[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Laparoscopic gastrectomy has recently been gaining popularity as a treatment for cancer; however, little is known about the benefits of intracorporeal (IC) gastrointestinal anastomosis with pure totally laparoscopic distal gastrectomy (LDG) compared with extracorporeal (EC) anastomosis with laparoscopy-assisted distal gastrectomy (LADG). METHODS: Between June 2000 and December 2011, we assessed 449 consecutive patients with early-stage gastric cancer who underwent LDG. The patients were classified into three groups according to the method of reconstruction LADG followed by EC hand-sewn anastomosis (LADG + EC) (n = 73), using any of three anastomosis methods (Billroth-I (B-I), Billroth-II (B-II) or Roux-en-Y (R-Y); LDG followed by IC B-I anastomosis (LDG + B-I) (n = 248); or LDG followed by IC R-Y anastomosis (LDG + R-Y) (n = 128)). The analyzed parameters included patient and tumor characteristics, operation details, and post-operative outcomes. RESULTS: The tumor location was significantly more proximal in the LDG + R-Y group than in the LDG + B-I group (P < 0.01). Mean operation time, intra-operative blood loss, and the length of post-operative hospital stay were all shortest in the LDG + B-I group (P < 0.05). Regarding post-operative morbidities, anastomosis-related complications occurred significantly less frequently in with the LDG + B-I group than in the LADG + EC group (P < 0.01), whereas there were no differences in the other parameters of patients' characteristics. CONCLUSIONS: Intracorporeal mechanical anastomosis by either the B-I or R-Y method following LDG has several advantages over at the LADG + EC, including small wound size, reduced invasiveness, and safe anastomosis. Although additional randomized control studies are warranted to confirm these findings, we consider that pure LDG is a useful technique for patients with early gastric cancer.
World Journal of Surgical Oncology 12/2012; 10(1):267. · 1.09 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Recently, laparoscopic-assisted distal gastrectomy (LADG) has become popular for the treatment of early gastric cancer. Furthermore, the use of totally laparoscopic gastrectomy (TLG), a more difficult procedure than LADG, has been increasing in Japan. Laparoscopic-assisted distal gastrectomy is currently performed more frequently than laparoscopic distal gastrectomy (LDG) in hospitals in Japan. METHOD: Reconstruction after LDG is commonly performed extra-abdominally and lymph node dissection of the lesser curvature is performed at the same time. We have developed a new method of intra-abdominal lymph node dissection for the lesser curvature. RESULTS: Our technique showed positive results, is easy to perform, and is reasonable in terms of general oncology theory. CONCLUSION: In oncological therapy, this technique could be a valuable surgical option for totally laparoscopic surgery.
World Journal of Surgical Oncology 09/2012; 10(1):205. · 1.09 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background/Aims: We compared functional outcomes between different types of reconstruction following open or laparoscopic 1/2- or 2/3-proximal gastrectomy for gastric cancer. Methodology: Resection and reconstruction were performed by one of the following 6 methods, depending on the depth of cancer invasion and the date of the procedure relative to introduction of laparoscopic proximal gastrectomy: open proximal 2/3-gastrectomy with jejunal interposition (2/3PG-int, n=7), open proximal 1/2-gastrectomy with jejunal interposition (1/2PG-int, n=5), laparoscopic proximal 1/2-gastrectomy followed by double tract reconstructions with small (3cm) jejunogastrostomy (L1/2 PG-DT(S), n=19) and laparoscopic proximal 1/2-gastrectomy followed by double tract reconstructions with large (6cm) jejunogastrostomy (L1/2PG-DT(L), n=10). Open total gastrectomy with jejunal interposition (TG, n=12) and laparoscopic total gastrectomy with Roux-en-Y reconstruction (LTG, n=14) represented control procedures. Results: Comparison of postoperative/preoperative body weight ratios and food intake ratios revealed better preservation among patients with a larger remnant stomach and with easy flow of food into the remnant stomach (the 1/2PG-int and L1/2PG-DT(L) groups). Conclusions: Better functional outcomes were observed in patients with a large remnant stomach and with easy flow of food into the remnant stomach regardless of whether they underwent open or laparoscopic procedures.
[Show abstract][Hide abstract] ABSTRACT: Randomized trials and cohort studies show that laparoscopic distal gastrectomy (LDG) achieves similar oncological results to open distal gastrectomy (ODG). However, studies have consistently demonstrated lower lymph node yield (LNY) for laparoscopic lymphadenectomy. Analysis of station-specific LNY may be useful in evaluating the reasons behind this difference.
Comparison of station-specific LNY, surgical, and oncological outcomes between LDG and ODG for early gastric cancer.
Patients who underwent R0 distal gastrectomy with histologically confirmed early gastric cancer were eligible for the study. All consecutive cases of LDG since the beginning of our experience with laparoscopic gastrectomy and synchronous cases of ODG with R0 resection were included in the study. Demographic, operative, histopathologic, and follow-up data were recorded in all patients.
A total of 259 cases of LDG and 95 cases of ODG were performed between 2000 and 2009. Patients undergoing LDG had longer operations but less bleeding (P<0.05). Postoperative complications were similar in both groups. The preoperatively planned extent of lymphadenectomy was D1 (stations 1, 3, 4sb, 4d, 5, 6, and 7), D1+ (D1with stations 8a and 9), or D2 (D1+ with stations 11p and 12a). During surgery, dissection of stations 3, 4d, 5, 6, and 7 was performed in all cases of LDG and ODG. Dissection of stations 1, 4sb, 8a, 9, 11p, and 12a was performed more frequently during ODG than during LDG. Consequently, the total LNY was 26.71 and 31.43 for LDG and ODG, respectively. Station-specific LNY was significantly lower for LDG than for ODG in the common hepatic artery nodes only (P<0.05). The mean follow-up was 43.6 months. Lymph node metastases, metastatic-to-resected lymph node ratio, recurrence, and cancer-related deaths were similar for LDG and ODG.
LDG was associated with less extensive lymph node dissection compared with ODG. Station-specific LNY was similar in all nodal stations except for the common hepatic artery nodes. In our experience, laparoscopic sub-D2 lymphadenectomy was adequate in the context of early gastric cancer and represents the future of gastric cancer resection in Japan.
[Show abstract][Hide abstract] ABSTRACT: In gastric cancer, various methods of gastric resection and reconstruction have been devised according to the location of the primary tumor and the depth of invasion. The functional outcomes of patients treated by laparoscopy-assisted or totally laparoscopic distal gastrectomy were compared with respect to the approach, size of the remnant stomach, and type of reconstruction.
Patients who required distal gastrectomy to treat early-stage cancer between May 2000 and December 2008 were treated by one of the four following procedures: Billroth Type I (B-1) reconstruction for 1/2 remnant stomach (1/2B1ML) or B-1 for 1/3 remnant stomach (1/3B1ML), through a mini-laparotomy following laparoscopy-assisted surgery; intra-corporeal B-1 for 1/2 remnant stomach (1/2 B1IC); or intra-corporeal Roux-en-Y for 1/3 remnant stomach (1/3RYIC). The primary outcome measure was digestive function, assessed by body weight, food intake, and degree of abdominal symptoms. The secondary outcome was morbidity.
The 1/2B1ML (n = 27) and 1/2B1IC (n = 56) groups were significantly superior to the 1/3 resection groups in terms of the preservation of body weight. The 1/3B1ML (n = 29) and 1/3RYIC (n = 64) groups were associated with significantly decreased food intake compared with the 1/2B1ML group. Endoscopy revealed a greater incidence of esophagitis and gastritis among the 1/3B1ML patients compared with the 1/3RYIC patients. There were no operative deaths, and no differences in morbidity between the groups.
Patients with early-stage cancer actually benefit from 1/2 gastrectomy rather than the typical 2/3 gastrectomy. B-1 reconstruction is appropriate for patients with large gastric remnants, and intra-corporeal reconstruction in experienced hands is associated with no apparent disadvantages, while offering a favorable cosmetic result.
Gastric Cancer 04/2011; 14(3):279-84. · 3.99 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Laparoscopic gastrectomy is gaining popularity. Increasingly, Roux-en-Y reconstruction after distal gastrectomy is preferred because of reduced reflux and associated symptoms. Therefore, efficient and reliable techniques for intracorporeal Roux-en-Y reconstruction are in demand.
To determine the surgical outcomes from laparoscopic distal gastrectomy and Roux-en-Y reconstruction in the treatment of gastric cancer.
Laparoscopic gastrectomy is indicated for gastric cancer up to stage T1N1. Our technique for laparoscopic Roux-en-Y reconstruction incorporates intracorporeal-stapled gastrojejunostomy with extracorporeal hand-sewn jejunojejunostomy, or more recently, totally intracorporeal reconstruction.
From 2003 to 2009, 82 patients underwent laparoscopic distal gastrectomy with Roux-en-Y reconstruction. The mean age of the patients was 64.6 years (range, 39 to 83 y) and the male:female ratio was 2.4:1. Most patients (85%) had stage I disease. The mean operation time was 354 minutes (SD 82.7). The conversion rate was 0%. The mean lymph node yield was 27.2 nodes (SD 12.4). Eleven patients had totally intracorporeal reconstruction. Overall, anastomotic leakage of the gastrojejunostomy occurred in 2 patients (2.4%) both requiring reoperation. There were 2 cases (2.4%) of duodenal stump leakage, which were treated conservatively. Postoperative stasis was encountered in 2 patients (2.4%). The mean follow-up was 21 months (range, 5 to 50 mo). None of the patients developed reflux symptoms or endoscopic evidence of reflux during follow-up. Recurrence occurred in 1 patient who was the only patient with metastasis to the third tier of lymph nodes.
Surgical outcomes from laparoscopic distal gastrectomy and Roux-en-Y reconstruction were acceptable in the context of early gastric cancer. Totally intracorporeal reconstruction was technically feasible, safe, and associated with no obvious drawbacks.
[Show abstract][Hide abstract] ABSTRACT: Limited gastrectomy for early gastric body cancers can offer a better functional outcome by preserving more remnant stomach. Intracorporeal stapled techniques result in cosmesis and avoid awkward anastomosis through a minilaparotomy.
Laparoscopic segmental gastrectomy is indicated for early gastric cancers of the body of the stomach with no evidence of lymph node involvement. Laparoscopic pylorus-preserving gastrectomy is a specific type of segmental resection for lower-body lesions with dissection of lymph nodes in station 6. Intracorporeal gastrogastric anastomosis is performed by the delta-shaped technique using linear staplers.
Since January 2008 we have performed 12 laparoscopic pylorus-preserving gastrectomies and 13 laparoscopic segmental gastrectomies. All procedures were completed by laparoscopy. One patient with minor anastomotic leakage was managed conservatively. Bleeding from the anastomosis was not encountered in any of the patients. One patient developed narrowing at the anastomotic site and was treated successfully by balloon dilatation. There was no stasis encountered in any of the patients.
Laparoscopic segmental gastrectomy with acceptable surgical outcomes is technically feasible. Although the impact of such resections on oncological outcomes remains to be further evaluated, laparoscopic segmental gastrectomy represents a minimally invasive limited resection that maximizes the potential for a better quality of life following gastric cancer surgery.
[Show abstract][Hide abstract] ABSTRACT: Laparoscopic gastrectomy (LG) is becoming increasingly popular for management of early gastric cancer (EGC). Although short-term efficacy is proven, reports on long-term effectiveness are still infrequent.
All patients with a diagnosis of gastric cancer undergoing LG from the beginning of our laparoscopic experience were included in the analysis. At our unit, LG is indicated for all cancers up to preoperative stage T2N1.
Six-hundred and one laparoscopic resections were included in the analysis. There were 392 men and 209 women. Mean age was 64.2 +/- 10.9 years. Distal gastrectomy was performed in 305 patients, pylorus-preserving gastrectomy in 148, segmental gastrectomy in 42, proximal gastrectomy in 53, total gastrectomy in 27, and wedge resection in 26. Histological staging revealed that 478 patients had stage IA disease, 47 had stage IB, 44 had stage IIA, 19 had stage IIB, 8 had stage IIIA, 3 had stage IIIB, and 2 had stage IIIC. Morbidity and mortality rates were 17.6% and 0.3%, respectively. Median follow-up was 35.9 months (range 3 to 113 months). Cancer recurrence occurred in 15 patients and metachronous gastric remnant cancer was detected in 6 patients. The 5-year overall and disease-free survival rates were 94.2% and 89.9%, respectively, for stage IA tumors, 87.4% and 82.7% for stage IB, 80.8% and 70.7% for stage IIA, and 69.6% and 63.1% for stage IIB.
In our experience, long-term oncological outcomes from LG for EGC are acceptable. Wherever expertise permits, LG should be considered as the primary treatment in patients with EGC.
Journal of the American College of Surgeons 07/2010; 211(1):33-40. · 4.50 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We assessed the value of magnetic resonance imaging (MRI), using ultrasmall superparamagnetic iron oxide (USPIO) with new diagnostic criteria, in the evaluation of regional lymph node metastases in gastric cancer.
Thirty-one patients with gastric cancer were enrolled. 1000 lymph nodes were dissected during surgery, and of these, 519 nodes (51.9%) were identified by currently used MRI imaging analysis. We evaluated lymph nodes on USPIO-post-contrast T2*-weighted images using the following two criteria: (1) we diagnosed the nodes on T2*-weighted images according to conventional criteria, where a node having an overall low signal intensity (pattern A) was nonmetastatic, while a node having partial (pattern B) or overall (pattern C) high signal intensity was metastatic; (2) we subdivided pattern B nodes on T1-weighted images using the new criteria, in which a node for which the high-intensity area on T2*-weighted images was not defined as adipose tissue on T1-weighted images (pattern B1) was metastatic, while a node for which the high-intensity area was defined as adipose tissue (pattern B2) was nonmetastatic.
(1) The results using the conventional criteria were 96.2% sensitivity, 92.5% specificity, 76.3% positive predictive value (PPV), 99.0% negative predictive value (NPV), and 93.3% accuracy. (2) The results using the new criteria were 96.2% sensitivity, 98.3% specificity, 90.1% PPV, 99.0% NPV, and 97.1% accuracy.
The assessment of lymph node metastases from USPIO-post-contrast MRI alone using the new criteria was useful in the diagnosis of regional lymph node metastases in gastric cancer.
Gastric Cancer 02/2008; 11(4):194-200. · 3.99 Impact Factor