Laparoscopy-assisted gastrectomy for advanced gastric cancer patients with situs inversus totalis: Two case reports and review of literature

BACKGROUND Situs inversus totalis(SIT)is a rare condition in which the positions of abdominal and thoracic organs present a“mirror image”of the normal ones in the median sagittal plane.Although minimally invasive surgery has evolved to achieve laparoscopic gastrectomy for gastric cancer(GC)patients with SIT,it is difficult to perform lymphadenectomy(LND)in such a transposed anatomical condition.Herein,we report the cases of two patients with SIT who successfully underwent laparoscopy-assisted gastrectomy(LAG)with D2 LND.CASE SUMMARY Case 1:A 65-year-old man was admitted for intermittent abdominal pain and distension,occasional belching,and acid reflux for 4 mo.He was diagnosed with GC(cT3N1-2M0)with SIT.Before surgery,he had undergone four cycles of neoadjuvant chemotherapy and immunotherapy.Then,the patient was evaluated as having a partial response,and laparoscopy-assisted distal gastrectomy with D2 LND and Billroth II reconstruction were performed.The operation was performed successfully within 240 min with an estimated blood loss of 50 mL and no severe complications.The patient was discharged on postoperative day(POD)9.Case 2:A 55-year-old man was admitted for upper abdominal distension with pain and discomfort after eating for 3 mo.He was diagnosed with GC(cT3N1M0)with SIT.He had a history of hypertension for more than 10 years;however,his blood pressure was well-controlled via regular medication.We performed laparoscopy-assisted total gastrectomy with D2 LND and Roux-en-Y reconstruction.The operation was performed successfully within 168 min with an estimated blood loss of 50 mL and no severe complications.The patient was discharged on POD 10.CONCLUSION LAG with D2 LND could be considered an accessible,safe,and curative procedure for advanced GC patients with SIT.

Influence of liver function after laparoscopy-assisted vs totally laparoscopic gastrectomy

BACKGROUND Previously,some studies have proposed that total laparoscopic gastrectomy(TLG)is superior to laparoscopic-assisted gastrectomy(LAG)in terms of safety and feasibility based on the related intraoperative operative parameters and incidence of postoperative complications.However,there are still few studies on the changes in postoperative liver function in patients undergoing LG.The present study compared the postoperative liver function of patients with TLG and LAG,aiming to explore whether there is a difference in the influence of TLG and LAG on the liver function of patients.AIM To investigate whether there is a difference in the influence of TLG and LAG on the liver function of patients.METHODS The present study collected 80 patients who underwent LG from 2020 to 2021 at the Digestive Center(including the Department of Gastrointestinal Surgery and the Department of General Surgery)of Zhongshan Hospital affiliated with Xiamen University,including 40 patients who underwent TLG and 40 patients who underwent LAG.Alanine aminotransferase(ALT),aspartate aminotransferase(AST),alkaline phosphatase(ALP),γ-glutamyltransferase(GGLT),total bilirubin(TBIL),direct bilirubin(DBIL)and indirect bilirubin(IBIL),and other liver function-related test indices were compared between the 2 groups before surgery and on the 1^(st),3^(rd),and 5^(th) d after surgery.RESULTS The levels of ALT and AST in the 2 groups were significantly increased on the 1st to 2nd postoperative days compared with those before the operation.The levels of ALT and AST in the TLG group were within the normal range,while the levels of ALT and AST in the LAG group were twice as high as those in the TLG group(P<0.05).The levels of ALT and AST in the 2 groups showed a downward trend at 3-4 d and 5-7 d after the operation and gradually decreased to the normal range(P<0.05).The GGLT level in the LAG group was higher than that in the TLG group on postoperative days 1-2,the ALP level in the TLG group was higher than that in the LAG group on postoperative days 3-4,and the TBIL,DBIL and IBIL levels in the TLG group were higher than those in the LAG group on postoperative days 5-7(P<0.05).No significant difference was observed at other time points(P>0.05).CONCLUSION Both TLG and LAG can affect liver function,but the effect of LAG is more serious.The influence of both surgical approaches on liver function is transient and reversible.Although TLG is more difficult to perform,it may be a better choice for patients with gastric cancer combined with liver insufficiency.

Laparoscopy-assisted total gastrectomy with trans-orally inserted anvil(OrVil^(TM)):A single institution experience

AIM:To investigate the feasibility of laparoscopyassisted total gastrectomy(LATG)using trans-orally inserted anvil(OrVilTM)in terms of operative characteristics and short term outcomes. RESULTS:Characteristics of 27 patients with gastric cancer who underwent LATG from October 2009 to October 2012 in the Foshan Affiliated Hospital of South Medical University were retrospectively reviewed. Among these patients,six were reconstructed by minilaparotomy and 21 by OrVilTM.The clinicopathological characteristics,total operation time,total blood loss, abdominal incision and complications of anastomosis including stenosis and leakage,were compared between the groups undergoing LATG with OrVilTM and the group undergoing minilaparotomy. RESULTS:The operations were successfully performed on all the patients without intraoperative complications or conversion to open surgery.Two(10%)patients received palliative procedure under laparoscope who were prepared for LATG preoperatively.One case had hepatic metastatic carcinoma and 1 case had tumor recurrence near the anastomosis 8 mo after surgery.The mean follow-up duration was 10 mo(range,2-24 mo). Operation time was significantly reduced by the use of OrVilTM(198.42±30.28 min vs 240.83±8.23 min). The postoperative course with regard to occurrence of stenosis and leakage was not different between the two groups.There were no significant differences in estimated blood loss.The upper abdominal incision was smaller in OrVilTM group than in minilaparotomy group (4.31±0.45 cm vs 6.43±0.38 cm). CONCLUSION:LATG using OrVil TM is a technically feasible surgical procedure with sufficient lymph node dissection,less operation time and acceptable morbidity.

Laparoscopy-assisted percutaneous endoscopic gastrostomy enables enteral nutrition even in patients with distorted anatomy

AIM:To analyzed whether laparoscopy-assisted percutaneous endoscopic gastrostomy(PEG)could be a valuable option for patients with complicated anatomy.METHODS:A retrospective analysis of twelve patients(seven females,five males;six children,six young adults;mean age 19.2 years)with cerebral palsy,spastic quadriparesis,severe kyphoscoliosis and interposed organs and who required enteral nutrition(EN)due to starvation was performed.For all patients,standard PEG placement was impossible due to distorted anatomy.All the patients qualified for the laparoscopyassisted PEG procedure.RESULTS:In all twelve patients,the laparoscopy-assisted PEG was successful,and EN was introduced four to six hours after the PEG placement.There were no complications in the perioperative period,either technical or metabolic.All the patients were discharged from the hospital and were then effectively fed using bolus methods.CONCLUSION:Laparoscopy-assisted PEG should become the method of choice for gastrostomy tube placement and subsequent EN if PEG placement cannot be performed safely.

Liver function alterations after laparoscopy-assisted gastrectomy for gastric cancer and its clinical significance

AIM: To evaluate the factors associated with liver function alterations after laparoscopy-assisted gastrectomy (LAG) for gastric cancer. METHODS: We collected the data of gastrectomy patients with gastric cancer and divided them into 2 groups: open gastrectomy (OG) and LAG. We also collected the data of patients with colon cancer to evaluate the effect of liver manipulations during surgery on liver function alterations. Serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), total bilirubin, and alkaline phosphatase were measured on the preoperative day and postoperative day 1 (POD1), POD3, POD5, and POD7. RESULTS: No changes in liver function were observed after the operation in patients with colon cancer (n = 121). However, in gastric cancer patients (n = 215), AST and ALT levels increased until POD5 compared to those in colon cancer patients and these findings were observed both in the LAG and OG without a significant difference except at POD1. The mean hepatic enzyme levels at POD1 in the LAG group were significantly higher than those in the OG group (P = 0.047 for AST and P = 0.039 for ALT). The factors associated with elevated ALT on POD1 in patients with gastric cancer were body mass index (P < 0.001), operation time (P < 0.001), intraoperative hepatic injury (P = 0.048), and ligation of an aberrant left hepatic artery (P = 0.052) but not type of operation (OG vs LAG, P = 0.094). CONCLUSION: We conclude that the liver function alteration after LAG may have been caused by direct liver manipulation or aberrant hepatic artery ligation rather than the CO2 pneumoperitoneum.

Laparoscopy-assisted transanal total mesorectal excision for lower rectal cancer:A feasible and innovative technique

BACKGROUND Transanal total mesorectal excision(taTME)is a new technique with many potential technical advantages.Laparoscopy-assisted taTME is a combination of transabdominal taTME and transluminal endoscopic surgery taTME.Laparoscopy-assisted taTME is a combination of techniques such as minimally invasive surgery,intersphincter-assisted resection,natural orifice extraction,ta minimally invasive surgery,and ultralow-level preservation of the anus.AIM To verify the feasibility and safety of an innovative technique of taTME for treatment of cancer located in the lower rectum.METHODS From January 2016 to March 2018,we attempted to perform laparoscopy-assisted taTME surgery in 24 patients with lower rectal cancer.RESULTS The new technique of laparoscopy-assisted taTME was successfully performed in all 24 patients.Mean operating time was 310.0 min and mean intraoperative blood loss was 69.1 mL.The mean time to passing of first flatus was 3.1 d,and mean postoperative hospital stay was 9.2 d.Two patients were given postoperative analgesics due to anal pain.Twenty-three patients were able to walk in first 2 d,and five patients had postoperative complications.CONCLUSION Laparoscopy-assisted taTME is suitable for selected patients with lower rectal cancer,and this technique is worthy of further recommendation.

Laparoscopy-assisted distal gastrectomy for advanced gastric cancer with situs inversus totalis:A case report

Situs inversus totalis(SIT) is a rare anomaly in which the abdominal and thoracic cavity structures are located opposite to their usual positions. Occasionally,patients with this condition are diagnosed with malignant tumors. We report a case of a 60-yearold woman with gastric cancer and SIT. Laparoscopyassisted distal gastrectomy(LADG) with D2 lymph node dissection and Billroth Ⅱ anastomosis were performed successfully on the patient by careful consideration of the mirror-image anatomy. The operation required 230 min, and no intraoperative complications occurred. The final pathological report was p T4 a N0M0,according to the American Joint Committee on Cancer 7th edition staging guidelines. The postoperative course was favorable, and the patient was discharged on postoperative day 8. We believe that this is the first case of LADG with D2 lymphadenectomy reported in a SIT patient with advanced gastric cancer.

Sigmoid colon endometriosis treated with laparoscopy-assisted sigmoidectomy:Significance of preoperative diagnosis

We present a female patient with sigmoid colon endometriosis who was diagnosed correctly preoperatively and underwent minimally invasive surgery. She was admitted to our hospital with rectal bleeding and constipation. We performed several workups. Colonoscopy and endoscopic ultrasonography showed sigmoid colon stenosis caused by submucosal tumor, and magnetic resonance imaging revealed a sigmoid colon tumor displaying signal hy- pointensity on both T1- and T2-weighted imaging. However, colonoscopic ultrasonography-assisted needle aspiration biopsy could not specify tumor characteristics. From these examinations, the lesion was diagnosed as sigmoid colon endometriosis and laparoscopy-assisted sigmoidectomy was performed. Pathological diagnosis from the resected specimen was identical to preoperative diagnosis, i.e., colonic endometriosis. Since differential diagnosis of intestinal endometriosis seems difficult, a cautious preoperative diagnosis is required to select treatments including minimally invasive surgery.

Adult intussusception with cecal adenocarcinoma:Successful treatment by laparoscopy-assisted surgery following preoperative reduction

We report a case of adult intussusception caused by cecal adenocarcinoma that was treated by laparoscopyassisted ileocecal resection following reduction by contrast enema and preoperative colonoscopy.A 68-yearold male with cecal cancer was admitted to our hospital because of colicky abdominal pain after taking a laxative.His abdomen was distended,and a mass was palpable in the right upper quadrant,which appeared as a target-or sausage-shaped lesion by ultrasonograhpy and computed tomography.A contrast enema using water-soluble material showed a cup-shaped filling defect characterized by intussusception in the ascending colon.This round defect with a clear margin was pushed gradually back into the cecum by the enema pressure.Re-occurrence of the intussusception is easilyreleased by colonoscopy.We performed laparoscopyassisted ileocecal resection of a protruding tumor measuring 6.5 cm × 5.0 cm × 3.5 cm from the cecum,with D3 lymph node dissection.Histological examination revealed a well-differentiated adenocarcinoma that had invaded the serosa without permeating the lymphatic or venous capillaries,as well as lymph node metastasis.The postoperative course was uneventful,and the patient has been well without evidence of disease recurrence for 5 years following the operation.Preliminary reduction of adult colonic intussusception before surgical resection is therefore an option in cases of an early and correct diagnosis of intussusception.

Preoperative assessment of vascular anatomy of inferior mesenteric artery by volume-rendered 3D-CT for laparoscopic lymph node dissection with left colic artery preservation in lower sigmoid and rectal cancer

AIM： To determine the distance between the branching point of the left colic artery （LCA） and the inferior mesenteric artery （IMA） by computed tomography （CT） scanning, for preoperative evaluation before laparoscopic colorectal operation. METHODS： From February 2004 to May 2005, 100 patients （63 men, 37 women） underwent angiography performed with a 16-scanner multi-detector row CT unit （Toshiba, Aquilion 16）. All images were analyzed on a workstation （AZE Ltd, Virtual Place Advance 300）. The distance from the root of the IMA to the bifurcation of the LCA was measured by curved multi-planar reconstruction on a workstation. RESULTS： The IMA could be visualized in all the cases, but the LCA was missing in two patients. The mean distance from the root of the IMA to the root of the LCA was 42.0 mm （range, 23.2-75.0 mm）. There were no differences in gender, arterial branching types, body weight, height, and body mass index. CONCLUSION： Volume-rendered 3D-CT is helpful to assess the vascular branching anatomy for laparoscopic surgery.

Strategies for gastric cancer in the modern era

Gastric cancer is one of the most common neoplasms in Japan, and it is also the second leading cause of cancer-related deaths worldwide. Nowadays, infection with Helicobacter pylori (H. pylori) is a known risk factor for the development of gastric cancer. Therefore, gastric cancer should be considered as an infectious disease, and in fact, prophylactic eradication of H. pylori may prevent the development of metachronous gastric carcinoma. Before the role of H. pylori was understood, a different approach was used. Recently even after the cancer has developed, some newer therapeutic approaches have been pursued. These newer treatments have been summarized as "minimally invasive therapies" and use endoscopic or laparoscopic techniques. In addition, robotic approaches are being developed that seem to hold a great potential to change the surgical approach. Since basic understanding and treatment of the disease have both changed signif icantly over the last decade, we present a review of current advances in gastric cancer research and therapy.

Sporadic gastric carcinoid tumor successfully treated by two-stage laparoscopic surgery:A case report

We report a case of sporadic gastric carcinoid tumor successfully treated by two-stage laparoscopic surgery.A 38-year old asymptomatic woman was referred to our hospital for evaluation of a submucosal tumor of the stomach.Endoscopic examination showed a solitary submucosal tumor without ulceration or central depression on the posterior wall of the antrum and biopsy specimens were not sufficient to determine the diagnosis.Endoscopic ultrasound revealed a tumor nearly 2 cm in diameter arising from the muscle layer and a computed tomography scan showed the tumor enhanced in the arterial phase.Laparoscopic wedge resection was performed for definitive diagnosis.Pathologically,the tumor was shown to be gastric carcinoid infiltrating the muscle layer which indicated the probability of lymph node metastasis.Serum gastrin levels were normal.As a radical treatment,laparoscopy-assisted distal gastrectomy with regional lymphadenectomy was performed 3 wk after the initial surgery.Finally,pathological examination revealed no lymph node metastasis.

Gastrojejunostomy followed by induction chemotherapy for incurable gastric cancer with outlet obstruction

A 72-year-old male gastric cancer patient with outlet obstruction underwent laparoscopic exploration. The examination disclosed intraperitoneal free cancer cells with no overt peritoneal, lymphatic, or hepatic metastasis. The patient underwent laparoscopy-assisted gastroje-junostomy (LAGJ) and started chemotherapy with S-1 plus cisplatin on postoperative day 13. Three course of the chemotherapy shrank the tumor markedly. Then, the patient underwent gastrectomy with a curative intent. Laparotomy revealed no intraperitoneal free cancer cells, and microscopically complete resection was achieved. The patient received S-1 chemotherapy as postoperative adjuvant treatment for 1 year, and is still alive with no evidence of peritoneal recurrence. LAGJ followed by S-1 plus cisplatin is one of the optional treatments that should be considered for patients with outlet obstruction as it may widen opportunities for potentially curative resection.

Exposed endoscopic full-thickness resection for duodenal submucosal tumors: Current status and future perspectives

Exposed endoscopic full-thickness resection(EFTR),with or without laparoscopic assistance,is an emergent natural orifice transluminal endoscopic surgery technique with promising safety and efficacy for the management of gastrointestinal submucosal tumors(SMTs)arising from the muscularis propria(MP),especially of the gastric wall.To date,evidence concerning duodenal exposed EFTR is lacking,mainly due to both the technical difficulty involved because of the special duodenal anatomy and concerns about safety and effectiveness of transmural wall defect closure.However,given the non-negligible morbidity and mortality associated with duodenal surgery,the recent availability of dedicated endoscopic tools for tissue-approximation capable to realize full-thickness defect closure could help in promoting the adoption of this endosurgical technique among referral centers.The aim of our study was to review the current evidence concerning exposed EFTR with or without laparoscopic assistance for the treatment of MP-arising duodenal SMTs.