Totally Laparoscopic Distal Gastrectomy Research Articles

Totally laparoscopic versus laparoscopy-assisted distal gastrectomy: the KLASS-07, a randomized controlled trial.

Strong evidence is lacking as no confirmatory randomized controlled trials (RCTs) have compared the efficacy of totally laparoscopic distal gastrectomy (TLDG) with laparoscopy-assisted distal gastrectomy (LADG). We performed an RCT to confirm if TLDG is different from LADG. The XXXXX trial is a multicentre, open-label, parallel-group, phase III, RCT of 442 patients with clinical stage I gastric cancer. Patients were enrolled from 21 cancer care centers in South Korea between January 2018 and September 2020 and randomized to undergo TLDG or LADG using blocked randomization with a 1:1 allocation ratio, stratified by the participating investigators. Patients were treated through R0 resections by TLDG or LADG as the full analysis set of the XXXXX trial. The primary endpoint was morbidity within postoperative day 30, and the secondary endpoint was QoL for 1 year. This trial is registered at ClinicalTrials.gov (NCT XXXXXXXX). 442 patients were randomized (222 to TLDG, 220 to LADG), and 422 patients were included in the pure analysis (213 and 209, respectively). The overall complication rate did not differ between the two groups (TLDG vs. LADG: 12.2% vs. 17.2%). However, TLDG provided less postoperative ileus and pulmonary complications than LADG (0.9% vs. 5.7%, P=0.006; and 0.5% vs. 4.3%, P=0.035, respectively). The QoL was better after TLDG than after LADG regarding emotional functioning at 6 months, pain at 3 months, anxiety at 3 and 6 months, and body image at 3 and 6 months (all P<0.05). However, these QoL differences were resolved at 1 year. The XXXXX trial confirmed that TLDG is not different from LADG in terms of postoperative complication but has advantages to reduce ileus and pulmonary complications. TLDG can be a good option to offer better QoL in terms of pain, body image, emotion, and anxiety at 3-6 months.

The benefits of R anastomotic technique for Billroth-II reconstruction with Braun anastomosis during totally laparoscopic distal gastrectomy: a propensity score matching analysis.

Currently, there is no consensus on the most appropriate anastomotic site, anastomotic line, and direction for Billroth-II reconstruction with Braun anastomosis (B-II-B anastomosis) during totally laparoscopic distal gastrectomy (TLDG). Herein, the authors presented a novel anastomotic technique called R anastomosis for B-II-B anastomosis and compared it with the conventional B-II-B anastomosis technique to assess its feasibility, safety, and effectiveness. Between March 2019 and September 2022 in our centre, R anastomosis was performed on 123 patients undergoing TLDG for distal gastric cancer. A retrospective review of a prospectively collected database identified patients who underwent TLDG between January 2010 and September 2022. Patients who underwent R anastomosis were matched in a 1:1 ratio with patients who underwent conventional anastomosis using a propensity score based on age, sex, preoperative BMI, American Society of Anesthesiologists (ASA) score, and the history of abdominal surgery. Surgical and postoperative outcomes and clinicopathological data were analyzed for both groups. During the study period, 246 patients were included, 123 in each group. No intraoperative complications associated with digestive tract reconstruction and no cases of conversion to open surgery were reported in either group; furthermore, no incidences of perioperative mortality were noted in either group. The R group had a significantly reduced anastomotic time compared to the control group (30 ± 4.1 vs. 36 ± 5.3 min, P < 0.001). Perioperatively, the incidences of Clavien-Dindo grade II or higher complications were 6.5% (8/123) and 12.2% (15/123) in the R and control groups with no significant difference between the two groups. Postoperative gastric emptying dysfunction was found in five and one patient in the control and R groups, respectively. R anastomosis is a safe and effective technique for B-II-B anastomosis following TLDG. This novel technique enhances the convenience of performing anastomosis and can reduce postoperative gastric emptying dysfunction.

Surgical Outcomes of Laparoscopic-assisted Distal Gastrectomy Versus Totally Laparoscopic Distal Gastrectomy Billroth I for Gastric Cancer.

The present study aimed to compare intraoperative and postoperative outcomes of laparoscopic-assisted distal gastrectomy versus totally laparoscopic distal gastrectomy (TLDG) Billroth I (BI) for gastric cancer and to assess the impact of the initial introduction phase of TLDG BI anastomosis. The study analyzed the prospectively collected data of patients who underwent laparoscopic distal gastrectomy BI from 2014 to 2021 at Seoul National University Hospital. Among 1116 patients, laparoscopic-assisted distal gastrectomy BI was performed in 566 patients and TLDG BI was performed in 550 patients. The total laparoscopic arm had a faster mean operative time (190 vs 208 min; P < 0.001) and a shorter postoperative hospital stay (7.4 vs 7.9 d; P < 0.001). Local complications were higher in the total laparoscopic group (17.6% vs 9.9%; P = 0.008) during the early introduction phase. The total laparoscopic approach for BI reconstruction is safe and effective with faster operative time, shorter hospital stays, and less wound infection, but it may be associated with an increase in postoperative surgical complications and hospital stay in the early introduction phase.

Comparative Study of the Short-Term Outcomes and Long-Term Outcomes using Total 3D and 2D Laparoscopic Distal Gastrectomy with Delta-Shaped Anastomosis for Gastric Cancer

Comparative Study of the Short-Term Outcomes and Long-Term Outcomes using Total 3D and 2D Laparoscopic Distal Gastrectomy with Delta-Shaped Anastomosis for Gastric Cancer

Short- and long-term outcomes of Roux-en-Y and Billroth II with Braun reconstruction in total laparoscopic distal gastrectomy: a retrospective analysis

BackgroundThe controversy surrounding Roux-en-Y (R-Y) and Billroth II with Braun (BII + B) reconstruction as an anti-bile reflux procedure after distal gastrectomy has persisted. Recent studies have demonstrated their efficacy, but the long-term outcomes and postoperative quality of life (QoL) among patients have yet to be evaluated. Therefore, we compared the short-term and long-term outcomes of the two procedures as well as QoL.MethodsThe clinical data of 151 patients who underwent total laparoscopic distal gastrectomy (TLDG) at the Gastrointestinal Surgery Department of the Second Hospital of Fujian Medical University from January 2016 to December 2019 were retrospectively analyzed. Of these, 57 cases with Roux-en-Y procedure (R-Y group) and 94 cases with Billroth II with Braun procedure were included (BII + B group). Operative and postoperative conditions, early and late complications, endoscopic outcomes at year 1 and year 3 after surgery, nutritional indicators, and quality of life scores at year 3 postoperatively were compared between the two groups.ResultsThe R-Y group recorded a significantly longer operative time (194.65 ± 21.52 vs. 183.88 ± 18.02 min) and anastomotic time (36.96 ± 2.43 vs. 27.97 ± 3.74 min) compared to the BII + B group (p < 0.05). However, no other significant differences were observed in terms of perioperative variables, including blood loss (p > 0.05). Both groups showed comparable rates of early and late complications. Endoscopic findings indicated similar food residuals at years 1 and 3 post-surgery for both groups. The R-Y group had a lower occurrence of residual gastritis and bile reflux at year 1 and year 3 after surgery, with a statistically significant difference (p < 0.001). Reflux esophagitis was not significantly different between the R-Y and BII + B groups in year 1 after surgery (p = 0.820), but the R-Y group had a lower incidence than the BII + B group in year 3 after surgery (p = 0.023). Nutritional outcomes at 3 years after surgery did not differ significantly between the two groups (p > 0.05). Quality of life scores measured by the QLQ-C30 scale were not significantly different between the two groups. However, on the QLQ-STO22 scale, the reflux score was significantly lower in the R-Y group than in the BII + B group (0 [0, 0] vs. 5.56 [0, 11.11]) (p = 0.003). The rest of the scores were not significantly different (p > 0.05).ConclusionBoth R-Y and B II + B reconstructions are equally safe and efficient for TLDG. Nevertheless, the R-Y reconstruction reduces the incidence of residual gastritis, bile reflux, and reflux esophagitis, as well as postoperative reflux symptoms, and provides a better quality of life for patients. R-Y reconstruction is superior to BII + B reconstruction for TLDG.

Book-Binding Technique in Totally Laparoscopic Distal Gastrectomy with Billroth I Reconstruction: Clinical Results and Outcomes in 188 Patients with Gastric Cancer.

Laparoscopic gastrectomy is widely used as a curative treatment for gastric cancer. Although delta-shaped anastomosis is commonly used for Billroth I anastomosis after totally laparoscopic distal gastrectomy (TLDG), it has some drawbacks. The book-binding technique (BBT) was developed as an alternative, and this study aimed to examine its short-term results in 188 consecutive cases. This retrospective study included patients who underwent BBT reconstruction after TLDG for gastric malignancy between 2011 and 2020. BBT is a technique for intracorporeal gastroduodenostomy, which is a triangular anastomosis with a linear stapler that does not require additional dissection or rotation of the duodenum. The short-term outcomes of BBT reconstruction and postoperative endoscopic findings were analyzed. This study evaluated 188 patients who underwent TLDG and BBT reconstruction. Anastomotic stenosis and leakage occurred in 1.1% and 0.5% of the patients, respectively. The median time to the first diet was 3.1 days, and the median postoperative hospital stay was 11.9 days. BBT anastomoses were performed by 19 surgeons and took an average of 32.8 minutes to complete, with completion times decreasing as the surgical team became more proficient. On endoscopy performed 1 year postoperatively, 5.2% had reflux esophagitis (grade A or higher), 67.8% had gastritis (grade 1 or higher), 37.4% had residual food (grade 1 or higher), and 37.4% had bile reflux (grade 1). BBT is a safe and feasible method for intracorporeal gastroduodenostomy in TLDG for patients with gastric malignancy and demonstrates good surgical outcomes.

Safety and efficacy of augmented-rectangle technique versus delta-shaped anastomosis for treating gastric cancer in total laparoscopic distal gastrectomy.

This study aimed to evaluate the safety and efficacy of augmented-rectangle technique (ART) versus delta-shaped anastomosis (DA) for treating gastric cancer in total laparoscopic distal gastrectomy. In total, 99 patients with distal gastric cancer who underwent ART (n = 60) or DA (n = 39) were considered. Operative data, postoperative recovery, complications, quality of life, and endoscopic findings of both groups were compared. The ART group had faster postoperative recovery than the DA group, and was better than DA regarding complications. The mode of reconstruction remained an independent predictor of complications, but not postoperative recovery. Dumping syndrome occurred in 3 (5.0%) and 2 patients (5.1%) of ART and DA groups within 30days after surgery, and 3 (5.0%) and 2 patients (5.1%) 1year after surgery. Regarding global health status on the EORTC-QLQ-C30 scale, the ART group had better outcomes than the DA group. Gastritis occurred in 38 (63.3%) and 27 (69.3%) patients of ART and DA groups, respectively. Residual food occurred in 8 (13.3%) and 11 (28.2%) patients of ART and DA groups. Reflux esophagitis occurred in 5 (8.3%) and 4 (10.3%) patients of ART and DA groups. Further, bile reflux occurred in 8 (13.3%) and 4 (10.3%) patients of ART and DA groups. ART has similar advantages to DA for total laparoscopic reconstruction and is superior to DA regarding the incidence of complications, complication grade, and global health status. Furthermore, ART may have potential advantages in postoperative recovery and anastomotic stenosis.

Effects of different radical distal gastrectomy on postoperative inflammatory response and nutritional status in patients with gastric cancer.

The inflammatory response caused by gastric cancer surgery and the low nutritional status of patients with gastric cancer can cause growth of tumour cells, reduce immunity, and increase tumour burden. We investigated the effects of different surgical methods on postoperative inflammatory response and nutritional status in patients with distal gastric cancer. Clinical data of 249 patients who underwent radical distal gastrectomy for distal gastric cancer from February 2014 to April 2017 were retrospectively analysed. Patients were divided according to the surgical method (open distal gastrectomy [ODG], laparoscopic-assisted distal gastrectomy [LADG] and total laparoscopic distal gastrectomy [TLDG]). Characteristics of different surgical procedures, including inflammation parameters and nutritional indicators, and different time points (preoperatively, 1 day postoperatively, and 1 week postoperatively) were compared using non-parametric test analysis. At postoperative day 1, white blood cell count [WBC], neutrophil count [N], neutrophil/lymphocyte ratio [NLR], and platelet/lymphocyte ratio [PLR] increased in the three groups, and ΔN and ΔNLR were significant; the smallest change was observed in TLDG (P < 0.05). Albumin [A]and prognostic nutrition index [PNI] significantly decreased; the smallest ΔA and ΔPNI, which were statistically significant, were noted in TLDG. One week postoperatively, WBC, N, NLR, and PLR decreased, and WBC, N, and NLR showed significant difference. A and PNI of the three groups increased after 1 week, and A and PNI showed significant differences. Postoperative inflammatory response and nutritional status of patients with distal gastric cancer are associated with the surgical technique. TLDG has little influence on the inflammatory response and nutritional level compared with LADG and ODG.

Effectiveness and safety of self-pulling and latter transected Roux-en-Y reconstruction in totally laparoscopic distal gastrectomy.

BackgroundSelf-pulling and latter transection (SPLT) reconstruction has been applied in total laparoscopic total gastrectomy and BI reconstruction (known as Delta SPLT) in total laparoscopic distal gastrectomy (TLDG) in some previous studies. This approach can reduce the technical difficulty of the surgery as well as the quantity of cartridges required, with manageable safety. Here, we used SPLT to complete Roux-en-Y reconstruction in TLDG and evaluated the safety and effectiveness of this novel method by comparing it with conventional Roux-en-Y reconstruction in laparoscopy-assisted distal gastrectomy (LADG).MethodsPatients with gastric cancer who underwent SPLT-TLDG or LADG between June 2019 and September 2021 were retrospectively analyzed. Baseline information and postoperative short-term surgical outcomes of the two groups were compared.ResultsA total of 114 patients with gastric cancer were included in the study. Patients underwent SPLT-TLDG (n = 73, 64.0%) or LADG (n = 41, 36.0%). No patient underwent open surgery. There were no differences in patient demographics or tumor characteristics between the two groups. The mean intraoperative blood loss was 47.1 ± 34.3 ml in the SPLT-TLDG group, which was significantly less than that in the LADG group (P = 0.022). There were no significant differences in operation time, harvested lymph nodes, time to first flatus, time to liquid intake, or postoperative hospital stay between the two groups. Nine and five patients had short-term postoperative complications in the SPLT-TLDG and LADG groups, respectively.ConclusionWe introduced a self-pulling and latter transected Roux-en-Y reconstruction (SPLT-RY) for use in TLDG. We showed that SPLT-RY reconstruction in TLDG is a safe and feasible surgical method in terms of short-term surgical outcomes and has the advantages of simplifying the reconstruction.

Application of Overlap Gastroduodenostomy in Billroth I Anastomosis after Totally Laparoscopic Distal Gastrectomy for Gastric Cancer.

Delta-shaped gastroduodenostomy (DSGD) and overlap gastroduodenostomy (OGD) are the two most widely used intracorporeal Billroth I anastomosis methods after distal gastrectomy. In this study, we compared the short-term outcomes of DSGD and OGD in total laparoscopic distal gastrectomy (TLDG). In a retrospective cohort study, we examined 92 gastric cancer patients who underwent TLDG performed by the same surgeon between January 2014 and June 2018. All patients underwent Billroth I reconstruction (OGD, n = 45; DSGD, n = 47) and D2 lymph node dissection. We retrospectively reviewed the surgical outcomes, clinical pathological results, and endoscopy results. Laparoscopic surgery was successfully performed in both groups without conversion to open surgery. The demographic and clinical characteristics were similar between the two groups (P > 0.05). There were no significant differences between the two groups in operation time (158.9 ± 13.6 min vs. 158.8 ± 14.8 min, P=0.955), anastomotic time (19.4 ± 3.0 min vs. 18.8 ± 2.9 min, P=0.354), intraoperative blood loss (88.9 ± 25.4 mL vs. 83.7 ± 24.3 mL, P=0.321), number of lymph node dissections (31.0 ± 7.1 vs. 29.2 ± 7.5, P=0.229), length of hospital stay (8.8 ± 2.7 days vs. 9.1 ± 3.0 days, P=0.636), fluid intake time (3.1 ± 0.7 days vs. 3.2 ± 0.7 days, P=0.914), and morbidity of postoperative complications (6.7% [3/45] vs. 10.6% [5/47], P=0.499). Endoscopy performed 6 months postoperatively showed that the residual food (P=0.033), gastritis (P=0.029), and bile (P=0.022) classification score significantly decreased in the OGD group, and there were no significant differences 12 months postoperatively. OGD is a safe and effective reconstruction technique with comparable postoperative surgical outcomes and endoscopy results when compared with those of DSGD.

A 3-year follow-up study of uncut Roux-en-Y reconstruction: clinical results and outcomes.

The goal of this study was to identify the clinical outcomes of uncut Roux-en-Y reconstruction in patients who underwent totally laparoscopic distal gastrectomy (TLDG) over 3-year follow-up. From January 2016 to December 2017, 269 patients who underwent TLDG were enrolled in the study and analyzed retrospectively. They were classified into two groups according to the reconstruction method: uncut Roux-en-Y reconstruction (uncut RY) (n = 154) and Billroth II with Braun anastomosis (B-II/Braun) (n = 115). Postoperative endoscopic findings (residual food, bile reflux, gastritis, and esophagitis) and nutritional status (body weight, serum hemoglobin, total protein, and albumin levels) were assessed every 6months for 3years. Residual food was less frequent in the uncut RY group in the 6th month after TLDG (p = 0.022), but there were no differences between the two groups for the rest of the study period. The incidence of bile reflux and gastritis was low in the uncut RY group during all postoperative periods (all p &lt; 0.001). In the B-II/Braun group, the frequency of reflux esophagitis was high in the 30th and 36th months after TLDG (both p &lt; 0.001), and there were no differences between the two groups during the preceding periods. No significant differences were found with respect to nutritional status, such as body weight, serum hemoglobin, total protein, and albumin levels during all postoperative periods. Three-year follow-up outcomes showed that uncut RY can effectively reduce the incidence of bile reflux and gastritis in the remnant stomach compared to B-II/Braun after TLDG.

Long-term outcomes of postgastrectomy syndrome after total laparoscopic distal gastrectomy using the augmented rectangle technique.

BACKGROUNDFor total laparoscopic distal gastrectomies for gastric cancer, the reconstruction method is critical to the clinical outcome of the procedure. However, which reconstruction technique is optimal remains controversial. We originally reported the augmented rectangle technique (ART) as a reconstruction option for total laparoscopic Billroth I reconstructions. Still, little is known about its effect on long-term outcomes, specifically the incidence of postgastrectomy syndrome and its impact on quality of life.AIMTo analyze postgastrectomy syndrome and quality of life after ART using the Postgastrectomy Syndrome Assessment Scale-37 (PGSAS-37) questionnaire. METHODSAt Juntendo University, a total of 94 patients who underwent ART for Billroth I reconstruction with total laparoscopic distal gastrectomies for gastric cancer between July 2016 and March 2020 completed the PGSAS-37 questionnaire. Multidimensional analysis was performed, comparing those 94 ART cases from our institution (ART group) to 909 distal gastrectomy cases with a Billroth I reconstruction from other Japanese institutions who also completed the PGSAS-37 as part of a larger national database (PGSAS group). RESULTSPatients in the ART group had significantly better total symptom scores in all the symptom subscales (i.e., esophageal reflux, abdominal pain, meal-related distress, indigestion, diarrhea, constipation, and dumping). The loss of body weight was marginally greater for those in the ART group than in the PGSAS group (-9.3% vs -7.9%, P = 0.054). The ART group scored significantly lower in their dissatisfaction of ongoing symptoms, during meals, and with daily life.CONCLUSIONART for Billroth I reconstruction provided beneficial long-term results for postgastrectomy syndrome and quality of life in patients undergoing total laparoscopic distal gastrectomies for gastric cancer.

Billroth II anastomosis maintains SMI and BMI better than Roux-en-Y anastomosis following totally laparoscopic distal gastrectomy: a propensity score-matched study.

Gastric cancer is a major public health problem around the globe. With the standardization of tumor treatment, surgery continues to be the most important treatment method for gastric cancer. However, changes in body composition and nutrition index parameters in patients with Billroth II and Roux-en-Y anastomosis following totally laparoscopic distal gastrectomy (TLDG) remain unclear. This was a single-center retrospective study. A total of 369 patients who underwent TLDG at the First Affiliated Hospital of Soochow University (Suzhou, China) between January 2016 and February 2019 were included and assigned to the Billroth II group or Roux-en-Y group according to the anastomosis method. After propensity score matching, body composition and relevant clinical data were compared between the two groups. The operation time for the Billroth II group was significantly shorter than for the Roux-en-Y group (174.12 ± 39.33min vs. 229.19 ± 28.12min, P < 0.001). In addition, the Billroth II group showed lower skeletal muscle loss. Specifically, the Billroth II group showed a - 4.77 ± 4.88% change in the skeletal muscle index (SMI), whereas the Roux-en-Y group showed a - 11.89 ± 8.68% change (P = 0.001). The Billroth II group also showed a smaller decrease in BMI than the Roux-en-Y group (- 6.67 ± 7.76% vs. - 13.12 ± 10.79%, P = 0.018). These results suggest that Billroth II anastomosis after TLDG has advantages over Roux-en-Y for maintaining patient body composition, especially in terms of SMI, and may serve as a useful reference when choosing an anastomosis method.

Prophylactic drains in totally laparoscopic distal gastrectomy: are they always necessary?

Prophylactic drains have always been a useful tool to detect early complications and prevent postoperative fluid collections, particularly in gastrointestinal surgery. Recently, the utilization of such drains has been debated, due to mounting evidence that they could be harmful rather than beneficial. Based on recent published articles, Liu et al reported that the routine use of prophylactic drains in total laparoscopic distal gastrectomy might not be necessary for all patients. Herein, we express our opinion regarding this interesting publication.

A Modified Billroth-II with Braun Anastomosis in Totally Laparoscopic Distal Gastrectomy: Initial Experience Compared with Roux-en-Y Anastomosis.

This retrospective study aimed to compare the feasibility and effectiveness of a modified Billroth-II with Braun (B-II Braun) reconstruction and those of a Roux-en-Y (R-Y) reconstruction after laparoscopic distal gastrectomy. From January 2016 to December 2019, 247 patients underwent total laparoscopic distal gastrectomy (TLDG), with B-II Braun reconstruction for 145 patients and R-Y reconstruction for 102 patients. The patients' data were collected prospectively and reviewed retrospectively. In this study, the median times of the operation were statistically shorter for B-II Braun than for R-Y (167 min [range, 110-331min] vs 191min [range, 123-384min]; p = 0.001), including anastomotic times (33min [range, 30-42min] vs 42min [range, 40-48min]; p = 0.001). After a short-term follow-up period, endoscopy showed 31 cases of bile reflux (21.4%), 15 cases of grade 2 gastritis (10.3%), and 6 cases of grade 2 food residue (4.1%) in the B-II Braun group after 6months. After 1year, 10 patients (6.9%) had grade 2 gastritis and 2 patients (1.4%) had grade 3 gastritis. However, the remnant stomach of the two groups did not differ significantly in the rate of gastric residue (p = 0.112 after 6months; p = 0.579 after 1year, respectively), gastritis (p = 0.726 after 6months; p = 0.261 after 1year, respectively), or bile reflux (p = 0.262 after 6months; p = 0.349 after 1year, respectively). For gastric cancer patients, TLDG with modified B-II Braun reconstruction could be technically feasible. It has an acceptable range of postoperative complications and is effective in preventing bile reflux into the gastric remnant.

Modification of book-binding technique during totally laparoscopic distal gastrectomy with Billroth I reconstruction.

The book-binding technique (BBT) has been developed to minimise extra detachment and mobilisation of the duodenum for totally laparoscopic distal gastrectomy (TLDG) with Billroth I reconstruction. Because of the cost-effectiveness and maximisation of the anastomotic lumen, we have modified the BBT in collaboration with the laparoscopic hand-sewing technique. Herein, we introduce a modified BBT (MBBT) and discuss its outcomes. The MBBT was performed using laparoscopic hand-sewing techniques with an absorbable barbed suture instead of using linear staples to close the defect of the anterior wall of the anastomosis site. The data of 163 patients with gastric cancer who underwent TLDG with Billroth I reconstruction performed with MBBT were retrospectively collected between April 2014 and December 2019. The mean anastomosis time was 25 min (interquartile range, 21 - 30). Postoperative complications of Clavien-Dindo grade II or greater occurred in 20 of the 163 patients (12.3%). Anastomotic leakage occurred in three patients (1.8%), whereas anastomotic stenosis occurred in one patient (0.6%). The cumulative incidence rate of anastomotic stenosis that required endoscopic dilation at 1 year was 1.2%. The MBBT method may be safe, practical, cost-effective and results in reduced staple use and anastomotic time.

Transpyloric optic navigation of tumor using a laparoscope during totally laparoscopic distal gastrectomy for gastric cancer.

PurposeThe purpose of this study was to describe the technique of intraoperative transpyloric optic navigation (TPON) and determine its efficacy and feasibility during totally laparoscopic distal gastrectomy (TLDG) in patients with gastric cancer.MethodsSeventy-nine patients who underwent laparoscopic gastrectomy with transpyloric optic localization of the tumor from January 2016 through December 2018 were enrolled in this study. After resecting the first portion of the duodenum, the distal part of the stomach was exteriorized through an extended supraumbilical trocar site, and a balloon trocar was introduced from the pylorus to determine the location of tumor and determine its resection margin. The clinicopathologic and surgical outcomes were analyzed.ResultsThe tumor was located in the lower third of the stomach in 39 cases, the middle third in 34 cases, and the upper-third in six cases. Tumor localization was successful in 67 patients. The mean proximal margin was 41.7 ± 26.8 mm. There was no morbidity related to the technique. By the fifth postoperative day, the average white blood cell count was within the normal range and the average level of C-reactive protein showed a decreasing pattern.ConclusionTPON of the tumor during TLDG is an effective and feasible method to determine the tumor location and to obtain an adequate resection margin.

Comparing short-term outcomes after totally laparoscopic distal gastrectomy and laparoscopy-assisted distal gastrectomy with Billroth I anastomosis: early experience of a single institution.

PurposeTo determine the safety and feasibility of totally laparoscopic distal gastrectomy (TLDG) with modified delta-shaped anastomosis, we compared the short-term outcomes of TLDG to those of laparoscopy-assisted distal gastrectomy (LADG) with Billroth I anastomosis.MethodsWe analyzed the characteristics of 85 patients with gastric cancer who underwent laparoscopic distal gastrectomy with Billroth I anastomosis between January 2013 and December 2018. After propensity score matching, each group had 35 patients.ResultsOf these 85 patients, 44 underwent TLDG and 41 underwent LADG. Propensity score matching was performed with three covariates (age, underlying disease, and hypertension), and 35 patients from each group were matched 11. After matching, the TLDG group was older than the LADG group (64.5 ± 10.6 years vs. 56.3 ± 11.2 years, p = 0.003) and had more patients with hypertension (57.1% vs. 22.9%, p = 0.003). Tumors were larger in the TLDG group than in the LADG group (23.4 ± 16.2 mm vs. 16.0 ± 7.9 mm, p = 0.018). A greater proportion of patients had fever in the TLDG group than the LADG group (42.9% vs. 20.0%, p = 0.039), and C-reactive protein from postoperative days 3 to 6 was greater in the TLDG group (11.4 ± 5.7 mg/dL vs. 7.0 ± 5.0 mg/dL, p = 0.001).ConclusionAlthough our data represent only our early experience performing TLDG with modified delta-shaped anastomosis, this procedure is relatively safe and feasible. Nevertheless, compared to LADG, which is the conventional method, the operative time for TLDG was longer. Surgeons must also watch out for anastomotic complications.

Comparison of totally laparoscopic and laparoscopic assisted gastrectomy after neoadjuvant chemotherapy in locally advanced gastric cancer

BackgroundNeoadjuvant chemotherapy (NACT) and laparoscopic surgery have been increasingly used in the treatment of gastric cancer, however, the feasibility and safety of totally laparoscopic gastrectomy after NACT still remain unknown. Materials and methodsAt the Gastrointestinal cancer center of Peking university cancer hospital and institute in Beijing, clinical and pathological data of patients who has received NACT, followed by radical laparoscopic gastrectomy was retrospectively reviewed between March 2011 and November 2019. Patients were divided into 2 groups according to whether intracorporeal anastomosis or extracorporeal anastomosis had been performed, short-term outcomes (post-operative recovery index and complications) and economic cost were compared between 2 groups. ResultAll of 139 patients underwent laparoscopic gastrectomy. 87 [62.6%] patients had totally laparoscopic gastrectomy (TLG) and 52 [37.4%] patients had laparoscopic-assisted gastrectomy (LAG). Overall complication rate was 28.8% in all patients. TLG group was significantly associated with lower overall complication rate (21.8% VS 40.4%; p = 0.019) and major complication rate (3.4% VS 13.5%; p = 0.001) compared with LAG group. Overall cost was similar (p = 0.077). In subgroup analysis, totally laparoscopic total gastrectomy (TLTG) group showed lower overall postoperative complication rate (19.0% VS 56.5%; p = 0.011), as well as marginal significant differences in major complication (0% VS 21.7%; p = 0.05) than laparoscopic-assisted total gastrectomy (LATG) group. Earlier first liquid diet (4 [3.5–5] day VS 6 [4–6.5] day; p = 0.047), earlier first aerofluxus (3 [3-4] day VS 4 [3–4.5] day; p = 0.02) and a shorter hospital stay (9 [8-12] day VS 12 [10-15] day; p = 0.004) were observed in TLTG group. Overall and major complication rate were similar in totally laparoscopic distal gastrectomy (TLDG) and laparoscopic assisted distal gastrectomy (LADG) group (22.7% VS 27.6%; p = 0.611; 4.5% VS 6.9%; p = 0.639; respectively). Significant differences were found between TLDG and LADG groups regarding time to first liquid diet (4 [3-5] day VS 6 [3.75–6] day; p = 0.006), time to first aerofluxus (3 [3–3] day VS 4 [3-6] day; p< 0.001), time to first defecation (4 [4-5] day VS 5 [4-6] day; p = 0.045), time to remove all drainage (7 [6-8] day VS 8 [6-9] day; p = 0.021), white blood cell count on postoperative Day 1 (9.54 ± 2.49 109/L VS 10.91 ± 2.89 109/L; p = 0.021)and postoperative hospital stay (9 [8-10] day VS 10 [9,13] day; p = 0.009). ConclusionFor patients with Locally advanced gastric cancer who received NACT, totally laparoscopic gastrectomy, including TLTG and TLDG, doesn’t increase complications and overall cost compared with LAG, and has advantages in gastrointestinal function recovery, incision length and postoperative hospital stay.

Intracorporeal semi-hand-sewn Billroth I reconstruction in total laparoscopic distal gastrectomy.

Intracorporeal Billroth I (B-I) reconstruction using an endoscopic linear stapler (ELS) is widely performed in total laparoscopic distal gastrectomy. However, conventional procedures require many ELSs for anastomosis. Here, we introduce the novel intracorporeal semi-hand-sewn (SHS) B-I reconstruction. After the transection of stomach and duodenum using ELS following adequate lymph node dissection, small entry holes were made on the anterior wall in the greater curvature of the stomach and the duodenal stump. The posterior walls of both the remnant stomach and the duodenum were attached with the ELS and fired to create the posterior wall of the B-I anastomosis. All the transection line of the duodenum and one-third of the transection line of the stomach were dissected; finally the anterior wall suturing at the anastomotic site was performed by the laparoscopic hand-sewn technique. SHS procedure was performed for 17 gastric cancer patients. There were no intraoperative complications or conversions to open surgery. One intra-abdominal abscess was observed although there was no anastomotic leakage. The median reconstruction time was 48 minutes (32-63). The SHS procedure was safe, feasible, and economical, although it requires sufficient laparoscopic suturing and ligation skill.