Byoung Jo Suh

Multicenter Prospective Comparative Study of Robotic Versus Laparoscopic Gastrectomy for Gastric Adenocarcinoma

OBJECTIVE To compare short-term surgical outcomes including financial cost of robotic and laparoscopic gastrectomy. BACKGROUND Despite a lack of supporting evidence, robotic surgery has been increasingly adopted as a minimally invasive modality for the treatment of gastric cancer because of its assumed technical superiority over conventional laparoscopy. METHODS A prospective, multicenter comparative study was conducted. Patients were matched according to the surgeon, extent of gastric resection, and sex. The primary endpoint was morbidity and mortality. Outcomes were analyzed on an intention-to-treat and per-protocol basis. RESULTS A total of 434 patients were enrolled for treatment with either robotic (n = 223) or laparoscopic (n = 211) gastrectomy for intention-to-treat analysis, and a total of 370 patients (n = 185 per treatment) were compared in per-protocol analysis. Results were similar between both analyses. In per-protocol analysis, both groups showed similar overall complication rates (robotic = 11.9% vs laparoscopic = 10.3%) and major complication rates (robotic = 1.1% vs laparoscopic = 1.1%) with no operative mortality in either group. Patients treated with robotic surgery showed significantly longer operative time (robotic = 221 minutes vs laparoscopic = 178 minutes; P < 0.001) and significantly higher total costs (robotic = US

Synchronous triple primary cancers occurring in the stomach, kidney, and thyroid

13,432 vs laparoscopic = US

Factors Related to Morbidity in Elderly Gastric Cancer Patients Undergoing Gastrectomies

8090; P < 0.001), compared with those who underwent laparoscopic gastrectomy. No significant differences between groups were noted in estimated blood loss, rates of open conversion, diet build-up, or length of hospital stay. CONCLUSIONS The use of robotic systems is assumed to provide a technically superior operative environment for minimally invasive surgery. However, our analysis of perioperative surgical outcomes indicated that robotic gastrectomy is not superior to laparoscopic gastrectomy. Clinical trials identification: NCT01309256.

A Case of Gastric Cancer with Situs Inversus Totalis

We report an unusual case of synchronous triple primary cancer of the stomach, kidney, and thyroid in a 50-year-old male patient. Initial esophagogastroduodenoscopy with biopsy for the medical check-up revealed poorly differentiated adenocarcinoma. We performed an abdominal/pelvic computed tomography scan for staging and incidentally found a 1.7-cm exophytic hypervascular mass in the left kidney. Thyroid ultrasonography showed suspicious malignant nodules suspicious with multiple lymph nodes (LNs) metastasis in the right side of the neck. Subsequent fine needle aspiration biopsy of a nodule and a LN was performed. Cytologic report revealed papillary thyroid carcinoma with lateral LNs metastasis. Our integrate oncology team performed radical subtotal gastrectomy, partial nephrectomy, and total thyroidectomy with modified radical neck dissection. The postoperative pathologic finding was well-differentiated gastric adenocarcinoma (T1N0M0; stage 1A), renal cell carcinoma (T1aN0M0; stage 1), and papillary thyroid carcinoma (T4bN1bM0; stage 4B). He received postoperative a radio-active iodine ablation and is doing well with no recurrence.

A Giant Retroperitoneal Liposarcoma Encasing the Entire Left Kidney and Adherent to Adjacent Structures: A Case Report.

Purpose The prevalence of gastric cancer in the elderly is increasing. The purpose of this study was to clarify factors related to morbidity following gastric cancer surgery in elderly patients. Materials and Methods For this study, data from 411 patients who underwent curative gastrectomies with lymph node dissections between March 2010 and January 2013 were retrospectively studied using a prospectively designed database. Patients were divided into 2 groups (<70 years vs. ≥70 years). For each group, perioperative factors were analyzed to determine if they were associated with postoperative morbidity and mortality. Results Comorbidities were more prevalent in the elderly group (≥70 years). Intraoperative and postoperative transfusions were also more frequently required in the elderly group. There was no significant difference in the number of retrieved lymph nodes between the 2 groups (44.3 vs. 46.6 nodes). In a comparison of the elderly versus non-elderly groups, the postoperative morbidity rates were 22.7% versus 8.9% (P<0.001) and the postoperative mortality rates were 4.2% versus 0% (P=0.002), respectively. Of the possible non-surgical complications, pulmonary problems were predominately found in the elderly group (P<0.001). Surgical complications were evenly distributed between the 2 groups (P=0.463). Postoperative morbidity was significantly associated with older age and postoperative transfusion. Multivariate analysis showed that higher body mass index (BMI) and postoperative transfusion were important factors associated with postoperative complications in the elderly group. Conclusions Pulmonary complications were frequently problematic in elderly patients. Higher BMI and postoperative transfusion were significant risk factors for postoperative complications in elderly patients with gastric cancer.

The Short-term Outcome and Safety of Laparoscopic Colorectal Cancer Resection in Very Elderly Patients

Situs inversus totalis (SIT) is a rare congenital anomaly that refers to a completely reversed location of the abdominal and thoracic organs. We report the case of 50-year-old man with gastric cancer and SIT who was diagnosed during a screening esophagogastroduodenoscopy. A chest X-ray, abdominopelvic computed tomography, and 18F-fluoro2-deoxyglucose-D-glucose-positron emission tomography scans revealed SIT. We performed a radical subtotal gastrectomy with D2 lymph node dissection. Advanced surgical skill is required to perform a precise lymphadenectomy in a patient with SIT by visualizing the exact mirror image of the anatomy during the operation. The patient had an uneventful intra- and postoperative course and was followed up at the outpatient department without any evidence of recurrence. In conclusion, surgery in a patient with gastric cancer and SIT can be safely performed by paying attention to the inverted anatomic structures during the operation.

Simultaneous robotic subtotal gastrectomy and right hemicolectomy for synchronous adenocarcinoma of stomach and colon

Retroperitoneal liposarcoma is a rare tumor. The dimension and weight of liposarcoma are variable; those over 20 kg are called ‘giant liposarcoma’. Herein, we report giant retroperitoneal liposarcoma measuring 45 cm in diameter and 25 kg in weight encasing the entire left kidney and adherent to adjacent structures. A 71-year-old woman presented for a regular checkup. Image study revealed a huge mass probably indicative of retroperitoneal liposarcoma encasing the entire left kidney and adherent to adjacent structures. We performed an organ-preserving surgical removal. The pathologic report was liposarcoma. At postoperative month 16, a follow-up CT revealed a locally recurrent tumor. The patient underwent surgical removal of the newly discovered mass. After the second surgery, the patient underwent regular follow-up CT for approximately 12 months, and to date, there has been no evidence of tumor recurrence. High-grade liposarcoma shows sensitivity to radiation therapy. However, the toxic effect of radiation therapy limits this option by treatment modality. The use of chemotherapy is also controversial. As a result, complete resection is the gold standard treatment. Here, we report a giant retroperitoneal liposarcoma encasing the entire left kidney and adherent to adjacent structures, describe successful organ-preserving surgical removal and discuss prognosis.

Prognostic Discrepancy of the 6th and 7th UICC N Classification for Lymph Node Staging in Gastric Cancer Patients after Curative Resection

Background/Aims Due to the recent increase in elderly population, laparoscopic surgery is more frequently performed in the elderly. This study aimed to compare the short-term outcomes of laparoscopic colorectal cancer surgery between the very elderly group (VEG), categorized as those with age over 80 years and the elderly group (EG), categorized as those with age 65 to 79 years. Methods We retrospectively compared 48 very elderly patients with 96 elderly patients (1:2 matched) who underwent laparoscopic resection for colorectal cancers at our institution between March 2010 and December 2014. The clinicopathologic parameters, surgical characteristics and short term outcomes were compared. Results There was no statistically significant difference in clinicopathologic characteristics between VEG and EG. Postoperative pain score (7 points vs. 6 points, p=0.264), time to first flatus (3 days vs. 3 days, p=0.335), hospital stay (15 days vs. 16.5 days, p=0.361), complication rates (47.9% vs. 26.0%, p=0.147) and major complication rate (25% vs. 20.8%, p=0.681) were not statistically different between the two groups. Before surgery, VEG had higher rate of neurologic underlying disease, such as dementia or cerebrovascular disease, than EG (25.0% vs. 7.3%, p=0.007). Conclusions There was no significant difference in the clinicopathologic characteristics, short-term outcomes, and complication rates for laparoscopic colorectal resection between VEG and EG, except delirium. Age over 80 years may be relevant for the application of laparoscopic colorectal cancer resection.

Gastric Schwannoma Mimicking Malignant Gastrointestinal Stromal Tumor Exhibiting Increased Fluorodeoxyglucose Uptake

Simultaneous laparoscopy-assisted resection for synchronous stomach and colon cancers has been reported frequently; however, robot-assisted gastrectomy and colectomy for these conditions are rarely reported. We report the successful use of robotic surgery for synchronous cancers of the stomach and colon. A 71-year-old woman with no specific medical history was diagnosed with early gastric cancer at the gastric angle and right colon cancer after undergoing esophagogastroduodenoscopy and colonofiberoscopy. Abdomino-pelvic computed tomography revealed that the stomach and colon lesions were limited to the mucosa without any lymph nodes or distant metastasis, which suggested the clinical stage for both cancers as T1N0M0. We performed robot-assisted radical subtotal gastrectomy and simultaneous right hemicolectomy through six ports. All procedures were successful without any perioperative complications. A 36-month postoperative follow-up of the patient at the outpatient department revealed no evidence of recurrence. We consider that concurrent robot-assisted subtotal gastrectomy and colectomy are technically feasible and safe.

Metachronous Liver Metastasis Resulting from Early Gastric Carcinoma after Subtotal Gastrectomy Following Endoscopic Resection: A Case Report

Background: The validity of N classification of the 7th edition of the American Joint Committee on Cancer/Union Internationale contre le Cancer (AJCC/UICC) tumor-node-metastasis (TNM) staging system is still under debate. The purpose of this study was to evaluate the prognostic efficacy of the 7th edition of the AJCC/UICC TNM staging system (focusing on N stage), in comparison with the 6th edition, at a single Eastern institution. Methods: We analyzed 1,435 patients with gastric cancer who underwent curative resection performed from September 1998 to August 2003 at the Memorial Jin-Pok Kim Korea Gastric Cancer Center. We analyzed the survival rate of the patients according to the AJCC/UICC 6th and 7th editions, and compared each stage, focusing on N stage. Results: Significant differences in the 5-year survival rates were observed between the 6th and the 7th AJCC/UICC staging system. In the 6th edition staging system, the Kaplan-Meier curves discriminated each N stage significantly. In contrast, there was no difference in terms of survival curves for N stage according to the 7th edition, especially between N1 and N2: the Kaplan-Meier plots of survival curves between N1 (77.0%) and N2 (78.1%) stages overlapped significantly (p < 0.05). Conclusion: Although the 7th UICC staging system is a more detailed and sophisticated system in the T category, there was no prognostic significance between the pN1 and pN2 stages according to our data. Therefore, we suggest establishing a new UICC staging system taking into consideration the application of the N stage.