoms such as reflux esophagitis, nausea, and abdominal pain compared with before MS therapy. After MS therapy they also had significantly decreased abdominal fullness compared with before MS therapy (P = 0.0026). Endoscopically, we found reflux esophagitis in 2 patients from the before MS therapy group but in no patients from the after MS therapy group. All patients in the before MS therapy group showed residual contents in the substitute stomach, and seven patients in the after MS therapy group showed residual contents in the substitute stomach (P < 0.0001). There was a significant difference between before and after MS therapy (P < 0.0001). (2) EFS; The time to 50% residual rate of the before MS therapy group (80.5 ± 16.2 min) was significantly slower than that of the after MS therapy patients (65.6 ± 9.4 min) (P = 0.0091). After MS therapy (28.4% ± 5.2%), the residual rates at 120 minutes were significantly decreased compared with patients before MS therapy (38.2% ± 5.7%) (P = 0.0372). Conclusions Patients from the after MS therapy group clearly had improved gastric stasis compared with the before MS therapy group. These results showed more satisfactory QOL in patients after MS therapy. It is possible that MS therapy improves abdominal fullness due to the postprandial stasis in the substitute stomach, contributing to the improvement of QOL of patients after DGP.     

Laparoscopy-Assisted Distal Gastrectomy for Early Gastric Cancer: A Video Demonstration

Background  

Laparoscopic gastrectomy with lymph node dissection, such as laparoscopy-assisted distal gastrectomy (LADG), has been widely accepted as the treatment for early gastric cancer with the risk of lymph node metastasis, especially in Asia since 1991.1 ^– 3     

Oncologic Outcomes of Laparoscopy-Assisted Distal Gastrectomy for Gastric Cancer

Background

In both advanced and early gastric cancer with preoperatively suspected lymph node metastasis, extended lymph node dissection is needed to achieve R0. Since extended lymph node dissection is difficult to perform laparoscopically, few reports have reported long-term outcomes in large numbers of patients. The purpose of this study was to investigate oncologic outcomes after laparoscopy-assisted distal gastrectomy (LADG) with extended lymph node dissection.

Methods

Between April 2004 and March 2010, LADG with extended lymph node dissection was performed at our hospital for 880 patients diagnosed with T1N0-1 or T2N0 (N is classified by Japanese topographic classification) gastric cancer in the lower or middle body of the stomach. D2 lymph node dissection was performed for stage IB (T1N1, T2N0) cancers. Modified D2 lymph node dissection was performed for stage IA (T1N0). Overall survival (OS), disease-free survival (DFS), and form of tumor recurrence at 4 years were investigated retrospectively.

Results

Median follow-up was 42 months. The 4-year OS was 98.2 % for all patients. By stage, OS/DFS were 99.0/99.0 % in stage IA patients, 95.9/95.9 % in stage IB, 92.6/92.0 % in stage IIA, and 90.0/92.9 % in stage IIB. A total of 11 patients died, including 4 deaths from recurrence (liver metastasis, n = 1; peritoneal dissemination, n = 2; distant lymph node and bone metastases, n = 1). There is 1 patient is alive with recurrence (liver). Mean time until recurrence was 14 months.

Conclusions

Oncologic outcomes were good in patients with T1N0-1 and T2N0 gastric cancer who underwent LADG with extended lymph node dissection. This approach appears effective for treating T1N0-1 and T2N0 gastric cancer.     

Proximal Gastrectomy Reconstructed by Jejunal Pouch Interposition for Upper Third Gastric Cancer: Prospective Randomized Study

Proximal gastrectomy with jejunal pouch interposition (PGJP) has been advocated as an alternative operation for upper third gastric cancer. However, there has been no prospective randomized trial comparing PGJP with total gastrectomy with Roux-en-Y esophagojejunostomy (TGRY). The aim of this study was to compare the short- and medium-term results of PGJP and TGRY in a randomized clinical trial. Fifty-one patients with upper third gastric cancer were randomized to either PGJP (n = 25) or TGRY (n = 26). Outcome measures were postoperative complications, nutritional status assessed by serum nutritional parameters, and postgastrectomy symptoms. There were no significant differences in operating time, hospital stay, and postoperative complications. Blood loss was significantly less in the PGJP group (P = 0.036). Nineteen patients (73%) in the TGRY group had one or more postgastrectomy symptoms, which was significantly more frequent than in the PGJP group (32%; P = 0.012). There were also significant differences between the two groups with regard to food intake, weight recovery, hemoglobin, and serum vitamin B₁₂ levels in favor of PGJP. In conclusion, proximal gastrectomy with jejunal pouch interposition for upper third gastric cancer is safe, and is associated with a greater reduction in postgastrectomy symptoms and better nutritional status compared with conventional total gastrectomy.     

The Long-Term Results of Distal Gastrectomy by Mini-laparotomy in Early Gastric Cancer Patients

Introduction  

Radical distal gastrectomy by mini-laparotomy is an alternative surgical treatment modality with technical feasibility in early gastric cancer (EGC) patients. The aim of this study is to assess the oncologic feasibility of distal gastrectomy by mini-laparotomy in EGC patients through a long-term survival analysis based on the prospectively collected data.     

Laparoscopy-Assisted Distal Gastrectomy for an Early Gastric Cancer Patient With Situs Inversus Totalis

Situs inversus totalis (SIT) is a congenital condition in which there is complete right to left reversal of the thoracic and abdominal organs. This report describes laparoscopy-assisted distal gastrectomy (LADG) for an early gastric cancer patient with SIT. The preoperative diagnosis was c-stage IA (cT1a cN0 cH0 cP0 cM0). LADG with D1+ dissection and Billroth-I reconstruction was successfully performed by standing at the opposite position. The operating time was 234 minutes and blood loss was 5 mL. Although a mechanical obstruction occurred after surgery, the patient recovered after re-operation with Roux-en-Y bypass.     

Jejunal Pouch Interposition with Fundic-Like Plication After Total Gastrectomy

Purpose We developed a technique of jejunal pouch interposition with a fundic-like jejunal plication (JPI-FP) for reconstruction after total gastrectomy (TG) for gastric cancer. The aim of this study was to investigate the advantages of JPI-FP over Roux-en-Y reconstruction (R-Y).Methods Twenty-two patients who had undergone TG more than 1 year earlier were classified into two groups according to the method of reconstruction used: Group A (n = 7) underwent R-Y, and group B (n = 15) underwent JPI-FP. Group B was subdivided into two groups to examine the usefulness of additional pylorus preservation: group B1 (n = 8), pylorus (−) and group B2 (n = 7), pylorus (+).Results Food intake and body weight were significantly higher in group B than in group A (P < 0.05). Reflux esophagitis was diagnosed in two of the group A patients, but in none of the group B patients. Excessive esophageal bile exposure, determined as the fraction time of esophageal bilirubin absorbance over 0.14 > 50%, was significantly higher in group A than in group B (P < 0.05). There was no significant difference in bile exposure in the jejunal pouch between groups B1 and B2.Conclusions JPI-FP is a superior method of reconstruction after TG to prevent excessive esophageal bile reflux and from a nutritional aspect. The advantage of pylorus preservation remains unconfirmed.     

Health-Related Quality of Life After Robot-Assisted Distal Gastrectomy in Early Gastric Cancer

Purpose

This study was designed to assess the chronological change in health-related quality of life (HRQOL) following robot-assisted distal gastrectomy (RADG) for early gastric cancer (EGC) and to compare the HRQOL of the patients undergoing RADG with that of the general population.

Methods

Patients undergoing RADG for EGC between March 2010 and May 2011 were enrolled. The European Organization for Research and Treatment of Cancer (EORTC) core questionnaire (QLQ-C30) and the gastric cancer-specific module (QLQ-STO22) were completed before the operation and at 1 week as well as 1, 3, 6, and 12 months postsurgery. HRQOL data of the enrolled patients were compared to reference values obtained from the general population.

Results

A total of 30 patients were enrolled, and the overall compliance for questionnaire response was 94.4 %. The worst scores for most of the domains were observed at 1 week postsurgery and usually returned to baseline levels within 3 months, except for fatigue, dysphagia, pain, and eating restriction. Diarrhea was the only symptom that did not recovered after 1 year. Before surgery, patients reported significantly worse social function and financial difficulties compared to the general population, which persisted for 1 year postsurgery.

Conclusions

The immediate deterioration of HRQOL after RADG was restored to baseline levels within 3 months postsurgery in the majority of the patients. Robotic assistance might aid in the rapid recovery of global health status after surgery in EGC patients. Prolonged impairment in social function compared with the general population suggests that psychological support is necessary even for EGC patients.     

Long-term Outcome after Proximal Gastrectomy with Jejunal Interposition for Gastric Cancer Compared with Total Gastrectomy

Background

Proximal gastrectomy (PG) has been widely accepted as treatment for early gastric cancer located in the upper third of the stomach. Reconstruction by jejunal interposition has been known to reduce reflux esophagitis for PG patients. The aim of this study was to compare the long-term outcomes of patients who underwent PG with jejunal interposition with those treated by total gastrectomy (TG).

Methods

Data on 102 cases of PG with jejunal interposition and 49 cases of TG with Roux-Y reconstruction for gastric cancer were analyzed retrospectively in terms of overall survival, weight maintenance, anemia and nutritional status, and endoscopic findings.

Results

Median follow-up time was 59 months in the both groups. There was no significant difference in the overall 5-year survival rate between the PG group (94 %) and the TG group (84 %). The PG group showed significantly better body weight maintenance at the first year. The laboratory blood tests showed that the PG group had a significantly better red blood cell count and hemoglobin and hematocrit levels at the second and third year. However, postoperative endoscopic surveillance detected reflux esophagitis (3 %), peptic ulcer (9 %), and metachronous gastric cancer (5 %) in the PG group.

Conclusions

Proximal gastrectomy maintains comparable oncological radicality to TG and is preferred over TG in terms of preventing postoperative anemia. However, periodic endoscopic follow-up is necessary to monitor the upper gastrointestinal tract.     

Surgical Complications and the Risk Factors of Laparoscopy-Assisted Distal Gastrectomy in Early Gastric Cancer

Background Information on surgical complications of laparoscopy-assisted distal gastrectomy (LADG) and their risk factors is limited in the literature despite increasing popularity of this procedure. This study was performed to identify the surgical complications and their associated risk factors of LADG in early gastric cancer. Methods LADG was performed in 347 gastric cancer patients from January 2002 to December 2006 at the Korean National Cancer Center by four surgeons with ample experience of open gastric surgery before LADG. LADG indications for cases of gastric cancer at our institution are preoperatively diagnosed cT1N0 or cT1N1, except in cases with an absolute indication for endoscopic resection. Lymph node dissection of more than D1 + β was performed in all patients. Intraoperative and postoperative complications were reviewed and their risk factors were retrospectively analyzed by prospective database information. Results Forty complications occurred in 34 patients (9.8%), but there was no mortality. Intraoperative complications occurred in nine patients (2.6%), and open conversion was performed in eight (2.3%) of these patients. Early and late postoperative complications occurred in 21 (6.1%) and 10 (2.9%) patients, respectively. The most serious complication was vascular injury resulting in bleeding or organ ischemia, which occurred in seven patients. Degree of lymph node dissection and surgical inexperience were found to be risk factors of surgical complication (P = .023, odds ratio 2.832, 95% confidence interval 1.155–6.946 vs. P = .028, odds ratio 2.975, 95% confidence interval 1.127–7.854). Conclusions Lymph node dissection during LADG should be performed cautiously to prevent surgical complications like vascular injuries, especially during the surgeon’s early learning period.     

Novel Operative Technique for Vagal Nerve- and Pyloric Sphincter-preserving Distal Gastrectomy Reconstructed by Interposition of a 5 cm Jejunal J Pouch with a 3 cm Jejunal Conduit for Early Gastric Cancer and Postoperative Quality of Life 5 Years after Operation

The importance of the vagal nerve and pyloric sphincter, the need for pouch reconstruction, and the ideal pouch volume are all matters of controversy. A novel operative technique for vagal nerve- and pyloric sphincter-preserving distal gastrectomy reconstructed by interposition of a 5 cm jejunal J pouch with a 3 cm jejunal conduit was developed as a function-preserving surgical technique to prevent postgastrectomy disorders. The application criteria and technique are outlined in this article. Postoperative quality of life was also investigated clinically. Twenty subjects who underwent this surgical operation (group A: 16 men and 4 women aged 41 to 70 years, mean age 59.5 years) were interviewed to inquire about postoperative gastrointestinal symptoms. These patients were compared with 44 others who underwent conventional distal gastrectomy with D2 lymphadenectomy (group B: 30 men and 14 women aged 43 to 73 years, mean age 62.6 years). Included were patients with early cancer [mucosal or submucosal 1 (SM1) cancer and no lymph node metastasis (N0)] in the middle or lower third of stomach (or both) who were either not eligible for endoscopic excision of gastric mucosa or for partial gastric excision in the mucosa = 3.5 cm or SM1 5.5 cm, or further in distance from the anal margin of the cancer to the pyloric sphincter. Cases in which the remnant stomach would become one-third or less of the original size were also applied. During excision with lymph nodes, the hepatic and celiac branches bifurcating from the anterior and posterior trunks of the vagal nerve were preserved. The antrum was severed 1.5 cm from the pyloric sphincter, preserving the arteria supraduodenalis. The substitute stomach was created as a 5 cm jejunal pouch with a 3 cm jejunal conduit for orthodromic peristaltic movement using an automatic suture instrument to complete a side-to-side anastomosis of the folded jejunum. The anal side of the gastric remnant was manually anastomosed with the jejunal J pouch, and anastomosis of the pyloric antrum with the jejunal conduit was manually completed by stratum anastomosis. Postoperatively, the procedure in group A alleviated gastrointestinal symptoms such as appetite loss, epigastric fullness, reflux esophagitis, early dumping syndrome, body weight loss, endoscopic reflux esophagitis, and endoscopic gastritis in the remnant stomach, postprandial stasis of the substitute stomach, and postgastrectomy cholecystolithiasis better than in group B. The results suggest that the proposed technique is a function-preserving gastric operation appropriate for preventing postgastrectomy disorder.     

Gastric Bypass Distal Roux-en-Y with Jejunal Interposition

Gastric bypass with jejunal interposition is a version of the distal Roux-en-Y. Ninety cm of the jejunum is interposed between the gastric stoma and the ileum. This new procedure initially was used in super-obese patients mainly to facilitate the gastric anastomosis.     

Postoperative Pancreatic Fistula and the Risk Factors of Laparoscopy-Assisted Distal Gastrectomy for Early Gastric Cancer

Background  

Laparoscopy-assisted distal gastrectomy (LADG) was introduced as minimally invasive surgery for early gastric cancer (EGC) in Japan. This study investigated postoperative pancreatic fistula (POPF) and associated risk factors of the procedure.     

Preliminary Experience of Fast-Track Surgery Combined with Laparoscopy-Assisted Radical Distal Gastrectomy for Gastric Cancer

Objective

The aim of this study was to evaluate the safety and effectiveness of fast-track surgery combined with laparoscopy-assisted radical distal gastrectomy for gastric cancer.

Methods

Eighty-eight eligible patients were randomly assigned into four groups: (1) fast-track surgery (FTS) + laparoscopy-assisted radical distal gastrectomy (LADG), treated with LADG and FTS treatment; (2) LADG, treated with LADG and traditional treatment; (3) FTS + open distal grastectomy (ODG), treated with ODG and FTS treatment; and (4) ODG, treated with ODG and traditional treatment. The clinical parameters and serum indicators were compared.

Results

Compared with the ODG group, the other three groups had earlier first flatus and shorter postoperative hospital stay (all P?<0.01; all P?<0.05), especially in the FTS + LADG group. The level of ALB was higher in the FTS + LADG group than in the LADG group at 4 and 7 days after surgery (P?<0.05, P?<0.01). The level of CRP in the FTS + LADG group was lower than in the FTS+ODG group at 4 and 7 days after surgery (P?<0.05, P?<0.05). The FTS + ODG group had lowest medical costs.

Conclusion

Combination of FTS and LADG in gastric cancer is safe, feasible, and efficient and can improve nutritional status, lessen postoperative stress, and accelerate postoperative rehabilitation. Compared with FTS + ODG and LADG, its advantages were limited in short-term follow-up.