Totally Laparoscopic Total Gastrectomy Research Articles

The safety and feasibility Assessment of Overlap Esophagojejunostomy with Self-pulling and Latter Transection Technique in Totally Laparoscopic Total Gastrectomy

BackgroundThis study presents an innovative technique in totally laparoscopic total gastrectomy (TLTG) for Overlap esophagojejunostomy, termed self-pulling and latter transection (Overlap SPLT). It evaluates the effectiveness and short-term outcomes of this novel method through a comparative analysis with the established functional end-to-end esophagojejunostomy incorporating self-pulling and latter transection (FETE SPLT). MethodsFrom September 2018 to September 2023, this study enrolled 68 gastric cancer patients who underwent totally laparoscopic total gastrectomy (TLTG) with Overlap SPLT anastomosis and 120 patients who underwent TLTG with FETE SPLT anastomosis. Clinicopathological characteristics, surgical and postoperative outcomes data for Overlap SPLT cases were gathered and retrospectively compared with those from FETE SPLT TLTG to evaluate the effectiveness and clinical safety. ResultsThe duration of anastomosis for Overlap SPLT was 25.3 ± 7.4minutes, significantly longer than that for the FETE SPLT (18.1 ± 4.0minutes, P = 0.031). Perioperatively, one anastomosis-related complication occurred in each group, but this did not constitute a statistically significant difference (P = 0.682). No statistically significant differences were found between the two groups in terms of operative time, postoperative hospital stay, operative cost, surgical margins, or number of lymph nodes removed. Postoperative morbidity rates were similar between the groups (4.4% vs. 5.8%, P = 0.676). ConclusionThe Overlap SPLT technique is regarded as a safe and feasible method for anastomosis. There were no apparent differences in complications between Overlap SPLT and FETE SPLT, but Overlap SPLT costed one additional stapler cartridge and required a longer duration.

Safety and effectiveness of totally laparoscopic total gastrectomy vs laparoscopic-assisted total gastrectomy: a meta-analysis.

For gastric cancer with total gastrectomy, the usual laparoscopic surgical approaches are totally laparoscopic total gastrectomy (TLTG) and laparoscopic-assisted total gastrectomy (LATG). Due to its difficult anastomotic technique, the adoption of TLTG is limited. Therefore, surgeons prefer using LATG, which also led to TLTG being somewhat overlooked, so there is no clear conclusion today as to which surgical procedure is more favorable to the patient's recovery. This article aimed to compare the safety and short-term outcomes of the two surgical approaches. Studies comparing TLTG and LATG, published up to December 2022, were searched in PubMed, Web of Science, and Embase databases. The study outcomes, including operative time, blood loss, anastomosis time, number of retrieved lymph nodes, proximal and distal resection margins, time to first fluid and soft diet, hospitalization duration, time to first flatus, and postsurgical and anastomotic complications, were compared between these two different surgical procedures. Statistics were analyzed with RevMan 5.4 and Stata 13.1. Fifteen publications were included in this study. The total sample included 3023 cases. The meta-analysis revealed no significant difference in overall postoperative complications between the two surgical approaches ( P >0.05). Compared with LATG, TLTG led to reduced intraoperative blood loss ( P <0.0001), an increased number of lymphatic node dissections ( P <0.0001), and decreased hospitalization duration ( P =0.002). However, operative time, anastomosis time, pulmonary infection, resection margins, time to first fluid and soft diet, time to first flatus and anastomosis-related complications were no significant difference between TLTG and LATG groups ( P >0.05). TLTG did not lead to an increase in overall postoperative complications, which is a reliable surgical approach for treatment of gastric cancer. Moreover, it may reduce harm to patients and enable them to obtain better surgical outcomes.

Improvement of esophagojejunostomy technique after total gastrectomy with overlap method: reduce the difficulty of surgery and shorten operation time.

Gastric cancer (GC) is one of the most malignant human cancers. Totally laparoscopic total gastrectomy (TLTG) is a difficult operation, especially esophagojejunostomy. Our team has adopted the method of suspending and pulling the esophagus with the visceral retractor and two needles of barbed wire interlocking to suture the common opening, which reduces the difficulty of the operation. From January to December 2020, 20 patients underwent TLTG with the overlap method by improved esophagojejunostomy technique and 20 patients with the traditional overlap method after TLTG were used as the control group. The surgery was performed using a five-trocar system. After lymphadenectomy, the esophagus was separated at least 2cm from the upper edge of the tumor. Improved esophagojejunostomy technique was completed by the following steps: (1) cutting end of the esophagus suspension; (2) jejuno-jejunostomy; (3) esophagojejunostomy; (4) close the esophagojejunum common incision opening. The results showed that the operative time, and anastomosis time of the modified group were shorter than those of the traditional group, There were no postoperative complications such as anastomotic leakage, anastomotic stenosis, duodenal stump fistula and Roux stasis syndrome in the both group. There was no statistically significant difference in postoperative complications between the two groups. Taken together, our modified esophagojejunostomy technique after total gastrectomy is feasible and safe. This procedure is an efficient method to shorten the operation time and reduce the difficulty of surgery in esophagojejunostomy of laparoscopic total gastrectomy.

Learning curve of laparoscopic and robotic total gastrectomy: A systematic review and meta-analysis.

Minimally-invasive total gastrectomy (MITG) is associated with lower morbidity in comparison to open total gastrectomy but requires a learning curve (LC). We aimed to perform a pooled analysis of the number of cases required to surmount the LC (NLC) in MITG. A systematic review of PubMed, Embase, Scopus and the Cochrane Library from inception until August 2022 was performed for studies reporting the LC in laparoscopic total gastrectomy (LTG) and/or robotic total gastrectomy (RTG). Poisson mean (95% confidence interval [CI]) was used to determine the NLC. Negative binomial regression was performed as a comparative analysis. There were 12 articles with 18 data sets: 12 data sets (n = 1202 patients) on LTG and 6 data sets (n = 318 patients) on RTG. The majority of studies were conducted in East Asia (94.4%). The majority of the data sets (n = 12/18, 66.7%) used non-arbitrary analyses. The NLC was significantly smaller in RTG in comparison to LTG [RTG 20.5 (95% CI 17.0-24.5); LTG 43.9 (95% CI 40.2-47.8); incidence rate ratio 0.47, p < 0.001]. The NLC was comparable between totally-laparoscopic total gastrectomy (TLTG) and laparoscopic-assisted total gastrectomy (LATG) [LATG 39.0 (95% CI 30.8-48.7); TLTG 36.0 (95% CI 30.4-42.4)]. The LC for RTG was significantly shorter for LTG. However existing studies are heterogeneous.

Feasibility and Potential of Reduced Port Surgery for Total Gastrectomy With Overlap Esophagojejunal Anastomosis Method.

Reduced port surgery (RPS) for gastric cancer has been frequently reported in distal gastrectomies but rarely in total gastrectomies. This study aimed to determine the feasibility of 3-port totally laparoscopic total gastrectomy (TLTG) with overlapping esophagojejunal (EJ) anastomosis. A total of 81 patients who underwent curative TLTG for gastric cancer (36 and 45 patients with 3-port and 5-port TLTG, respectively) were evaluated. All 3-port TLTG procedures were performed with the same method as 5-port TLTG, including EJ anastomosis with the intracorporeal overlap method using a linear stapler, except for the number of ports and assistants. Short-term outcomes, including the number of lymph nodes (LNs) harvested by station and postoperative complications, were analyzed retrospectively. Clinical characteristics were not significantly different among the groups, except that the 3-port TLTG group was younger and had a lower rate of pulmonary comorbidity. There were no cases of open conversion or additional port placement. All operative details and the number of harvested LNs did not differ between the groups, but the rate of suprapancreatic LN harvest was higher in the 3-port TLTG group. No significant differences were observed in the overall complication rates between the 2 groups. Three-port TLTG with overlapping EJ anastomoses using a linear stapler is a feasible RPS procedure for total gastrectomy to treat gastric cancer.

Totally laparoscopic total gastrectomy with Uncut Roux-en-Y for gastric cancer may improve prognosis: A propensity score matching comparative study.

Laparoscopic total gastrectomy (LTG) with Roux-en-Y (RY) is often accompanied by a series of complications. Uncut RY (URY) can effectively reduce Roux stasis syndrome (RSS) in laparoscopic distal gastrectomy. To determine whether totally LTG (TLTG) with URY for gastric cancer (GC) can replace RY in short-term and long-term prognosis. This comparative retrospective study selected GC patients from 2016 to 2022. The patients were divided into URY group and RY group. Cox multivariate proportional hazard regression analysis was used to explore the independent prognostic factors. Propensity score matching (PSM) was used to reduce bias. A total of 100 GC patients met the inclusion criteria. Compared to RY group, URY group showed significant advantages in operation time and length of hospital stay. In addition, URY group can significantly reduce short-term and long-term complications, especially RSS. The 1-, 3- and 5-year progression free survival (PFS) of URY group and RY group were 90.4% vs. 67.8% (P=0.005), 76.6% vs. 52.6% (P=0.009) and 76.6% vs. 32.8% (P<0.001), respectively. After PSM, the advantage of URY in PFS was verified again, while there was no significant difference in overall survival (OS) between the two groups. Cox multivariate analysis suggested that lower RSS was associated with better PFS. TLTG with URY for GC helps control disease progression, speed up recovery and reduce short and long-term complications, especially RSS.

Patient-Reported Outcomes of Individuals with Gastric Cancer Undergoing Totally Laparoscopic Versus Laparoscopic-Assisted Total Gastrectomy: A Real-World, Propensity Score-Matching Analysis.

Totally laparoscopic total gastrectomy (TLTG) and laparoscopic-assisted total gastrectomy (LATG) are two types of minimally invasive radical gastrectomy procedures to treat gastric cancer (GC). This study compared the long-term prognosis and postoperative health-related quality of life (HRQoL) between TLTG and LATG. A total of 106 patients who underwent TLTG and 1,076 patients who underwent LATG at the Union Hospital of Fujian Medical University (Fuzhou, China) between January 2014 and April 2018 were included in the propensity score matching (PSM, 1:2). Patient-reported outcomes at 3, 6, and 12 months after gastrectomy were analyzed. The questionnaire referred to the European Organization for Research and Treatment of Cancer (EORTC) 30-item core QoL (QLQ-C30)and the GC module (QLQ-STO22) questionnaire. After PSM, there were no significant differences in clinicopathological characteristics between the TLTG (n = 104) and the LATG groups (n = 208). Operative time and volume of blood loss were significantly lower in the TLTG group than in the LATG group. Kaplan-Meier survival analysis revealed similar 3-year survival rates between the TLTG and LATG groups (83.7 vs. 80.3%, respectively; P = 0.462). Tolerance to nonliquid diet, decrease in body weight, and albumin levels were also significantly lower in the TLTG group than in the LATG group (all P < 0.05). The HRQoL scale demonstrated that the overall score in the TLTG group was better than that in the LATG group at 3, 6, and 12 months after gastrectomy (all P < 0.05). Patients with GC undergoing TLTG reported better HRQoL and experienced faster recovery of social function than those undergoing LATG, although the two groups demonstrated similar short-term outcomes and long-term prognosis.

Functional end to end esophagojejunostomy without previous resection of esophagus and jejunum by linear stapler in the totally laparoscopic gastrectomy: Experience in 106 patients

Abstract Introduction: 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 (TLTG) and report experience in 106 patients. Patients and 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 in TLTG between July 2017 and July 2022. Results: We included 106 patients with a mean age of 63.2 ± 11.7 (26 – 88). 10.4% of patients having tumors in the upper third of the stomach and 88.7% of patients having tumors in the middle of the stomach. There were 4.7% of cases having incidents during the surgery and 3.6% of cases having complications after the surgery. There were 2 (1.8%) cases of technical errors in making functional end to end esophagojejunostomy during surgery. No anastomotic leakage or death was observed after the surgery. The operation time was 201.5 ± 29.0 (145 - 270) minutes. The mean hospital stay was 7.56 ± 2.23 (5 - 15) days. 04 (3.6%) cases of reflux esophagitis, and 03 (2.7%) mild stenosis of the anastomosis after surgery, and 1 (0.9%) recurrence at the anastomosis after surgery. Conclusion:The technique of functional end-to-end esophagojejunostomy by linear stapler without previous resection of esophagus and jejunum was safe and effective in TLTG. Keywords: Esophagojejunostomy in laparoscopy, The technique of functional end-to-end.

Quality of life after totally laparoscopic versus laparoscopic-assisted total gastrectomy: a retrospective cohort study with propensity score matching

Objective: To evaluate the postoperative quality of life in patients after totally laparoscopic total gastrectomy (TLTG). Methods: A retrospective cohort study based on propensity score matching was performed. Clinical and follow-up data of patients who underwent laparoscopic radical gastrectomy at Union Hospital of Fujian Medical University from January 2014 to May 2015 were collected. Case indusion criteria: (1) primary gastric cancer confirmed by postoperative pathology; (2) receiving TLTG or laparoscopic-assisted total gastrectomy (LATG);(3) R0 resection; (4) completing follow-up for 12 months and complete follow-up data. Exclusion criteria: (1) gastric stump cancer; (2) concurrent tumor; (3) distal metastasis found during operation; (4) history of upper abdominal operation. According to surgical procedures, patients were divided into the LATG group (1076 cases) and the TLTG group (106 cases). To eliminate potential bias in baseline data between the two groups, the propensity score was calculated using a logistic regression model with the following covariates, including age, sex, body mass index, American Society of Anesthesiologists score, tumor location, tumor size, pathology type, and stage. The two groups were matched using a 1:2 propensity assessment ratio and a caliper width of 0.01 standard deviation was specified. The primary outcomes were the quality of life of the two groups at 3, 6 and 12 months after gastrectomy, including physical symptoms and social function. Higher function score indicated better function, and higher symptom score presented worse symptoms. Quality of life score = (100 - somatic symptom scale score + social function scale score) / 2. The secondary outcomes were postoperative nutritional recovery and food tolerance at 3, 6 and 12 months after gastrectomy. The categorical variables were expressed as n(%), and compared using the χ2 test or Fisher exact test. The continuous variables conforming to the normal distribution were represented by Mean ± SD and compared with the paired t-test. Repeated measurement of variance was used to compare nutrition-related indicators within the group among pre-operation, postoperative 1, 3, 6, 12 months. Results: After PSM, there were no significant differences in clinicopathological baseline data between the TLTG group (n=104) and the LATG group (n=208) (all P>0.05). The physical symptoms scores in the TLTG group before operation and 3, 6 and 12 months after operation were 8.6±5.8, 15.5±8.4, 10.1±5.9 and 6.1±2.4 respectively (F=43.493, P<0.001). In the LATG group, the above mentioned scores were 9.7±6.9, 23.7±10.4, 13.3±8.3 and 8.5±4.2 respectively (F=112.588, P<0.001). Compared with the LATG group, the symptom scores in the TLTG group were lower at 3 and 6 months after operation, and the differences were statistically significant (t=-3.653, P<0.001; t=-2.513, P=0.012). At 12 months after operation, although the physical symptom score in the TLTG group was also lower than that in LATG group, the difference was not statistically significant (t=-1.487, P=0.138). The social function scores in the TLTG group before operation and 3, 6 and 12 months after operation were 90.3±8.9, 77.5±14.3, 87.4±10.3 and 91.7±6.7 respectively (F=28.524, P<0.001). In the LATG group, the above mentioned scores were 92.5±6.3, 68.5±16.8, 79.8±14.7 and 84.7±11.1 respectively (F=57.975, P<0.001). Compared with the LATG group, the social function scores of patients in the LATG group were higher at 3, 6 and 12 months after operation (t=3.543, P<0.001; t=3.216, P=0.001; t=2.235, P=0.026). The total scores of quality of life at 3, 6 and 12 months after operation in the TLTG group were 81.0±15.6, 88.3±8.1 and 93.3±9.1 respectively, and the above mentioned scores in the LATG group were 72.4±13.6, 83.3±11.5 and 88.1±7.7 respectively, whose differences at corresponding time point were all significant between the two groups (all P<0.05). The change of total body mass[(-8.4±1.4)% vs. (-13.2±1.6)%, t=2.273, P=0.024], serum albumin[(-5.1±0.7)% vs. (-7.4±0.8)%,t=2.095, P=0.037], meal quantity [(-15.6±4.7)% vs. (-24.1±6.0)%, t=2.885, P=0.004] and meal times [(20.8±7.1)% vs. (30.6±11.5)%, t=3.043, P<0.001] in the TLTG group were significantly lower than those in the LATG group one year after operation (all P<0.05). At 3, 6 and 12 months after operation, the diet proportions of solid and soft food in the TLTG group were higher than those in the LATG group (all P<0.05). Conclusions: Compared with LATG, patients with gastric cancer undergoing TLTG have better health-related quality of life and faster recovery of nutrition.

Modified π-shaped esophagojejunostomy in totally laparoscopic total gastrectomy: a report of 40 consecutive cases from a single center.

ObjectiveIntracorporeal esophagojejunostomy remains a challenging technique in totally laparoscopic total gastrectomy (TLTG) because of the lack of an established standard anastomosis method. However, π-shaped esophagojejunostomy in TLTG is reportedly safe and feasible. Therefore, we evaluated the short-term surgical outcomes of our modified π-shaped esophagojejunostomy in TLTG.MethodsThis study involved patients without neoadjuvant therapy diagnosed with gastric cancer who underwent TLTG by the same surgeon with modified π-shaped esophagojejunostomy from April 2018 to October 2019. Clinicopathologic data were collected and retrospectively analyzed.ResultsForty patients diagnosed with gastric cancer were included. The mean operative time and estimated blood loss were 264.6 ± 56.9 minutes and 68.5 ± 53.3 mL, respectively. Postoperative flatus occurred at 4.6 ± 1.7 days. The mean time to resumption of diet was 7.4 ± 1.7 days postoperatively. One patient was diagnosed with anastomotic leakage and managed with conservative therapy. Pleural effusion was the most common complication, occurring in four (10%) patients. One patient developed intra-abdominal bleeding that required reoperation. Other complications were atrial fibrillation and wound infection. No mortality occurred during the 6-month follow-up.ConclusionsModified π-shaped esophagojejunostomy is safe and feasible for intracorporeal anastomosis in TLTG and showed favorable surgical outcomes in this study.

Application of Half-Transected and Self-Pulling Esophagojejunostomy in Total Laparoscopic Gastrectomy for Gastric Cancer: A Safe and Feasible Technique.

Objective This study introduces a technique for esophagojejunostomy with half transected and self-pulling (HTSP) and evaluates the safety, feasibility, and clinical results of this technique in totally laparoscopic total gastrectomy (TLTG). Materials and Methods From May 2019 to March 2021, 42 patients (HTSP group) who underwent HTSP-TLTG surgery in the Department of Abdominal Tumor Surgery of Jiangxi Cancer Hospital were included in this study. The control group consisted of 50 patients undergoing conventional TLTG surgery (conventional anastomosis group) performed by the same surgical team from March 2018 to March 2020. The clinical data of the two groups were retrospectively analyzed and compared. Results The mean operation time of the HTSP-TLTG surgery was 166.7 ± 13.1 minutes and the anastomosis time was 20.8 ± 2.0 minutes, which were significantly shorter than those of traditional TLTG (P < 0.05). There were no significant differences between the two groups in blood loss, time to first exhaust, postoperative hospital stay, and incidence of surgery-related complications. Conclusion HTSP is a safe and feasible way of endoscopic esophagojejunal anastomosis, which requires a relatively low suture technique under endoscopy, and is suitable for promotion.

Technical details of gastrointestinal reconstruction using linear stapler in totally laparoscopic total gastrectomy

With the development of instrument, equipment and surgical skills, especially the emergence of a series of high-level medical evidence, the laparoscopic techniques in the field of gastric surgery has been further expanded. Totally laparoscopic total gastrectomy (TLTG) has certain technical difficulties, and more challenges are reflected in the digestive tract reconstruction. The use of linear staplers has reduced the difficulty of digestive tract reconstruction to a certain extent and has strongly promoted the transition from laparoscopic-assisted total gastrectomy to TLTG. However, for TLTG, there are still many details that should be carefully concerned, so as to effectively avoid the surgical pitfalls and ensure the fluency and safety of the procedure. In this article, we discuss the surgical details based on our own experiences, including how to obtain surgical field exposure well, how to manage specific accidents when using linear stapler for esophagojejunostomy, how to prevent intra-abdominal hernias and Roux stasis syndrome, and how to prevent the stapled lines of the esophageal or jejunal stumps from direct contact with aorta.

Overlap esophagojejunostomy with multi-mode modifications in totally laparoscopic total gastrectomy: safety and feasibility of 152 cases from a single center

Objective: Currently, the Overlap anastomosis is one of the most favored reconstruction methods of intracorporeal esophagojejunostomy (EJS). Despite many advantages of the method, it remains some shortcomings to be improved when it comes to the retraction of the esophagus stump, the insertion of the anvil fork of the linear stapler into a "pseudo" lumen, and the closure of the common entry hole. This study aims to investigate the safety and feasibility of a multi-mode modified Overlap anastomosis. Methods: A descriptive case series study was conducted. Medical records of 152 consecutive patients who underwent totally laparoscopic total gastrectomy (TLTG) with our multi-mode modified Overlap EJS method by the same surgical team at our department from February 2017 to June 2020 were retrospectively analyzed. The multi-mode modified Overlap method mainly included (1) After ensuring the safety of tumor resection margin (proximal margin was at least 3 cm from the tumor), the esophagus was partially transected from left to right (with 5-8 mm width esophagus continuation). The specimen was then placed in a plastic bag which was tied up at the mouth using strings with a part of the esophageal wall poking through. Then the plastic bag containing the specimen was transferred to the right lumbar region, while the patient's body position was adjusted so that the abdominal esophagus could be pulled by the gravity of the specimen. (2) Using the "three-direction traction" method. The esophageal lumen was properly exposed, then guided by the gastric tube, the anvil fork was accurately placed into the esophageal lumen for completing the side-to-side EJS. (3) The 3-0 barbed suture was used in the closure of the common entry hole of the stapler from dorsally to ventrally with simple one-layer continuous suture (the stitch going from inside to inside) followed by continuous Lembert's suture (the stitch going from outside to outside). Combined with clinicopathological characteristics, the perioperative outcomes and postoperative complications of the whole group were analyzed and evaluated. Results: The study cohort included 129 men and 23 women, with a mean age of (60.2±9.1) years and a mean body mass index (BMI) of (23.2±3.1) kg/m(2). Of the 152 patients, 23 patients (15.1%) had a history of previous abdominal surgery; dentate line was invaded by tumor in 21 patients (13.8%). The mean length of the proximal resection margin was (3.3±0.3) cm and the postoperative pathological examination indicated negative resection margin tumor. The mean operative time and anastomotic time were (302.1±39.9) minutes and (29.8±5.4) minutes, respectively. The mean estimated blood loss was (87.9±46.4) ml. The mean length of postoperative hospital stay was (12.3±7.3) days. The overall severe postoperative complications (Clavien-Dindo ≥ II) occurred in 22 patients (14.5%). Six cases of pancreatic leakage were successfully recovered by adequate drainage, inhibition of pancreatic exocrine secretion and nutritional support. Ten cases of pneumonia and three cases of abdominal infection were cured with anti-infection and physical therapy. Two patients developed anastomotic leakage postoperatively. One case was caused by excessive tension of the Roux loop of the jejunum and excessive opening on the side of the jejunum after side-to-side anastomosis, and the other case was caused by an accidental intraoperative occurrence of "nasogastric tube stapled to the side-to-side anastomosis". Both of them recovered after conservative treatment including adequate drainage, anti-infection, and adequate nutritional support. One patient underwent immediate open surgery because of Peterson's hernia 7 days after TLTG, and the patient died due to extensive small bowel necrosis. Conclusions: Multi-mode modified overlap method simplifies the operation and reduces the difficulty of EJS. It is a safe and feasible method for EJS.

Effect of different oesophagojejunostomy methods on the quality of life of gastric cancer patients after totally laparoscopic total gastrectomy with self-pulling and latter transected technique: study protocol for a randomised trial

IntroductionGastric cancer is the fifth most common cancer worldwide and the detection rate of proximal gastric cancer has been increasing. Currently, surgical resection using gastrectomy and proper perigastric lymphadenectomy is...

Totally laparoscopic total gastrectomy using the "enjoyable space" approach coupled with self-pulling and latter transection reconstruction versus laparoscopic-assisted total gastrectomy for upper gastric cancer: short-term outcomes.

IntroductionWith the development of minimally invasive surgery in recent years, totally laparoscopic total gastrectomy (TLTG) has attracted more attention.AimTo introduce the more comprehensive “enjoyable space” approach coupled with the self-pulling and latter transaction (SPLT) reconstruction technique to perform TLTG and investigate its safety and feasibility.Material and methodsNinety-seven patients with primary upper gastric cancer underwent laparoscopic radical total gastrectomy between January 2020 and December 2020. Among these patients, 46 underwent laparoscopic-assisted total gastrectomy (LATG), and 51 underwent TLTG. We compared the clinicopathological characteristics, surgical outcomes and postoperative complications between the two groups.ResultsThere were no significant differences in the clinicopathological characteristics between the two groups (p > 0.05). However, the TLTG group had a slightly lower mean operative time and mean blood loss than the LATG group (p < 0.05 each). Although there were similarities in the mean times to first flatus, liquid diet, and soft diet, the duration of hospital stay was significantly reduced in the TLTG group (p < 0.05). No significant differences in overall complications and E-J-related complications were found between the two groups (15.2% vs. 25.4%, p > 0.05).ConclusionsTLTG is a safe and feasible procedure for treating upper gastric cancer. The enjoyable space approach in conjunction with SPLT reconstruction is an appropriate comprehensive technique with several advantages over LATG.

Feasibility of totally laparoscopic total gastrectomy in obese patients with gastric cancer.

This study aimed to evaluate the short- and long-term outcomes in obese patients with gastric cancer undergoing totally laparoscopic total gastrectomy (TLTG) to clarify its feasibility in this population. We examined 136 consecutive patients who underwent TLTG for gastric cancer (GC) between 2013 and 2018. A total of 45 patients with a body mass index (BMI) ≥ 25kg/m2 were defined as the obese group (obese and overweight patients by the WHO classification), and 91 patients with a BMI < 25kg/m2 were defined as the non-obese group. Short- and long-term outcomes were compared, and the correlation between obesity and postoperative complications was examined in patients who underwent TLTG. Although the operation time (min) was significantly longer in the obese group than in the non-obese group (329 vs 307, p = 0.002), there were no significant differences in the total volume of blood loss (mL) (118 vs 60, p = 0.059) or the rate of conversion to laparotomy between the two groups (2 vs 2, p = 0.466). Moreover, there was no significant difference in the incidence of postoperative complications between the two groups (16% vs 19%, p = 0.653). In the multivariate analysis, obesity was not identified as a risk factor for postoperative complications among patients who underwent TLTG. The rate of overall survival was not significantly different between the groups (p = 0.512). TLTG is feasible for obese Japanese patients with GC. To validate the results of the present study, it is necessary to conduct a prospective study of a large population of patients with GC.

Postoperative morbidity and quality of life between totally laparoscopic total gastrectomy and laparoscopy-assisted total gastrectomy: a propensity-score matched analysis

BackgroundThis study aimed to evaluate the surgical outcome and quality of life (QoL) of totally laparoscopic total gastrectomy (TLTG) compared with laparoscopy-assisted total gastrectomy (LATG) in patients with clinical stage I gastric cancer.MethodsFrom 2012 to 2018, EGC patients who underwent TLTG (n = 223), including the first case with intracorporeal hemi-double stapling, were matched to those who underwent LATG (n = 114) with extracorporeal circular stapling, using 2:1 propensity score matching (PSM). Prospectively collected morbidity was compared between the TLTG and LATG groups in conjunction with the learning curve. The European Organization for Research and Treatment of Cancer (EORTC) QoL questionnaires QLQ-C30, STO22, and OG25 were prospectively surveyed during postoperative 1 year for patient subgroups.ResultsAfter PSM, grade I pulmonary complication rate was lower in the TLTG group (n = 213) than in the LATG group (n = 111) (0.5% vs. 5.4%, P = 0.007). Other complications were not different between the groups. The learning curve of TLTG was overcome at the 26th case in terms of the comprehensive complication index. The TLTG group after learning curve showed lower grade I pulmonary complication rate than the matched LATG group (0.5% vs. 4.7%, P = 0.024). Regarding postoperative QoL, the TLTG group (n = 63) revealed less dysphagia (P = 0.028), pain (P = 0.028), eating restriction (P = 0.006), eating (P = 0.004), odynophagia (P = 0.023) than the LATG group (n = 21). Multivariate analyses for each QoL item demonstrated that TLTG was the only common independent factor for better QoL.ConclusionsTLTG reduced grade I pulmonary complications and provided better QoL in dysphagia, pain, eating, odynophagia than LATG for patients with clinical stage I gastric cancer.

Digestive tract reconstruction of laparoscopic total gastrectomy for gastric cancer: a comparison of the intracorporeal overlap, intracorporeal hand-sewn anastomosis, and extracorporeal anastomosis.

The application of esophagojejunostomy has certain difficulties in totally laparoscopic total gastrectomy (TLTG). This is due to the higher requirement for surgical techniques and the lack of any unified standards. This study aim to explore the practicability and safety of intracorporeal overlap and intracorporeal hand-sewn anastomosis compared with extracorporeal anastomosis. The clinical pathological data of 56 patients who underwent TLTG from March 2016 to December 2020 in the Harbin Medical University Cancer Hospital were retrospectively analyzed. According to the method of anastomosis, the patients were divided into the overlap (n=36) and the hand-sewn anastomosis (n=20). Patients who receive laparoscopic-assisted total gastrectomy (LATG; n=74) formed the control group. The basic clinical data, and intraoperative and postoperative results of the patients were assessed. Compared with the control group, the overlap anastomosis and hand-sewn anastomosis groups showed no significant differences in clinicopathological data and short-term postoperative recovery. There were no significant differences between the overlap and the control group in operation time nor anastomosis time. However, the anastomosis time of the hand-sewn anastomosis group was significantly prolonged compared to the control group (53.20±14.14 vs. 43.01±12.53 minutes, P=0.002). Compared with the control group, the operation cost was significantly higher in the overlap group (CNY 81,300±6,100 vs. CNY 76,600±6,800, P=0.001), but significantly lower in the hand-sewn anastomosis group (CNY 71,900±1,700 vs. CNY 76,600±6,800, P=0.003). Early postoperative complications occurred in 5 cases (13.9%) in the overlap group, 3 cases (15.0%) in the hand-sewn anastomosis group, and 11 cases (14.9%) in the control group. There were 3 cases (8.3%) of postoperative anastomotic-related complications in the overlap group. No anastomotic-related complications were observed in the hand-sewn anastomosis group. The overlap anastomosis and hand-sewn anastomosis are practical and safe. Furthermore, the overlap anastomosis may be more suitable for patients with lower cardia and fundic lesions. The hand-sewn method has a wider range of indications pending advanced surgical skills, and is an effective supplementary technique for instrument anastomosis.

Totally laparoscopic total gastrectomy using the modified overlap method and conventional open total gastrectomy: A comparative study

BACKGROUNDAlthough several methods of totally laparoscopic total gastrectomy (TLTG) have been reported. The best anastomosis technique for LTG has not been established.AIMTo investigate the effectiveness and surgical outcomes of TLTG using the modified overlap method compared with open total gastrectomy (OTG) using the circular stapled method.METHODSWe performed 151 and 131 surgeries using TLTG with the modified overlap method and OTG for gastric cancer between March 2012 and December 2018. Surgical and oncological outcomes were compared between groups using propensity score matching. In addition, we analyzed the risk factors associated with postoperative complications.RESULTSPatients who underwent TLTG were discharged earlier than those who underwent OTG [TLTG (9.62 ± 5.32) vs OTG (13.51 ± 10.67), P < 0.05]. Time to first flatus and soft diet were significantly shorter in TLTG group. The pain scores at all postoperative periods and administration of opioids were significantly lower in the TLTG group than in the OTG group. No significant difference in early, late and esophagojejunostomy (EJ)-related complications or 5-year recurrence free and overall survival between groups. Multivariate analysis demonstrated that body mass index [odds ratio (OR), 1.824; 95% confidence interval (CI): 1.029-3.234, P = 0.040] and American Society of Anaesthesiologists (ASA) score (OR, 3.154; 95%CI: 1.084-9.174, P = 0.035) were independent risk factors of early complications. Additionally, age was associated with ≥ 3 Clavien-Dindo classification and EJ-related complications.CONCLUSIONAlthough TLTG with the modified overlap method showed similar complication rate and oncological outcome with OTG, it yields lower pain score, earlier bowel recovery, and discharge. Surgeons should perform total gastrectomy cautiously and delicately in patients with obesity, high ASA scores, and older ages.

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.