Laparoscopic Subtotal Gastrectomy Research Articles

Comparison of subjective quality of life after endoscopic submucosal resection or surgery for early gastric cancer

Quality of life (QoL) has become an important issue after early gastric cancer (EGC) treatment. We aimed to compare the QoL of EGC survivors after ESD (n = 241) or laparoscopic subtotal gastrectomy (n = 241) without recurrence and to evaluate the QoL over the 5-year period after adjusting for various confounding factors related to QoL. QoL related to the gastric cancer subscale (GCS) was significantly higher in the ESD group than surgery group (p < 0.001). After adjusting for all possible confounding factors, survivors who underwent ESD still had higher QoL related to CSG than those who underwent surgery. On the analysis of interaction effects for all QoL subscales, higher QoL related to GCS of ESD group than those of surgery group has been kept over time (p = 0.983). Therefore, we concluded that EGC survivors who undergo ESD have significantly better QoL related to GCS over a 5-year period after treatment than those who undergo surgery. This may be a useful consideration when selecting treatment modalities for patients with EGC.

Laparoscopic resection for gastric GISTs: surgical and long-term outcomes of 133 cases

Background It aims to evaluate the surgical efficacy and long-term survival of different laparoscopic surgeries for gastric GISTs. Methods From a prospectively collected database, 133 patients with primary gastric GISTs undergoing laparoscopic surgery were selected from January 2008 to December 2014. They were divided into three groups according to the different operations that were performed, including laparoscopic gastric wedge resection (LWR Group, n=103), laparoscopic subtotal gastrectomy (LSG Group, n=18) and laparoscopic total gastrectomy (LTG group, n=12). Clinicopathological features and short- and long-term outcomes were analyzed retrospectively. Results All patients had received R0 resection. There were no differences among the three groups in age, BMI or NIH risk classification. Compared with the LSG group and LTG group, the LWR group had a shorter operative time, less blood loss, fewer operative complications and shorter time to ground activities, semi-liquid diet and hospital stay (P&lt;0.05). There was no statistically significant difference in time to first flatus and liquid diet or in the rate of postoperative complications (P&lt;0.05). In the patients with a large tumor (size≥5 cm), LWR was significantly associated with shorter operative time, less blood loss and shorter hospital stay compared with the laparoscopic gastric non-wedge resection (N-LWR) (P&lt;0.05). The median follow-up was 30 months, with 4 cases of recurrence and 3 deaths. The 5-year cumulative survival rate was similar among the three groups (P&gt;0.05). Conclusions Compared with LSG and LTG, more favorable minimally invasive results can be achieved from LWR for gastric GISTs, which may be the optimal surgical procedure.

Size-dependent differences in the proximal remnant stomach: how much does a small remnant stomach after subtotal gastrectomy work?

The application of laparoscopic subtotal gastrectomy (LsTG) in the management of early gastric cancer located in the upper third of the stomach creates an extremely small remnant stomach (SRS). However, it is unclear whether retaining such an SRS improves patients' postoperative outcomes in a similar manner to a conventional remnant stomach (CRS). Four hundred and nine of 878 patients undergoing laparoscopic distal gastrectomy (LDG) between 2006 and 2012 underwent Roux-en-Y reconstruction. Among them, we selected 73 patients who underwent LsTG with an SRS (SRS group), and 83 patients with the tumor in the lower third of the stomach who underwent LDG with a CRS (CRS group). The surgical outcomes at 1 and 6 months, 1, 2, and 3 years after gastrectomy were retrospectively analyzed and compared between the two groups. One year after gastrectomy, the postoperative:preoperative bodyweight ratio of the SRS group was 2% lower than that of the CRS group. Both groups had comparable total protein and albumin levels, and incidence of reflux esophagitis; however, hemoglobin was lower in the SRS group. This difference in hemoglobin level between the SRS and CRS groups became larger over time, although the total protein and albumin levels of the two groups remained similar. An SRS slightly decreases bodyweight and hemoglobin level compared with a CRS. Several objective outcomes of the SRS group are almost equal to those of the CRS group, which suggests LsTG is worth performing even though its remnant stomach is very small.

An Optimal Surgical Approach for Suprapancreatic Area Dissection in Laparoscopic D2 Gastrectomy with Complete Mesogastric Excision

BackgroundDuring the radical operation, the suprapancreatic area is featured by anatomical complexity, and the lymph node dissection for this area is technically difficult and demanding.1-4 Previously, we have demonstrated the presence of disseminated cancer cells in the mesogastrium5,6 and presented a mesogastrium model for gastrectomy.7 As a consequence, laparoscopic D2 lymphadenectomy plus complete mesogastric excision (D2+CME) was proposed as a new concept in the surgical treatment of advanced gastric cancer.8 D2+CME procedure has been shown to be associated to lower number of free intraperitoneal cancer cells and with a better disease-free survival than conventional D2 gastrectomy.9 Under the concept of mesogastrium model, the proposed D2+CME procedure could help surgeons better define the anatomical boundaries of suprapancreatic mesogastrium, thus using it to achieve a complete and standard excision of the suprapancreatic area dissection. Here, we briefly present perioperative results of our case series with the laparoscopic curative subtotal gastrectomy and D2+CME with a R0 resection and present a video to detail the technical aspects of a laparoscopic D2+CME approach for suprapancreatic area dissection. MethodsAll patients in this study underwent laparoscopic subtotal gastrectomy (D2+CME) with a curative R0 resection. This study was approved by the Tongji Hospital Ethics Committee (Unique Reference Number: TJ-IRB20180811). The procedures in the video are described as follows. Based on our previous mesogastrium model (also named “Table model”, Supplemental Figure 1), the suprapancreatic mesogastrium is attached to the lesser curvature or the posterior gastric wall and extended to the suprapancreatic area, respectively.7 Surgeon stands on patient left side, and the assistant lifts the stomach upward and cephalic to expose the suprapancreatic mesogastrium including left gastric mesentery (LGM), right gastric mesentery (RGM) and posterior gastric mesentery (PGM). First of all, towards to the left side of the suprapancreatic area, the “tri-junction” point of LGM is exposed. Using an energy devise, surgeon opens serosa layer and identifies the retrogastric space. The LGM and PGM are mobilized bluntly, between which a fusion retrogastric space is revealed. Both the LGM and PGM are covered by smooth and shiny surfaces of fascial propria and regarded as the “meso-bed” mutually. Secondly, at the inner side of duodenum, surgeon bluntly separates the adjuvant tissues along gastro-duodenal artery (GDA) upward and exposes right gastric mesentery (RGM). Next, after mobilizing the left gastric mesentery, surgeon removes the adipose tissue adherent to the common hepatic artery (CHA) and exposes the root of the left gastric artery after dissecting the perivascular sheath with triple-clips. Then, surgeon dissects RGM along the CHA and portal vein (HPV) towards the right side of the suprapancreatic area; afterwards, the right gastric vessels and RGM are identified and ligated. Lastly, the superior border of splenic vessels is dissected. The anterior lobe of the PGM is raised up with ligated posterior gastric vessels. Remarkably, posterior gastric vessels may be absent in some cases. Reconstruction of the alimentary tract is Roux-en-Y method. Standard recovery protocols are followed in postoperative treatments. ResultsBetween August 28th 2017 and December 27th 2018, 107 patients receiving laparoscopic curative subtotal gastrectomy (D2+CME) with a R0 resection were retrospective collected in this study. After exposing the suprapancreatic mesogastrium including RGM, PGM and LGM with D2+CME procedure, the LNs and fat tissues around 7, 9, 8a, 12a and 11p were removed en bloc in all patients. This study recruited 67 males and 40 females. The median age was 55 years, with body mass index (BMI) 23.0 kg/m2 (Supplemental Table 1). The median number of retrieved regional lymph nodes was 31 (range 25–41), including 22 (range 17–27.5) suprapancreatic lymph nodes. The median volume of blood loss was 14 ml (range 6-34). The median total operation time was 287 min (range 265.5–313.5) and laparoscopic surgery time was 132 min (range 116–142) (Supplemental Table 2). Postoperative morbidity occurred at a rate of 9.3 %, and the mortality rate was 0% (Supplemental Table 3). The median follow-up was 10 months (range 8–13). No patient was lost during follow-up (Supplemental Table 4). ConclusionA laparoscopic subtotal gastrectomy with D2+CME procedure provides for a complete and standardized en bloc excision of the suprapancreatic area dissection.

Outcomes of Total and Subtotal Laparoscopic Gastrectomy with D2 Lymphadenectomy in Advanced Gastric Cancer in a Brazilian Hospital

Background: Although laparoscopic gastrectomy is becoming more popular as a curative therapy for gastric cancer, there are concerns about its oncological adequacy. We have compared the outcomes of laparoscopic total gastrectomy (LTG) and laparoscopic subtotal gastrectomy (LSG), both with modified D2 lymphadenectomies for the treatment of advanced gastric cancers. Aim: To compare the outcomes of laparoscopic (total and subtotal) gastrectomy with modified D2 lymphadenectomy for the treatment of gastric cancer, contributing to the literature regarding the overall survival of these patients and postoperative complications. Methods: From 1993 to 2014, 239 patients were operated on laparoscopic gastrectomy at our department. The routinely laparoscopic gastrectomy was performed in all patients with gastric cancer including those presenting with obstruction and bleeding. Data could be collected, on a retrospective way, from 2006 to 2014, from the medical records of 103 patients who underwent LSG (n = 72) or LTG (n = 31). We excluded patients with metastatic disease and those who could not have a complete tumor resection. Results: Most patients were in advanced stages of cancer. Adenocarcinoma was the most common find, with 43% of cases in stage IIA and 31% in stage IIIB. Intracorporeal Roux-en-Y or Billroth II anastomoses were employed. Postoperative complications, for LSG and LTG, were 18% and 35.4%; mortality rate, during hospital stay, was 4.9% and 7.7%; three-year survival rate, 53.1% and 59.3%; and five-year survival rate, 46.9% and 40.7%. Mean hospital stay was 7.08 days, being significantly lower in LSG group (p < 0.05). Hospital acquired pneumonia was the most prevalent clinical complication, while deaths arising from surgical complications were caused mainly by gastro-jejunal or esophago-jejunal anastomosis leaks. Conclusions: Both LSG and LTG with modified D2 lymphadenectomy are feasible alternatives to open surgery and survival rates were comparable. The increased risk of complications observed in LTG did not influence the overall mortality rate. We hope that these findings should contribute to improve the acceptance of laparoscopic gastrectomy as a safe procedure for gastric cancer treatment.

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.

Kết quả phẫu thuật nội soi cắt đoạn dạ dày trong điều trị ung biểu mô dạ dày tại Bệnh viện Hữu nghị Đa khoa Nghệ An

Tóm tắt Đặt vấn đề: Đánh giá tính an toàn và hiệu quả của phẫu thuật nội soi cắt đoạn dạ dày nạo vét hạch trong điều trị ung thư biểu mô dạ dày. Phương pháp nghiên cứu: Nghiên cứu hồi cứu mô tả, tất cả người bệnh ung thư biểu mô dạ dày được phẫu thuật nội soi cắt đoạn dạ dày từ 2012 đến 2019. Kết quả: 278 người bệnh ung thư dạ dày được phẫu thuật nội soi cắt đoạn dạ dày, tuổi trung bình 60,2 (33 -78), tỷ lệ nam/nữ 3,3. Ung thư ở giai đoạn IA, IB, IIA, IIB, IIIA và IIIB lần lượt là 2,2%, 9,7%, 22,3%, 30,9%, 27,3% và 7,5%. Số hạch vét được trung bình 12,2 hạch, số hạch di căn trung bình 3,1 hạch. Tỷ lệ tai biến, biến chứng chung là 2,5%. Không có tử vong trong và sau mổ. Thời gian mổ trung bình là 185 phút, nằm viện sau mổ 8,1 ngày. Thời gian sống sau mổ 1 năm, 2 năm, 3 năm và 5 năm là 95,7%, 80,2%, 71,1% và 53,4%. Kết luận: Phẫu thuật nội soi cắt đoạn dạ dày nạo vét hạch là khả thi, an toàn và hiệu quả trong điều trị ung thư biểu mô dạ dày, thời gian hồi phục và nằm viện ngắn. Abstract Introduction: To assess the initial outcomes including the effectiveness, safety of laparoscopic subtotal gastrectomy with lymph nodes dissection for gastric adenocarcinoma. Material and Methods: Prospective study conducted from 2012 to 2019 in Nghe An Friendship General Hospital. All the patients underwent the laparoscopic subtotal gastrectomy with lymph nodes dissection for gastric adenocarcinoma enrolled. Results: 278 patients underwent laparoscopic subtotal gastrectomy with lymph nodes dissection, mean age was 60.2 (33 - 78). Male and female ratio was 3.3. Stages of the tumor were 2.2% IA, 9.7% IB, 22.3% IIA, 30.9% IIB, 27.3% IIIA and 7.5% IIIB. The mean of lymph nodes removed were 12.2 and mean lymph nodes metastasis were 3.1. The overall complication and incident rates were 2.5%. No per-operative and post-operative mortality was observed. The mean operative time was 185 min. The mean postoperative length stays were 8.1 days. Overall survival rates for one year, two years, three year and five years were 95.7%, 80.2%, 71,1% and 53.4% respectively. Conclusion: Laparoscopic subtotal gastrectomy with lymph node resection for gastric adenocarcinoma is safe and effective, shorten recovery time and hospitalization. Keyword: Laparoscopic subtotal gastrectomy.

Gastrointestinal (GI) Hemorrhage Secondary to Stromal Tumor (GIST) in Excluded Stomach

Roux-En-Y gastric bypass procedure is one of the commonly performed bariatric surgeries. The “excluded” stomach pouch is difficult to assess by endoscopic procedures and various radiographic studies. Gastrointestinal bleeding is a common complication after gastric bypass. Sources of bleeding include sites of anastomosis and bypassed stomach. Particularly true for bypassed stomach, diagnostic modalities can be challenging let alone interventional options. A 74-year-old Caucasian male presented with melena for 2 weeks. He presented earlier to GI clinic for a positive fecal occult blood test referred from his primary doctor. His hemoglobin dropped from 13 to 8 in a matter of 1 month. Patient denies hematemesis. Patient has history of Roux-En-Y gastric bypass surgery in 2009. Work up of bleeding included a colonoscopy along with EGD which did not show any bleeding source. Tagged RBC scan failed to show a bleeding lesion despite active bleeding. Push enterosocpy could not identify any cause, although endoscopist failed to access bypassed stomach. CT enterography showed gastric mass in bypassed stomach of 5.4 cm in size. Surgery service recommended transfer to another facility for a double balloon endoscopy. Patient underwent DBE with biopsies taken from bypassed stomach suggestive of malignancy. Patient was scheduled for laparoscopic subtotal gastrectomy. Operative report noted large mass in gastric remnant which was resected with adequate margins pass the pylorus. Surgical pathology showed malignancy suggestive of GIST, low grade with positive KIT mutation. Oncologist opted to hold off Imatinib given that tumor was totally resected and it was low grade on histology. Decision was to perform surveillance with CT imaging of abdomen, pelvis and chest every 3 months for recurrence. Our patient underwent various diagnostic tests initially with no bleeding source identification. This reflects how challenging working up acute bleeding in GI tract especially with altered anatomy. Patient was found to have gastric mass in bypassed stomach on CT scan of abdomen. Gastric mass was relatively large at 5.4 cm with significant bleeding based on hemoglobin drop. It was also challenging to obtain pathological diagnosis and it required DBE to obtain enough tissue. Patient fortunately had low grade GIST with clean margins after resection. Our case shows an uncommon lesion in bypassed stomach along with high-risk uncommon presentation.2021 Figure 1 No Caption available.

Laparoscopic subtotal gastrectomy with a new marking technique, endoscopic cautery marking: preservation of the stomach in patients with upper early gastric cancer.

Laparoscopic subtotal gastrectomy (LsTG) has several advantages, including technical safety and preservation of postoperative function, compared with total or proximal gastrectomy for early gastric cancer. However, LsTG has some technical issues with respect to achieving a safe resection margin and patency in patients with lesions close to the cardia or fornix. When LsTG is performed for lesions located rather close to the cardia or fornix, conventional marking clips can physically hinder transection by an endoscopic linear stapler. Additionally, tracing the tumor boundary to create a precise resection line is difficult. To resolve these issues, we introduced a new marking technique called endoscopic cautery marking (ECM) involving the creation of small cauterized spots. Of 791 patients who underwent laparoscopic gastrectomy from 2015 to 2017, 16 underwent LsTG with ECM. Before surgery, ECM was performed and the pathological tumor boundary was traced according to preoperative biopsies. Under intraoperative endoscopic guidance, we divided the stomach with an endoscopic linear stapler on the proximal side of the ECM site and examined the stump by pathological frozen section analysis to confirm the absence of cancer. The median length of the endoscopically measured distance from the esophagogastric junction to the tumor was 30.0mm (range 15-40mm), and the median pathological proximal margin was 11.5mm (range 0-26mm). Although the ECM site was completely resected in all patients, frozen section analysis showed a positive margin in one lesion, which had an unclear tumor boundary due to gastritis. For this patient, we converted the procedure to laparoscopic completion gastrectomy. No severe complications or recurrences occurred. LsTG with ECM was technically feasible, and short-term outcomes were acceptable in this preliminary study. Further experience and investigations are imperative to verify the oncological and functional implications of LsTG with ECM.

Laparoscopic gastrectomy and adjuvant hyperthermic intraperitoneal chemotherapy (HIPEC) using a closed system with turbulent-flow circuit: technical aspects and preliminary results of a pilot study

Intraoperative hyperthermic chemotherapy (HIPEC) is increasingly used in combination with cytoreductive surgery for the treatment of peritoneal carcinomatosis. The potential survival benefit of adjuvant HIPEC after curative gastrectomy has not been conclusively demonstrated. We describe a newly developed closed system for HIPEC and report the preliminary results of a pilot study. Patients with locally advanced gastric carcinoma at a high risk for peritoneal recurrence were identified from a prospectively collected database. Laparoscopic total or subtotal gastrectomy combined with standard D2 lymphadenectomy was performed. Immediately after resection and 15 min before HIPEC treatment, intravenous induction chemotherapy with folinic acid and 5‑fluorouracil was administered. A closed-system HIPEC with turbulent-flow circuit (Combat PRS™, Peritoneum Recirculation System, Galmaz Biotech, Madrid, Spain) was used to perfuse the peritoneal cavity with a solution of oxaliplatin and glucose during 60 min. After washout of the peritoneal cavity and re-establishment of pneumoperitoneum, a Roux-en-Y esophagojejunostomy or gastrojejunostomy was performed. Between June 2017 and February 2018, 6 patients were treated according to this protocol. No major postoperative complications occurred. There were no intra- or postoperative complications related to the HIPEC procedure. All patients are alive and disease-free at 3–11 months of follow-up. The preliminary results of this pilot study indicate the safety and feasibility of the closed HIPEC system with CO2 recirculation in selected patients undergoing laparoscopic total or subtotal gastrectomy for locally advanced gastric carcinoma.

Clinicopathological features of gastroenteropancreatic neuroendocrine tumors: A retrospective evaluation of 42 cases.

Neuroendocrine tumors arise from neuroendocrine cells in any part of the body; approximately two thirds of these tumors are located in the gastrointestinal tract and pancreas. Although gastroenteropancreatic neuroendocrine tumors are known as rare neoplasms, their prevalence has recently increased due to advanced diagnostic methods and increased awareness of the disorder. In the present study, we aimed to review patients who were treated and followed up for gastroenteropancreatic neuroendocrine tumors at our clinic in terms of clinical picture, pathological findings, and prognosis. Data from 42 patients diagnosed with gastroenteropancreatic neuroendocrine tumors who were treated and followed up at our Training and Research Hospital from August 2011 to December 2015 were retrospectively evaluated. A total of 42 patients aged 17-81 years (mean age 46.9 years) were enrolled in the study. The most common symptom was abdominal pain, which was seen in 31 (73.8%) patients. gastroenteropancreatic neuroendocrine tumors were detected in the stomach (n=5, 35.7%), appendix (n=11, 26.2%), rectum (n=6, 14.3%), pancreas (n=4, 9.5%), ileum and colon (n=2, 4.8%), and duodenum and jejunum (n=1, 2.4%). Local excision was performed in seven (16.7%) patients. Nine (21.4%) patients underwent gastric wedge resections, either by a laparoscopic procedure (n=3) or by open surgery (n=6). Total gastrectomy and laparoscopic subtotal gastrectomy were performed on three (7.1%) patients and two patients (4.8%), respectively. After the surgical procedures, the patients were followed up for a mean period of 36 months (15-57 months); the one-year and three-year survival rates were determined to be 100% and 97.6%, respectively. Management of gastroenteropancreatic neuroendocrine tumors requires accumulation of knowledge and experience to establish a standardized approach. Therefore, we believe that collecting regular national data from these cases in every country will contribute to understanding the details of this entity worldwide.

Laparoscopic Subtotal Gastrectomy for Advanced Gastric Cancer: Technical Aspects and Surgical, Nutritional, and Oncological Outcomes

Laparoscopic Subtotal Gastrectomy for Advanced Gastric Cancer: Technical Aspects and Surgical, Nutritional, and Oncological Outcomes

Short-term outcomes and nutritional status after laparoscopic subtotal gastrectomy with a very small remnant stomach for cStage I proximal gastric carcinoma.

Total or proximal gastrectomy is usually performed for early proximal gastric carcinoma, but the optimal type of gastrectomy is still unknown. We evaluated short-term outcomes and nutritional status after laparoscopic subtotal gastrectomy (LsTG) in comparison with laparoscopic total gastrectomy (LTG) and laparoscopic proximal gastrectomy (LPG). We analyzed 113 patients who underwent LsTG (n=38), LTG (n=48), or LPG (n=27) for cStage I gastric cancer located in the upper third of the stomach. Postoperative morbidities, nutritional status including body weight, serum albumin, hemoglobin, the prognostic nutritional index (PNI), and endoscopic findings at 1year after surgery were compared between LsTG and both LTG and LPG. Operation time and intraoperative blood loss were similar among the three groups. The incidence of postoperative morbidities was lower in LsTG than in LTG. The degree of body weight loss was significantly smaller in LsTG than in LTG at 6 and 12months. At 12months, LsTG resulted in better serum albumin and PNI than LPG, and better hemoglobin than LTG. Endoscopic examination demonstrated that one LsTG patient and two LPG patients had reflux esophagitis. Remnant gastritis was observed more frequently in LPG than in LsTG. No LsTG patient had bile reflux, although it was observed in four LPG patients. LsTG with a very small remnant stomach had favorable short-term outcomes and nutritional status compared with LTG and LPG, so it may be a better treatment option for cStage I proximal gastric carcinoma.

Laparoscopic subtotal gastrectomy for the treatment of advanced gastric cancer: a comparison with open procedure at the beginning of the learning curve

Background:In the last decades, after some initial concern, laparoscopic subtotal gastrectomy (LSG) is gaining popularity also for the treatment of advanced gastric cancer (AGC). The aim of this study is to compare a single surgeon initial experience on LSG and open subtotal gastrectomy in terms of surgical safety and radicality, postoperative recovery and midterm oncological outcomes.Methods:a case control study was conducted matching the first 13 LSG for AGC with 13 open procedures performed by the same surgeon. Operative and pathological data, postoperative parameters and midterm oncological outcomes were analyzed.Results:There was no significant difference in mortality (0%) and morbidity, while the laparoscopic approach allowed lower analgesic consumption and faster bowel movement recovery. Operation time was significantly higher in LSG patients (301.5 vs 232 min, p: 0.023), with an evident learning curve effect. Both groups had a high rate of adequate lymph node harvest, but the number was significantly higher in LSG group (p: 0.033). No significant difference in survival was registered. Multivariate analysis identified age at diagnosis, diffuse-type tumor, pN and LODDS as independent predictors of worse prognosis.Conclusions:LSG can be safely performed for the treatment of AGC, allowing faster postoperative recovery. (www.actabiomedica.it)

Adult gastric duplication: an unknown condition within the spectrum of gastric submucosal lesions

Gastric duplication is an uncommon condition in adults representing only 4-8% of all gastrointestinal duplications. It develops as a cystic growth within the thick gastric wall that is surrounded by a layer of smooth muscle and lined with gastric mucosa. It is usually asymptomatic but may present with nonspecific abdominal symptoms as well as cyst-related complications such as gastrointestinal (GI) bleeding, ulceration and even pancreatitis. They are difficult to distinguish from other gastric submucosal lesions and may also mimic a gastrointestinal tumor (GIST) or mucinous cyst of the pancreas. Endoscopic ultrasound (EUS) is the most widely used diagnostic procedure and histology provides a definitive diagnosis. We report the case of a 36-year-old female patient with a history of a "contained" perforated gastric ulcer that was managed conservatively. The patient was diagnosed with a gastric GIST which prompted a laparoscopic subtotal gastrectomy and Roux-en-Y reconstruction with a good postoperative outcome. The definitive histological diagnosis was gastric duplication. Thus, the previous diagnosis of a "contained" perforated gastric ulcer was in fact a complication of the gastric duplication itself.

Totally Laparoscopic Subtotal Gastrectomy (D2+) with Jejunal Roux-en-Y Reconstruction and Aberrant Left Hepatic Artery: A Case Report

Totally Laparoscopic Subtotal Gastrectomy (D2+) with Jejunal Roux-en-Y Reconstruction and Aberrant Left Hepatic Artery: A Case Report

NOSE laparoscopic gastrectomies for early gastric cancer may reduce morbidity and hospital stay: early results from a prospective nonrandomized study

Background: Natural orifice specimen extraction – NOSE laparoscopy is a promising technique that avoids mini-laparotomy, possibly reducing postoperative pain, wound infections and hospital stay. Recent systematic reviews have shown that postoperative morbidity associated with laparoscopically assisted gastrectomies is similar to that after open gastrectomies. More specifically, there is no difference in wound infection rate. The study objective was to evaluate whether postoperative morbidity and hospital stay may be reduced by transoral specimen extraction after laparoscopically assisted gastrectomy for early gastric cancer (EGC).Material and methods: A prospective, nonrandomized study was carried out starting in August 2012. Data from all patients operated on during the first year, with minimum 18 months follow-up, were collected to assess feasibility, oncologic results, postoperative morbidity, hospital stay and functional results. Overall, 14 patients were included and followed-up. After gastric resection, a 3 cm opening was created on the gastric stump, and the specimen, divided into three segments stitched one to each other, was sutured to the gastric tube and retrieved through the mouth.Results: Postoperative morbidity was 7.14% (1/14): one case of pneumonia. No wound infection occurred. The mean postoperative hospital stay was 4.7 ± 1.0 days.Conclusions: NOSE laparoscopic subtotal gastrectomy is feasible and safe, with similar oncologic results as LAG, but decreased morbidity and hospital stay.

일개 종합병원 복강경 위절제술 환자의 표준진료지침 적용효과

본 연구는 새롭게 개발된 복강경 위절제술의 표준진료지침(Critical pathway, CP) 적용효과를 분석하기 위해 수행되었다. 연구대상은 전라남도에 소재한 C병원 위장관클리닉에서 위암으로 진단받고 복강경 위아전절제술을 시행하고 퇴원한 20세 이상의 성인 환자로, 실험군은 2008년 10월부터 2009년 9월까지 CP를 적용하여 복강경 위아전절제술을 시행한 환자 102명으로 하였고, 대조군은 2007년 9월부터 2008년 9월까지 CP를 적용하지 않고 복강경 위아전절제술을 시행한 환자 63명으로 하였다. 본 연구결과 퇴원시 통증에서는 CP적용군이 비적용군보다 퇴원 당일 통증이 있는 경우가 0.07배 낮았다(Odds ratio [OR], 0.07; 95% Confidence interval [CI], 0.03-0.21). 총 재원일수는 CP적용군에서는 평균(표준오차)은 8.95(1.33)일, 비적용군에서는 평균 10.69(4.04)일로 유의한 차이를 보였고(p<0.001), 수술 후 재원일수 또한 CP적용군이 평균 7.16(0.94)일, 비적용군이 평균 8.79(3.90)일로 통계적으로 유의한 차이(p<0.001)를 보였다. 본 연구 결과 복강경 위절제술에 대한 CP의 적용은 퇴원시 통증감소, 총 재원일수 및 수술 후 재원일수를 단축시키는 효과를 보였다. This study is aim to investigate how applying a critical pathway(CP) to stomach cancer patients affects their recovery and treatment. The subjects were 165 patients over the age of 20 who were diagnosed with stomach cancer at the gastrointestinal clinic of C hospital and who underwent laparoscopic subtotal gastrectomy. The case group inclueded 102 patients who underwent laparoscopic subtotal gastrectomy with applying the CP from October 2008 to September 2009. The control group included 63 patients who underwent laparoscopic subtotal gastrectomy without applying the CP from September 2007 to September 2008. Pain at the time of discharge was significantly lower in the CP applicated group than in the non-applicated group (Odds ratio [OR], 0.07; 95% Confidence interval [CI], 0.03-0.21). The CP applied group was significantly lower than non-applied group in total hospitalization days (CP applied group: 8.95[1.33], non-applied group: 10.69[4.04], p<0.001) and in postoperative hospitalization days (CP applied group: 7.16[0.94], non-applied group: 8.79[3.90], p<0.001). In conclusion, application of a critical pathway to laparoscopic subtotal gastrectomy reduced pain at the time of discharge, total hospitalization days and postoperative hospitalization days.

A5244 - Laparoscopic Gastric Sleeve With And Without The Gastrectomy – Three Years Follow Up

Lesser curve gastric tube operation has been performed at late eighties as Magenstrasse and Mill procedure. This operation was transformed from open operation into laparoscopic subtotal gastrectomy (sleeve gastrectomy). We compare the laparoscopic sleeve gastroplasty with the sleeve gastrectomy.

Efficacy of laparoscopic subtotal gastrectomy with D2 lymphadenectomy for locally advanced gastric cancer: the protocol of the KLASS-02 multicenter randomized controlled clinical trial.

BackgroundDespite the well-described benefits of laparoscopic surgery such as lower operative blood loss and enhanced postoperative recovery in gastric cancer surgery, the application of laparoscopic surgery in patients with locally advanced gastric cancer (AGC) remains elusive owing to a lack of clinical evidence. Recently, the Korean Laparoscopic Surgical Society Group launched a new multicenter randomized clinical trial (RCT) to compare laparoscopic and open D2 lymphadenectomy for patients with locally AGC. Here, we introduce the protocol of this clinical trial.Methods/designThis trial is an investigator-initiated, randomized, controlled, parallel group, non-inferiority trial. Gastric cancer patients diagnosed with primary tumors that have invaded into the muscle propria and not into an adjacent organ (cT2–cT4a) in preoperative studies are recruited. Another criterion for recruitment is no lymph node metastasis or limited perigastric lymph node (including lymph nodes around the left gastric artery) metastasis. A total 1,050 patients in both groups are required to statistically show non-inferiority of the laparoscopic approach with respect to the primary end-point, relapse-free survival of 3 years. Secondary outcomes include postoperative morbidity and mortality, postoperative recovery, quality of life, and overall survival. Surgeons who are validated through peer-review of their surgery videos can participate in this clinical trial.DiscussionThis clinical trial was designed to maintain the principles of a surgical clinical trial with internal validity for participating surgeons. Through the KLASS-02 RCT, we hope to show the efficacy of laparoscopic D2 lymphadenectomy in AGC patients compared with the open procedure.Trial registrationClinicalTrial.gov, NCT01456598.