Laparoscopy-assisted Distal Gastrectomy For Early Gastric Cancer Research Articles

Laparoscopy-assisted distal gastrectomy for early gastric cancer poses few limitations for selected elderly patients: a single-center experience.

BackgroundThe safety and efficacy of laparoscopy-assisted distal gastrectomy (LADG) for early gastric cancer have been demonstrated in clinical studies. The aim of this study was to clarify the safety and efficacy of LADG in patients ≥80 years of age with early gastric cancer, an American Society of Anesthesiologists (ASA) classification of 1–2, and a performance status (PS) of 0–1.Case presentationFrom April 2009 to July 2011, 12 elderly patients aged ≥80 years and 43 younger patients underwent LADG for early gastric cancer. Seven of the 55 patients underwent LADG and simultaneous surgery including surgery for colorectal cancer, cholecystectomy, or other conditions. Forty-eight of the 55 patients who underwent only LADG were studied. Demographics and postoperative outcomes were compared.ResultsThe postoperative complication rate, time to first ambulation, time to first flatus, time to first fluid intake, and postoperative hospital stay were similar in these two groups. Nutritional status as assessed by body weight, serum albumin, and total protein at 1 and 3 months after surgery was also similar in these two groups.ConclusionsPostoperative outcomes were acceptable in the elderly patients included in the study. LADG for early gastric cancer is a safe and effective treatment in elderly patients aged ≥80 years with an ASA status of 1–2 and PS of 0–1.

Pylorus-Preserving Gastrectomy for Gastric Cancer.

Pylorus-preserving gastrectomy (PPG) is a function-preserving surgery for the treatment of early gastric cancer (EGC), aiming to decrease the complication rate and improve postoperative quality of life. According to the Japanese gastric cancer treatment guidelines, PPG can be performed for cT1N0M0 gastric cancer located in the middle-third of the stomach, at least 4.0 cm away from the pylorus. Although the length of the antral cuff gradually increased, from 1.5 cm during the initial use of the procedure to 3.0 cm currently, its optimal length still remains unclear. Standard procedures for the preservation of pyloric function, infra-pyloric vessels, and hepatic branch of the vagus nerve, make PPG technically more difficult and raise concerns about incomplete lymph node dissection. The short- and long-term oncological and survival outcomes of PPG were comparable to those for distal gastrectomy, but with several advantages such as a lower incidence of dumping syndrome, bile reflux, and gallstone formation, and improved nutritional status. Gastric stasis, a typical complication of PPG, can be effectively treated by balloon dilatation and stent insertion. Robot-assisted pylorus-preserving gastrectomy is feasible for EGC in the middle-third of the stomach in terms of the short-term clinical outcome. However, any benefits over laparoscopy-assisted PPG (LAPPG) from the patient's perspective have not yet been proven. An ongoing Korean multicenter randomized controlled trial (KLASS-04), which compares LAPPG and laparoscopy-assisted distal gastrectomy for EGC in the middle-third of the stomach, may provide more clear evidence about the advantages and oncologic safety of PPG.

Laparoscopy-assisted distal gastrectomy for gastric cancer

Laparoscopy-assisted distal gastrectomy (LADG) is a minimally invasive surgical technique, and also an important development of modern surgery. According to Japanese Gastric Cancer Treatment Guideline, indications of LADG must be strictly limited in early gastric cancer patients, while it should be investigated in advanced gastric cancer. Based on available studies, the short-term advantage of LADG for early gastric cancer has been generally accepted, but the totally laparoscopic technique for early gastric cancer is still to be further studied. LADG for advanced gastric cancer continues to be controversial, which needs the relevant final results of randomized controlled trials from China, Japanese, and Korean to determine, although some current studies have demonstrated similar efficacy of LADG plus D2 lymphadenectomy as compared to open gastrectomy.

Potentially fatal complications for elderly patients after laparoscopy-assisted distal gastrectomy

The safety of surgery for gastric cancer in the elderly has been shown previously. However, potentially fatal complications based on an established severity grading system were not well described, and associated risk factors have not been assessed. The present study sought to examine severity-dependent postoperative complications after laparoscopy-assisted distal gastrectomy (LADG) in elderly patients and risk factors of potentially fatal postoperative complications. The study included 189 patients aged 70years or older and who underwent LADG for early gastric cancer. Patient characteristics, perioperative outcomes, postoperative complications including severity assessment using the Clavien-Dindo classification, and risk factors related to postoperative complications were analyzed. The overall complication rate was 24.9% (47/189). The most frequent complication was abdominal fluid collection (9 cases, 4.8%). Severe complications classified as grade III or above in the Clavien-Dindo grading system were found in 20 (10.6%) patients. Multivariate analysis identified preoperative serum albumin concentration (odds ratio, 5.200; 95% CI, 1.706-15.850), Roux-en-Y reconstruction (odds ratio, 3.611; 95% CI, 1.103-11.817), and simultaneous cholecystectomy (odds ratio, 5.008; 95% CI, 1.378-18.201) as independent predictors of a higher rate of severe postoperative complications after LADG in elderly patients. The incidence of severe complications after LADG in the elderly was quite acceptable considering the risks associated with radical surgery with extensive lymphadenectomy. Preoperative serum concentrations of albumin (<4.0g/dl), Roux-en-Y reconstruction, and simultaneous cholecystectomy are independent risk factors for severe postoperative complications in these patients.

Pre- and Intraoperative Lidocaine Injection for Preemptive Analgesics in Laparoscopic Gastrectomy: A Prospective, Randomized, Double-Blind, Placebo-Controlled Study

The preemptive intravenous injection of local anesthetics is known to improve postoperative pains in abdominal surgery. The aim of this study is to assess the effect of intravenous lidocaine injection and analyze the precise amount of pain by computerized patient-controlled analgesia (PCA) in patients who had undergone laparoscopy-assisted distal gastrectomy (LADG). A double-blind placebo control study was designed, and 34 patients undergoing LADG for early gastric cancer were divided into two groups. Preoperatively and throughout the surgery, Group I received intravenous lidocaine injection, and Group C received normal saline injection for placebo. Postoperative outcomes, including the visual analog scale (VAS), the button hit counts (BHC) from PCA, and amount of fentanyl consumed, were measured. The demographic data were similar between the groups. The VAS score, BHC, and fentanyl consumption were lower in Group I compared with Group C (P<.05). In particular, fentanyl consumption and BHC in Group I showed a significant decrease during the first 12 hours of the study (P<.05). Postoperative adverse events showed no difference except that nausea was more frequent in the placebo group (P=.039). In this study, intravenous lidocaine injection showed a significant reduction in fentanyl consumption and pain during the earlier postoperative time with more favorable outcomes.

Laparoscopy versus open distal gastrectomy by expert surgeons for early gastric cancer in Japanese patients: short-term clinical outcomes of a randomized clinical trial

Short-term outcomes of laparoscopy-assisted distal gastrectomy (LADG) and open DG (ODG) have been investigated in previous clinical trials, but operative techniques and concomitant treatments have evolved, and up-to-date evidence produced by expert surgeons is required to provide an accurate image of the relative efficacies of the treatments. The purpose of this study was to compare laparoscopic versus ODG with respect to specific primary and secondary short-term outcomes. From October 2005 to February 2008, a total of 64 patients with early gastric cancer were randomly assigned to the LADG or the ODG group. One patient was excluded due to concurrent illness unrelated to the intervention, so the data from 63 patients were analyzed. The primary short-term outcome was the 4-day postoperative use of analgesics. Secondary short-term outcomes were postoperative residual pain, complications, days hospitalized, blood data, days with fever, and days to first flatus. There was a significant difference in favor of LADG for postoperative use of analgesics (P = 0.022). Unexpectedly, there was no significant difference in degree of pain in the immediate postoperative period, putatively due to the optimal use of analgesics. Of the secondary outcomes, residual pain at postoperative day 7 (P = 0.003) and days to first flatus (P = 0.001) were significantly better with LADG. Postoperative complications, number of days hospitalized, and number of days with fever were also better with LADG, but the differences were not significant. Blood data representing inflammation (WBC and CRP) showed marked differences, especially on postoperative day 7 (P = 0.0016 and P = 0.0061, respectively). LADG performed by expert surgeons results in less postoperative pain accompanied by decreased surgical invasiveness and is associated with fewer postoperative inconveniences. No preliminary suggestions of changes in long-term curability were observed. LADG for early gastric cancer is a feasible and safe procedure with short-term clinical results superior to those of ODG.

Surgical stress after robot-assisted distal gastrectomy and its economic implications

There is a lack of reports evaluating the outcomes of robotic gastrectomy and conventional laparoscopic surgery. The aim of this study was to compare the surgical stress response and costs of robot-assisted distal gastrectomy (RADG) with those of laparoscopy-assisted distal gastrectomy (LADG). This prospective study compared a cohort of patients who had RADG with a cohort that underwent conventional LADG for early gastric cancer between March 2010 and May 2011. The surgical outcomes including Eastern Cooperative Oncology Group performance status and complications, surgical stress response and overall costs were compared between the two groups. Thirty patients were enrolled in the RADG group and 120 in the LADG group. There were no conversions. Median duration of operation was longer in the RADG group (218 (interquartile range 200-254) versus 140 (118-175) min; P < 0·001). Postoperative abdominal drain production was less (P = 0·001) and postoperative performance status was worse (P < 0·001) in the RADG group. C-reactive protein (CRP) levels on postoperative days 1 and 3, and interleukin (IL) 6 level on the third postoperative day, were lower in the LADG compared with the RADG group (CRP: P = 0·002 and P = 0·014 respectively; IL-6: P < 0·001). Costs for robotic surgery were much higher than for laparoscopic surgery (difference €3189). RADG did not reduce surgical stress compared with LADG. The substantial RADG costs due to robotic system expenses may not be justified.

Laparoscopy-assisted distal gastrectomy for early gastric cancer with versus without prophylactic drainage

Little has been reported on routine prophylactic abdominal drainage after gastrectomy, especially after laparoscopy-assisted distal gastrectomy (LADG). We conducted this retrospective study on patients undergoing LADG to evaluate the benefit of routine drainage in LADG procedures. The subjects were 21 patients who underwent surgery for early gastric cancer (EGC) between January 2004 and March 2008. They comprised 10 who underwent LADG with drainage before January 2006 and 11 who underwent LADG without drainage after February 2006. We compared patient and tumor characteristics, operative results, and postoperative outcomes between the groups. The no-drain group of patients were able to eat their first meal significantly sooner than the drain group patients (P < 0.01); however, the time to start ambulating, passing flatus, and drinking was similar in the two groups. There were no significant differences between the groups in the postoperative complication rate or the postoperative hospital stay. The drain did not seem to add benefit, and no complications due to the lack of drain placement were noted in the no-drain group. Routine prophylactic abdominal drainage after LADG for EGC may not be necessary.

Long‐term outcomes and survival after laparoscopy‐assisted distal gastrectomy for gastric cancer: Three‐year survival analysis of a single‐center experience in Korea

Laparoscopy-assisted distal gastrectomy (LADG) has been established as an alternative treatment for early gastric cancer (EGC) because of excellent short-term results. However, only a few reports have considered the long-term outcomes of LADG. In this study, we investigated the 3-year outcome and survival of patients who underwent LADG. We assessed 182 patients with gastric adenocarcinoma who underwent LADG. The indication for LADG was confined to EGCs (T1N0 or T1N1 cases). The clinicopathological characteristics and long-term survival data of all patients were analyzed. The overall morbidity and mortality rates of the patients were 11% and 0%, respectively. An analysis of the final pathological stages of the patients revealed that 160 had stage Ia, 20 had stage Ib, and only 2 had stage II. The median follow-up period was 44 months (range, 2-73 months), and there were two recurrences. Five patients died of other causes, but no patients died of a gastric cancer recurrence. The 3-year overall and disease-specific survival rates were 97.3% and 100%, respectively. LADG for EGC is acceptable in terms of both short- and long-term outcomes. Thus, LADG can be considered a primary treatment for EGC.

The Impact of Visceral Fat Accumulation on Laparoscopy-Assisted Distal Gastrectomy for Early Gastric Cancer

Laparoscopy-assisted distal gastrectomy (LADG) has been widely accepted for the treatment for early gastric cancer. Obesity is a rapidly growing epidemic, and the number of obese patients with gastric cancer is increasing, but the impact of visceral fat (VF) accumulation on laparoscopic gastric surgery remains unknown. The aim of the present study was to determine the impact of VF accumulation on LADG. The medical charts of 30 patients who underwent LADG for early gastric cancer in our hospital between November 2000 and November 2006 were analyzed retrospectively. The patients were divided into two groups on the basis of VF accumulation measured on cross-sectional computed tomography at the level of the umbilicus. Twelve patients had high VF accumulation (> or =100 cm2) and 18 had low VF accumulation (<100 cm2). Although subcutaneous fat accumulation was not correlated with operation time or operative blood loss, VF accumulation was strongly, and significantly, correlated with both operation time and operative blood loss. The high-VF-accumulation group had a significantly longer operation time and significantly more operative blood loss than the low-VF-accumulation group. There was no significant difference in the rate of postoperative complications or conversion to open laparotomy between the two groups. There were no operative deaths or requirements for blood transfusion in either group. VF accumulation was significantly correlated with operative difficulties during LADG. Although LADG was as safe for patients with high VF accumulation as for patients with low VF accumulation, a longer operative time and more operative blood loss were observed in patients with high VF accumulation. VF accumulation appears to be a possible risk factor in LADG and should be considered when making a decision about treating early gastric cancer with LADG.

Comparison of long-term outcomes of laparoscopy-assisted and open distal gastrectomy for early gastric cancer

Application of laparoscopy-assisted distal gastrectomy (LADG) for early gastric cancer (EGC) is still controversial because of scant evidence of long-term safety and feasibility. We evaluated the long-term outcome of LADG compared with conventional open distal gastrectomy (ODG) for EGC. Between March 1999 and July 2006, 106 patients underwent LADG and 105 patients underwent ODG for EGC. Clinicopathologic characteristics, postoperative outcomes, hospital course, postoperative morbidity, postoperative mortality, and long-term outcomes, including cancer recurrence and survival, were retrospectively compared between the two groups. Survival of all patients was confirmed with 55-month median follow-up. Postoperative recovery was significantly faster in the LADG group; passing flatus occurred earlier, starting a liquid diet began sooner, and postoperative hospital stay was shorter (p < 0.05). Mean operation time was significantly longer in the LADG group. Postoperative complications in the LADG group occurred less frequently compared with in the ODG group (4.7% versus 13.3%, p = 0.046). Tumor recurrence occurred in two cases (0.9%) and death related to recurrence occurred in only one patient (0.5%). Overall 5-year survival rate (5-YSR) of all patients was 95.5%, while disease-specific 5-YSR was 98.8%. There was no significant difference in survival rates between the two groups; overall 5-YSR of the ODG and LADG groups was 94.9% and 95.9%, respectively. Our data suggest that LADG for EGC is feasible and safe. We expect the results of the present study to be confirmed by prospective randomized analysis.

The impact of obesity on LADG for early gastric cancer

Laparoscopy-assisted distal gastrectomy (LADG) has become a viable alternative treatment for patients suffering with early gastric cancer. Surgeons have long thought that obesity might increase the rate of intraoperative or postoperative complications. We set out to clarify the effect that obesity has on performing LADG for the treatment of early gastric cancer. We retrospectively reviewed 97 patients who had undergone LADG for early gastric cancer between May 1998 and March 2004. We measured the degree of obesity by using the body mass index (BMI; kg/m(2)), and we compared the surgical outcomes between the normal BMI group (BMI < 23 kg/m(2)) and the high BMI group (BMI > or = 23 kg/m(2)). We further subdivided the patients into four groups: normal BMI males and normal BMI females, and high BMI males and high BMI females, and we analyzed them in terms of operation times, numbers of retrieved lymph nodes, and rates of postoperative complications. There were no significant differences between the normal and high BMI groups in terms of the patients' characteristics, surgical outcomes, postoperative courses, postoperative complications, and operation times. There were no statistically significant differences in the number of retrieved lymph nodes or in the rate of postoperative complications among the four groups (P = 0.5030 and P = 0.3489, respectively). However, there was a statistically significant difference in operation times among the four groups (P = 0.004). Specifically, the males in the high BMI group required a longer operation time than did the females with a normal BMI (P = 0.006) and the females with a high BMI (P = 0.019). For LADG in patients with early gastric cancer, obesity may affect the operation time, and men with high BMI require a longer operation time than do women with normal or high BMI.

Meta-analysis of short-term outcomes after laparoscopy-assisted distal gastrectomy

To elucidate the current status of laparoscopy-assisted distal gastrectomy (LADG) with regard to its short-term outcomes by comparing it with conventional open distal gastrectomy (CODG). Original articles published from January 1991 to August 2006 were searched in the MEDLINE, EMBASE, and Cochrane Controlled Trials Register. Clinical appraisal and data extraction were conducted independently by 2 reviewers. A meta-analysis was performed using a random effects model. Outcomes of 1611 procedures from 4 randomized controlled trials and 12 retrospective studies were analyzed. Compared to CODG, LADG was a longer procedure (weighted mean difference [WMD] 54.3; 95% confidence interval [CI] 38.8 to 69.8; P < 0.001), but was associated with a lower associated morbidity (odds ratio [OR] 0.54; 95% CI 0.37 to 0.77; P < 0.001); this was most significant for postoperative ileus (OR 0.27; 95% CI 0.09 to 0.84; P = 0.02). There was no significant difference between the two groups in anastomotic, pulmonary, and wound complications and mortality. Duration from surgery to first passage of flatus was faster (WMD -0.68; 95% CI -0.85 to -0.50; P < 0.001) and the frequency of additional analgesic requirement (WMD -1.36; 95% CI -2.44 to -0.28; P = 0.01), and duration of hospital stay (WMD -5.51; 95% CI -7.61 to -3.42; P < 0.001) were significantly lower after LADG. However, a significantly higher number of lymph nodes were dissected by CODG (WMD -4.35; 95% CI -5.73 to -2.98; P < 0.001). LADG for early gastric cancer is associated with a lower morbidity, less pain, faster bowel function recovery, and shorter hospital stay.