[Show abstract][Hide abstract] ABSTRACT: Despite the well-described benefits of laparoscopic surgery such as lower operative blood loss and enhanced postoperative recovery in gastric cancer surgery, the application of laparoscopic surgery in patients with locally advanced gastric cancer remains elusive owing to a lack of clinical evidence. Recently, the Korean Laparoscopic Surgical Society Group launched a new multicenter randomized clinical trial to compare laparoscopic and open D2 lymphadenectomy for patients with locally advanced gastric cancer. Here, we introduce the protocol of this clinical trial.
This trial is an investigator-initiated, randomized, controlled, parallel group, non-inferiority trial. Gastric cancer patients diagnosed with primary tumors that have invaded into the muscle propria and not into an adjacent organ (cT2-cT4a) in preoperative studies are recruited. Another criterion for recruitment is no lymph node metastasis or limited perigastric lymph node (including lymph nodes around the left gastric artery) metastasis. A total 1,050 patients in both groups are required to statistically show non-inferiority of the laparoscopic approach with respect to the primary end-point, relapse-free survival of 3 years. Secondary outcomes include postoperative morbidity and mortality, postoperative recovery, quality of life, and overall survival. Surgeons who are validated through peer-review of their surgery videos can participate in this clinical trial. Surgeons who are validated through peer-review of their surgery videos can participate in this clinical trial.
This clinical trial was designed to maintain the principles of a surgical clinical trial with internal validity for participating surgeons. Through the KLASS-02 RCT, we hope to show the efficacy of laparoscopic D2 lymphadenectomy in AGC patients compared with the open procedure.
ClinicalTrial.gov, NCT01456598 .
BMC Cancer 05/2015; 15(1):355. DOI:10.1186/s12885-015-1365-z · 3.32 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Inflammatory myofibroblastic tumors (IMTs) of the stomach are extremely rare in adults, and their oncologic prognosis is not well understood. We present a 28-year-old man with a proximal gastric IMT. The patient visited the emergency department of Yeouido St. Mary's Hospital with syncope and hematemesis. Hemoglobin levels were <5.5 g/dl. Gastric fibroscopy showed a protruding mass 4×4 cm in size, with central ulceration on the posterior wall of the fundus and diffuse wall thickening throughout the cardia and anterior wall of the upper body. Endoscopic biopsy revealed indeterminate spindle cells, along with inflammation. Given the risk of rebleeding, an operation was performed despite the uncertain diagnosis. Because the mass was circumferential, laparoscopic proximal gastrectomy and double-tract anastomosis were performed to ensure a safe resection margin. The pathological diagnosis was consistent with an IMT originating from the stomach, although the tumor was negative for anaplastic lymphoma kinase gene mutation.
Journal of Gastric Cancer 03/2015; 15(1):64-67. DOI:10.5230/jgc.2015.15.1.64
[Show abstract][Hide abstract] ABSTRACT: Laparoscopy-assisted total gastrectomy (LATG) has not been as popular as laparoscopy-assisted distal gastrectomy (LADG) because of its undetermined safety and postoperative complications compared with LADG. Therefore, LATG requires further study.
A total of 663 patients who underwent LADG or LATG for gastric cancer in a single institution from April 2004 to April 2014 were included. The clinicopathologic characteristics and risk factors related to major complications (Clavien-Dindo grade ≥ IIIa) were analyzed between the LADG (n = 569) and LATG groups (n = 94).
The incidence of major postoperative complications was significantly higher for LATG (LADG vs. LATG: 8.1 vs. 18.1 %, P = 0.002). Although postoperative bleeding was not different between the groups (3.2 vs. 3.2 %, P = 0.991), the incidence of bowel leakage was significantly higher for LATG (2.6 vs. 6.8 %, P = 0.028). Leakage from the anastomosis site was more frequent following LATG (5.3 %) compared with LADG (0.5 %) (P < 0.001). Leakage from the duodenal stump tended to be more frequent, though not significant, for LADG (2.0 vs. 1.1 %, P = 0.602). Advanced gastric cancer, LATG, and longer operation time were significant factors that affected the incidence of postoperative complications in a univariate analysis. In multivariate analysis, there were no independent risk factors, but LATG was nearly a significant, independent risk factor (odds ratio 1.89; 95 % CI 0.965-3.71, P = 0.063).
More major complications were observed for LATG, particularly with esophagojejunostomy. These results show that LATG is more invasive than LADG in terms of the postoperative morbidity. More caution and experience are needed when performing LATG.
[Show abstract][Hide abstract] ABSTRACT: Whether signet ring cell (SRC) histology carries a worse prognosis than other forms of gastric adenocarcinoma has been questioned. The present study investigated the differences in clinicopathologic features and survival between SRC and non-SRC adenocarcinoma. The prospectively collected data of 2643 patients who had undergone curative gastrectomy between 1998 and 2005 by 10 surgeons were reviewed. Additionally, we employed analysis of covariance, propensity-score risk adjustment, and propensity-based matching to account for possible selection bias. The baseline characteristics of prematched patients with SRC or non-SRC adenocarcinoma histology differed: SRC presented in younger patients and less often in men, was more likely found in the middle stomach, and was more likely to be Stage I. After applying the propensity-score strata and propensity-score matching, there was no difference in the baseline characteristics, and SRC was not an independent risk factor for mortality in the same stage. SRC is not an independent predictor of poor prognosis after curative resection for gastric cancer in Korea.
Medicine 12/2014; 93(27):e136. DOI:10.1097/MD.0000000000000136 · 4.87 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The macroscopic diagnosis of tumor invasion through the serosa during surgery is not always distinct in patients with gastric cancer. The prognostic impact of the difference between macroscopic findings and pathological diagnosis of serosal invasion is not fully elucidated and needs to be re-evaluated.
A total of 370 patients with locally advanced pT2 to pT4a gastric cancer who underwent curative surgery were enrolled in this study. Among them, 155 patients with pT3 were divided into three groups according to the intraoperative macroscopic diagnosis of serosal invasion, as follows: serosa exposure (SE)(-) (no invasion, 72 patients), SE(±) (ambiguous, 47 patients), and SE(+) (definite invasion, 36 patients), and the clinicopathological features, surgical outcomes, and disease-free survival (DFS) were analyzed.
A comparison of the 5-year DFS between pT3_SE(-) and pT2 groups and between pT3_SE(+) and pT4a groups revealed that the differences were not statistically significant. In addition, in a subgroup analysis of pT3 patients, the 5-year DFS was 75.1% in SE(-), 68.5% in SE(±), and 39.4% in SE(+) patients (P<0.05). In a multivariate analysis to evaluate risk factors for tumor recurrence, macroscopic diagnosis (hazard ratio [HR], SE(-) : SE(±) : SE(+)=1 : 1.01 : 2.45, P=0.019) and lymph node metastasis (HR, N0 : N1 : N2 : N3=1 : 1.45 : 2.20 : 9.82, P<0.001) were independent risk factors for recurrence.
Gross inspection of serosal invasion by the surgeon had a strong impact on tumor recurrence in gastric cancer patients. Consequently, the gross appearance of serosal invasion should be considered as a factor for predicting patients' prognosis.
Journal of Gastric Cancer 12/2014; 14(4):252-8. DOI:10.5230/jgc.2014.14.4.252
[Show abstract][Hide abstract] ABSTRACT: Pancreatic fistula (PF) has traditionally been a source of significant morbidity and mortality after pancreaticoduodenectomy (PD). External drainage of pancreatic duct with stent and Blumgart anastomosis had reduced PF after PD in some studies. We applied compounding described two methods for pancreaticojejunostomy (PJ) during PD, and investigated the effectiveness of this modified PJ technique to prevent PF.
Between March 2002, and March 2013, 90 patients who underwent PD were enrolled. The patients were divided into 2 groups according to pancreatienterostomy method. Group 1 contain patients who did not undergo modified PJ (n=70) compared with group 2 (n=20) those who did undergo the modified PJ technique. We compared clinical data between two groups.
No differences were noted in the demographics and operation-related factors, between the 2 groups. A PF occurred in 38 of 70 patients in group 1 (54.3%) and in 2 of 20 in group 2 (10.0%). Group 2 had a significantly lower incidence of PF (P=.0016), and these fistulas were classified as being grade A using the International Study Group on Pancreatic Fistula Definition. Mortality in group 1 was 10.0% and no mortality in group 2.
External drainage with Blumgart method of PJ showed reducing high grade PF after PD.
[Show abstract][Hide abstract] ABSTRACT: Adrenal metastasis following gastrectomy for gastric cancer is often encountered as part of advanced systemic dissemination, which is usually unresectable. Thus, there are very few published case reports describing metastasectomy for adrenal metastasis from gastric cancer. Herein we present our experience in treating two patients diagnosed and treated for adrenal metastasis 6 years following initial surgery for advanced gastric cancer (pT2bN1M0 and pT2bN0M0, respectively, according to the classification system set forth in the sixth edition of The TNM Classification of Malignant Tumours by the International Union against Cancer). They underwent successful en bloc R0 resections, followed by systemic chemotherapy with close postoperative follow-up for another recurrence, and have remained alive without recurrence for 1 year. These results suggest that active surgical treatment for resectable metastatic gastric cancer in the adrenal glands has an important role in prolonging survival in selected patients.
World Journal of Surgical Oncology 04/2014; 12(1):116. DOI:10.1186/1477-7819-12-116 · 1.20 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The present study aims to elucidate the treatment strategies of laparoscopic resection for gastroduodenal submucosal tumors (SMTs).
Data of 125 gastroduodenal STMs were collected retrospectively resected from August, 2004 to February, 2013. Surgical outcomes according to tumor locations, pathologic results and survival data for gastrointestinal stromal tumors (GISTs) were collected and analyzed.
There were 55 male and 70 female patients with mean age 57.9 ± 12.7 years old. Mean tumor size of gastric SMTs was 2.7 ± 1.64 cm (range, 0.4-8.5 cm). GIST was the most common (n = 70, 56%). Regarding the tumor location, all the fundic lesions were GISTs and leiomyoma was occurred 58.8% of cardiac lesions. Ectopic pancreas and schwannomas were mostly located at body portion, 73% and 80%, respectively. SMTs located at duodenal bulb comprise 4 GISTs and 3 carcinoids. Surgical results comparing between lesions located at cardia, near-pylorus and else had no difference in operation time, hospital stay and complications. In terms of outcome of GIST, all patients underwent curative resection except one case of peritoneal sarcomatosis. There was one recurrence in a high risk group following resection. The cumulative 5-year disease free survival rate was 93.5% in all GISTs. There were two postoperative complications, one gastric outlet obstruction and one leakage following wedge resection.
Laparoscopic wedge resection is a safe and feasible procedure for the small to medium sized gastroduodenal SMTs even their locations are near cardia or pylorus.
Annals of Surgical Treatment and Research 04/2014; 86(4):199-205. DOI:10.4174/astr.2014.86.4.199
[Show abstract][Hide abstract] ABSTRACT: Minimally invasive surgery has been slowly introduced into the field of advanced gastric cancer (AGC) surgery. However, the appropriate extent of omentectomy during laparoscopic gastrectomy for AGC is unknown.
From July 2004 to December 2011, 146 patients with serosa-negative advanced gastric cancer were divided into the total omentectomy group (TO group, n = 80) and the partial omentectomy group (PO group, n = 66). The clinicopathologic characteristics, surgical outcomes, recurrence pattern and survival were analyzed.
There were no significant differences in the clinicopathologic features between the two groups, except for depth of invasion; more T3 (subserosal invasion) cases (65%) were included in total omentectomy group (P = 0.011). The mean time for PO was significantly shorter (35.1 +/- 13.0 min) than TO (50.9 +/- 15.3 min) (P <0.001), and there were two omentectomy-related complications in the TO group: spleen and mesocolon injuries. Recurrence occurred in 14 (17.5%) and 5 (7.6%) cases in the TO and PO group, respectively (P = 0.054). Disease-free survival (TO versus PO: 81.5% versus 89.3%, P = 0.420) and disease-specific survival (TO versus PO: 89% versus 94.7%) were not significantly different between the two groups. In the case-matched analysis using propensity score matching, there was no difference in disease-free survival (TO versus PO: 83.3% versus 90.5%, P = 0.442).
Partial omentectomy might be an oncologically safe procedure during laparoscopic gastrectomy for serosa-negative advanced gastric cancer, similar to early gastric cancer.
World Journal of Surgical Oncology 03/2014; 12(1):64. DOI:10.1186/1477-7819-12-64 · 1.20 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Aims/IntroductionLittle is known about the long-term effects of Roux-en-Y gastric bypass (RYGB) in severely obese Asian individuals.Methods and MaterialsA total of 33 severely obese patients with type 2 diabetes underwent RYGB. All patients were followed up for 2 years. Visceral and abdominal subcutaneous fat areas were assessed using computed tomography (CT) before, and 12 and 24 months after RYGB. The muscle attenuation (MA) of paraspinous muscles observed by CT were used as indices of intramuscular fat.ResultsThe mean percentage weight loss was 22.2 ± 5.3% at 12 months, and 21.3 ± 5.1% at 24 months after surgery. Compared with the baseline values, the visceral fat area was 53.6 ± 17.1% lower 24 months after surgery, and the abdominal subcutaneous fat area was 32.7 ± 16.1% lower 24 months after surgery. The MA increased from 48.7 ± 10.0 at baseline to 52.2 ± 8.9 (P = 0.009) 12 months after surgery. The MA after the first 12 months maintained changes until 24 months. Triglycerides and free fatty acids were reduced after surgery, whereas the high-density lipoprotein cholesterol levels were increased significantly after surgery. At the last follow-up visit, 18 patients (55%) had diabetes remission. The percentage of iron and vitamin D deficiency was 30% and 52%, respectively.Conclusions
We found that patients subjected to RYGB had significant sustained reductions in visceral and intramuscular fat. There were durable improvements in the cardiometabolic abnormalities without any significant comorbidities. However, there were mild nutritional deficiencies in these patients despite daily supplementation with multivitamins and minerals.
[Show abstract][Hide abstract] ABSTRACT: The oncologic outcomes of laparoscopy-assisted gastrectomy for the treatment of gastric cancer have not been evaluated. The aim of this study is to validate the efficacy and safety of laparoscopic gastrectomy for gastric cancer in terms of long-term survival, morbidity, and mortality retrospectively.
The study group comprised 2,976 patients who were treated with curative intent either by laparoscopic gastrectomy (1,477 patients) or open gastrectomy (1,499 patients) between April 1998 and December 2005. The long-term 5-year actual survival analysis in case-control and case-matched population was conducted using the Kaplan-Meier method. The morbidity and mortality and learning curves were evaluated.
In the case-control study, the overall survival, disease-specific survival, and recurrence-free survival (median follow-up period, 70.8 months) were not statistically different at each cancer stage with the exception of an increased overall survival rate for patients with stage IA cancer treated via laparoscopy (laparoscopic group; 95.3%, open group: 90.3%; P < .001). After matching using a propensity scoring system, the overall survival, disease-specific survival, and recurrence-free survival rates were not statistically different at each stage. The morbidity of the case-matched group was 15.1% in the open group and 12.5% in the laparoscopic group, which also had no statistical significance (P = .184). The mortality rate was also not statistically significant (0.3% in the open group and 0.5% in the laparoscopic group; P = 1.000). The mean learning curve was 42.
The long-term oncologic outcomes of laparoscopic gastrectomy for patients with gastric cancer were comparable to those of open gastrectomy in a large-scale, multicenter, retrospective clinical study.
[Show abstract][Hide abstract] ABSTRACT: Peritoneal dissemination is one of the treatment failures following gastric cancer surgery. We present a case with very early peritoneal recurrence, detected 8 days following curative surgery. A 39-year-old man, with Borrmann-4 advanced gastric cancer with signet ring cell type, underwent curative open total gastrectomy. However, focal peritoneal nodules on the left side of the diaphragmatic surface, which did not exist at the initial operation, were incidentally found during the reoperation for a postoperative intestinal obstruction via a laparoscopic approach. The pathologic result of the biopsied nodule revealed signet ring cell carcinoma. The patient underwent combination chemotherapy for several months without tumor regression. He suffered from intestinal obstruction again due to carcinomatosis peritonei, and died 9 months following initial surgery. Through this case report, we can carefully suspect that very early progression of cancer cells to carcinomatosis can occur in just several days after an operation.
Annals of Surgical Treatment and Research 01/2014; 86(1):45-9. DOI:10.4174/astr.2014.86.1.45
[Show abstract][Hide abstract] ABSTRACT: An 85 year male patient complaining epigastric discomfort was admitted. From the esophagogastroduodenoscopy, three early gastric cancer (EGCa) lesions had been identified and these were diagnosed as adenocarcinoma with poorly differentiated cell type. The patient underwent operation. From the post-operative mapping, however, additional 4 EGCa lesions were found, and the patient was diagnosed with 7 synchronous EGCa. Out of the 7 EGCa lesions, 6 had shown invasion only to the mucosal layer and one had shown invasion into the 1/3 layer of submucosa. In spite of such superficial invasions, 28 of 48 lymph nodes had been identified as metastases. The multiple lesions of EGCa do not increase the risk of lymph node metastasis, but if their differentiations are poor or if they have lympho-vascular invasion, multiple lymph node metastases could incur even if the depth of invasion is limited to the mucosal layer or the upper portion of the submucosal layer.
World Journal of Gastroenterology 11/2013; 19(44):8141-5. DOI:10.3748/wjg.v19.i44.8141 · 2.43 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Serum bone morphogenic protein- (BMP-) 4 levels are associated with human adiposity. The aim of this study was to investigate changes in serum levels of BMP-4 and inflammatory cytokines after Roux-en-Y gastric bypass (RYGB). Fifty-seven patients with type 2 diabetes underwent RYGB. Serum levels of BMP-4 and various inflammatory markers, including high-sensitivity C-reactive protein (hsCRP), free fatty acids (FFAs), and plasminogen activator inhibitor- (PAI-) 1, were measured before and 12 months after RYGB. Remission was defined as glycated hemoglobin <6.5% for at least 1 year in the absence of medications. Levels of PAI-1, hsCRP, and FFAs were significantly decreased at 1 year after RYGB. BMP-4 levels were also significantly lower at 1 year after RYGB than at baseline (P = 0.024). Of the 57 patients, 40 (70%) had diabetes remission at 1 year after surgery (remission group). Compared with patients in the nonremission group, patients in the remission group had lower PAI-1 levels and smaller visceral fat areas at baseline. There was a difference in the change in the BMP-4 level according to remission status. Our data demonstrate a significant beneficial effect of bariatric surgery on established cardiovascular risk factors and a reduction in chronic nonspecific inflammation after surgery.
International Journal of Endocrinology 09/2013; 2013(6):681205. DOI:10.1155/2013/681205 · 1.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: There have been several attempts to develop a unique and easier way to perform esophagojejunostomy during laparoscopy-assisted total gastrectomy or laparoscopy-assisted proximal gastrectomy. The OrVilTM system (Covidien, Mansfield, MA, USA) is one of those methods, but its technical and oncologic feasibility have not been proven and need to be observed.
Among 87 patients who underwent laparoscopy-assisted total gastrectomy (LATG; 79 cases) and laparoscopy-assisted proximal gastrectomy with double tract anastomosis (LAPG_DT; 8 cases) from April 2004, 47 patients underwent the conventional extracorporeal method (Group I; 2004--2008) were compared with 40 patients treated with the intracorporeal OrVilTM system (Group II; 2009--2012).
There was no significant difference in clinicopathologic characteristics between the two groups except tumor location; more cardia lesions were involved in group II (p = 0.012). The mean time for esophagojejunostomy (E-J), defined as the time from anvil insertion to closure of the jejunal entry site has no significant difference (Group I vs II: 22.2 +/- 3.2 min vs 18.6 +/- 3.5 min, p = 0.623). In terms of anastomotic complication, there was no significant difference in E-J leakage and stricture. E-J leakage occurred in 2 out of 47 (4.3%) cases in group I and 2 out of 40 (5%) in group II (p = 0.628); half of them were treated conservatively in each group and the others underwent reoperation. E-J stricture occurred in 2 (4.3%) cases in group I and 1 (2.5%) in group II (p = 0.561), which required postoperative gastrofiberscopic balloon dilatation.
Esophagojejunostomy using the OrVilTM system was a feasible and safe technique compared with the conventional extracorporeal method through mini-laparotomy in terms of anastomotic complications. Moreover, it can help to reduce surgeon's stress regarding esophagojejunostomy because it needs no purse-string procedure and serves a secure operation view laparoscopically.
World Journal of Surgical Oncology 08/2013; 11(1):209. DOI:10.1186/1477-7819-11-209 · 1.20 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Afferent loop (A-loop) obstruction is an uncommon postgastrectomy complication following Billroth-II (B-II) or Roux-en-Y reconstruction. Moreover, its development after laparoscopic gastrectomy has not been reported. Here we report 4 cases of A-loop obstructions after laparoscopic distal gastrectomy (LDG) with B-II reconstruction.
Among the 396 patients who underwent LDG with a B-II anastomosis between April 2004 and December 2011, 4 patients had A-loop obstruction. Their data were obtained from a prospectively maintained institutional database and analyzed for outcomes.
Four patients (1.01%) developed A-loop obstruction. All were male, and their median age was 52 years (range, 30 to 73 years). The interval between the initial gastrectomies and the operation for A-loop obstruction ranged from 4 to 540 days (median, 33 days). All 4 patients had symptoms of vomiting and abdominal pain and were diagnosed by abdominal computed tomographic (CT) scan. The causes of the A-loop obstructions were adhesions (2 cases) and internal herniations (2 cases) that were treated with Braun anastomoses and reduction of the herniated small bowels, respectively. All patients recovered following the emergency operations.
A-loop obstruction is a rare but serious complication following laparoscopic and open gastrectomy. It should be considered when a patient complains of continuous abdominal pain and/or vomiting after LDG with B-II reconstruction. Prompt CT scan may play an important role in diagnosis and treatment.
Journal of the Korean Surgical Society 05/2013; 84(5):281-6. DOI:10.4174/jkss.2013.84.5.281 · 0.62 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Although the absolute indication for endoscopic resection (ER) in gastric cancer is widely accepted, expanded indication for endoscopic submucosal dissection (ESD) is still regarded as investigational because of the risk of concomitant lymph node (LN) metastasis or recurrence following ESD. However, LN metastasis in early gastric cancer confined to absolute indication for ER cannot be negligible. Herein we report a 72-year-old man who underwent laparoscopic distal gastrectomy for LN metastasis around the common hepatic artery following curative ESD to the lesion that had met as an absolute indication for ER 1 year ago. There was only one metastatic LN near the common hepatic artery (LN 8), without malignancy at the ESD site or other harvested LNs.
Gastric Cancer 04/2013; 17(2). DOI:10.1007/s10120-013-0260-z · 4.83 Impact Factor