Beom Su Kim

Comparison of Totally Laparoscopic Total Gastrectomy and Open Total Gastrectomy for Gastric Cancer

BACKGROUND The technique of totally laparoscopic total gastrectomy (TLTG) has been developed for gastric cancer, but its feasibility and surgical outcomes remain unclear. This is the first study comparing the early surgical outcomes of TLTG with those of conventional open total gastrectomy (OTG) for gastric cancer. PATIENTS AND METHODS Between January 2011 and December 2011, 139 patients underwent TLTG, and 207 patients underwent OTG for gastric cancer; surgical procedures were selected by means of preoperative diagnostic tests under T3N2M0. Clinicopathologic characteristics and early surgical outcomes in the two groups were compared retrospectively. RESULTS There were no significant difference in preoperative characteristics between the two groups, and the durations of surgery were not significantly different. However, TLTG was superior to OTG in terms of time to first flatus, time to commencement of soft diet, pain score (visual analog scale), need for analgesics, length of hospital stay, and overall postoperative complications (each P<.05). The median number of lymph nodes harvested was significantly higher in the TLTG group (37 versus 34; P=.039). Resection margins were negative in all patients. CONCLUSIONS TLTG should be considered as a safe and practicable alternative to OTG for the treatment of gastric cancer. Moreover, it is less invasive and results in faster recovery than OTG.

Signet ring cell type and other histologic types: Differing clinical course and prognosis in T1 gastric cancer

BACKGROUND The behavior of early stage signet ring cell carcinoma (SRC) is controversial. The purpose of this study was to clarify the behavior of early gastric SRC. METHODS We retrospectively analyzed data from 2,085 patients who had undergone curative gastrectomy for early gastric cancer between 1989 and 2000. Clinicopathologic outcomes and prognoses were evaluated, and we investigated whether these variables were correlated with histopathologic type. RESULTS Patients with early gastric SRC were younger and had a greater proportion of females than other histologic types. Lymph node metastasis was the only independent prognostic factor for both mucosal and submucosal forms of SRC. Mucosal SRC had a similar rate of lymph node metastasis to poorly differentiated (PD) tubular adenocarcinoma (TUB), and a higher rate than well-differentiated (WD) or moderately differentiated (MD)-TUB. However, its submucosal form had a similar rate of lymph node metastasis to WD-TUB, and a lower rate than MD- or PD-TUB. There was no difference in tumor recurrence or disease-related death according to histopathologic type or depth of invasion. CONCLUSION In mucosal gastric cancer, SRC has an unfavorable risk factor of lymph node metastasis than that of others and should not be considered for endoscopic resection. In submucosal gastric cancer, SRC is a more favorable risk factor of lymph node metastasis than that of other histologic types.

Influence of Obesity on Early Surgical Outcomes of Laparoscopic-assisted Gastrectomy in Gastric Cancer

Background The aim of this study is to estimate the impact of obesity on surgical outcomes of laparoscopic-assisted gastrectomy for gastric cancer. Study Design Between January 2005 and January 2010, 1100 consecutive patients who underwent laparoscopic-assisted distal gastrectomy for gastric cancer were reviewed to evaluate the impact of obesity. The patients were classified into 3 groups according to the World Health Organization classification, as normal weight [body mass index (BMI) 18.5 to 24.9 kg/m2], overweight (BMI 25 to 29.9 kg/m2), and obese patients (BMI ≥30 kg/m2). Results The postoperative complication rates for normal weight, overweight, and obese patients were 5.7%, 10.0%, 15.4%, respectively. Overweight and obese patients had a significantly prolonged operation time, increased intraoperative blood loss, prolonged first flatus, day of commencement of soft diet, increased number of administration of analgesics, and prolonged hospital stay. Conclusions Overweight and obesity were associated with poor early surgical outcomes of laparoscopic-assisted gastrectomy. This study suggested that greater cautions and improved surgical techniques were required to improve early surgical outcomes of laparoscopic-assisted gastrectomy for overweight and obese patients.

Comparison of Early Outcomes of Intracorporeal and Extracorporeal Gastroduodenostomy After Laparoscopic Distal Gastrectomy for Gastric Cancer

BACKGROUND Totally laparoscopic distal gastrectomy (TLDG) has several advantages over laparoscopic-assisted distal gastrectomy (LADG), including a shorter incision, less pain, and earlier recovery. We compared the feasibility and early surgical outcomes of TLDG and LADG in patients with gastric cancer. METHODS Between September 2008 and December 2009, 180 patients with gastric cancer underwent TLDG with intracorporeal gastroduodenostomy using linear staplers; and between January 2006 and December 2009, 268 patients with gastric cancer underwent LADG with extracorporeal gastroduodenostomy using circular staplers. Clinical features and early surgical outcomes were compared between the two groups. RESULTS There were no between-group differences in postoperative clinical course and complications. Postoperative pain and the amount of pain killer administered were significantly lower (P<.05 each), and postoperative scars were smaller in the TLDG group. CONCLUSIONS TLDG with intracorporeal gastroduodenostomy is as safe and feasible as LADG for patients with gastric cancer. Moreover, TLDG is less invasive and more comfortable for patients than LADG.

Prognostic factors and recurrence pattern in node-negative advanced gastric cancer

AIMS Despite better overall survival in node-negative advanced gastric cancer (AGC), a significant proportion of patients develop recurrence and they may benefit from adjuvant therapy. The aim of this study was to evaluate the prognostic factors and recurrence pattern of node-negative AGC. METHODS A total of 424 patients who underwent curative gastrectomy with extended lymphadenectomy for node-negative AGC between 2003 and 2005 were retrospectively reviewed. Patients with tumor involvement of adjacent organs (T4b), gastric cancer recurrence, tumor in the remnant stomach, less than 15 harvested lymph nodes, and those who received neoadjuvant chemotherapy were excluded. RESULTS Invasion to deeper layers, undifferentiated histology, signet ring cell type compared with tubular adenocarcinoma, and tumor size larger than 6.3 cm correlated with poorer prognosis in univariate analysis. In multivariate one, however, only differentiation and depth of invasion, especially the presence of serosa involvement were significant. The 5-year survival rates of the four groups classified by differentiation and depth of invasion [T2/3 (differentiated type), T2/3 (undifferentiated type), T4a (differentiated type), and T4a (undifferentiated type)] were 98%, 92%, 80%, and 72%, respectively (P < 0.01). In terms of recurrence pattern, Laurens type and depth of invasion were significant. Recurrence with peritoneal seeding was associated with the diffuse type and invasion into the subserosa or serosa, while hematogenous metastasis was related to the intestinal type and invasion to the proper muscle or subserosa layer. CONCLUSIONS Differentiation and serosa involvement should be considered to stratify patients with node-negative AGC for adjuvant treatment.

Comparison of Totally Laparoscopic Total Gastrectomy and Laparoscopic-Assisted Total Gastrectomy Methods for the Surgical Treatment of Early Gastric Cancer Near the Gastroesophageal Junction

UNLABELLED Abstract Background: Several investigators have suggested methods for performing totally laparoscopic total gastrectomy (TLTG). However, even surgeons experienced in laparoscopic gastrectomy find it very hard to perform TLTG safely because it is a complex procedure. The aim of the present study was to evaluate the safety and efficacy of our TLTG method for the surgical treatment of early gastric cancer (EGC) located near the gastroesophageal junction (GEJ). SUBJECTS AND METHODS Between January 2010 and June 2011, 113 patients at a single institution underwent TLTG (n=90) or laparoscopic-assisted total gastrectomy (LATG) (n=23). Early surgical outcomes of the two techniques were compared to assess the effectiveness of TLTG for treating EGC near the GEJ. RESULTS The TLTG group included patients with higher body mass indexes (23.2 versus 22.2 kg/m(2), P=.037) and more overweight patients (22.2% versus 4.0%, P=.041) than the LATG group. Despite this, the two groups had similar early surgical outcomes, such as mean operation time, intraoperative events, postoperative complications, time to first flatus, time to starting a soft diet, pain scores, analgesic requirements, and lengths of hospital stay. CONCLUSIONS The results of TLTG were favorable even though a high proportion of the subjects were overweight. TLTG for EGC near the GEJ could be the best way to improve early surgical outcomes of EGC in overweight patients provided it is performed by surgeons who are experienced in laparoscopic gastrectomy.

A comparison between single-incision and conventional laparoscopic cholecystectomy.

BACKGROUND Single-incision laparoscopic surgery is becoming a more widely accepted surgical approach. However, the feasibility and safety of single-incision laparoscopic cholecystectomy (SILC) are yet to be established. The present study compared outcomes following the use of SILC or conventional laparoscopic cholecystectomy (CLC) on patients with gallbladder disease. SUBJECTS AND METHODS The study involved 190 symptomatic gallbladder disease patients treated between March 2009 and February 2011. Ninety-six patients underwent SILC, and 94 patients underwent CLC. Clinical and surgical outcomes were compared. RESULTS The SILC and CLC groups were similar in terms of age, gender ratio, body mass index, and diagnoses. The two groups were also found to be similar in terms of postoperative clinical course and complications. The SILC group had a longer operation time, less postoperative pain, and a shorter hospital stay than the CLC group (P<.05 for all variables). CONCLUSIONS SILC using the OCTO port system (Darim Corp., Korea) was as safe and feasible as CLC. Additionally, SILC is less invasive and more comfortable for patients than CLC.

Totally Laparoscopic Total Gastrectomy Using Endoscopic Linear Stapler: Early Experiences at One Institute

BACKGROUND Totally laparoscopic total gastrectomy (TLTG) for gastric cancer is still uncommon because of the technical difficulty of performing the esophagojejunostomy laparoscopically. We have developed a secure technique for intracorporeal esophagojejunostomy and successfully performed the TLTG method using an endoscopic linear stapler. Our experiences with this method are reported here. SUBJECTS AND METHODS Between July 2009 and May 2010, 124 patients with gastric cancer underwent TLTG using endoscopic linear staplers in one institution. The clinicopathological data and surgical outcomes of the first 70 cases and the subsequent 54 cases were reviewed retrospectively and compared because technical improvements were instituted after the 70th case. RESULTS The two groups differed significantly in terms of mean operation time (189.0 versus 148.3 minutes, P<.001), overall postoperative complication rate (37.1% versus 13.0%, P=.003), severe postoperative complication rate (15.7% versus 3.7%, P=.030), and intraoperative event rate (12.9% versus 1.9%, P=.042). CONCLUSIONS The early period of performing TLTG using an endoscopic linear stapler was associated with a high morbidity rate. This improved significantly when key technical changes were introduced. However, surgeons who are inexperienced in laparoscopic gastrectomy should be careful when performing TLTG because it involves many complex processes. The account in this report of our experiences with TLTG may help surgeons to master this method faster and more safely.

Large Metastatic Lymph Node Size, Especially More Than 2 cm: Independent Predictor of Poor Prognosis in Node-Positive Gastric Carcinoma

The presence of metastatic lymph nodes (MLNs) is the most important prognostic factor for gastric carcinoma, with the number of MLNs thought to be predictive of the prognosis. However, there have been long-standing debates on how to classify node-positive patients into prognostic groups appropriately. Recent findings in patients with colon and esophageal cancer have suggested that MLN size, more than MLN number, is an important prognostic factor; but less is known about the impact of MLN size on the prognosis of patients with gastric carcinoma. We therefore assessed the prognostic impact of large MLNs, especially those ≥2 cm, in patients with gastric carcinoma. A total of 1190 patients who underwent curative resection for gastric carcinoma between 2001 and 2003 and had lymph node metastases were divided into two groups according to the size of the largest MLN: ≥2 cm (n = 51) vs. <2 cm (n = 1139). Clinicopathologic data, including tumor recurrence and survival, were reviewed retrospectively. The median follow-up for living patients was 47 months (range 30–80 months). Age, sex ratio, type of surgery, and histologic classification did not correlate with MLN size. The depth of invasion did correlate with MLN size (T1–2 vs. T3–4, p = 0.045) but not with the number of MLNs (N stage, p = 0.311). The two groups showed similar distribution of stage according to the UICC/AJCC TNM staging system. Disease-free survival (34% vs. 53%, p < 0.001) and overall survival (40% vs. 63%, p = 0.011) were significantly worse in the large MLN group. Univariate analysis with the log-rank test showed that MLN ≥2 cm, type of surgery, T stage, N stage, and histologic classification had a significant impact on overall survival. Multivariate analysis with the Cox proportional hazard model showed that MLN ≥2 cm was an independent prognostic factor (hazard ratio 1.76, p = 0.006), along with T stage and N stage. MLN ≥2 cm is an independent additional predictor of poor prognosis in patients with node-positive gastric carcinoma.

Differing Clinical Courses and Prognoses in Patients With Gastric Neuroendocrine Tumors Based on the 2010-WHO Classification Scheme

AbstractThe aim of this study is to test the prognostic accuracy of the 2010-WHO classification for postsurgery survival in nonmetastatic gastric neuroendocrine tumor (NET) cases. Whether the 2010-WHO classification of NETs can predict relapse after surgical resection has not yet been established.We selected 175 nonmetastatic gastric NET patients at Asan Medical Center, Seoul, Korea between 1996 and 2013. All tumors were classified using the WHO-2010 scheme.Among 175 patients with gastric NETs, we diagnosed 39 cases as WHO grade 1, 13 cases as grade 2, 66 cases as grade 3 (neuroendocrine carcinomas; NECs), and 57 cases as mixed with adenocarcinoma. Patients with grade 3 had a lower relapse-free survival (RFS) and overall survival (OS) than those with WHO grade 1/2 and had a lower OS than patients with mixed type tumors. Patients with grade 1/2 had a better OS than patients with mixed type. There was no significant difference in RFS and OS between small and large cell type lesions. Among WHO grade 1/2 patients with ⩽1 cm sized lesions, none exhibited lympho-vascular, perineural, mucosal, or submucosal invasion, and we detected no lymph node metastases or recurrences.Our findings strongly suggest that WHO grade 3 behaves more aggressively than adenocarcinoma. Additionally, the survival of cases with large and small cell NEC was similar. Among WHO grade 1/2 patients who had ⩽1 cm lesions, none exhibited lympho-vascular, perineural, mucosal, or submucosal invasion and all could be treated by endoscopic resection or minimally invasive surgery without node dissection.