A comparative study of totally laparoscopic distal gastrectomy versus laparoscopic-assisted distal gastrectomy in gastric cancer patients: Short-term operative outcomes at a high-volume center

Objective： Laparoscopic gastrectomy has been established as a standard treatment for early gastric cancer, and its use is increasing recently. Compared with the conventional laparoscopy-assisted distal gastrectomy （LADG）, totally laparoscopic distal gastrectomy （TLDG） involves intracorporeal reconstruction, which can avoid the additional incision, resulting in pain reduction and early recovery. This study aimed to compare the short-term postoperative outcomes of TLDG vs. LADG in gastric cancer in a high-volume center.Methods： A retrospective cohort study was conducted on 1,322 patients who underwent laparoscopic distal gastrectomy from June 2012 to June 2017 at the National Cancer Center, Korea. LAD G was performed in the early period before July 2015, and TLDG was applied in the later period. Postoperative short-term outcomes were compared in terms of complication and clinical course between the two groups. Pain score was measured by rating the pain intensity from 0 to 10 points on postoperative day （POD） 1 and 3. Results： A total of 667 patients underwent LADG and 655 patients underwent TLDG. Clinieopathologic characteristics were not different in both groups. Intraoperative estimated blood loss （EBL） was significantly lower in the TLDG group （P〈0.001）. Postoperative pain scores were significantly lower in the TLDG group than in the LADG group on POD 1 （5.1±1.5 vs. 4.8±1.4, P=0.015）. First flatus passage after operation was significantly earlier in the TLDG group （3.4±0.8 d vs. 3.2±0.6 d, P〈0.001）. There were no differences in postoperative complications and hospital stay between the two groups. Conclusions： Based on the reported short-term postoperative outcomes, TLDG is safe and feasible as well as LADG. Moreover, compared with LADG, TLDG can reduce intraoperative EBL and postoperative pain and enhance the bowel motility in gastric cancer surgery.

Direct Instruction by an Experienced Surgeon Can Shorten the Learning Curve for Laparoscopic-Assisted Distal Gastrectomy

Aim: Laparoscopy-assisted distal gastrectomy (LADG) with regional lymph node dissection is a treatment option for patient with early gastric cancer. However, LADG is a technically complex and advanced procedure, which is challenging for inexperienced surgeons. In this report, we retrospectively evaluated the learning curve for LADG of a single surgeon with no previous experience in LADG and the usefulness of direct instruction by a surgeon experienced in LADG in shortening the learning curve. Patients and Methods: This study was analyzed 80 consecutive patients, who underwent LADG by a single surgeon (first assistant in 10 cases and operator in 70 cases) between January 2008 and December 2012. Patients were divided into 3 sequential groups of 10 (training period), 30 (learning period), and 40 (operating period) cases in each group. Median operation time and estimated blood loss for these 3 groups were determined. Other learning indicators, including transfusion requirement, postoperative complications, number of lymph node harvested, and rate of conversion open gastrectomy, were also evaluated. Results: During the training period, median operation time and estimated blood loss were 219.5 min and 83.0 ml, respectively. During the learning period, the operation time was significantly longer than that of training period. In the operating period, the operation time was significantly lesser than that during the learning period. However, the operation time was not different from that during the training period and reached a plateau. The estimated blood loss during the operating period was significantly lesser than that during the learning period. The difference in the number of lymph nodes retrieved between each group was not significant. Conclusions: Direct instructions by an experienced surgeon can decrease the number of cases required for learning. Because LADG is technically more complex than other laparoscopic procedures, standardization of LADG and an effective training system for performing it should be established.

Laparoscopic-assisted radical gastrectomy for distal gastric cancer

A 48-year-old female patient was diagnosed with a superficial depressed type early gastric cancer （type IIc） of 1.0 cm at the gastric angle as indicated by gastroscopy. Laparoscopic-assisted greater omentumpreserving D2 radical gastrectomy was performed in combination with Billroth I reconstruction under general anesthesia for the distal gastric cancer on April 5, 2013. The postoperative recovery was satisfying without complications. The patient was discharged seven days after surgery.

Optimal choice of stapler and digestive tract reconstruction method after distal gastrectomy for gastric cancer:A prospective case–control study

BACKGROUND Gastric cancer is the most common cause of cancer-related deaths,and is classified according to its location in the proximal,middle,or distal stomach.Surgical resection is the primary approach for treating gastric cancer.This prospective study aimed to determine the best reconstruction method after distal gastrectomy for gastric cancer.AIM To explore the efficacy of different staplers and digestive tract reconstruction(DTR)methods after radical gastrectomy and their influence on prognosis.METHODS Eighty-seven patients who underwent radical gastrectomy for distal gastric cancer at our institution between April 2017 and April 2020 were included in this study,with a follow-up period of 12-26 mo.The patients were assigned to four groups based on the stapler and DTR plan as follows:BillrothⅠ(B-I)reconstruction+linear stapler group(group A,22 cases),B-I reconstruction+circular stapler group(group B,22 cases),Billroth II(B-II)reconstruction+linear stapler group(group C,22 cases),and B-II reconstruction+circular stapler group(group D,21 cases).The pathological parameters,postoperative gastrointestinal function recovery,postoperative complications,and quality of life(QOL)were compared among the four groups.RESULTS No significant differences in the maximum diameter of the gastric tumors,total number of lymph nodes dissected,drainage tube removal time,QLQ(QOL questionnaire)-C30 and QLQ-STO22 scores at 1 year postoperatively,and incidence of complications were observed among the four groups(P>0.05).However,groups A and C(linear stapler)had significantly lower intraoperative blood loss and significantly shorter anastomosis time,operation time,first fluid diet intake time,first exhaust time,and length of postoperative hospital stay(P<0.05)than groups B and D(circular stapler).CONCLUSION Linear staplers offer several advantages for postoperative recovery.B-I and B-II reconstruction methods had similar effects on QOL.The optimal solution can be selected according to individual conditions and postoperative convenience.

Comparison of totally laparoscopic total gastrectomy using an endoscopic linear stapler with laparoscopic-assisted total gastrectomy using a circular stapler in patients with gastric cancer: a single-center experience

AIM To evaluate the safety and efficacy of totally laparoscopic total gastrectomy(TLTG) with esophagojejunostomy using a linear stapler compared with laparoscopic-assisted total gastrectomy(LATG) using a circular stapler in gastric cancer patients.METHODS We retrospectively reviewed 687 patients who underwent laparoscopic total gastrectomy for gastric cancer at a single institution from August 2008 to August 2014. The patients were divided into two groups according to the type of operation: 421 patients underwent TLTG and 266 underwent LATG. Clinicopathologic characteristics and surgical outcomes in the two groups were compared and analyzed.RESULTS The TLTG group had higher mean ages at the time of operation(57.78 ± 11.20 years and 55.69 ± 11.96 years,P = 0.020) and more histories of abdominal surgery(20.2% and 12.4%,P = 0.008) compared with the LATG group. Surgical outcomes such as intraoperative and postoperative transfusions,combined operations,pain scores and administration of analgesics,and complications were similar between the two groups. However,compared with the LATG group,the TLTG group required a shorter operation time(149 min vs 170 min,P < 0.001),had lower postoperative hematocrit change(3.49% vs 4.04%,P = 0.002),less intraoperative events(3.1% vs 10.2%,P < 0.001),less intraoperative anastomosis events(2.4% vs 7.1%,P = 0.003),faster postoperative recovery such as median time to first flatus(3.30 d vs 3.60 d,P < 0.001),faster median commencement of soft diet(4.30 d vs 4.60 d,P < 0.001) and shorter length of postoperative hospital stay(6.75 d vs 7.02 d,P = 0.005). CONCLUSION The intracorporeal method for reconstruction of esophagojejunostomy using a linear stapler may be considered a feasible procedure comparing with extracorporeal anastomosis using circular stapler because TLTG is simpler and more straightforward than LATG. Therefore,TLTG can be recommended as an appropriate procedure for gastric cancer.

Efficacy of totally laparoscopic compared with laparoscopic-assisted total gastrectomy for gastric cancer: A meta-analysis

BACKGROUND Laparoscopic radical gastrectomy is currently the most common surgical approach for gastric cancer.The main difference between totally laparoscopic total gastrectomy(TLTG)and laparoscopic-assisted total gastrectomy(LATG)is the route of digestive tract reconstruction.However,TLTG is currently not widespread as the safety and feasibility of intracorporeal esophagojejunostomy is uncertain.AIM To compare the short-term efficacy of TLTG and LATG for radical gastrectomy of gastric cancer,and to determine the safety and feasibility of intracorporeal esophagojejunostomy.METHODS PubMed,EMBASE,and Web of Science databases were searched for all relevant articles regarding TLTG vs LATG for gastric cancer published up to October 1,2019.Inclusion and exclusion criteria were established.All the basic conditions of patients and important clinical data related to surgery were extracted,and a meta-analysis was performed with RevMan 5.3 software.RESULTS Eight studies involving a total of 1883 cases(869 cases in the TLTG group and 1014 cases in the LATG group)were included.Compared with the LATG group,reduced intraoperative blood loss(weighted mean difference=-35.37,95%CI:-61.69--9.06,P=0.008)and a larger number of retrieved lymph nodes(weighted mean difference=3.11,95%CI:-2.60-12.00,P=0.01)were found in the TLTG group.There were no significant differences in operating time,anastomotic time,tumor size,proximal resection margin length,postoperative pain score,time to first flatus,time to first oral intake,postoperative hospital stay,postoperative anastomosis-related complication rate and overall complication rate between the two groups(P>0.05).CONCLUSION Intracorporeal esophagojejunostomy is safe and feasible.TLTG has the advantages of being minimally invasive,reduced intraoperative blood loss and easier access to lymph nodes compared with LATG.Totally laparoscopic gastrectomy is likely to be the surgical trend for gastric cancer in the future.

Laparoscopic-assisted vs open transhiatal gastrectomy for Siewert type Ⅱ adenocarcinoma of the esophagogastric junction: A retrospective cohort study

BACKGROUND The studies of laparoscopic-assisted transhiatal gastrectomy(LTG) in patients with Siewert type Ⅱ adenocarcinoma of the esophagogastric junction(AEG) are scarce.AIM To compare the surgical efficiency of LTG with the open transhiatal gastrectomy(OTG) for patients with Siewert type Ⅱ AEG.METHODS We retrospectively evaluated a total of 578 patients with Siewert type Ⅱ AEG who have undergone LTG or OTG at the First Medical Center of the Chinese People’s Liberation Army General Hospital from January 2014 to December 2019. The short-term and long-term outcomes were compared between the LTG(n = 382) and OTG(n = 196) groups.RESULTS Compared with the OTG group, the LTG group had a longer operative time but less blood loss, shorter length of abdominal incision and an increased number of harvested lymph nodes(P < 0.05). Patients in the LTG group were able to eat liquid food, ambulate, expel flatus and discharge sooner than the OTG group(P < 0.05). No significant differences were found in postoperative complications and R0 resection. The 3-year overall survival and disease-free survival performed better in the LTG group compared with that in the OTG group(88.2% vs 79.2%, P = 0.011;79.7% vs 73.0%, P = 0.002, respectively). In the stratified analysis, both overall survival and disease-free survival were better in the LTG group than those in the OTG group for stage Ⅱ/Ⅲ patients(P < 0.05) but not for stage I patients.CONCLUSION For patients with Siewert type Ⅱ AEG, LTG is associated with better short-term outcomes and similar oncology safety. In addition, patients with advanced stage AEG may benefit more from LTG in the long-term outcomes.

3D laparoscopic-assisted vs open gastrectomy for carcinoma in the remnant stomach: A retrospective cohort study

BACKGROUND Three-dimensional(3D) laparoscopic technique has gradually been applied to the treatment of carcinoma in the remnant stomach(CRS), but its clinical efficacy remains controversial.AIM To compare the short-term and long-term results of 3D laparoscopic-assisted gastrectomy(3DLAG) with open gastrectomy(OG) for CRS.METHODS The clinical data of patients diagnosed with CRS and admitted to the First Medical Center of Chinese PLA General Hospital from January 2016 to January 2021 were retrospectively collected. A total of 84 patients who met the inclusion and exclusion criteria were enrolled. All their clinical data were collected and a database was established. All patients were treated with 3DLAG or OG by experienced surgeons and were divided into two groups based on the different surgical methods mentioned above. By using outpatient and telephone follow-up,we were able to determine postoperative survival and tumor status. The postoperative short-term efficacy and 1-year and 3-year overall survival(OS) rates were compared between the two groups.RESULTS Among 84 patients with CRS, 48 were treated with OG and 36 with 3DLAG. All patients successfully completed surgery. There was no significant difference between the two groups in terms of age, gender, body mass index, ASA score,initial disease state(benign or malignant), primary surgical anastomosis method,interval time of carcinogenesis, and tumorigenesis site. Patients in the 3DLAG group experienced less intraoperative blood loss(188.33 ± 191.35 mL vs 305.83 ± 303.66 mL;P =0.045) and smaller incision(10.86 ± 3.18 cm vs 20.06 ± 5.17 cm;P < 0.001) than those in the OG group. 3DLAGC was a more minimally invasive method. 3DLAGC retrieved significantly more lymph nodes than OG(14.0 ± 7.17 vs 10.73 ± 6.82;P = 0.036), whereas the number of positive lymph nodes did not differ between the two groups(1.56 ± 2.84 vs 2.35 ± 5.28;P = 0.413). The complication rate(8.3% vs 20.8%;P = 0.207) and intensive care unit admission rate(5.6% vs 14.5%;P = 0.372) were equivalent between the two groups. In terms of postoperative recovery, the 3DLAGC group had a lower visual analog score, shorter indwelling time of gastric and drainage tubes, shorter time of early off-bed motivation, shorter time of postoperative initial flatus and initial soft diet intake, shorter postoperative hospital stay and total hospital stay, and there were significant differences, showing better short-term efficacy. The 1-year and 3-year OS rates of OG group were 83.2% [95% confidence interval(CI): 72.4%-95.6%] and 73.3%(95%CI: 60.0%-89.5%)respectively. The 1-year and 3-year OS rates of the 3DLAG group were 87.3%(95%CI: 76.4%-99.8%) and 75.6%(95%CI: 59.0%-97.0%), respectively. However, the 1-year and 3-year OS rates were similar between the two groups, which suggested that long-term survival results were comparable between the two groups(P = 0.68).CONCLUSION Compared with OG, 3DLAG for CRS achieved better short-term efficacy and equivalent oncological results without increasing clinical complications. 3DLAG for CRS can be promoted safely and effectively in selected patients.

Observation on the Therapeutic Effect and Complication Rate of Totally Laparoscopic Total Gastrectomy and Laparoscopic-Assisted Total Gastrectomy in the Treatment of Gastric Cancer

Objective:To investigate the effect and complication rate of totally laparoscopic and laparoscopic-assisted total gastrectomy in the treatment of gastric cancer.Methods:From March 2019 to July 2021,60 patients with gastric cancer were selected as the subjects in this study;the patients in group A underwent laparoscopic-assisted total gastrectomy,whereas those in group B underwent totally laparoscopic total gastrectomy;the treatment effect and complication rate were compared between the two groups.Results:The postoperative recovery of group B was significantly better than that of group A,and the postoperative complications(10.00%)of group B were significantly lower than that of group A(33.33%)(P<0.05).Conclusion:For patients with gastric cancer,totally laparoscopic total gastrectomy has better therapeutic effect and lower postoperative complications,which is worthy of popularization.

Roux-en-Y versus BillrothⅠreconstruction after distal gastrectomy for gastric cancer:A meta-analysis

AIM:To conduct a meta-analysis to compare Rouxen-Y(R-Y) gastrojejunostomy with gastroduodenal Billroth Ⅰ(B-Ⅰ) anastomosis after distal gastrectomy(DG) for gastric cancer.METHODS:A literature search was performed to identify studies comparing R-Y with B-Ⅰ after DG for gastric cancer from January 1990 to November 2012 in Medline,Embase,Science Citation Index Expanded and the Cochrane Central Register of Controlled Trials in The Cochrane Library.Pooled odds ratios(OR) or weighted mean differences(WMD) with 95%CI were calculated using either fixed or random effects model.Operative outcomes such as operation time,intraoperative blood loss and postoperative outcomes such as anastomotic leakage and stricture,bile reflux,remnant gastritis,reflux esophagitis,dumping symptoms,delayed gastric emptying and hospital stay were the main outcomes assessed.Meta-analyses were performed using RevMan 5.0 software(Cochrane library).RESULTS:Four randomized controlled trials(RCTs) and 9 non-randomized observational clinical studies(OCS) involving 478 and 1402 patients respectively were included.Meta-analysis of RCTs revealed that R-Y reconstruction was associated with a reduced bile reflux(OR 0.04,95%CI:0.01,0.14;P < 0.00 001) and remnant gastritis(OR 0.43,95%CI:0.28,0.66;P = 0.0001),however needing a longer operation time(WMD 40.02,95%CI:13.93,66.11;P = 0.003).Metaanalysis of OCS also revealed R-Y reconstruction had a lower incidence of bile reflux(OR 0.21,95%CI:0.08,0.54;P = 0.001),remnant gastritis(OR 0.18,95%CI:0.11,0.29;P < 0.00 001) and reflux esophagitis(OR 0.48,95%CI:0.26,0.89;P = 0.02).However,this reconstruction method was found to be associated with a longer operation time(WMD 31.30,95%CI:12.99,49.60;P = 0.0008).CONCLUSION:This systematic review point towards some clinical advantages that are rendered by R-Y compared to B-Ⅰ reconstruction post DG.However there is a need for further adequately powered,welldesigned RCTs comparing the same.

Application value of enhanced recovery after surgery for total laparoscopic uncut Roux-en-Y gastrojejunostomy after distal gastrectomy

AIM To evaluate the safety and feasibility of enhanced recovery after surgery(ERAS) for total laparoscopic uncut Roux-en-Y gastrojejunostomy after distal gastrectomy.METHODS The clinical data of 42 patients who were divided into an ERAS group(n = 20) and a control group(n = 22) were collected. The observed indicators included operation conditions, postoperative clinical indexes, and postoperative serum stress indexes. Measurement data following a normal distribution are presented as mean ± SD and were analyzed by t-test. Count data were analyzed by χ~2 test.RESULTS The operative time, volume of intraoperative blood loss, and number of patients with conversion to opensurgery were not significantly different between the two groups. Postoperative clinical indexes, including the time to initial anal exhaust, time to initial liquid diet intake, time to out-of-bed activity, and duration of hospital stay of patients without complications, were significantly different between the two groups(t = 2.045, 8.685, 2.580, and 4.650, respectively, P < 0.05 for all). However, the time to initial defecation, time to abdominal drainage-tube removal, and the early postoperative complications were not significantly different between the two groups. Regarding postoperative complications, on the first and third days after the operation, the white blood cell count(WBC) and C reactive protein(CRP) and interleukin-6(IL-6) levels in the ERAS group were significantly lower than those in the control group.CONCLUSION The perioperative ERAS program for total laparoscopic uncut Roux-en-Y gastrojejunostomy after distal gastrectomy is safe and effective and should be popularized. Additionally, this program can also reduce the duration of hospital stay and improve the degree of comfort and satisfaction of patients.

Comparison between uncut Roux-en-Y and Roux-en-Y reconstruction after distal gastrectomy for gastric cancer: A meta-analysis

AIM To compare uncut Roux-en-Y(U-RY) gastrojejunostomy with Roux-en-Y(RY) gastrojejunostomy after distal gastrectomy(DG) for gastric cancer.METHODS A literature search was conducted in Pubmed, Embase, Web of Science, Cochrane Library, Science Direct, Chinese National Knowledge Infrastructure, Wanfang, and China Science and Technology Journal Database to identify studies comparing U-RY with RY after DG for gastric cancer until the end of December 2017. Pooled odds ratio or weighted mean difference with 95% confidence interval was calculated using either fixed-or random-effects models. Perioperative outcomes such as operative time, intraoperative blood loss, and hospital stay; postoperative complications such as anastomotic bleeding, stricture and ulcer, reflux gastritis/esophagitis, delayed gastric emptying, and Roux stasis syndrome; and postoperative nutritional status(serum hemoglobin, total protein, and albumin levels) were the main outcomes assessed. Metaanalyses were performed using RevM an 5.3 software.RESULTS Two randomized controlled trials and four nonrandomized observational clinical studies involving 403 and 488 patients, respectively, were included. The results of the meta-analysis showed that operative time [weighted mean difference(WMD):-12.95; 95%CI:-22.29 to-3.61; P = 0.007] and incidence of reflux gastritis/esophagitis(OR: 0.40; 95%CI: 0.20-0.80; P = 0.009), delayed gastric emptying(OR: 0.29; 95%CI: 0.14-0.61; P = 0.001), and Roux stasis syndrome(OR: 0.14; 95%CI: 0.04-0.50; P = 0.002) were reduced; and the level of serum albumin(WMD: 0.71; 95%CI: 0.24-1.19; P = 0.003) was increased in patients undergoing U-RY reconstruction compared with those undergoing RY reconstruction. No differences were found with respect to intraoperative blood loss, hospital stay, anastomotic bleeding, anastomotic stricture, anastomotic ulcer, the levels of serum hemoglobin, and serum total protein. CONCLUSION U-RY reconstruction has some clinical advantages over RY reconstruction after DG.

Prognostic value and nomograms of proximal margin distance in gastric cancer with radical distal gastrectomy

Objective:The proximal margin(PM)distance for distal gastrectomy(DG)of gastric cancer(GC)remains controversial.This study investigated the prognostic value of PM distance for survival outcomes,and aimed to combine clinicopathologic variables associated with survival outcomes after DG with different PM distance for GC into a prediction nomogram.Methods:Patients who underwent radical DG from June 2004 to June 2014 at Department of General Surgery,Nanfang Hospital,Southern Medical University were included.The first endpoints of the prognostic value of PM distance(assessed in 0.5 cm increments)for disease-free survival(DFS)and overall survival(OS)were assessed.Multivariate analysis by Cox proportional hazards regression was performed using the training set,and the nomogram was constructed,patients were chronologically assigned to the training set for dates from June 1,2004 to January 30,2012(n=493)and to the validation set from February 1,2012 to June 30,2014(n=211).Results:Among 704 patients with p TNM stage I,p TNM stage II,T1-2,T3-4,N0,differentiated type,tumor size≤5.0 cm,a PM of(2.1-5.0)cm vs.PM≤2.0 cm showed a statistically significant difference in DFS and OS,while a PM>5.0 cm was not associated with any further improvement in DFS and OS vs.a PM of 2.1-5.0 cm.In patients with p TNM stage III,N1,N2-3,undifferentiated type,tumor size>5.0 cm,the PM distance was not significantly correlated with DFS and OS between patients with a PM of(2.1-5.0)cm and a PM≤2 cm,or between patients with a PM>5.0 cm and a PM of(2.1-5.0)cm,so there were no significant differences across the three PM groups.In the training set,the C-indexes of DFS and OS,were 0.721 and 0.735,respectively,and in the validation set,the C-indexes of DFS and OS,were 0.752 and 0.751,respectively.Conclusions:It is necessary to obtain not less than 2.0 cm of PM distance in early-stage disease,while PM distance was not associated with long-term survival in later and more aggressive stages of disease because more advanced GC is a systemic disease.Different types of patients should be considered for removal of an individualized PM distance intra-operatively.We developed a universally applicable prediction model for accurately determining the 1-year,3-year and 5-year DFS and OS of GC patients according to their preoperative clinicopathologic characteristics and PM distance.

Initial experience of single-incision plus one port left-side approach totally laparoscopic distal gastrectomy with uncut Roux-en-Y reconstruction

BACKGROUND Single incision plus one port left-side approach(SILS+1/L)totally laparoscopic distal gastrectomy(TLDG)is an emerging technique for the treatment of gastric cancer.Reduced port laparoscopic gastrectomy has a number of potential advantages for patients compared with conventional laparoscopic gastrectomy:relieving postoperative pain,shortening hospital stay and offering a better cosmetic outcome.Nevertheless,there are no previous reports on the use of SILS+1/L TLDG with uncut Roux-en-Y(uncut R-Y)reconstruction.AIM To investigate the initial feasibility of SILS+1/L TLDG with uncut Roux-en-Y digestive tract reconstruction(uncut R-Y reconstruction)to treat distal gastric cancer.METHODS A total of 21 patients who underwent SILS+1/L TLDG with uncut R-Y reconstruction for gastric cancer were enrolled.All patients were treated at The Second Hospital of Shandong University.Reconstructions were performed intracorporeally with 60 mm endoscopic linear stapler and 45 mm no-knife stapler.The clinicopathological characteristics,surgical details,postoperative short-term outcomes,postoperative follow-up upper gastrointestinal radiography findings and endoscopy results were analyzed retrospectively.RESULTS All SILS+1/L operations were performed by SILS+1/L TLDG successfully.The patient population included 13 men and 8 women with a mean age of 48.2 years(ranged from 40 years to 70 years)and median body mass index of 22.8 kg/m^2.There were no conversions to open laparotomy,and no other port was placed.The mean operation time was 146 min(ranged 130-180 min),and the estimated mean blood loss was 54 mL(ranged 20-110 mL).The mean duration to flatus and discharge was 2.3(ranged 1-3.5)and 7.3(ranged 6-9)d,respectively.The mean number of retrieved lymph nodes was 42(ranged 30-47).Two patients experienced mild postoperative complications,including surgical site infection(wound at the navel incision)and mild postoperative pancreatic fistula(grade A).Follow-up upper gastrointestinal radiography and endoscopy were carried out at 3 mo postoperatively.No patients experienced moderate or severe food stasis,alkaline gastritis or bile reflux during the follow-up period.No recanalization of the biliopancreatic limb was found.CONCLUSION SILS+1/L TLDG with uncut R-Y reconstruction could be safely performed as a reduced port surgery.

Progression of remnant gastric cancer is associated with duration of follow-up following distal gastrectomy

AIM: To re-evaluate the recent clinicopathological features of remnant gastric cancer (RGC) and to develop desirable surveillance programs. METHODS: Between 1997 and 2008, 1149 patients underwent gastrectomy for gastric cancer at the Department of Digestive Surgery, Kyoto Prefectural University of Medicine, Japan. Of these, 33 patients underwent gastrectomy with lymphadenectomy for RGC. Regarding the initial gastric disease, there were 19 patients with benign disease and 14 patients with gastric cancer. The hospital records of these patients were reviewed retrospectively. RESULTS: Concerning the initial gastric disease, the RGC group following gastric cancer had a shorter interval [P < 0.05; gastric cancer vs benign disease: 12 (2-22) vs 30 (4-51) years] and were more frequently reconstructed by Billroth-Ⅰ procedure than those following benign lesions (P < 0.001). Regarding reconstruction, RGC following Billroth-Ⅱ reconstruction showed a longer interval between surgical procedures [P < 0.001; Billroth-Ⅱ vs Billroth-Ⅰ: 32 (5-51) vs 12 (2-36) years] and tumors were more frequently associated with benign disease (P < 0.001) than those following Billroth-Ⅰ reconstruction. In tumor location of RGC, after Billroth-Ⅰ reconstruction, RGC occurred more frequently near the suture line and remnant gastric wall. After Billroth-Ⅱ reconstruction, RGC occurred more frequently at the anastomotic site. The duration of follow-up was significantly associated with the stage of RGC (P < 0.05). Patients diagnosed with early stage RGC such as stage Ⅰ-Ⅱ tended to have been followed up almost every second year. CONCLUSION: Meticulous follow-up examination and early detection of RGC might lead to a better prognosis. Based on the initial gastric disease and the procedure of reconstruction, an appropriate follow-up interval and programs might enable early detection of RGC.

Gastric cancer arising from the remnant stomach after distal gastrectomy:A review

Gastric stump carcinoma was initially reported by Balfore in 1922,and many reports of this disease have since been published. We herein review previous reports of gastric stump carcinoma with respect to epidemiology,carcinogenesis,Helicobacter pylori(H. pylori) infection,Epstein-Barr virus infection,clinicopathologic characteristics and endoscopic treatment. In particular,it is noteworthy that no prognostic differences are observed between gastric stump carcinoma and primary upper third gastric cancer. In addition,endoscopic submucosal dissection has recently been used to treat gastric stump carcinoma in the early stage. In contrast,many issues concerning gastric stump carcinoma remain to be clarified,including molecular biological characteristics and the carcinogenesis of H.pylori infection.We herein review the previous pertinent literature and summarize the characteristics of gastric stump carcinoma reported to date.

Treatment of gastric remnant cancer post distal gastrectomy by endoscopic submucosal dissection using an insulation-tipped diathermic knife

AIM: To evaluate the effectiveness of endoscopic submucosal dissection using an insulation-tipped diathermic knife (IT-ESD) for the treatment of patients with gastric remnant cancer. METHODS: Thirty-two patients with early gastric cancer in the remnant stomach, who underwent distal gastrectomy due to gastric carcinoma, were treated with endoscopic mucosal resection (EMR) or ESD at Sumitomo Besshi Hospital and Shikoku Cancer Center in the 10-year period from January 1998 to December 2007, including 17 patients treated with IT-ESD. Retrospectively, patient backgrounds, the one-piece resection rate, complete resection (CR) rate, operation time, bleeding rate, and perforation rate were compared between patients treated with conventional EMR and those treated with IT-ESD. RESULTS: The CR rate (40% in the EMR group vs 82% in the IT-ESD group) was significantly higher in the IT-ESD group than in the EMR group; however, the operation time was significantly longer for the IT- ESD group (57.6 ± 31.9 min vs 21.1 ± 12.2 min). No significant differences were found in the rate of underlying cardiopulmonary disease (IT-ESD group, 12% vs EMR group, 13%), one-piece resection rate (100% vs 73%), bleeding rate (18% vs 6.7%), and perforation rate (0% vs 0%) between the two groups. CONCLUSION: IT-ESD appears to be an effective treatment for gastric remnant cancer post distal gastrectomy because of its high CR rate. It is useful for histological confirmation of successful treatment. Thelong-term outcome needs to be evaluated in the future.

Roux-en-Y reconstruction does not require gastric decompression after radical distal gastrectomy

AIM: To determine whether routine nasogastric (NG) decompression benefitted patients undergoing radical gastric surgery. METHODS: Between January 1998 and December 2008, 519 patients who underwent distal gastrectomy for gastric cancer were retrospectively divided into 2 time-period cohorts; those treated with Billroth Ⅱ (BⅡ) reconstruction in the first 6 years and those with Roux-en-Y (RY) reconstruction in the last 5 years. In the latter group, the patients were further divided into 2 subgroups; with and without nasogastric decompression.RESULTS: Postoperatively, there were no significant differences in the number of anastomotic leaks between the 3 groups. In the tubeless RY group, time to semiliquid diet was significantly shorter than in the other 2 groups (4.4 d ± 1.4 d vs 7.2 d ± 1.3 d and 5.9 d ± 1.2 d, P = 0.005). The length of postoperative stay was significantly increased in patients with BⅡ reconstruction compared with patients with RY reconstruction with/without NG decompression (15.4 d ± 4.3 d in BⅡ group vs 12.6 d ± 3.1 d in decompressed RY and 11.4 d ± 3.4 d in the tubeless RY group, P = 0.035). The postoperative pneumonia rate was lowest in the tubeless group and highest in the BⅡ group (1.4% vs 4.6%, P = 0.01). Severe sore throat was noted in 59 (20.7%) members of the BⅡ group, 18 (17.4%) members of the decompressed RY group and 6 (4.2%) members of the tubeless RY group. Fewer patients in the tubeless group complained of severe sore throat (P = 0.001). CONCLUSION: This study provides support for abandoning routine NG decompression in patients undergoing subtotal gastrectomy with Roux-en-Y gastrojejunostomy.

The Requirements for Laparoscopy-Assisted Distal Gastrectomy to Become Standard Procedure for Gastric Cancer: Based on Qualitative Study of Surgeons’ Experiences

Laparoscopy-assisted distal gastrectomy (LADG) has become one of the standard surgical procedures for gastric cancer in Japan and Korea. However, LADG is currently listed as being in the clinical research phase under the Gastric Cancer Treatment Guidelines. The aim of this study is to report surgeons’ opinions of what is needed if LADG is to become a standard procedure. We conducted questionnaire survey with open questions in hospitals that either applied or did not apply LADG and compared the answers. We labeled and categorized the collected data using content analysis. The number of hospitals which applied LADG more than doubled from 5 to 12 hospitals over 3 years. Overall, hospitals reported that the necessary elements for LADG to become a standard procedure are: clinical trials of LADG (n = 5, 22.7%), surgeons’ practical experience in performing LADG (n = 4, 18.2%), stability of radical treatment (n = 4, 18.2%), and a shorter operative duration (n = 3, 13.6%) for the procedure. Surgeons’ practical experience was chosen as the most important requirement in the hospitals which applied LADG while clinical trials (n = 2, 40.0%) and stability of radical treatment (n = 2, 40.0%) were the most common answers in the hospitals which did not apply LADG. Hospitals and surgeons’ practical experience, stabilizing radical cure, and the large scale of clinical trials are for LADG to become a standard procedure and to gain equivalent importance as open distal gastrectomy in treating gastric cancer.

Radical gastrectomy for D2 distal gastric cancer

Patient＇s information The patient is a 56-year-old man who visited our hospital for ＂repeated epigastric pain for more than two months.＂ Physical examination showed nearly pale appearance; abdomen was soft and no mass palpable; left supraclavicular lymph node （-）; and digital rectal examination （-）.