Holger Steffen

Chirurgische Perspektiven in der NOTES-Entwicklung

NOTES (natural orifice transluminal endoscopic surgery), eine neue Operationsmethode, bei der flexible Endoskope durch natürliche Körperöffnungen in die Bauchhöhle eingeführt werden, ist derzeit noch nicht als medizinischer Standard etabliert. Die theoretisch möglichen und erhofften Vorteile von NOTES müssen in der Praxis verifiziert werden, und die jeweiligen NOTES-Eingriffe müssen sich an den aktuellen medizinischen Standardverfahren messen lassen, ohne dabei Kompromisse bezüglich peri- und postoperativer Komplikationen einzugehen. Wenn dies gelingt, werden NOTES-Eingriffe in der klinischen Praxis zunehmend zum Einsatz kommen.

Totally Laparoscopic versus Open Gastrectomy for Gastric Cancer: a Matched Pair Analysis

BACKGROUND Laparoscopic gastrectomy has been established for treatment of early gastric cancer (EGC) especially in Eastern Asian countries. Currently, it still needs evaluation for advanced gastric cancer (AGC, T ≥ 2). Difficulty is how far Asian study data are valid for western conditions. METHODS Out of 502 patients who underwent gastric cancer surgery between 2003 and 2016 at Klinikum Suedstadt Rostock 90 patients were selected for a retrospective study to compare totally laparoscopic D2-gastrectomy (LG, n = 45) with open D2-gastrectomy (OG, n = 45). The groups were matched by age, gender and tumour stage (TNM). RESULTS Average age was 62.9 years (33 - 83), 42.2% were female. There were no differences between both study groups concerning BMI, ECOG and comorbidities. Amounts of EGC and AGC were 35.5% and 64.4% in LG, 28.9% and 71.0% in OG (p = 0.931). In LG-group 53.3% of the patients and in OG-group 51.1% of the patients were nodal negative (p = 0.802). 31.1% of patients in LG and in 33.3% in OG (p = 0.821) undergone perioperative chemotherapy. Total gastrectomy was performed in 73.3% in LG and 82.2% in OG, subtotal resections were done in 26.7% in LG and 17.8% in OG (p = 0.310). Resection free margins (R0) were recognized in 97.8% of the patients in both groups, and for EGC in all cases (p = 0.928). Total numbers of retrieved lymph nodes were significant higher in LG (33.1, 17 - 72) than in OG (28.2, 14 - 57). A significant longer operation time was noticed for laparoscopic gastrectomy in contrast to open surgery (+ 43.0 ± 27.2 min, p = 0.0054). Overall morbidity in OG (44.4%) was twice as high as in LG (22.2%, p < 0.05) due to lower rate of minor complications (Clavien I - II) in LG (LG vs. OG: 13.3% vs. 37.8%, p = 0.0078). For major complications (Clavien ≥ III) no difference between both groups was detected (LG vs. OG: 8.8% vs. 6.6%, p = 0.69). LG showed a significant faster postoperative recovery with earlier oral fluid intake (LG vs. OG: 25.9 h vs. 46.2 h) and shorter time to first flatus (LG vs. OG: 81.6 vs. 102.6 h). Patients after LG were earlier out of bed (LG vs. OG: 69.7 h vs. 108.7 h) and also hospital stay was significantly shorter (11.9 days in LG vs. 16.3 days in OG, p = 0.037). 30- and 90-days mortality was equal for LG and OG (0 and 2.2% per group). After a median follow up of 51.9 month (1 - 117) there were similar results for 3- and 5-year overall survival (OS for LG: 75.6% and 64.6% vs. OG: 68.9% and 64.6%, p = 0.446). Also no differences for 3- and 5-year OS were detected concerning patients without lymph node metastases (LG: 91.7% and 83.4% vs. OG: 91.3% and 78.3%, p = 0.658) or lymph node positive patients (LG: 47.6% and 38.1% vs. OG: 40.9% and 31.8%, p = 0.665). CONCLUSION Despite western conditions laparoscopic D2 gastrectomy is certainly a save and feasibly approach for surgical therapy of EGC and AGC with low morbidity and mortality, and faster postoperative recovery. The oncologic outcome seems to be equivalent to open surgery.