Conventional Laparoscopic Gastrectomy Research Articles

Current Issues in Reduced-Port Gastrectomy: A Comprehensive Review.

Reduced-port gastrectomy (RPG) includes all procedures derived from various efforts to minimize surgical invasiveness, with single-incision laparoscopic gastrectomy (SILG) being the ultimate reduced-port technique. However, there are challenges related to its feasibility, oncological validity, training, and education. This review describes the current issues and challenges, as well as the future prospects of RPG for gastric cancer. Gastrectomy, which started as an open surgery, has evolved into a laparoscopic surgery. With the advancements in laparoscopic technology, SILG has been used to minimize surgical scarring. However, owing to the technical difficulties of SILG, cases involving the addition of 1 trocar or needle grasper alongside the multichannel port have also been reported. Additionally, 3-port laparoscopic gastrectomy (3PLG) using only 3 trocars is also being performed. RPG, as a concept, includes a range of approaches such as SILG, 2-port laparoscopic gastrectomy, and 3PLG. These techniques aimed to reduce the number of ports or incisions required for laparoscopic gastrectomy. Despite technical difficulties, RPGs offer numerous advantages, including minimal invasiveness, excellent cosmetic outcomes, and the potential for improved post-operative recovery, such as reduced length of hospital stay and post-operative pain. It could be considered similar to conventional laparoscopic gastrectomy, and may not be oncologically inferior. Ongoing studies, such as the KLASS 12, are required to gain further insights.

Fluorescence-guided Two-port Robotic Gastrectomy Versus Conventional Laparoscopic Gastrectomy: A Nonrandomized Controlled Trial.

To compare the number of retrieved lymph nodes between conventional laparoscopic gastrectomy (CLG) and robotic gastrectomy integrated with fluorescence guidance and a two-port system (integrated robotic gastrectomy, IRG). The benefits of robotic surgery over laparoscopic surgery for gastric cancer have not yet been established. Using built-in features of robotic system, further benefit can be provided to the patients with effective lymphadenectomy and enhanced recovery. A nonrandomized controlled trial was performed by a single surgeon at single-center, tertiary referral hospital between January 2018 and October 2021. Overall, 140 patients scheduled to undergo minimally invasive subtotal gastrectomy for early gastric cancer were enrolled. The primary endpoint was the number of retrieved lymph nodes. Secondary endpoints were complications, hospital stay, pain score, body image, and operative cost. This study analyzed 124 patients in the per-protocol group (IRG, 64; CLG, 60). The number of retrieved lymph nodes was higher in the IRG group than those in the CLG group (IRG vs CLG; 42.1 ± 17.9 vs 35.1 ± 14.6, P = 0.019). Moreover, other surgical parameters, such as hospital stay (4.1 ± 1.0 vs 5.2 ± 1.8, P < 0.001) and body image scale (better in 4 of the 10 questions), were significantly better in the IRG than in the CLG. Robotic surgical procedures integrated with fluorescence guidance and a reduced-port system yielded more retrieved lymph nodes. In addition, the IRG group showed better perioperative surgical outcomes, particularly regarding the length of hospital stay and postoperative body image. NCT03396354.

Solo surgery in robot-assisted gastrectomy versus laparoscopic gastrectomy for gastric cancer: a propensity score-matched analysis.

Robot-assisted gastrectomy (RG) for gastric cancer is still not well standardized. This study aimed to explore the feasibility and effectiveness of solo surgery in robot-assisted gastrectomy (SRG) for gastric cancer compared to laparoscopic gastrectomy (LG). This was a single-center retrospective comparative study between SRG and conventional LG. Between April 2015 and December 2022, 510 patients underwent gastrectomy, and data from a prospectively collected database were analyzed. We identified 372 patients who underwent LG (n = 267) and SRG (n = 105) and the remaining 138 patients were excluded because of remnant gastric cancer, esophagogastric junction cancer, open gastrectomy, concurrent surgery for concomitant malignancies, RG before starting SRG, or cases in which the author was unable to perform or supervise gastrectomy. Propensity score matching was performed at a ratio of 1:1 to reduce bias from confounding patient-related variables, and short-term outcomes were compared between the groups. After propensity score matching, 90 pairs of patients who underwent LG and SRG were selected. In the propensity-matched cohort, the operation time was significantly shorter in the SRG group than that in the LG group (SRG = 305.7 ± 74.0min vs. LG = 340.3 ± 91.65min, p < 0.0058), less estimated blood loss was observed in the SRG group than that in the LG group (SRG = 25.6 ± 50.6mL vs. LG = 76.1 ± 104.2mL, p < 0.0001) and postoperative hospital stay was shorter in the SRG group than that in the LG group (SRG = 7.1 ± 0.8days vs. LG = 9.1 ± 7.7days, p = 0.015). We found that SRG for gastric cancer was technically feasible and effective with favorable short-term outcomes, including shorter operative time, less estimated blood loss, shorter hospital stays, and lower postoperative morbidity than those in LG.

Advantages of robotic gastrectomy for overweight patients with gastric cancer: a comparison study of robotic gastrectomy and conventional laparoscopic gastrectomy.

A high body mass index (BMI) generally increases the risk of postoperative complications because of the intraperitoneal adipose tissue. Robotic gastrectomy (RG) decreases the surgical difficulty of conventional laparoscopic gastrectomy (LG) for these patients. We conducted the present study to identify the advantages of RG over LG for overweight patients. We reviewed clinical data on patients who underwent either LG or RG at the National Cancer Center Hospital East between January, 2014 and May, 2022. The 1298 patients eligible patients were divided into a non-overweight cohort (n = 996) (LG, n = 818; RG, n = 178) and an overweight cohort (n = 302) (LG, n = 250; RG, n = 52) according to a BMI cut-off of 25kg/m2. In the overweight cohort, the RG group had a lower incidence of grade ≥ III postoperative complications (0.0 vs. 8.8%, p = 0.01) and grade ≥ II postoperative complications (11.5 vs. 22.0%, p = 0.12) than the LG group. Multivariate analysis identified that RG was significantly associated with a lower incidence of grade ≥ II postoperative complications in the overweight cohort (odds ratio, 0.33; 95% confidence interval, 0.12-0.87; p = 0.02). RG may reduce the risk of postoperative complications, compared with conventional LG, in overweight patients.

The usefulness of indocyanine green (ICG)–guided lymphadenectomy in robotic gastrectomy for advanced gastric cancer: A single-center retrospective study.

390 Background: In performing radical gastrectomy for advanced gastric cancer, the method to evaluate the achievement of lymphadenectomy is under debate. According to the current guideline, obtaining at least 16 lymph nodes is recommended, but in previous studies on advanced gastric cancer, some suggested mid-20 or 30 as a cut-off. This study aimed to find significant factors affecting successful lymphadenectomy for gastric cancer by applying a more stringent condition than the current guideline. Methods: A total of 1 948 patients who underwent laparoscopic and robotic gastrectomy for gastric cancer between January 2016 and February 2022 at Seoul St. Mary’s Hospital were recruited in this study. After exclusion, 393 patients with a pathologically advanced stage were included in the analysis, and their clinicopathological data, including the information about the indocyanine green (ICG)-guided lymphadenectomy, were retrospectively reviewed. Results: Among 393 patients, there were 288 patients in the conventional laparoscopy group (G1), 61 patients in the ICG-guided laparoscopy group (G2), and 44 patients in the ICG-guided robotic surgery group (G3). Patients in the G3 group had a significantly higher proportion of younger patients and a lower proportion with comorbidity. There was a similar trend in stage II and III ratio between the groups and the number of examined lymph nodes (ELNs) did not show a significant difference between groups (45.2±20.3 vs. 51.6±24.5 vs. 50.8±19.6, P=0.058). The ratio of 30 or fewer ELNs was the lowest in G3 (24% vs. 19.7% vs. 9.1%, P=0.050). The rate of exceeding 30 ELNs was increased in the case of higher node stage and more advanced cancer. In the multivariable analysis, the ICG-guided robotic surgery group was confirmed to be a significant factor for more than 30 ELNs (OR=3.151, 1.074~9.245, P=0.037). Conclusions: ICG-guided robotic gastrectomy could be useful in obtaining &gt;30 ELNs compared to conventional laparoscopic gastrectomy in selected cases.

Assessment of Laparoscopic Spleen-Preserving Hilar Lymphadenectomy for Advanced Proximal Gastric Cancer Without Invasion Into the Greater Curvature

The survival benefit of laparoscopic total gastrectomy combined with spleen-preserving splenic hilar lymphadenectomy (LSTG) for locally advanced proximal gastric cancer (APGC) without invasion into the greater curvature remains uncertain. To compare the long-term and short-term efficacy of LSTG (D2 + No. 10 group) and conventional laparoscopic total gastrectomy (D2 group) for patients with APGC that has not invaded the greater curvature. In this open-label, prospective randomized clinical trial, a total of 536 patients with clinical stage cT2 to 4a/N0 to 3/M0 APGC without invasion into the greater curvature were enrolled from January 2015 to October 2018. The final follow-up was on October 31, 2021. Data were analyzed from December 2021 to February 2022. Eligible patients were randomized to the D2 + No. 10 group or the D2 group. The primary outcome was 3-year disease-free survival (DFS). The secondary outcomes were 3-year overall survival (OS) and morbidity and mortality within 30 days after surgery. Of 526 included patients, 392 (74.5%) were men, and the mean (SD) age was 60.6 (9.6) years. A total of 263 patients were included in the D2 + No. 10 group, and 263 were included in the D2 group. The 3-year DFS was 70.3% (95% CI, 64.8-75.8) for the D2 + No. 10 group and 64.3% (95% CI, 58.4-70.2; P = .11) for the D2 group, and the 3-year OS in the D2 + No. 10 group was better than that in the D2 group (75.7% [95% CI, 70.6-80.8] vs 66.5% [95% CI, 60.8-72.2]; P = .02). Multivariate analysis revealed that splenic hilar lymphadenectomy was not an independent protective factor for DFS (hazard ratio [HR], 0.86; 95% CI, 0.63-1.16) or OS (HR, 0.81; 95% CI, 0.59-1.12). Stratification analysis showed that patients with advanced posterior gastric cancer in the D2 + No. 10 group had better 3-year DFS (92.9% vs 39.3%; P < .001) and OS (92.9% vs 42.9%; P < .001) than those in the D2 group. Multivariate analysis confirmed that patients with advanced posterior gastric cancer could have the survival benefit from No. 10 lymph node dissection (DFS: HR, 0.10; 95% CI, 0.02-0.46; OS: HR, 0.12; 95% CI, 0.03-0.52). Although LSTG could not significantly improve the 3-year DFS of patients with APGC without invasion into the greater curvature, patients with APGC located posterior gastric wall may benefit from LSTG. ClinicalTrials.gov Identifier: NCT02333721.

Comparison of clinical safety and feasibility between reduced-port laparoscopic radical gastrectomy and conventional laparoscopic radical gastrectomy: A retrospective study.

BackgroundTraditional open gastric cancer surgery has evolved from porous to reduced-hole, single-hole, or even natural cavity surgery to laparoscopic surgery, due to the continuous development of minimally invasive concepts and medical technologies, as well as awareness for the concept of rapid recovery. Conventional laparoscopic radical gastrectomy is quite mature in age at the moment, but how to progress to minimally invasive surgery without increasing the difficulty of surgery while ensuring clinical safety and feasibility is worth further investigation. Therefore, the clinical safety and feasibility of reduced port laparoscopic radical gastrectomy were assessed in this study.MethodsInformation on the clinical data of patients undergoing laparoscopic radical gastric cancer surgery in a single centre between May 2020 and May 2022 was collected, and a total of 232 patients were included in this study according to the study protocol design. The clinical data of 232 patients with gastric cancer treated by two different surgical methods, namely, reduced port laparoscopic surgery (RPLS) or conventional laparoscopic surgery (CLS), were retrospectively analysed. The intraoperative indices, postoperative pathological indices, and short-term postoperative complications (within 30 days) of the two different surgical methods were evaluated, as well as the surgical methods’ feasibility and short-term postoperative recovery effect.ResultsThere was no significant difference between the general data of patients with RPLS and CLS (P > 0.05). Compared with CLSG, the operation time, digestive tract reconstruction time and lymph node dissection time of RPLSG are shorter. The intraoperative blood loss was less, and the incision was minimally invasive (P < 0.05). In the short-term postoperative effect, the level of white blood cell count on the first day, the time of getting out of bed, the time of removing drainage tube, the time of hospitalization and the VAS of pain on the first, third and fifth days after operation, RPLSG was obviously superior to CLSG (P < 0.05). There was no significant difference between RPLSG and CLSG in terms of pathological indices (P > 0.05).ConclusionsThe treatment of gastric cancer with RPLS has good safety, feasibility and short-term postoperative effects, which is in line with the implementation of the modern concept of rapid rehabilitation surgery.

Advantages of a robotic approach compared with laparoscopy gastrectomy for patients with high visceral fat area.

Gastric cancer surgery for obese patients is regarded as a technically challenging procedure. The morbidity after gastrectomy has been reported to be significantly higher in patients with high visceral fat area (VFA). Robotic gastrectomy (RG) is expected to be advantageous for complicated operations. However, whether RG is superior to conventional laparoscopic gastrectomy (LG) for patients with visceral fat obesity remains unclear. The present study aimed to clarify the impact of RG on the short- and long-term outcomes of patients with high VFAs. This study included 1306 patients with clinical stage I/II gastric cancer who underwent minimally invasive gastrectomy between January 2012 and December 2020. The patients were subclassified according to VFA. The short- and long-term outcomes of RG were compared with those of LG in two VFA categories. This study included 394 (high-VFA, 151; low-VFA, 243) and 882 patients (high-VFA, 366; low-VFA, 516) in the RG and LG groups, respectively. RG was associated with a significantly longer operative time than LG (high-VFA, P < 0.001; low-VFA, P < 0.001). The incidence rates of overall and intra-abdominal infectious complications in the high-VFA patients were lower in the RG group than in the LG group (P = 0.019 and P = 0.048, respectively) but not significantly different from those in the low-VFA patients. In the multivariate analysis, LG was identified as the only independent risk factor of overall (odds ratio [OR] 3.281; P = 0.012) and intra-abdominal infectious complications (OR 3.462; P = 0.021) in the high-VFA patients. The overall survival of high-VFA patients was significantly better in the RG group than in the LG group (P = 0.045). For patients with visceral fat obesity, RG appears to be advantageous to LG in terms of reducing the risk of complications and better long-term survival.

Comparison of robotic gastrectomy and laparoscopic gastrectomy for gastric cancer: a propensity score-matched analysis.

The benefits of robotic gastrectomy (RG) over laparoscopic gastrectomy (LG) remain controversial. This single-center, propensity score-matched study aimed to compare the outcomes of RG with those of LG for treating gastric cancer. We searched the prospective gastric cancer database of our institute for patients with gastric cancer who underwent RG or LG between January 2014 and December 2019, excluding patients with remnant stomach cancer and those who underwent concurrent surgery for comorbid malignancies. One-to-one propensity score matching was performed to reduce bias from confounding patient-related variables, and short- and long-term outcomes were compared between the groups. We identified 1189 patients who underwent LG (n = 979) or RG (n = 210). After propensity score matching, we selected 210 pairs of patients who underwent LG (distal gastrectomy, 138; total or proximal gastrectomy, 72) or RG (distal gastrectomy, 143; total or proximal gastrectomy, 67). RG was associated with a significantly shorter operative time (RG = 201min vs. LG = 231min, p = 0.0051), less blood loss (RG = 13mL vs. LG = 42mL, p < 0.0001), lower postoperative morbidity (RG = 1.0% vs. LG = 4.8%, p = 0.0066), and a shorter postoperative hospital stay (p = 0.0002) than LG. Drain amylase levels on postoperative Days 1 and 3 in the RG group were significantly lower than those in the LG group (p < 0.0001). RG is a safe and feasible treatment for gastric cancer, with a shorter operative time, less blood loss, and lower postoperative morbidity than LG. The application of robotics in minimally invasive gastric cancer surgery may offer an alternative to conventional surgery. Multicenter, prospective, randomized controlled trials comparing RG with conventional LG are needed to establish the feasibility and efficacy of minimally invasive gastric cancer surgery.

Comparisons of surgical outcomes between robotic and laparoscopic total gastrectomy in patients with clinical stage I/IIA gastric cancer.

The robotic approach is especially promising for challenging surgeries, such as total gastrectomy. However, it remains unclear whether robotic total gastrectomy (RTG) is superior to conventional laparoscopic total gastrectomy (LTG). The present study aimed to clarify the impact of RTG on short- and long-term outcomes for patients with clinical stage I/IIA gastric cancer. This study included 98 patients with clinical stage I/IIA gastric cancer who underwent minimally invasive total gastrectomy from October 2013 to December 2020 at the Shizuoka Cancer Center. The short- and long-term outcomes of RTG were compared with those of LTG. This study included 36 RTG and 58 LTG patients. RTG was associated with a significantly longer operative time than LTG (p = 0.023). All complications tended to be lower in the RTG group than in the LTG group (2.8% and 15.5%, respectively; p = 0.083). There were no patients with anastomotic leakage in the RTG group. The multivariate analysis identified LTG as the only independent risk factor for postoperative complications (odds ratio, 6.620; 95% confidence interval, 1.132-126.4; p = 0.034). The survival of the RTG and LTG groups was equivalent. RTG reduced the risk of complications compared to LTG. Patients treated using the two approaches showed equivalent survival.

Laparoscopic-Assisted Natural Orifice Specimen Extraction Gastrectomy Using an Auxiliary Incision-Free Tube for Gastric Cancer

Laparoscopic-assisted natural orifice specimen extraction (LA-NOSE) gastrectomy effectively avoids the need for an abdominal incision, unlike conventional laparoscopic gastrectomy. In this study, we documented our experience with LA-NOSE gastrectomy using an auxiliary incision-free tube (Cai tube, a homemade invention: ZL201410168748.2) in 9 gastric cancer patients and summarized the clinical results. From July 2018 to June 2020, a total of 9 patients with gastric cancer were recruited for this study. LA-NOSE gastrectomy (subtotal or total) using the auxiliary incision-free tube and D2 lymph node dissection were performed. Specimens were extracted through the anterior wall of the upper rectum in 4 male patients and the posterior fornix of the vagina in 5 female patients using the auxiliary incision-free tube. All 9 patients underwent successful laparoscopic gastrectomy with NOSE using the auxiliary incision-free tube. No perioperative death, re-admission within 60 days post operation, natural orifice wound infection or tumor implantation was observed. The mean operating time was 365.3±41.7 min, and the mean estimated blood loss was 87.8±39.3 ml. The mean duration of hospital stay was 11.3±1.2 days, while the mean maximum pain score (visual analogue score, VAS) was 2.3±0.9 on postoperative day (POD) 1, and the mean time to ambulation was 1.3±0.5 days. The 60-day postoperative morbidity rate was 11.1% (1/9). After a mean follow-up of 14.7±9.6 months, there was no transrectal or transvaginal access-site recurrence, no anterior rectectomy or posterior fornix colpotomy-related complications, and no local recurrence or distant metastasis. Our preliminary experience indicates that this new technique, LA-NOSE gastrectomy using the auxiliary incision-free tube, is feasible for selected patients with gastric cancer.

Challenges in improving the minimal invasiveness of the surgical treatment for gastric cancer using robotic technology.

The number of operations performed using the da Vinci Surgical System® (DVSS) has been increasing worldwide in the past decade. We introduced robotic gastrectomy for gastric cancer (GC) in January 2009 to overcome the disadvantage of conventional laparoscopic gastrectomy. Initially, we experienced some troubles in the technical aspect and cost of robotic surgery. After extensive trial and error, we were able to develop the “double bipolar method” and the “da Vinci's plane theory” to use DVSS effectively. We then conducted “Senshiniryo B,” which was a multi‐institutional prospective single‐arm study to determine the safety, feasibility, and effectiveness of robotic gastrectomy for GC in 2014. In that study, we demonstrated that the morbidity rate in the robotic group (2.45%) was significantly lower than that in the historical control group (6.4%). As a consequence of that clinical trial, 12 procedures, including robotic gastrectomy for GC, have been covered under the Japanese national insurance in 2018. An additional seven procedures were newly covered in April 2020. In the first half of this article, we describe the history of robotic surgery in the world and Japan and demonstrate the “double bipolar method” and “da Vinci's plane theory.” In the latter half, we explain the Japanese systems for the safe dissemination of robotic surgery and state our efforts to solve some problems in robotic surgery.

Reduction in postoperative complications by robotic surgery: a case\u2013control study of robotic versus conventional laparoscopic surgery for gastric cancer

BackgroundRobotic gastrectomy (RG) is being increasingly performed globally; it is considered an evolved type of conventional laparoscopic surgery with excellent dexterity and precision, but higher costs and longer operation time. Thus, there is a need to identify the benefits from RG and its specific candidates.MethodsThis retrospective study analyzed data from a prospectively collected clinical database at our center. Data of patients with primary gastric cancer undergoing either robotic or laparoscopic radical gastrectomy from June 2014 to June 2020 were reviewed. Surgical outcomes were compared between the two groups, and multivariable analyses were performed to elucidate the relevant factors for postoperative complications in several subgroups.ResultsA total of 1172 patients were divided into those who underwent RG (n = 152) and those who underwent laparoscopic gastrectomy (LG) (n = 1020). Baseline characteristics were similar in the two groups, except the RG group included more patients undergoing total/proximal gastrectomy (TG/PG) and patients at clinical stage III. Compared with the LG group, the RG group had lower incidences of postoperative complications ≥ Clavien-Dindo grade III (2/152 (1.3%) versus 72/1020 (7.1%); P = 0.004), and intraabdominal complications ≥ grade II (6/152 (3.9%) versus 119/1020 (11.7%); P = 0.004). Multivariable analysis revealed that RG was a significant relevant factor for reducing overall postoperative complications (≥ grade III) (odds ratio (OR) 0.16, P = 0.013), and intraabdominal complications (≥ grade II) (OR 0.29, P = 0.002). Subgroup analyses demonstrated that this tendency was enhanced in patients undergoing TG/PG (OR 0.29, P = 0.021) or at clinical stage II/III (OR 0.10, P = 0.027).ConclusionsRG reduces the incidence of postoperative complications compared with conventional LG and this tendency may be enhanced in technically complicated procedures with demanding anastomosis or D2 lymphadenectomy. Patients requiring such procedures would most benefit from RG.

Robotic Gastrectomy Compared with Laparoscopic Gastrectomy for Clinical Stage I/II Gastric Cancer Patients: A Propensity Score-Matched Analysis.

Robotic gastrectomy (RG) has been developed to address the drawbacks of laparoscopic gastrectomy (LG); however, whether or not RG is superior to conventional LG remains to be seen. The present study aimed to clarify the impact of RG on clinical stage I/II gastric cancer patients. The present study included 1208 patients with clinical stage I/II gastric cancer who had minimally invasive gastrectomy from January 2012 to March 2020 at the Shizuoka Cancer Center. The short- and long-term outcomes of RG and LG were compared after propensity score matching. This study involved 835 LG and 345 RG patients. After propensity score matching, there were 342 patients each in the RG and LG groups, with an improved balance of confounding factors between the two groups. RG was associated with a significantly longer operative time and lower amylase concentration in the drainage fluid on the first postoperative day than LG. Furthermore, the incidence of intra-abdominal infectious complications in the RG was lower than that in the LG (4.4% vs. 9.4%; P = 0.015). The survival of the RG and LG groups was equivalent. RG reduced the risk of intra-abdominal infectious complications in comparison with LG in the propensity score-matched analysis. Patients treated by the two approaches showed equivalent survival.

Hybrid Robotic and Laparoscopic Gastrectomy for Gastric Cancer: Comparison with Conventional Laparoscopic Gastrectomy.

PurposeThe benefits of robotic gastrectomy remain controversial. We designed this study to elucidate the advantages of a hybrid robot and laparoscopic gastrectomy over conventional laparoscopic surgery.Materials and MethodsA total of 176 patients who underwent gastrectomy for gastric cancer were included in this study. We compared 88 patients treated with hybrid robotic and laparoscopic gastrectomy (HRLG) and 88 patients who underwent conventional laparoscopic gastrectomy (CLG). In HRLG, suprapancreatic lymph node (LN) dissection was performed in a robotic setting. Clinicopathological characteristics, operative details, and short-term outcomes were analyzed for the patients.ResultsThe number of LNs retrieved from the suprapancreatic area was significantly greater in the HRLG group (11.27±5.46 vs. 9.17±5.19, P=0.010). C-reactive protein levels were greater in the CLG group on both postoperative day (POD) 1 (5.11±2.64 vs. 4.29±2.38, P=0.030) and POD 5 (9.86±6.51 vs. 7.75±5.17, P=0.019). In addition, the neutrophil-to-lymphocyte ratio was significantly greater in the CLG group on both POD 1 (7.44±4.72 vs. 6.16±2.91, P=0.031) and POD 5 (4.87±3.75 vs. 3.81±1.87, P=0.020). Pulmonary complications occurred only in the CLG group (4/88 [4.5%] vs. 0/88 [0%], P=0.043).ConclusionsHRLG is superior to CLG in terms of suprapancreatic LN dissection and postoperative inflammatory response.

Initial experience of single-incision plus one port left-side approach totally laparoscopic distal gastrectomy with uncut Roux-en-Y reconstruction.

BACKGROUNDSingle incision plus one port left-side approach (SILS+1/L) totally laparoscopic distal gastrectomy (TLDG) is an emerging technique for the treatment of gastric cancer. Reduced port laparoscopic gastrectomy has a number of potential advantages for patients compared with conventional laparoscopic gastrectomy: relieving postoperative pain, shortening hospital stay and offering a better cosmetic outcome. Nevertheless, there are no previous reports on the use of SILS+1/L TLDG with uncut Roux-en-Y (uncut R-Y) reconstruction.AIMTo investigate the initial feasibility of SILS+1/L TLDG with uncut Roux-en-Y digestive tract reconstruction (uncut R-Y reconstruction) to treat distal gastric cancer.METHODSA total of 21 patients who underwent SILS+1/L TLDG with uncut R-Y reconstruction for gastric cancer were enrolled. All patients were treated at The Second Hospital of Shandong University. Reconstructions were performed intracorporeally with 60 mm endoscopic linear stapler and 45 mm no-knife stapler. The clinicopathological characteristics, surgical details, postoperative short-term outcomes, postoperative follow-up upper gastrointestinal radiography findings and endoscopy results were analyzed retrospectively.RESULTSAll SILS+1/L operations were performed by SILS+1/L TLDG successfully. The patient population included 13 men and 8 women with a mean age of 48.2 years (ranged from 40 years to 70 years) and median body mass index of 22.8 kg/m2. There were no conversions to open laparotomy, and no other port was placed. The mean operation time was 146 min (ranged 130-180 min), and the estimated mean blood loss was 54 mL (ranged 20-110 mL). The mean duration to flatus and discharge was 2.3 (ranged 1-3.5) and 7.3 (ranged 6-9) d, respectively. The mean number of retrieved lymph nodes was 42 (ranged 30-47). Two patients experienced mild postoperative complications, including surgical site infection (wound at the navel incision) and mild postoperative pancreatic fistula (grade A). Follow-up upper gastrointestinal radiography and endoscopy were carried out at 3 mo postoperatively. No patients experienced moderate or severe food stasis, alkaline gastritis or bile reflux during the follow-up period. No recanalization of the biliopancreatic limb was found.CONCLUSIONSILS+1/L TLDG with uncut R-Y reconstruction could be safely performed as a reduced port surgery.

Safety and Efficacy of Indocyanine Green Tracer-Guided Lymph Node Dissection During Laparoscopic Radical Gastrectomy in Patients With Gastric Cancer

The application of indocyanine green (ICG) imaging in laparoscopic radical gastrectomy is in the preliminary stages of clinical practice, and its safety and efficacy remain controversial. To investigate the safety and efficacy of ICG near-infrared tracer-guided imaging during laparoscopic D2 lymphadenectomy in patients with gastric cancer. Patients with potentially resectable gastric adenocarcinoma (clinical tumor stage cT1-cT4a, N0/+, M0) were enrolled in a prospective randomized clinical trial at a tertiary referral teaching hospital between November 2018 and July 2019. Patients were randomly assigned to the ICG group or the non-ICG group. The number of retrieved lymph nodes, rate of lymph node noncompliance, and postoperative recovery data were compared between the groups in a modified intention-to-treat analysis. Statistical analysis was performed from August to September 2019. The ICG group underwent laparoscopic gastrectomy using near-infrared imaging after receiving an endoscopic peritumoral injection of ICG to the submucosa 1 day before surgery. Total number of retrieved lymph nodes. Of 266 participants randomized, 133 underwent ICG tracer-guided laparoscopic gastrectomy, and 133 underwent conventional laparoscopic gastrectomy. After postsurgical exclusions, 258 patients were included in the modified intention-to-treat analysis, which comprised 129 patients (86 men and 43 women; mean [SD] age, 57.8 [10.7] years) in the ICG group and 129 patients (87 men and 42 women; mean [SD] age, 60.1 [9.1] years) in the non-ICG group. The mean number of lymph nodes retrieved in the ICG group was significantly more than the mean number retrieved in the non-ICG group (mean [SD], 50.5 [15.9] lymph nodes vs 42.0 [10.3] lymph nodes, respectively; P < .001). Significantly more perigastric and extraperigastric lymph nodes were retrieved in the ICG group than in the non-ICG group. In addition, the mean total number of lymph nodes retrieved in the ICG group within the scope of D2 lymphadenectomy was also significantly greater than the mean number retrieved in the non-ICG group (mean [SD], 49.6 [15.0] lymph nodes vs 41.7 [10.2] lymph nodes, respectively; P < .001). The lymph node noncompliance rate of the ICG group (41 of 129 patients [31.8%]) was lower than that of the non-ICG group (74 of 129 patients [57.4%]; P < .001). The postoperative recovery process was comparable, and no significant difference was found between the ICG and non-ICG groups in the incidence (20 of 129 patients [15.5%] vs 21 of 129 [16.3%], respectively; P = .86) or severity of complications within 30 days after surgery. Indocyanine green can noticeably improve the number of lymph node dissections and reduce lymph node noncompliance without increased complications in patients undergoing D2 lymphadenectomy. Indocyanine green fluorescence imaging can be performed for routine lymphatic mapping during laparoscopic gastrectomy, especially total gastrectomy. ClinicalTrials.gov Identifier: NCT03050879.

Non-exposure Simple Suturing Endoscopic Full-thickness Resection with Sentinel Basin Dissection in Patients with Early Gastric Cancer: the SENORITA 3 Pilot Study.

PurposeRecently, non-exposure simple suturing endoscopic full-thickness resection (NESS-EFTR) was developed to prevent tumor exposure to the peritoneal cavity. This study aimed to evaluate the feasibility of NESS-EFTR with sentinel basin dissection for early gastric cancer (EGC).Materials and MethodsThis was the prospective SENORITA 3 pilot. From July 2017 to January 2018, 20 patients with EGC smaller than 3 cm without an absolute indication for endoscopic submucosal dissection were enrolled. The sentinel basin was detected using Tc99m-phytate and indocyanine green, and the NESS-EFTR procedure was performed when all sentinel basin nodes were tumor-free on frozen pathologic examination. We evaluated the complete resection and intraoperative perforation rates as well as the incidence of postoperative complications.ResultsAmong the 20 enrolled patients, one dropped out due to large tumor size, while another underwent conventional laparoscopic gastrectomy due to metastatic sentinel lymph nodes. All NESS-EFTR procedures were performed in 17 of the 18 other patients (94.4%) without conversion, and the complete resection rate was 83.3% (15/18). The intraoperative perforation rate was 27.8% (5/18), and endoscopic clipping or laparoscopic suturing or stapling was performed at the perforation site. There was one case of postoperative complications treated with endoscopic clipping; the others were discharged without any event.ConclusionsNESS-EFTR with sentinel basin dissection is a technically challenging procedure that obtains safe margins, prevents intraoperative perforation, and may be a treatment option for EGC after additional experience.Trial RegistrationClinicalTrials.gov Identifier: NCT03216174

Laparoscopic Gastrectomy Using Instruments with a Minimal Diameter for Early Gastric Cancer: A Feasible Alternative to Conventional Laparoscopic Gastrectomy for Experienced Surgeons.

Background: The application of laparoscopic surgery using instruments that are 3 mm or less in diameter for patients with early gastric cancer (EGC) has not yet been established. We aimed to evaluate the feasibility and safety of laparoscopic gastrectomy using instruments with minimal diameter. Methods: We retrospectively analyzed 41 patients who underwent laparoscopic subtotal gastrectomy with D1-positive lymph node dissection for EGC. Among them, 17 patients underwent laparoscopic gastrectomy using instruments with a minimal diameter (experimental group), while 24 patients underwent conventional laparoscopic gastrectomy (control group). In the experimental group, we used two 3-mm trocars, one 5-mm trocar, and the GelPOINT® Advanced Access Platform. We compared operative outcomes between the two groups and assessed the learning curve of laparoscopic gastrectomy using instruments with minimal diameter. Results: The operative outcomes were similar between the two groups. The preoperative-to-postoperative day 2 ratio of neutrophil count in the experimental group was significantly lower than in the control group (2.07 versus 2.65; P = .038). Morbidity was not observed in the experimental group and 3 patients experienced complications in the control group, although it was not significantly different (P = .252). The operation time according to the accumulation of cases was stable without any significant change in the experimental group. Conclusions: Laparoscopic gastrectomy using instruments with minimal diameter is technically feasible and safe for EGC and could also be a good alternative to conventional laparoscopic gastrectomy to minimize the impact of surgical invasiveness when performed by experienced surgeons.

Should robotic gastrectomy become a standard surgical treatment option for gastric cancer?

Robotic gastrectomy (RG) using the da Vinci Surgical System for gastric cancer was approved for national medical insurance coverage in Japan in April, 2018, and has been used increasingly since. We reviewed the current evidence on RG, open gastrectomy (OG), and conventional laparoscopic gastrectomy (LG) to identify differences in surgical outcomes between Japan and other countries. Briefly, three independent reviewers systematically reviewed the data collected from a comprehensive literature search by an independent organization and focused on the following nine endpoints: mortality, morbidity, operative time, estimated volume of blood loss, length of postoperative hospital stay, long-term oncologic outcome, quality of life, learning curve, and cost. Overall, the mortality rate of the three approaches did not differ, but RG and LG had less intraoperative blood loss and resulted in a shorter postoperative hospital stay than OG. RG had longer operative times and incurred higher costs than LG and OG. However, in Japan, RG may be more effective than LG and OG for decreasing morbidity. Further studies are needed to establish the specific indications for RG, optimal robotic setup, and dissection methods to best utilize the surgical robot.