Laparoscopy-assisted Proximal Gastrectomy Research Articles

The Short-Term and Long-Term Outcomes of Laparoscopy-Assisted Proximal Gastrectomy with Double-Tract Reconstruction versus Laparoscopy-Assisted Total Gastrectomy with Roux-en-Y Reconstruction for Adenocarcinoma of the Esophagogastric Junction: A Multicenter Study Based on Propensity Score Matching Analysis.

To compare the antireflux effect, long-term nutritional levels, and quality of life (QoL) between laparoscopy-assisted proximal gastrectomy with double-tract reconstruction (LPG-DTR) and laparoscopy-assisted total gastrectomy with Roux-en-Y reconstruction (LTG-RY) for adenocarcinoma of the esophagogastric junction (AEG). This multicenter retrospective cohort study collected clinicopathological and follow-up data of AEG patients from January 2016 to January 2021 at five high-volume surgery centers. The study included patients who underwent digestive tract reconstruction with LPG-DTR or LTG-RY after tumor resection. Propensity score matching (PSM) was utilized to minimize confounding factors. The comparison after PSM included postoperative complications, reflux esophagitis, long-term nutritional levels, and QoL. A total of 151 consecutive patients underwent either LPG-DTR or LTG-RY. After PSM, 50 patients from each group were included in the analysis. The frequency of reflux esophagitis and Clavien-Dindo classification did not significantly differ between the two groups (P > 0.05). At 1 year after surgery, the LPG-DTR group showed significantly higher weight and hemoglobin levels than the LTG-RY group (P < 0.05). The overall postoperative Visick grade differed significantly between the groups (P < 0.05), but there was no significant difference in the proportion of patients with Visick≥III (P > 0.05). Both LPG-DTR and LTG-RY are safe and feasible methods for digestive tract reconstruction in patients with AEG. Both methods have similar antireflux effects and postoperative QoL. However, LPG-DTR resulted in superior nutritional levels compared to LTG-RY. Therefore, LPG-DTR is considered a relatively effective method for digestive tract reconstruction in AEG patients.

Safety and short-term outcomes of a modified valvuloplastic esophagogastrostomy versus gastric tube anastomosis after laparoscopy-assisted proximal gastrectomy: a retrospective cohort study

BackgroundThere is no optimal reconstruction method after proximal gastrectomy. The valvuloplastic esophagogastrostomy can reduce postoperative reflux esophagitis, but it is technically complex with a long operation time. The gastric tube anastomosis is technically simple, but the incidences of reflux esophagitis and anastomotic stricture are higher.MethodsWe have devised a modified valvuloplastic esophagogastrostomy after laparoscopy-assisted proximal gastrectomy (LAPG), the arch-bridge anastomosis. After reviewing our prospectively maintained gastric cancer database, 43 patients who underwent LAPG from November 2021 to April 2023 were included in this cohort study, with 25 patients received the arch-bridge anastomosis and 18 patients received gastric tube anastomosis. The short-term outcomes were compared between the two groups to evaluate the efficacy of the arch-bridge anastomosis. Reporting was consistent with the STROCSS 2021 guideline.ResultsThe median operation time was 180 min in the arch-bridge group, significantly shorter than the gastric tube group (p = 0.003). In the arch-bridge group, none of the 25 patients experienced anastomotic leakage, while one patient (4%) experienced anastomotic stricture requiring endoscopic balloon dilation. The postoperative length of stay was shorter in the arch-bridge group (9 vs. 11, p = 0.034). None of the patients in the arch-bridge group experienced gastroesophageal reflux and used proton pump inhibitor (PPI), while four (22.2%) patients in the gastric tube group used PPI (p = 0.025). The incidence of reflux esophagitis (Los Angeles grade B or more severe) by endoscopy was lower in the arch-bridge group (0% vs. 25.0%).ConclusionThe arch-bridge anastomosis is a safe, time-saving, and feasible reconstruction method. It can reduce postoperative reflux and anastomotic stricture incidences in a selected cohort of patients undergoing laparoscopy-assisted proximal gastrectomy.Graphical abstract

Long-term outcomes after laparoscopy-assisted total or proximal gastrectomy with nodal dissection for clinical stage I gastric cancer: Japan Clinical Oncology Group study (JCOG1401).

305 Background: JCOG0912 supports the non-inferiority of laparoscopy-assisted distal gastrectomy (LADG) compared with open distal gastrectomy (ODG) for clinical stage I gastric cancer relapse-free survival (RFS), suggesting that LADG should be considered a standard treatment option when performed by experienced surgeons. No prospective study evaluating laparoscopy-assisted total gastrectomy (LATG) and laparoscopy-assisted proximal gastrectomy (LAPG) has been completed in terms of both safety and long-term survival. Considering that the results of the phase III trial to evaluate the long-term outcome of LADG (JCOG0912) could guarantee that of LATG/LAPG, we conducted a single-arm confirmatory trial (JCOG1401) to evaluate the safety of LATG/LAPG for clinical stage I proximal gastric cancer and JCOG1401 confirmed the safety of LATG/LAPG. Long-term outcomes as the secondary endpoints of this study are reported here after 5-year follow-up period. Methods: Laparoscopic operators were limited to credentialed surgeons. The extent of nodal dissection was selected based on the Gastric Cancer Treatment Guidelines in Japan. The primary endpoint was the proportion of grade 2 (CTCAE ver. 4.0) or greater esophageal anastomotic leak. The sample size was determined to be 245 considering a threshold of 8% and expected value of 3% with a one-sided alpha error of 2.5% and statistical power of 90%. The secondary endpoints were overall survival (OS) and RFS. Results: Between April 2015 and February 2017, 245 patients were enrolled. Among them, 1 patient was excluded from safety analysis due to ineligible. LATG/LAPG was performed in 195/49. 170/47/17/8/2 patients had pStage IA/IB/II/IIIA/IIIB disease and 190/31/15/8 patients had pT1/T2/T3/T4 disease, respectively. Grade 2 or greater esophageal anastomotic leak was 2.5% (6/244) (95% CI 0.9-5.3), as previously reported. 5-year OS was 91.2% (95% CI 86.9-94.2). 5-year RFS was 90.0% (95% CI 85.5-93.2). Among 22 deaths, 14 patients died without recurrence and 8 patients died with recurrence. Twelve recurrences were observed in 5/2/4/1 patients for pT1/T2/T3/T4. The sites of recurrence were peritoneal metastasis in 2 cases, hematogenous metastasis in 9 cases (liver: 6, bone: 2, lung: 1), and other in 1 case. Conclusions: The long-term outcomes of LATG/LAPG for Stage I gastric cancer patients were excellent and seem comparable to those of open procedures. Similar to JCOG0912, JCOG1401 guarantee the long-term survival of LATG/LAPG. Clinical trial information: UMIN000017155 .

Short-term and long-term comparisons of laparoscopy-assisted proximal gastrectomy with esophagogastrostomy by the double-flap technique and laparoscopy-assisted total gastrectomy for proximal gastric cancer.

BackgroundAlthough proximal gastrectomy (PG) is a recognized surgical procedure for early proximal gastric cancer, total gastrectomy (TG) is sometimes selected due to concern about severe gastroesophageal reflux. Esophagogastrostomy by the double-flap technique (DFT) is an anti-reflux reconstruction after PG, and its short-term effectiveness has been reported. However, little is known about the long-term effects on nutritional status and quality of life (QOL).MethodsGastric cancer patients who underwent laparoscopy-assisted PG (LAPG) with DFT or laparoscopy-assisted TG (LATG) between April 2011 and March 2014 were retrospectively analyzed. Body weight (BW), body mass index (BMI), and prognostic nutritional index (PNI) were reviewed to assess nutritional status, and the Postgastrectomy Syndrome Assessment Scale (PGSAS)-45 was used to assess QOL.ResultsA total of 36 patients (LATG: 17, LAPG: 19) were enrolled. Four of 17 LATG patients (24%) were diagnosed with Stage ≥II after surgery, and half received S-1 adjuvant chemotherapy. BW and PNI were better maintained in LAPG than in LATG patients until 1-year follow-up. Seven of 16 LATG patients (44%) were categorized as “underweight (BMI<18.5 kg/m2)” at 1-year follow-up, compared to three of 18 LAPG patients (17%; p = 0.0836). The PGSAS-45 showed no significant difference in all QOL categories except for decreased BW (p = 0.0132). Multivariate analysis showed that LATG was the only potential risk factor for severe BW loss (odds ratio: 3.03, p = 0.0722).ConclusionsLAPG with DFT was superior to LATG in postoperative nutritional maintenance, and can be the first option for early proximal gastric cancer.

A Novel Technique of Hand-Sewn Purse-String Suturing by Double Ligation Method (DLM) for Intracorporeal Circular Esophagojejunostomy.

PurposeThe optimal method for intracorporeal esophagojejunostomy remains unclear because a purse-string suture for fixing the anvil into the esophagus is difficult to perform with a laparoscopic approach. Therefore, this study aimed to evaluate our novel technique to fix the anvil into the esophagus.Materials and MethodsThis retrospective study included 202 patients who were treated at our institution with an intracorporeal circular esophagojejunostomy in a laparoscopy-assisted total gastrectomy with a Roux-en-Y reconstruction (166 cases) or a laparoscopy-assisted proximal gastrectomy with jejunal interposition (36 cases). After incising 3/4 of the esophageal wall, a hand-sewn purse-string suture was placed on the esophagus. Next, the anvil head of a circular stapler was introduced into the esophagus. Finally, the circular esophagojejunostomy was performed laparoscopically. The clinical characteristics and surgical outcomes were evaluated and compared with those of other methods.ResultsThe average operation time was 200.3 minutes. The average hand-sewn purse-string suturing time was 6.4 minutes. The overall incidence of postoperative complications (Clavien–Dindo classification grade ≥II) was 26%. The number of patients with an anastomotic leakage and stenosis at the esophagojejunostomy site were 4 (2.0%) and 12 (6.0%), respectively. All patients with stenosis were successfully treated by endoscopic balloon dilatation. There was no mortality. Regarding the materials and devices for anvil fixation, only 1 absorbable thread was needed.ConclusionsOur procedure for hand-sewn purse-string suturing with the double ligation method is simple and safe.

Lower Esophageal Sphincter-preserving Anastomosis Is an Acceptable Reconstruction Method Following Laparoscopy-assisted Proximal Gastrectomy.

Our study aimed to compared 3-year results following laparoscopy-assisted proximal gastrectomy (LAPG)-double tract anastomosis (DTA) and lower esophageal sphincter-preserving LAPG (LES-LAPG). Nine patients who underwent LES-LAPG and 23 LAPG-DTA were compared regarding 3-year follow-up complications, the anemia-related parameter and albumin levels. During the 3-year follow-up period, no patient (0%) in the LES-LAPG and six patients (6/23, 26.1%) in the LAPG-DTA group developed reflux symptoms. Reflux symptoms were well controlled with PPI in all patients, except for one in the LAPG-DTA group. In the laboratory study, there were no differences in serum ferritin and vitamin B12 levels between the two groups. However, mean hemoglobin and albumin levels were significantly higher in the LES-LAPG group from 18 months postoperatively. LES-LAPG provided acceptable results for the prevention of reflux esophagitis. Moreover, LES-LAPG may be advantageous for anemia prevention and nutritional status improvement compared to LAPG-DTA.

Robot-Assisted Versus Laparoscopy-Assisted Proximal Gastrectomy for Early Gastric Cancer in the Upper Location: Comparison of Oncological Outcomes, Surgical Stress, and Nutritional Status.

Background:An increasing amount of attention has been paid to minimally invasive function-preserving gastrectomy, with an increase in incidence of early gastric cancer in the upper stomach. This study aimed to compare oncological outcomes, surgical stress, and nutritional status between robot-assisted proximal gastrectomy (RAPG) and laparoscopy-assisted proximal gastrectomy (LAPG).Methods:Eighty-nine patients were enrolled in this retrospective study between November 2011 and December 2013. Among them, 27 patients underwent RAPG and 62 underwent LAPG. Perioperative parameters, surgical stress, nutritional status, disease-free survival, and overall survival were compared between the 2 groups.Results:Sex, age, and comorbidity were similar in the RAPG and LAPG groups. There were also similar perioperative outcomes regarding operation time, complications, and length of hospital stay between the groups. The reflux esophagitis rates following RAPG and LAPG were 18.5% and 14.5%, respectively (P = .842). However, patients in the RAPG group had less blood loss (P = .024), more harvested lymph nodes (P = .021), and higher costs than those in the LAPG group (P < .001). With regard to surgical stress, no significant differences were observed in C-reactive protein concentrations and white blood cell count on postoperative days 1, 3, and 7 between the groups (Ps > .05). There appeared to be higher hemoglobin levels at 6 months (P = .053) and a higher body mass index at 12 months (P = .056) postoperatively in patients in the RAPG group compared with those in the LAPG group, but this difference was not significant. Similar disease-free survival and overall survival rates were observed between the groups.Conclusions:RAPG could be an alternative to LAPG for patients with early gastric cancer in the upper stomach with comparable oncological safety and nutritional status. Further well-designed, prospective, large-scale studies are needed to validate these results.

Laparoscopically Assisted Proximal Gastrectomy with Esophagogastrostomy Using a Novel “Open-Door” Technique

Laparoscopy-assisted proximal gastrectomy (LAPG) with esophagogastrostomy using a novel “open-door” technique was introduced recently, with the aim of preventing gastroesophageal reflux. However, quantitate assessment of gastroesophageal reflux after this surgery has not been performed till date. The aims of the current study were to investigate the safety and feasibility of this operation and to elucidate the postoperative reflux status. Twenty consecutive patients (18 men) with (y)cStage I gastric cancer in the upper third of the stomach who underwent LAPG at Kitasato University Hospital from May 2015 through September 2016 were retrospectively reviewed. We performed 24-h impedance-pH monitoring 3 months after surgery for the first eight patients and analyzed the postoperative reflux status. Median operation time was 333 min, while median anastomotic time was 81 min. None of the 20 patients experienced anastomotic leakage while two patients experienced anastomotic stricture requiring endoscopic balloon dilatation. No patient experienced heartburn without antacid drugs. During the 24-h impedance-pH monitoring, all but one patient had normal gastroesophageal acid reflux with the acid percent time of <1.1% and reflux percent time of <1.4%. One patient with marginally abnormal postoperative gastroesophageal reflux had a normal DeMeester score of 3.0. Our results showed that esophagogastrostomy using the “open-door” technique is a safe and feasible procedure for LAPG. The degree of gastroesophageal reflux was acceptable using this technique. Randomized controlled trials with long-term follow-ups are required to confirm that this technique would be superior to the others.

Two atypical cases of esophagogastric junctional bronchogenic cyst: one case included squamous cell carcinoma

Bronchogenic cysts are congenital lesions that are derived from the lung bud and are often found in the thoracic cavity, and intra-abdominal bronchogenic cysts are really rare. They are associated with respiratory symptoms and typically require surgical resection. Herein, we describe two cases with esophagogastric junctional bronchogenic cysts. Our first case was a man in his 30s who had a submucosal tumor at esophagogastric junction, which required laparoscopic enucleation. The second case was a woman in her 50s who underwent laparoscopy-assisted proximal gastrectomy. The resected tumor was diagnosed as a bronchogenic cyst, with squamous cell carcinoma at the mucosal surface. Bronchogenic cysts are occasionally associated with complications and malignancies, and thus, preventive and diagnostic resection is recommended.

Efficacy analysis of laparoscopy-assisted total gastrectomy and proximal gastrectomy in treatment of adenocarcinoma of esophagogastric junction

Objective To investigate the clinical efficacy of laparoscopy-assisted total gastrectomy (LATG) and laparoscopy-assisted proximal gastrectomy (LAPG) in treatment of adenocarcinoma of esophago-gastric junction (AEG). Methods The retrospective cohort study was conducted. The clinicopathological data of 130 patients with AEG who underwent laparoscopy-assisted radical gastrectomy at the Peking University Cancer Hospital between May 2009 and February 2016 were collected. Among 130 patients, 91 undergoing LATG were allocated into the LATG group and 39 undergoing LAPG were allocated into the LAPG group. D2 lymph node dissection was applied to patients in the 2 groups according to the Japanese gastric cancer treatment guidelines. Patients received digestive tract reconstruction though a small midline incision in the epigastric region after laparoscopy-assisted lymph node dissection: patients in the LATG group and LAPG group received respectively Roux-en-Y esophagojejunostomy and residual stomach-esophagus anastomosis. Observation indicators included: (1) intra- and post-operative situations: overall surgical situation, number of patients with conversion to open surgery, operation time, volume of intraoperative blood loss, number of patients with intraoperative blood transfusion, number of lymph node dissected, time to anal exsufflation and duration of postoperative hospital stay. (2) Occurrence of complications: overall complications, surgery-related complications (slight and severe complications), reoperation, medical complications and death from surgery-related complication within 30 days postoperatively. Severity of complications was evaluated according to Clavien-Dindo classification. (3) Follow-up situations. Patients were followed up by outpatient examination, telephone interview and correspondence up to August 31, 2016. Follow-up included the tumor recurrence and metastasis. Overall survival time was counted from operation date to end of follow-up or time of death. Because follow-up time of 48 patients who underwent surgery from September 2014 to February 2016 was less than 2 years, survival analysis of the other 82 patients who underwent surgery from May 2009 to August 2014 was done. Measurement data with normal distribution were represented as ±s and comparison between groups was analyzed using the independent-sample t test. Measurement data with skewed distribution were represented as M (range) and comparison between groups was analyzed using the nonparametric test. Comparison of count data was analyzed using the chi-square test, and ranked data was analyzed using the nonparametric test. Survival curve was drawn by the Kaplan-Meier method, and survival analysis was done using the Log-rank test. Results (1) Intra- and post-operative situations: all the 130 patients underwent successful radical gastrectomy, and 7 patients converted to open surgery due to local tumor progression invading adjacent organs, abdominal adhesions and obesity. Operation time and number of lymph node dissected were (280±46)minutes, 28 (range, 14-80) in the LATG group and (258±57)minutes, 23 (range, 14-46) in the LAPG group, respectively, with statistically significant differences between the 2 groups (t=-2.305, Z=-4.168, P 0.05). The same patients may have multiple complications. Patients with complications received reoperation or corresponding treatment, 1 with anastomotic bleeding and 1 with intra-abdominal bleeding died and other patients had a smooth recovery. (3) Follow-up situations: 128 of 130 patients were followed up for 1-82 months with a median time of 39 months. During the follow-up, 28 patients died, including 25 dying of tumor recurrence and 3 dying of non-tumor causes. Of 82 patients in survival analysis, 3-year overall survival rate was 77.9% in 45 patients of LATG group and 72.2% in 37 patients of LAPG group, showing no statistically significant difference between the 2 groups (χ2=1.432, P>0.05). Conclusion Safety of LATG in treatment of AEG is equal to that of LAPG, and LATG can dissect more lymph nodes. Key words: Esophagogastric junction neoplasms, adenocarcinoma; Gastrectomy; Laparoscopy; Safety; Long-term outcomes

Modified esophagogastrostomy in laparoscopy-assisted proximal gastrectomy: A reverse-Tornado anastomosis.

The aim of this study was to introduce and examine a modified mechanical end-to-side esophagogastrostomy method ("reverse-Tornado" anastomosis) in laparoscopy-assisted proximal gastrectomy. Five patients with gastric cancer who underwent laparoscopy-assisted proximal gastrectomy were analyzed retrospectively. Esophagogastrostomy in the anterior wall was performed in three patients, and esophagogastrostomy in the posterior wall was performed in two patients. Clinicopathological features, operative outcomes (operative time, operative blood loss), and postoperative outcomes (complications, postoperative hospital stay, reflux esophagitis) were evaluated. Operative time was normal (278min). There was no marked operative blood loss, postoperative complications, prolonged hospital stay, or reflux esophagitis. Esophagogastrostomy was completed in a normal time with reverse-Tornado anastomosis. This method can be safe and can enable good postoperative quality of life.

Laparoscopy-assisted Proximal Gastrectomy with Double Tract Anastomosis Is Beneficial for Vitamin B12 and Iron Absorption.

Double tract anastomosis (DTA) is a recently revisited reconstruction method for preventing reflux esophagitis in laparoscopy-assisted proximal gastrectomy (LAPG). However, only few studies have shown the advantages of LAPG-DTA. Seventeen patients underwent LAPG-DTA compared to 17 patients undergoing laparoscopy-assisted total gastrectomy (LATG) matched with preoperative stage. Laboratory results, including hemoglobin, serum ferritin, serum iron and vitamin B12, were compared. Reflux esophagitis developed in two and one patient in the LAPG-DTA and LATG groups, respectively. In the laboratory analysis, fewer patients experienced decrease of serum ferritin below the low normal limit in the LAPG-DTA group. There was a significantly lower proportion of patients in the LAPG-DTA group whose vitamin B12 level decreased below the low normal limit. LAPG-DTA has the advantages of allowing absorption of iron and vitamin B12 without reflux esophagitis in proximal early gastric cancer compared to LATG.

Restoration of gastrointestinal motility ameliorates nutritional deficiencies and body weight loss of patients who undergo laparoscopy-assisted proximal gastrectomy.

Esophagogastrostomy after proximal gastrectomy (PG) is a simple and safe reconstruction, but it leads to a high incidence of reflux esophagitis and impairs postoperative quality of life. We have already reported gastric tube (GT) reconstruction after PG and performed it on more than 100 patients. No studies have reported long-term outcomes after PG-GT. The aim of this study was to investigate long-term outcomes, including nutrition indices, such as body weight, serum albumin, total protein, hemoglobin, and ferritin after PG, and observe recovery of upper gastrointestinal tract motility. We analyzed body weight loss and laboratory findings at our outpatient clinic at 1, 6, 12, 24, 36, 48, and 60months postoperatively. Manometric recording was carried out at 1, 2, 3, 4, and 5years after surgery. The percentage change in body weight in the PG-GT group was significantly larger than that in the PG-JI and TG-RY groups at 2.5, 3, 4, and 5years after surgery. The levels of hemoglobin and ferritin in the PG-GT and PG-JI groups were significantly higher than those in the TG-RY group at all time points except 6months after surgery. In the fasted state, the phase III originated at the gastric tube was propagated to the duodenum 3years after surgery. In the fed state, phasic contractions of the duodenum were in harmony with gastric tube contractions 3years after surgery. PG-GT is the least invasive procedure, and restoration of gastrointestinal motilities in the gastric tube and duodenum may ameliorate body weight loss and nutritional status, including anemia, in patients after PG.

Laparoscopy-Assisted Proximal Gastrectomy with the Hinged Double Flap Method.

No standard proximal gastrectomy method for gastric cancer of the upper third of the stomach (UGC) has been established because few of the current methods prevent gastro-esophageal reflux and allow easy postoperative endoscopic surveillance. In the present study, we describe laparoscopic proximal gastrectomy with the hinged double flap method (Kamikawa's method) in detail and examine the short- to medium-term outcomes of this approach, which resulted in excellent postoperative function. Between 2011 and 2015, 24 patients with early-stage primary UGC underwent laparoscopic proximal gastrectomy with the above-mentioned method. The celiac and hepatic nerves were preserved without pyloroplasty. A hand-sewn esophagogastric anastomosis was produced intracorporeally. There were no in-hospital deaths, and none of the patients were converted to open surgery. Complications occurred in two patients in the early part of this study (minor anastomotic leakage in one case and an abdominal abscess in the other). None of the patients exhibited symptoms of reflux. Regarding the patients' postoperative endoscopic classifications, 17, 2, and 1 patient were considered to have grade N or M, grade A, and grade B esophagitis, respectively. All of the patients remain alive, and no cases of postoperative bowel obstruction or recurrent cancer have been observed. This method can be performed safely and achieves excellent outcomes in terms of preventing gastro-esophageal reflux. It deserves further evaluation in a multi-center clinical study.

Non-Randomized Confirmatory Trial of Laparoscopy-Assisted Total Gastrectomy and Proximal Gastrectomy with Nodal Dissection for Clinical Stage I Gastric Cancer: Japan Clinical Oncology Group Study JCOG1401

Several prospective studies on laparoscopy-assisted distal gastrectomy for early gastric cancer have been initiated, but no prospective study evaluating laparoscopy-assisted total gastrectomy or laparoscopy-assisted proximal gastrectomy has been completed to date. A non-randomized confirmatory trial was commenced in April 2015 to evaluate the safety of laparoscopy-assisted total gastrectomy and laparoscopy-assisted proximal gastrectomy for clinical stage I gastric cancer. A total of 245 patients will be accrued from 42 Japanese institutions over 3 years. The primary endpoint is the proportion of patients with anastomotic leakage. The secondary endpoints are overall survival, relapse-free survival, proportion of patients with completed laparoscopy-assisted total gastrectomy or laparoscopy-assisted proximal gastrectomy, proportion of patients with conversion to open surgery, adverse events, and short-term clinical outcomes. The UMIN Clinical Trials Registry number is UMIN000017155.

Clinical Outcome of Modified Laparoscopy-Assisted Proximal Gastrectomy Compared to Conventional Proximal Gastrectomy or Total Gastrectomy for Upper-Third Early Gastric Cancer with Special References to Postoperative Reflux Esophagitis.

PurposeThis study evaluated the functional and oncological outcomes of proximal gastrectomy (PG) in comparison with total gastrectomy (TG) for upper-third early gastric cancer (EGC).Materials and MethodsThe medical records of upper-third EGC patients who had undergone PG (n=192) or TG (n=157) were reviewed. The PG group was further subdivided into patients who had undergone conventional open PG (cPG; n=157) or modified laparoscopy-assisted PG (mLAPG; n=35). Patients who had undergone mLAPG had a longer portion of their intra-abdominal esophagus preserved than patients who had undergone cPG. Surgical morbidity, recurrence, long-term nutritional status, and the incidence of reflux esophagitis were compared between the groups.ResultsThe rate of postoperative complications was significantly lower for PG than TG (16.7% vs. 31.2%), but the five-year overall survival rate was comparable between the two groups (99.3% vs. 96.3%). Postoperative levels of hemoglobin and albumin were significantly higher for patients who had undergone PG. However, the incidence of reflux esophagitis was higher for PG than for TG (37.4% vs. 3.7%; P<0.001). mLAPG was related to a lower incidence of reflux esophagitis after PG (P<0.001).ConclusionsCompared to TG, PG showed an advantage in terms of postoperative morbidity and nutrition, and there was a comparable prognosis between the two procedures. Preserving the intra-abdominal esophagus may lower the incidence of reflux esophagitis associated with PG.

A newly modified esophagogastrostomy with a reliable angle of His by placing a gastric tube in the lower mediastinum in laparoscopy-assisted proximal gastrectomy.

An optimal reconstruction method for proximal gastrectomy (PG) remains elusive. Esophagogastrostomy (EG) is technically simple but suffers from the disadvantage of gastroesophageal reflux. Jejunal interposition (JI) has a low rate of gastroesophageal reflux, but the procedure is more complicated, and delayed gastric emptying is a problem. We created a modified EG and have used the modified technique for PG since 2006. The procedure involves shaping the remnant stomach into a gastric conduit. The EG is performed high on the anterior wall, and the conduit is kept straight by applying a circular stapler inserted from the anterior wall of the antrum. The tip of the gastric conduit is then inserted into the lower mediastinum, creating a sharp angle of His. In this retrospective cohort study, the clinical and physiological outcomes were compared between 25 patients who underwent this procedure and 21 patients who underwent JI from 2001 to 2005. Laparoscopic procedures were performed more frequently, and residual food and bile reflux were less common in the EG group than in the JI group. No significant differences in remnant gastritis or reflux esophagitis were observed between the two groups. However, the late complication of intestinal obstruction occurred only in the JI group. The modified EG technique has advantages over the JI technique because of its simplicity and low incidence of residual food and bile reflux. The next step would be to explore this technique further by a prospective multi-institutional study to confirm the reproducibility of its benefits. Miniabstract: The modified EG technique has advantages over the JI technique because of its simplicity, high rate of laparoscopy use, and low incidence of gastroesophageal reflux.

Safety of intracorporeal circular stapling esophagojejunostomy using trans-orally inserted anvil (OrVil™) following laparoscopic total or proximal gastrectomy - comparison with extracorporeal anastomosis

BackgroundThere have been several attempts to develop a unique and easier way to perform esophagojejunostomy during laparoscopy-assisted total gastrectomy or laparoscopy-assisted proximal gastrectomy. The OrVil™ system (Covidien, Mansfield, MA, USA) is one of those methods, but its technical and oncologic feasibility have not been proven and need to be observed.MethodsAmong 87 patients who underwent laparoscopy-assisted total gastrectomy (LATG; 79 cases) and laparoscopy-assisted proximal gastrectomy with double tract anastomosis (LAPG_DT; 8 cases) from April 2004, 47 patients underwent the conventional extracorporeal method (Group I; 2004–2008) were compared with 40 patients treated with the intracorporeal OrVil™ system (Group II; 2009–2012).ResultsThere was no significant difference in clinicopathologic characteristics between the two groups except tumor location; more cardia lesions were involved in group II (p = 0.012). The mean time for esophagojejunostomy (E-J), defined as the time from anvil insertion to closure of the jejunal entry site has no significant difference (Group I vs II: 22.2 ± 3.2 min vs 18.6 ± 3.5 min, p = 0.623). In terms of anastomotic complication, there was no significant difference in E-J leakage and stricture. E-J leakage occurred in 2 out of 47 (4.3%) cases in group I and 2 out of 40 (5%) in group II (p = 0.628); half of them were treated conservatively in each group and the others underwent reoperation. E-J stricture occurred in 2 (4.3%) cases in group I and 1 (2.5%) in group II (p = 0.561), which required postoperative gastrofiberscopic balloon dilatation.ConclusionsEsophagojejunostomy using the OrVil™ system was a feasible and safe technique compared with the conventional extracorporeal method through mini-laparotomy in terms of anastomotic complications. Moreover, it can help to reduce surgeon’s stress regarding esophagojejunostomy because it needs no purse-string procedure and serves a secure operation view laparoscopically.

Function-Preserving Gastrectomy for Early Gastric Cancer

The number of early gastric cancer (EGC) cases has been increasing because of improved diagnostic procedures. Applications of function-preserving gastric cancer surgery may therefore also be increasing because of its low incidence of lymph node metastasis, excellent survival rates, and the possibility of less-invasive procedures such as laparoscopic gastrectomy being used in combination. Pylorus-preserving gastrectomy (PPG) with radical lymph node dissection is one such function-preserving procedure that has been applied for EGC, with the indications, limitations, and survival benefits of PPG already reported in several retrospective studies. Laparoscopy-assisted proximal gastrectomy has also been applied for EGC of the upper third of the stomach, although this procedure can be associated with the 2 major problems of reflux esophagitis and carcinoma arising in the gastric stump. In the patient with EGC in the upper third of the stomach, laparoscopy-assisted subtotal gastrectomy with a preserved very small stomach may provide a better quality of life for the patients and fewer postoperative complications. Finally, the laparoscopy endoscopy cooperative surgery procedure combines endoscopic submucosal dissection with laparoscopic gastric wall resection, which prevents excessive resection and deformation of the stomach after surgery and was recently applied for EGC cases without possibility of lymph node metastasis. Function-preserving laparoscopic gastrectomy is recommended for the treatment of EGC if the indication followed by accurate diagnosis is strictly confirmed. Preservation of remnant stomach sometimes causes severe postoperative dysfunctions such as delayed gastric retention in PPG, esophageal reflux in PG, and gastric stump carcinoma in the remnant stomach. Moreover, these techniques present technical difficulties to the surgeon. Although many retrospective studies showed the functional benefit or oncological safety of function-preserving gastrectomy, further prospective studies using large case series are necessary.

Laparoscopy-assisted proximal gastrectomy for early gastric cancer is an ugly duckling with unsolved concerns: oncological safety, late complications, and functional benefit

Laparoscopy-assisted proximal gastrectomy for early gastric cancer is an ugly duckling with unsolved concerns: oncological safety, late complications, and functional benefit