Hylke J. F. Brenkman

Worldwide practice in gastric cancer surgery

AIM To evaluate the current status of gastric cancer surgery worldwide. METHODS An international cross-sectional survey on gastric cancer surgery was performed amongst international upper gastro-intestinal surgeons. All surgical members of the International Gastric Cancer Association were invited by e-mail to participate. An English web-based survey had to be filled in with regard to their surgical preferences. Questions asked included hospital volume, the use of neoadjuvant treatment, preferred surgical approach, extent of the lymphadenectomy and preferred anastomotic technique. The invitations were sent in September 2013 and the survey was closed in January 2014. RESULTS The corresponding specific response rate was 227/615 (37%). The majority of respondents: originated from Asia (54%), performed > 21 gastrectomies per year (79%) and used neoadjuvant chemotherapy (73%). An open surgical procedure was performed by the majority of surgeons for distal gastrectomy for advanced cancer (91%) and total gastrectomy for both early and advanced cancer (52% and 94%). A minimally invasive procedure was preferred for distal gastrectomy for early cancer (65%). In Asia surgeons preferred a minimally invasive procedure for total gastrectomy for early cancer also (63%). A D1+ lymphadenectomy was preferred in early gastric cancer (52% for distal, 54% for total gastrectomy) and a D2 lymphadenectomy was preferred in advanced gastric cancer (93% for distal, 92% for total gastrectomy) CONCLUSION Surgical preferences for gastric cancer surgery vary between surgeons worldwide. Although the majority of surgeons use neoadjuvant chemotherapy, minimally invasive techniques are still not widely adapted.

Postoperative Outcomes of Minimally Invasive Gastrectomy Versus Open Gastrectomy During the Early Introduction of Minimally Invasive Gastrectomy in the Netherlands : A Population-based Cohort Study

Objective: To compare postoperative outcomes of minimally invasive gastrectomy (MIG) to open gastrectomy (OG) for cancer during the introduction of MIG in the Netherlands. Background: Between 2011 and 2015, the use of MIG increased from 4% to 53% in the Netherlands. Methods: This population-based cohort study included all patients with curable gastric adenocarcinoma that underwent gastrectomy between 2011 and 2015, registered in the Dutch Upper GI Cancer Audit. Patients with missing preoperative data, and patients in whom no lymphadenectomy or reconstruction was performed were excluded. Propensity score matching was applied to create comparable groups between patients receiving MIG or OG, using year of surgery and other potential confounders. Morbidity, mortality, and hospital stay were evaluated. Results: Of the 1697 eligible patients, 813 were discarded after propensity score matching; 442 and 442 patients who underwent MIG and OG, respectively, remained. Conversions occurred in 10% of the patients during MIG. Although the overall postoperative morbidity (37% vs 40%, P = 0.489) and mortality rates (6% vs 4%, P = 0.214) were comparable between the 2 groups, patients who underwent MIG experienced less wound complications (2% vs 5%, P = 0.006). Anastomotic leakage occurred in 8% of the patients after MIG, and in 7% after OG (P = 0.525). The median hospital stay declined over the years for both procedures (11 to 8 days, P < 0.001). Overall, hospital stay was shorter after MIG compared with OG (8 vs 10 days, P < 0.001). Conclusions: MIG was safely introduced in the Netherlands, with overall morbidity and mortality comparable with OG, less wound complications and shorter hospitalization.

Recurrent laryngeal nerve injury after esophagectomy for esophageal cancer: incidence, management, and impact on shortand long-term outcomes

BACKGROUND Recurrent laryngeal nerve (RLN) injury caused by esophagectomy may lead to postoperative morbidity, however data on long-term recovery are scarce. The aim of this study was to evaluate the consequences of RLN palsy (RLNP) in terms of pulmonary morbidity and long-term functional recovery. METHODS Patients who underwent a 3-stage transthoracic (McKeown) or a transhiatal esophagectomy for esophageal carcinoma in the University Medical Center Utrecht (UMCU) between January 2004 and March 2016 were included from a prospective database. Multivariable analyses were conducted to assess the association between RLNP and pulmonary complications and hospital stay. Data regarding long-term recovery were summarized using descriptive statistics. RESULTS Out of the 451 included patients, 47 (10%) were diagnosed with RLNP. Of the patients with RLNP, 34 (7%) had a unilateral lesion, 8 (2%) had a bilateral lesion, and in 5 (1%) the location of the lesion was unknown. The incidence of RLNP was 3/127 (2%) in the transhiatal group, and 44/324 (14%) in the McKeown group. RLNP after McKeown esophagectomy was associated with a higher incidence of pulmonary complications (OR 2.391; 95% CI 1.222-4.679; P=0.011), as well as a longer hospital stay (+4 days) (P=0.001). Of the RLNP patients with more than 6 months follow up almost half recovered fully {median follow-up of 17.5 [7-135] months}. Of the remainder, six required a surgical intervention and the others had residual symptoms. CONCLUSIONS RLNP after McKeown esophagectomy is associated with an increased pulmonary complication rate, longer hospital stay, and a moderate long-term recovery. Further studies are necessary that examine technologies, which may reduce RLNP incidence and contribute to the early detection and treatment of RLNP.

Robot-Assisted Laparoscopic Hiatal Hernia Repair: Promising Anatomical and Functional Results.

BACKGROUND There is no consensus on the optimal technique for hiatal hernia (HH) repair, and considerable recurrence rates are reported. The aim of this study was to evaluate the perioperative outcomes, quality of life (QoL), and recurrence rate in patients undergoing robot-assisted laparoscopic HH repair. MATERIALS AND METHODS All patients who underwent robot-assisted laparoscopic HH repair between July 2011 and March 2015 were evaluated. The procedure consisted of hernia sac reduction, crural repair without mesh, and Toupet fundoplication. Postoperative radiological imaging or endoscopy was performed in all symptomatic patients to exclude recurrence. Perioperative results were collected retrospectively from the patient records. QoL was evaluated with Short Form-36 (SF-36), Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQOL), and Gastrointestinal Quality of Life Index (GIQLI) questionnaires. RESULTS A total of 40 patients were identified. The majority (75%) had a type III HH. Median operation time was 118 (62-173) minutes; median blood loss was 20 (10-934) mL, and one procedure was converted to an open procedure. In 6 (15%) patients, postoperative complications occurred, including 2 grade II and 1 grades I, III, IV, and V, according to the Clavien-Dindo classification. Median hospital stay was 3 (1-15) days. At a median follow-up of 11 months, radiological imaging was performed on indication in 12 (30%) patients, and 1 recurrence was found. Overall QoL scores were satisfactory, and there was no difference related to the time elapsed since surgery. CONCLUSION Robot-assisted laparoscopic HH repair followed by Toupet fundoplication demonstrated a very low short-term recurrence rate. Postoperative morbidity was minimal, and a satisfactory QoL was achieved.

Surgical anatomy of the omental bursa and the stomach based on a minimally invasive approach: different approaches and technical steps to resection and lymphadenectomy

BACKGROUND It is imperative for surgeons to have a proper knowledge of the omental bursa in order to perform an adequate dissection during minimally invasive surgery (MIS) of the upper gastrointestinal (GI) tract. This study aimed to describe (1) the various approaches which can be used to enter the bursa and to perform a complete lymphadenectomy, (2) the boundaries and anatomical landmarks of the omental bursa as seen during MIS, and (3) whether a bursectomy should be performed for oncological reasons in upper GI cancer. METHODS In this observational study, videos of 20 patients undergoing different MIS procedures were reviewed, and the findings were verified prospectively in 5 patients undergoing a total gastrectomy and in a transversely sectioned cadaver. A systematic literature review (PubMed) was performed on the additive value of bursectomy during gastrectomy for cancer. RESULTS The omental bursa can be surgically entered through the hepatogastric ligament, gastrocolic ligament, gastrosplenic ligament or through the transverse mesocolon. Anatomical boundaries of the omental bursa could be clearly identified, and new anatomical landmarks were described (gastro-omental folds). The cranial part of the omental bursa consists of two compartments (splenic recess and superior recess), separated by the gastropancreatic fold, communicating at the level of the pancreas, and extending distally as the inferior recess. There is no clear evidence regarding beneficial effect of a bursectomy in upper GI oncology. CONCLUSIONS The description of the omental bursa in this study may help surgeons perform a more adequate oncological dissection during MIS. Bursectomy should not be routinely performed during oncological resections.

Postoperative complications and weight loss following jejunostomy tube feeding after total gastrectomy for advanced adenocarcinomas

Objective Patients undergoing total gastrectomy for cancer are at risk of malnourishment. The aim of this self-controlled study was to examine the effect of jejunostomy tube feeding (JTF) and other factors on postoperative weight and the incidence of jejunostomy-related complications in patients undergoing total gastrectomy for cancer. Methods All consecutive patients who underwent total gastrectomy for gastric cancer with jejunostomy placement were included from a prospective single-center database (2003–2014). Jejunostomy-related complications and postoperative weight changes were evaluated up to 12 months after surgery. Multivariable linear regression analysis was performed to identify factors associated with weight loss 12 months after gastrectomy. Results Of 113 patients operated in the study period, 65 received JTF after total gastrectomy for a median duration of 18 d [interquartile range (IQR), 10–55 d]. Jejunostomy-related complications occurred in 11 (17%) patients, including skin leakage (n=3) and peritoneal leakage (n=2), luxation (n=3), occlusion (n=2), infection (n=1) and torsion (n=1). In 2 (3%) patients, a reoperation was needed due to jejunostomy-related complications. The mean preoperative weight of patients was 71.8 kg (100%), and remained stable during JTF (73.9 kg, 103%, P=0.331). After JTF was stopped, the mean weight of patients decreased to 64.9 kg (90%) at 12 months after surgery (P<0.001). A high preoperative body mass index (BMI) (≥25 kg/m2) was associated with high postoperative weight loss compared to patients with a low BMI (<25 kg/m2) (16.3% vs. 8.6%, P=0.016). Conclusions JTF can prevent weight loss in the early postoperative phase. However, this is at the prize of possible complications. As weight loss in the long term is not prevented, routine JTF should be re-evaluated and balanced against the selected use in preoperatively malnourished patients. Special attention should be paid to patients with a high preoperative BMI, who are at risk of more postoperative weight loss.

Surgical Anatomy of the Omental Bursa

During Minimall Invasive Surgery (MIS) of the Upper Gastrointestinal (GI) tract, such as esophagectomy, gastrectomy, pancreatectomy, and transverse colectomy, it is imperative to have a thorough knowledge of the omental bursa (or: lesser sac) in order to perform an adequate dissection of those organs and an appropriate lymphadenectomy. Yet the surgical anatomy of the omental bursa seems very complex as the rotational embryological development of the upper abdominal organs results in a crossroads of these organs with accompanying vessels and lymph nodes [1], hence making surgery around these organs quite difficult.