Laparoscopic Total Gastrectomy Research Articles

Comparison of Outcomes of Totally Laparoscopic Total Gastrectomy (Overlap Reconstruction) versus Laparoscopic-Assisted Total Gastrectomy for Advanced Siewert III Esophagogastric Junction Cancer and Gastric Cancer of Upper and Middle Third of Stomach: Study Protocol for a Single-Center Randomized Controlled Trial.

BackgroundTotally laparoscopic total gastrectomy (TLTG) using the overlap reconstruction method is associated with fewer postoperative complications and fast recovery than laparoscopic-assisted radical total gastrectomy (LATG). However, evidence on the safety and feasibility of TLTG (overlap reconstruction) in patients with advanced Siewert III esophagogastric junction cancer and gastric cancer of the upper and middle third of the stomach is scarce.MethodsThis study is a prospective, single-center, single-blind, two-arm randomized controlled trial designed to include 292 patients with advanced Siewert III esophagogastric junction cancer and gastric cancer of the upper and middle third of the stomach who will be randomly assigned to two groups: a TLTG overlap group (n=146) and an LATG group (n=146). The patients’ demographics, pathological characteristics, intraoperative variables, postoperative complications, postoperative recovery variables, 3-year disease-free survival and 3-year overall survival will be collected and analyzed. The primary outcome is the postoperative complications within 30 days after surgery including intra-abdominal hemorrhage, anastomotic leakage, duodenal stump fistula, pancreatic fistula, chyle leakage, abdominal infection, intestinal obstruction, wound complications, pulmonary infection, pleural effusion, pulmonary embolism, cardiovascular and cerebrovascular complications, and deep vein thrombosis. The secondary outcomes are the 3-year disease-free survival and 3-year overall survival.DiscussionThis trial will provide high-level evidence for the safety and feasibility of TLTG (overlap reconstruction) compared with LATG in advanced Siewert III esophagogastric junction cancer and the upper and middle third of gastric cancer.Trial RegistrationThis trial has been registered at the Chinese Clinical Trial Registry: ChiCTR1900025667 (registration date: September 4, 2019).

Double PTEG (percutaneous trans-esophageal gastro-tubing) was useful in nutrition and decompression for a gastric cancer patient with pyloric stenosis: a case report

Background For gastric cancer patients with strong pyloric stenosis, decompression by nasogastric tube insertion for gastric distension and central venous nutrition management have been performed. However long-term indwelling of the nasogastric tube is accompanied by pain, and Central venous catheter placement is inferior to enteral nutrition from infection risk and nutritional viewpoint. Furthermore, these generally require management in hospitalization. Case presentation An 81-year-old male was referred to our hospital for gastric cancer accompanied by pyloric stenosis. Blood test resulted in low nutrition and anemia. CT showed thickening of the wall from the anterior gastric part to the pylorus and enlargement of 50mm in the regional lymph node, and gastric distention. We planned resection after preoperative chemotherapy. We performed double PTEG (Percutaneous Tran Esophageal Gastro-tubing) from cervical co-wound for decompression and nutrition management of the stomach. Total laparoscopic gastrectomy was performed on day 114 after insertion of the double PTEG. During which time he had been good nutrition and no gastric distention with stayed at home for 42 days. On the 10th postoperative day, he was clinically released from hospital without any complications. Conclusions We conducted a new management to reduce and nourish patients with gastric cancer who had a pyloric stenosis by double PTEG (percutaneous trans-esophageal gastro-tubing), and can perform curative surgery after preoperative chemotherapy including home management period.

Risk Factors for the Severity of Complications in Minimally Invasive Total Gastrectomy for Gastric Cancer: a Retrospective Cohort Study.

PurposeMinimally invasive gastrectomy is a promising surgical method with well-known benefits, including reduced postoperative complications. However, for total gastrectomy of gastric cancers, this approach does not significantly reduce the risk of complications. Therefore, we aimed to evaluate the incidence and risk factors for the severity of complications associated with minimally invasive total gastrectomy for gastric cancer.Materials and MethodsThe study included 392 consecutive patients with gastric cancer who underwent either laparoscopic or robotic total gastrectomy between 2011 and 2019. Clinicopathological and operative characteristics were assessed to determine the features related to postoperative complications after minimally invasive total gastrectomy. Binomial and multinomial logistic regression models were used to identify the risk factors for overall complications and mild and severe complications, respectively.ResultsOf 103 (26.3%) patients experiencing complications, 66 (16.8%) and 37 (9.4%) developed mild and severe complications, respectively. On multivariate multinomial regression analysis, independent predictors of severe complications included obesity (OR, 2.56; 95% CI, 1.02−6.43; P=0.046), advanced stage (OR, 2.90; 95% CI, 1.13−7.43; P=0.026), and more intraoperative bleeding (OR, 1.04; 95% CI, 1.02−1.06; P=0.001). Operation time was the only independent risk factor for mild complications (OR, 1.06; 95% CI, 1.001−1.13; P=0.047).ConclusionsThe risk factors for mild and severe complications were associated with surgery, indicating surgical difficulty. Surgeons should be aware of these potential risks that are related to the severity of complications so as to reduce surgery-related complications after minimally invasive total gastrectomy for gastric cancer.

ARE THERE DIFFERENCES IN LAPAROSCOPIC GASTRECTOMY MORBIDITY AND MORTALITY BETWEEN YOUNG AND OLDER?

ABSTRACT Background:Due to the longer life expectancy and consequently an increase in the elderly population, a higher incidence of gastric cancer is expected in this population in the coming decades. Aim:To compare the results of laparoscopic GC surgical treatment between individuals aged<65 years (group I) and ≥ 65 years (group II), according to clinical, surgical, and histopathological characteristics. Methods:A observational retrospective study was performed by analyzing medical charts of patients with gastric cancer undergoing total or subtotal laparoscopic gastrectomy for curative purposes by a single oncologic surgery team. Results:Thirty-six patients were included in each group. Regarding the ASA classification, 31% of the patients in group I was ASA 1, compared to 3.1% in group II. The mean number of concomitant medications in group II was statistically superior to group I (5±4.21 x 1.42±3.08, p<0.001). Subtotal gastrectomy was the most performed procedure in both groups (69.4% and 63.9% in groups I and II, respectively) due to the high prevalence of distal tumors in both groups, 54.4% group I and 52.9% group II. According to Lauren's classification, group I presented a predominance of diffuse tumors (50%) and group II the intestinal type (61.8%). There was no difference between the two groups regarding the number of resected lymph nodes and lymph node metastases and the days of hospitalization and mortality. Conclusion:Laparoscopic gastrectomy showed to be a safe procedure, without a statistical difference in morbidity, mortality, and hospitalization time between both groups.

155P Surgical outcomes and technical performance of robotic versus laparoscopic total gastrectomy for gastric cancer: A prospective comparative study FUGES-014

155P Surgical outcomes and technical performance of robotic versus laparoscopic total gastrectomy for gastric cancer: A prospective comparative study FUGES-014

130P Reappraisal of the role of no. 10 lymphadenectomy for proximal gastric cancer in the era of minimal invasive surgery during total gastrectomy: A pooled analysis of 4 prospective trials

For patients with locally advanced proximal gastric cancer (LAPGC), the individualized selection of patients with highly suspected splenic hilar (No. 10) lymph node (LN) metastasis to undergo splenic hilar lymphadenectomy, is a clinical dilemma. This study aimed to re-evaluate the feasibility and safety of laparoscopic spleen-preserving splenic hilar lymphadenectomy (LSPSHL) and to identify the population who would benefit from it. A total of 1068 patients (D2 group=409; D2+No. 10 group=659) who underwent laparoscopic total gastrectomy from four prospective trials between January 2015 and July 2019 were analyzed. No significant difference in the incidence (16.9% vs. 16.4%; P = 0.837) of postoperative complications were found between the two groups. The metastasis rate of No. 10 LN among patients in the D2+No. 10 group was 10.3% (68/659). Based on the decision tree, patients with LAPGC with tumor invading the greater curvature (Gre), patients with non-Gre-invading LAPGC with a tumor size >5 cm and clinical positive locoregional LNs were defined as the high-priority No. 10 dissection group. The metastasis rate of No. 10 LNs in the high-priority group was 19.4% (41/211). In high-priority group, the 3-year overall survival of the D2+No. 10 group was better than that of the D2 group (74.4% vs. 42.1%; P = 0.005), and the therapeutic index of No. 10 was higher than the indices of most suprapancreatic stations. LSPSHL for LAPGC is safe and feasible when performed by experienced surgeons. LSPSHL could be recommended for the high-priority group patients even without invasion of the Gre.

Totally laparoscopic total gastrectomy with technique of functional end-to-end esophagojejunostomy by linear stapler without previous resection of the esophagus and jejunum

Background: The technique of esophagojejunostomy in totally laparoscopic total gastrectomy is difficult and had a high frequency of incidents during surgery and anastomotic leakage. We aimed to evaluate the outcomes of the technique of functional end-to-end esophagojejunostomy by linear stapler without previous resection of the esophagus and jejunum in the totally laparoscopic total gastrectomy with D2 lymph node dissection in the treatment of gastric cancer.Methods: A prospective observational study on patients received technique of functional end-to-end esophagojejunostomy by linear stapler without previous resection of esophagus and jejunum between July 2017 to July 2020.Results: We included 70 patients with a mean age of 62.5. There were 80% of patients having tubular adenocarcinoma and papillary adenocarcinoma, 11.4% of patients having tumors in the upper third of the stomach, and 81.4% of patients having tumors in the middle of the stomach. There were 4.2% of cases having incidents during the surgery and 2.8% of cases having complications after the surgery. No anastomotic leakage or death was observed after the surgery. The mean lymph node was 23, and the mean metastatic lymph node was 2.7. The operation time was 203.8 minutes. The mean hospital stay was 8.0 days. The one year survival after the surgery was 97.9%, and two year survival was 93.1%. The mean survival was 35.3 months.Conclusions: TLTG with D2 lymph node dissection using functional end-to-end esophagojejunostomy by linear stapler without previous resection of esophagus and jejunum was safe and effective in gastric cancer treatment.

Effects of early oral feeding after radical total gastrectomy in gastric cancer patients.

BACKGROUNDGastric cancer (GC) is a heavy burden in China. Nutritional support for GC patients is closely related to postoperative rehabilitation. However, the role of early oral feeding after laparoscopic radical total gastrectomy in GC patients is unclear and high-quality research evidence is scarce.AIMTo prospectively explore the safety, feasibility and short-term clinical outcomes of early oral feeding after laparoscopic radical total gastrectomy for GC patients.METHODSThis study was a prospective cohort study conducted between January 2018 and December 2019 based in a high-volume tertiary hospital in China. A total of 206 patients who underwent laparoscopic radical total gastrectomy for GC were enrolled. Of which, 105 patients were given early oral feeding (EOF group) after surgery, and the other 101 patients were given the traditional feeding strategy (control group) after surgery. Perioperative clinical data were recorded and analyzed. The primary endpoints were gastrointestinal function recovery time and postoperative complications, and the secondary endpoints were postoperative nutritional status, length of hospital stay and expenses, etc.RESULTSCompared with the control group, patients in the EOF group had a significantly shorter postoperative first exhaust time (2.48 ± 1.17 d vs 3.37 ± 1.42 d, P = 0.001) and first defecation time (3.83 ± 2.41 d vs 5.32 ± 2.70 d, P = 0. 004). In addition, the EOF group had a significant shorter postoperative hospitalization duration (5.85 ± 1.53 d vs 7.71 ± 1.56 d, P < 0.001) and lower postoperative hospitalization expenses (16.60 ± 5.10 K¥ vs 21.00 ± 7.50 K¥, P = 0.014). On the 5th day after surgery, serum prealbumin level (214.52 ± 22.47 mg/L vs 204.17 ± 20.62 mg/L, P = 0.018), serum gastrin level (246.30 ± 57.10 ng/L vs 223.60 ± 55.70 ng/L, P = 0.001) and serum motilin level (424.60 ± 68.30 ng/L vs 409.30 ± 61.70 ng/L, P = 0.002) were higher in the EOF group. However, there was no significant difference in the incidence of total postoperative complications between the two groups (P = 0.507).CONCLUSIONEarly oral feeding after laparoscopic radical total gastrectomy can promote the recovery of gastrointestinal function, improve postoperative nutritional status, reduce length of hospital stay and expenses while not increasing the incidence of related complications, which indicates its safety, feasibility and potential benefits for gastric cancer patients.

Short-Term and Quality of Life Outcomes of Patients Using Linear or Circular Stapling in Esophagojejunostomy after Laparoscopic Total Gastrectomy

BackgroundStudies comparing the incidence of reflux esophagitis (RE) and patients’ quality of life (QoL) when using circular stapler (CS) and linear stapler (LS) in esophagojejunostomy (EJS) after laparoscopic total gastrectomy (LTG) are rare, and certainly there are not enough to make a definitive decision on best practice. Presented herein is a study on the comparison of the short-term outcomes, QoL of the patients with the focus on the incidence of RE after both linear and circular stapling in LTG. MethodsFrom January 2014 to October 2018, 120 patients were analyzed; of these, 42 patients underwent laparoscopy-assisted total gastrectomy (LATG) with CS (CS group) and 78 patients who underwent totally laparoscopic total gastrectomy (TLTG) with LS (LS group). We examined the results obtained in terms of perioperative outcomes, reflux-related assessments (GerdQ questionnaire and endoscopy findings with all cases; 24-h pH monitoring with limited cases), and EORTC QLQ-C30 and QLQ-STO22. In addition, questionnaires were also supplied to patients and the results were recorded. ResultsThe incidence of anastomotic stenosis (7.1% vs. 0; P < 0.05) and the median intraoperative blood loss (180.0 vs. 100.0 mL; P < 0.05) of the CS group were higher than the LS group. The factor aside, no significant differences were observed between the two groups with regard to the incidence of RE assessed by the QLQ-STO22 reflux scale, the GerdQ scores, endoscopy (in all cases), or the percent time of pH > 7 (in limited cases) (P > 0.05). In the EORTC QLQ-C30 and QLQ-STO22, it was noted that the score of constipation [0 (0, 0) vs. 0 (0, 33.3); P = 0.028] and postoperative dysphagia [0 (0, 0) vs. 0 (0, 22.2); P = 0.046] of the LS group in a 1-year follow-up were lower than the CS group. ConclusionsTLTG with LS generated better results than LATG with CS in terms of the incidence of anastomotic stenosis, intraoperative blood loss, and postoperative constipation and dysphagia. Furthermore, when compared with circular stapling, linear stapling in EJS did not increase the incidence of RE assessed by the QLQ-STO22 reflux scale, the GerdQ scores, endoscopy (in all cases), or the percent time of pH > 7 (in limited cases).

Comparison of reverse puncture device and overlap in laparoscopic total gastrectomy for gastric cancer.

Background:Intracorporeal oesophagojejunostomy is one of the key steps in laparoscopic total gastrectomy (LTG). At present, there is no widely accepted anastomosis technique in oesophagojejunostomy.Materials and Methods:We retrospectively studied 63 patients with gastric cancer who underwent LTG. Two types of anastomosis techniques have been applied during LTG: the reverse puncture device (RPD) (28 patients) and overlap (35 patients).Results:A total of 63 patients (51 males and 12 females: mean age = 58 years and mean body mass index [BMI] = 26.3 kg/m2) were enrolled in this study. There were no significant difference in age, BMI, duration of surgery, duration of anastomosis, blood loss, post-operative hospital stay, tumour location, tumour size, degree of tumour differentiation, Borrmann type, total number of lymph nodes, number of positive lymph nodes, hospital stay, hospitalisation costs, intra-operative complications, post-operative complications and prognosis between the RPD group and the overlap group. RPD group showed a significant advantage in terms of the distance between the top border of tumours and the top resection margin (P < 0.001). We further found that the oesophageal lateral negative surgical margin distance of the upper gastric cancer in the RPD group was significantly longer than that in the overlap group (P < 0.001).Conclusions:Both the RPD and overlap techniques are safe and applicable in LTG. However, RPD has the advantage of obtaining an adequate safe margin compared with that of overlap technique, especially in patients with gastro-oesophageal junction carcinoma.

Enhanced Recovery after Surgery in Elderly Gastric Cancer Patients Undergoing Laparoscopic Total Gastrectomy

BackgroundThe aim of this study was to evaluate the effects of the enhanced recovery after surgery (ERAS) program versus conventional perioperative care on the short-term postoperative outcomes among elderly patients with gastric cancer who are undergoing laparoscopic total gastrectomy. MethodsElderly patients with gastric cancer (age ≥ 65 y) who are undergoing laparoscopic total gastrectomy were randomized to ERAS or conventional perioperative care groups. Short-term postoperative outcomes, including postoperative hospital stay, mortality, complications, readmission rate, and reoperation rate were compared between the two groups. In addition, blood samples were taken preoperatively (baseline) and on postoperative days 1, 3, and 5. Systemic human leukocyte antigen (HLA)-DR expression on monocytes and C-reactive protein (CRP) were analyzed. ResultsOf the 171 eligible patients, 85 patients were assigned to receive ERAS program treatment (ERAS group) and 86 patients to receive conventional care (conventional group). The patients’ characteristics were comparable. Postoperative hospital stay was shorter in the ERAS group than in the conventional group (11 [7-11] versus 13 [8-20] d, P < 0.001). Hospital mortality, overall morbidity, morbidity ≥ Clavien-Dindo (C-D) grade II, readmission rate, and reoperation rate did not show significant differences between the two groups. However, morbidity ≥ C-D grade IIIa was lower in the ERAS group than that in the conventional group (8.2% versus 18.6%, P = 0.047). The ERAS program shortened the number of days to postoperative first flatus, first defecation, semifluid diet, and soft bland diet. Moreover, the ERAS program increased the HLA-DR expression on monocytes and decreased the CRP levels on postoperative days 1, 3, and 5. ConclusionsThe ERAS program was feasible and effective for elderly patients with gastric cancer who are undergoing laparoscopic total gastrectomy. The benefits of ERAS were associated with improvement of impaired immune function and suppression of inflammatory reaction.

Gastrectomía total oncológica laparoscópica

&#x0D; Introducción &#x0D; La gastrectomía oncológica laparoscópica ha aumentado en los últimos años debido a los beneficios postoperatorios, manteniendo los principios oncológicos. &#x0D; Describimos los principales aspectos técnicos de la gastrectomía total oncológica laparoscópica.&#x0D; Descripción de contenidos&#x0D; Paciente portador de un adenocarcinoma gástrico avanzado subcardial.&#x0D; Comenzamos con lavado peritoneal, apertura del epiplón mayor, resecando los ganglios del grupo 4 y 5, sección del pedículo gastroepiploico derecho resecando el grupo 6. Sección del duodeno y linfadenectomía del grupo 8, 9 y 11.&#x0D; Sección de la arteria coronaria estomáquica (grupo 7). Resección del epiplón menor hasta el hiato esofágico y resecamos los grupos ganglionares 1, 2 y 3.&#x0D; Seccionamos el esófago, extraemos la pieza y resección del epiplón mayor. Reconstrucción del tránsito digestivo en Y de Roux.&#x0D; Conclusiones&#x0D; La gastrectomía laparoscópica oncológica es una técnica factible y segura. Su realización requiere experiencia en cirugía oncológica esofagogastrica y en cirugía laparoscópica de avanzada.

The technique of fourth jejunal artery-based jejunal conduit for oesophagojejunostomy after thoracolaparoscopic oesophagogastrectomy for locally advanced Siewert type II tumour.

Background:Locally advanced long Siewert type II tumor requires total gastrectomy and D2 lymphadenectomy with distal esophagectomy and mediastinal lymphadenectomy for curative resection. In this scenario, a laparoscopic transhiatal approach is not feasible, and the conventional left thoracoabdominal approach is associated with increased morbidity.Aims and Objectives:To describe a novel technique of fourth jejunal artery based jejunal conduit for thoracoscopic esophagojejunostomy after laparoscopic esophagogastrectomy.Materials and Methods:The laparoscopic total gastrectomy with distal esophagectomy specimen is extracted through the periumbilical incision. A pedicled jejunal conduit based on the fourth jejunal artery is prepared, and the jejunal conduit is placed in the mediastinum under laparoscopic guidance. Using the thoracoscopic approach in a prone position, additional esophageal clearance and subcarinal lymphadenectomy are performed. Handsewn end to side esophagojejunostomy is performed at the level of the carina.Results:Three patients with long Siewert type II underwent this procedure after neoadjuvant chemotherapy. None of the patients had conduit related complications. All three patients had abdominal lymph node involvement and two patients had mediastinal lymph node involvement.Conclusion:Pedicled jejunal conduit based on the fourth jejunal artery is safe for intrathoracic anastomosis after minimally invasive esophagogastrectomy for locally advanced Siewert type II tumor.

Our experience with laparoscopic total gastrectomy for gastric cancer: A case series

Background: Though laparoscopic distal gastrectomy has become a standard procedure for treatment of gastric cancer, laparoscopic total gastrectomy has not been widely accepted as it requires more dexterity and lack of evidence about its feasibility and safety. Methods: Here retrospectively we review a series of 12 cases of gastric cancer undergone laparoscopic total gastrectomy with D1 or D2 lymphadenectomy over a period of 7 years at a tertiary care hospital. The patient demographic characteristics were reviewed and the outcomes after surgery was analyzed in terms of extent of lymphadenectomy, mean operative time, mean intraoperative blood loss median number of lymph nodes harvested, median time for postoperative ambulation, median time for postoperative oral feeding, median time of postoperative hospital stay, postoperative complications and mortality. Results: All patients had total gastrectomy entirely through laparoscopic method. Mean operative time was 282 minutes, mean intraoperative blood loss was 120 ml, median time for ambulation and oral feeding was 3 days and 6 days respectively. Median time of hospital stay was 16 days and 2 patients had complications as pancreatic fistula and port site abscess. No mortality was observed. Conclusion: With zero mortality and accepted rate of complications, laparoscopic total gastrectomy appears to be technically feasible and safe for management of gastric cancer. But more studies have to be conducted with comparison to other standard gastrectomies and long term follow up to be done to establish its standardized application.

Morbidity and Mortality of Laparoscopic vs Open Total Gastrectomy for Clinical Stage I Gastric Cancer

The safety of laparoscopic total gastrectomy (LTG) for the treatment of gastric cancer remains uncertain given the lack of high-level clinical evidence. To compare the safety of LTG for clinical stage I gastric cancer with that of conventional open total gastrectomy (OTG). The Chinese Laparoscopic Gastrointestinal Surgery Study (CLASS) Group CLASS02 study was a prospective, multicenter, open-label, noninferiority, randomized clinical trial that compared the safety of LTG vs OTG with lymphadenectomy for patients with clinical stage I gastric cancer. From January 2017 to September 2018, a total of 227 patients were enrolled. Final follow-up was in October 2018. Eligible patients were randomized to LTG (n = 113) or OTG (n = 114) by an interactive web response system. The primary outcome was the morbidity and mortality within 30 days following surgeries between LTG and OTG with a noninferiority margin of 10%. The secondary outcomes were recovery courses and postoperative hospital stays. A total of 214 patients were analyzed for morbidity and mortality (105 patients in the LTG group and 109 patients in the OTG group). The mean (SD) age was 59.8 (9.4) years in the LTG group and 59.4 (9.2) years in the OTG group, and most were male (LTG group, 75 of 105 [71.4%]; OTG group, 80 of 109 [73.4%]). The overall morbidity and mortality rates were not significantly different between the groups (rate difference, -1.1%; 95% CI, -11.8% to 9.6%). Intraoperative complications occurred in 3 patients (2.9%) in the LTG group and 4 patients (3.7%) in the OTG group (rate difference, -0.8%; 95% CI, -6.5% to 4.9%). In addition, there was no significant difference in the overall postoperative complication rate of 18.1% in the LTG group and 17.4% in the OTG group (rate difference, 0.7%; 95% CI, -9.6% to 11.0%). One patient in the LTG group died from intra-abdominal bleeding secondary to splenic artery hemorrhage. However, there was no significant difference in mortality between the LTG group and the OTG group (rate difference, 1.0%; 95% CI, -2.5% to 5.2%), and the distribution of complication severity was similar between the 2 groups. The results of the CLASS02 trial showed that the safety of LTG with lymphadenectomy by experienced surgeons for clinical stage I gastric cancer was comparable to that of OTG. ClinicalTrials.gov Identifier: NCT03007550.

Corrosive Esophagitis and Gastritis Secondary to Alkali Ingestion Treated with Video-Assisted Thoracoscopic Esophagectomy and Laparoscopic Total Gastrectomy Followed by Second-Stage Reconstruction

Corrosive Esophagitis and Gastritis Secondary to Alkali Ingestion Treated with Video-Assisted Thoracoscopic Esophagectomy and Laparoscopic Total Gastrectomy Followed by Second-Stage Reconstruction

Reappraise role of No. 10 lymphadenectomy for proximal gastric cancer in the era of minimal invasive surgery during total gastrectomy: a pooled analysis of 4 prospective trial.

For patients with locally advanced proximal gastric cancer (LAPGC), the individualized selection of patients with highly suspected splenic hilar (No. 10) lymph node (LN) metastasis to undergo splenic hilar lymphadenectomy, is a clinical dilemma. This study aimed to re-evaluate the feasibility and safety of laparoscopic spleen-preserving splenic hilar lymphadenectomy (LSPSHL) and to identify the population who would benefit from it. A total of 1068 patients (D2 group = 409; D2 + No. 10 group = 659) who underwent laparoscopic total gastrectomy from four prospective trials between January 2015 and July 2019 were analyzed. No significant difference in the incidence (16.9% vs. 16.4%; P = 0.837) of postoperative complications were found between the two groups. The metastasis rate of No. 10 LN among patients in the D2 + No. 10 group was 10.3% (68/659). Based on the decision tree, patients with LAPGC with tumor invading the greater curvature (Gre), patients with non-Gre-invading LAPGC with a tumor size > 5cm and clinical positive locoregional LNs were defined as the high-priority No. 10 dissection group. The metastasis rate of No. 10 LNs in the high-priority group was 19.4% (41/211). In high-priority group, the 3-year overall survival of the D2 + No. 10 group was better than that of the D2 group (74.4% vs. 42.1%; P = 0.005), and the therapeutic index of No. 10 was higher than the indices of most suprapancreatic stations. LSPSHL for LAPGC is safe and feasible when performed by experienced surgeons. LSPSHL could be recommended for the high-priority group patients even without invasion of the Gre.

Implementation of minimally invasive gastrectomy for gastric cancer in a western tertiary referral center

BackgroundMinimally invasive techniques have gradually come to take a leading position in the surgical treatment of gastrointestinal malignancies. In order to define an effective process for the implementation of similar techniques in the treatment of gastric cancer, patient caseload represents a pivotal factor for education and training, but is a prerequisite not fulfilled in most Western countries. Additionally, as opposed to the East, a variety of additional factors such as the usually advanced stage of the disease and differences in patient characteristics are prevailing and raise further obstacles. Hereby we report a strategy for a safe and effective process for the implementation of laparoscopic gastric cancer surgery in a Western tertiary referral center.MethodsThe present study describes the stepwise implementation of laparoscopic gastrectomy for the treatment of gastric cancer at a tertiary referral center, comprising the time period 2012–2019. This process was facilitated by a close collaboration with two high-volume centers in Japan, as well as exchanging fellowships and observerships between the Karolinska University Hospital and other European centers. From the initially strict selection of cases for laparoscopic surgery, laparoscopic gastrectomy has gradually become the preferred approach also in patients with locally advanced tumors.ResultsFrom January 1st 2010 until December 31st 2019, 249 patients were operated for gastric cancer, of whom 141 (56.6%) had an open and 108 (43.4%) a laparoscopic procedure. In the latter group, total gastrectomy was performed in 33.3% of the patients. While blood loss, operation time and length of stay decreased during the first years after implementation, these variables increased slightly during the last years of the study period, probably due to the higher proportion of advanced gastric cancer cases, as well as the higher rate of laparoscopic total gastrectomy with more extended lymphadenectomy.ConclusionsLaparoscopic surgery is currently a valid therapeutic option for gastric cancer, which has expanded to also embrace total gastrectomy and locally advanced tumors. Collaboration between centers in the East and West, centralization to high-volume centers and application of enhanced recovery protocols are essential components in the implementation and further refinement of minimally invasive gastrectomy.

Comparative outcomes between totally laparoscopic total gastrectomy with the modified overlap method for early gastric cancer and advanced gastric cancer: review of 149 consecutive cases.

IntroductionTotally laparoscopic total gastrectomy (TLTG) for advanced gastric cancer (AGC) has not been conclusively substantiated.AimTo evaluate TLTG treatment of AGC by comparing its effectiveness and surgical outcomes to those of TLTG treatment of early gastric cancer (EGC).Material and methodsWe performed TLTG with the (modified) overlap method for 149 gastric cancer cases between March 2012 and December 2018. We evaluated clinicopathologic characteristics, complications (including esophagojejunostomy site complications), and surgical outcomes. We also evaluated these variables in terms of their associations with EGC and AGC.ResultsNinety-two males and 57 females, with a mean age of 60.7 years, were included. The mean operation time was 147.7 min. The mean number of harvested lymph nodes was 39.6. Thirteen (8.7%) patients experienced early complications, and 6 (4.0%) experienced late complications (Clavien-Dindo classification ≥ III). Eight (5.4%) patients underwent reoperation, and 8 (5.4%) were readmitted due to complications. There were no statistically significant differences in operation time, hospital stay, or surgical mortality between EGC and AGC. However, there were significant differences in early complications, late complications, rate of reoperation, and rate of readmission between EGC and AGC.ConclusionsAlthough it has some limitations, TLTG with the (modified) overlap method for AGC treatment is feasible, safe, and associated with favorable outcomes.

Intracorporeal esophagojejunostomy using a linear stapler in laparoscopic total gastrectomy: comparison with circular stapling technique

BackgroundLaparoscopic total gastrectomy for gastric cancer is feasible but less commonly performed compared to laparoscopic distal gastrectomy due to technical difficulties such as reconstruction. There is no standard esophagojejunal anastomosis technique in laparoscopic total gastrectomy due to a lack of evidence.MethodsWe retrospectively analyzed data from 213 patients with gastric cancer who underwent laparoscopic total gastrectomy from October 2012 to December 2016. Of these, 109 and 104 patients underwent esophagojejunostomy with linear and circular stapling, respectively. We compared short-term postoperative outcomes, including surgical complications and anastomosis costs between both groups.ResultsThe mean operation time in the linear stapler group was longer than the circular stapler group (Linear stapler, 235.3 ± 57.9 vs. Circular stapler, 217.1 ± 55.8 min; P = 0.021); however, D2 lymph node dissection was performed more in the linear stapler group (Linear stapler, 36.7% vs. Circular stapler, 23.1%; P = 0.030). There were two anastomosis leakages in each group (Linear stapler, 1.8% vs. Circular stapler, 1.9%; P > 0.999). Anastomosis stenosis only occurred in the circular stapler group (Linear stapler, 0% vs. Circular stapler, 7.7%; P = 0.003). Although the linear stapling technique used more stapler cartridges (Linear stapler, 7.6 ± 1.1 vs. Circular stapler, 4.8 ± 0.9; P < 0.001), costs related to anastomosis were lower in the linear stapler group (Linear stapler, 1,904,679 ± 342,116 vs. Circular stapler, 2,246,150 ± 427,136KRW; P < 0.001).ConclusionsEsophagojejunostomy with the linear stapling technique reduces anastomosis stenosis in laparoscopic total gastrectomy. It can be recommended as a safe and more cost-effective method for esophagojejunal anastomosis.