Ichiro Uyama

A Multicenter Study on Oncologic Outcome of Laparoscopic Gastrectomy for Early Cancer in Japan

Background:Laparoscopic surgery for gastric cancer is technically feasible, but it is not widely accepted because it has not been evaluated from the standpoint of oncologic outcome. We conducted a retrospective, multicenter study of a large series of patients in Japan to evaluate the short- and long-term outcomes of laparoscopic gastrectomy for early gastric cancer (EGC). Methods:The study group comprised 1294 patients who underwent laparoscopic gastrectomy during the period April 1994 through December 2003 in 16 participating surgical units (Japanese Laparoscopic Surgery Study Group). The short- and long-term outcomes of these patients were examined. Results:Distal gastrectomy was performed in 1185 patients (91.5%), proximal gastrectomy in 54 (4.2%), and total gastrectomy in 55 (4.3%); all were performed laparoscopically. The morbidity and mortality rates associated with these operations were 14.8% and 0%, respectively. Histologically, 1212 patients (93.7%) had stage IA disease, 75 (5.8%) had stage IB disease, and 7 (0.5%) had stage II disease (the UICC staging). Cancer recurred in only 6 (0.6%) of 1294 patients treated curatively (median follow-up, 36 months; range, 13–113 months). The 5-year disease-free survival rate was 99.8% for stage IA disease, 98.7% for stage IB disease, and 85.7% for stage II disease. Conclusions:Although our findings may be considered preliminary, our data indicate that laparoscopic surgery for EGC yields good short- and long-term oncologic outcomes.

Laparoscopic total gastrectomy with distal pancreatosplenectomy and D2 lymphadenectomy for advanced gastric cancer

The standard lymph node dissection for advanced gastric cancer is a D2 dissection. Although D2 laparoscopy-assisted total gastrectomy with distal pancreatosplenectomy has been reported, no studies have reported a completely intra-abdominal laparoscopic approach, because of the technical difficulty of the procedure. We successfully performed this novel procedure in two patients with advanced gastric cancer located in the upper portion of the stomach. In fact, this surgery is technically feasible, and has a potential curability comparable with that of open surgery.

Completely laparoscopic extraperigastric lymph node dissection for gastric malignancies located in the middle or lower third of the stomach

Abstract:Dissection of the extraperigastric lymph nodes is necessary in most submucosal gastric cancers. Laparoscopy-assisted gastrectomy with extraperigastric lymph node dissection via minilaparotomy has been performed, but, to our knowledge, completely laparoscopic extraperigastric lymph node dissection has never been reported. We successfully performed completely laparoscopic distal gastrectomy with extraperigastric lymph node dissection in 12 patients, of whom 11 had early gastric cancer and 1 had malignant lymphoma. This surgery is technically feasible, has an acceptable complication rate, and a curability similar to that with open surgery.

Laparoscopic Total Gastrectomy With D2 Lymph Node Dissection for Gastric Cancer

OBJECTIVE To evaluate the safety and effectiveness of laparoscopic total gastrectomy with D2 lymphadenectomy for gastric cancer. DESIGN Review of findings from a prospectively acquired institutional database. SETTING University hospital. PATIENTS Fifty-five consecutive patients operated on by the same surgeon between October 1997 and March 2008. MAIN OUTCOME MEASURES Blood loss, complication rate, and survival. RESULTS All operations were accomplished without conversion to open laparotomy. The median operative time was 406 minutes. The median blood loss was 102 mL. A median of 46 lymph nodes were harvested. The TNM stages of the tumor were I in 17 patients (31%), II in 12 (22%), III in 16 (29%), and IV in 10 (18%). A total of 21 complications occurred in 18 patients (33%) with no postoperative mortality. At last follow-up, 44 of the 55 patients were alive without tumor recurrence and 3 with recurrence at a median follow-up of 16 months, whereas 8 had died of recurrence or another cause. CONCLUSIONS The mortality rate of zero and acceptable morbidity of our series indicate that laparoscopic total gastrectomy with D2 lymphadenectomy is technically feasible and safe in the hands of experienced surgeons. Long-term follow-up is mandatory to validate oncologic outcome.

Laparoscopic D2 lymph node dissection for advanced gastric cancer located in the middle or lower third portion of the stomach.

Abstract The standard lymph node dissection for advanced gastric cancer is a D2 dissection, performed in accordance with the new Japanese classification of gastric carcinoma (13th edition). Although laparoscopic D2 dissections according to the General rules for gastric cancer study (12th edition) have been reported, no studies have reported laparoscopic D2 dissections according to the revised classification for advanced gastric cancers located in the middle or lower portions of the stomach. The lack of such studies is due to the perceived technical difficulty of the procedure. However, we successfully performed this novel procedure in five patients with advanced gastric cancer located in the middle or lower portions of the stomach. In fact, this surgical procedure is technically feasible and safe.

Completely laparoscopic proximal gastrectomy with jejunal interposition and lymphadenectomy1

Proximal gastrectomy with gastroesophagostomy or jejunal interposition is being performed widely in Japan for early-stage gastric neoplasm in the upper portion of the stomach. Its frequent use is partially attributable to the improved postoperative fat absorption, nutrition, and release of gut hormones associated with the procedure as compared with total gastrectomy. Whether gastroesophagostomy or jejunal interposition should be selectively performed after proximal gastrectomy is a controversial matter of opinion. Although gastroesophagostomy is a simple, easy, and safe procedure, it results in a high incidence of reflux esophagitis. In this respect, jejunal or jejunal pouch interposition is superior to gastroesophagostomy as a followup procedure to proximal gastrectomy. Recently, to achieve less invasive surgery, laparoscopic distal partial gastrectomies have been performed. Although the laparoscopy-assisted proximal gastrectomy with gastroesophagostomy was previously reported, no studies have reported laparoscopic proximal gastrectomy with jejunal interposition. Such a lack of studies is likely caused by the procedure’s technical difficulty. We successfully performed completely laparoscopic proximal gastrectomy with jejunal interposition using a functional end to end anastomotic technique. We describe our new procedure and the initial clinical results in this article. METHODS

Linear stapling forms improved anastomoses during esophagojejunostomy after a total gastrectomy

BACKGROUND Circular stapling devices are commonly used to form esophagojejunal anastomoses after total gastrectomy. However, the technique has potential problems with placement of the purse-string suture and insertion of the anvil of the instrument. METHODS We describe an improved technique for esophagojejunostomy by functional end-to-end anastomosis with linear stapling devices. RESULTS Three patients with gastric cancer underwent this procedure after total gastrectomy. No anastomotic leakage or clinical evidence of stenosis was encountered. The maximum diameters of the anastomoses, evaluated by radiography with barium at 6 months after surgery, were 3.5 cm and 4.0 cm in 2 patients. Endoscopic examination revealed clear lines of anastomosis with a straight continuity between the distal esophagus and the jejunum. CONCLUSIONS Our improved technique for esophagojejunostomy by functional end-to-end anastomosis with two linear staplers is a convenient, safe and reliable procedure that is independent of the width of the esophagus and the depth of the esophageal hiatus.

Laparoscopic Right Hemicolectomy with Radical Lymph Node Dissection Using the No-Touch Isolation Technique for Advanced Colon Cancer

Abstract The treatment of advanced right-sided colon cancer presents numerous challenges for the surgeon who must aim to minimize the invasiveness of surgery, achieve curative resection, and prevent port-site recurrences. To overcome these issues, we performed a totally intra-abdominal laparoscopic right hemicolectomy with radical lymph node dissection based on a no-touch isolation technique. To perform this no-touch technique, we initially dissected the lymph nodes along the surgical trunk, then transected the transverse colon, terminal ileum, and mesentery without tumor manipulation. Finally, the right side of the colon was freed retroperitoneally. We performed this surgical technique on three patients and no intraoperative complications were encountered. Curative resection was achieved in all three patients, as curability A according to the Japanese Classification of Colorectal Carcinoma, and their postoperative courses were uneventful. Therefore, this novel technique proved to be both feasible and safe. Furthermore, it enabled us to minimize the invasiveness of surgery, while providing clear access to resect the right-sided advanced colon cancer.

A Protective Technique for Retraction of the Liver During Laparoscopic Gastrectomy for Gastric Adenocarcinoma: Using a Penrose Drain

BackgroundRetraction of the liver is necessary to ensure an adequate working space in laparoscopic surgery, but the retraction force applied may cause transient liver dysfunction. We have introduced the technique using a Penrose drain to suspend the liver with the performance of laparoscopic gastrectomy for gastric adenocarcinoma.Methods111 patients with gastric adenocarcinoma underwent laparoscopic gastrectomy using either a Penrose drain (n = 47) or a Nathanson’s retractor (n = 64) for displacement of the liver. Serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin, alkaline phoshatase (ALP) and albumin were compared among the groups at baseline, immediately after operation, and on postoperative days (POD) 1, 2, 3, 5, and 7.ResultsThe levels of ALT on POD 2, 3, and 5 were significant higher in the Nathanson’s retractor group than in the Penrose drain group. Levels of AST on POD 2 and 3 were also higher in the Nathanson’s retractor group than in the Penrose drain group. There was no significant difference in total bilirubin, ALP, and serum albumin levels between groups.ConclusionsThe use of the Penrose drain for retraction of the liver appears to attenuate postoperative liver dysfunction during laparoscopic gastrectomy for gastric adenocarcinoma.

Clinical Outcome and Clinicopathological Characteristics of Recurrence after Laparoscopic Gastrectomy for Advanced Gastric Cancer

Background: Although laparoscopic gastrectomy has been recognized as a treatment of early gastric cancer, the indication for laparoscopic gastrectomy with D2 lymph node dissection has remained controversial. D2 lymph node dissection is considered to be feasible for advanced gastric cancer in some high-volume institutions specifically trained for the laparoscopic procedure. This study was undertaken to determine the clinical outcome and clinicopathological characteristics of patients who showed recurrence following laparoscopic gastrectomy for advanced gastric cancer. Methods: From August 1999 through February 2009, among 805 patients who underwent laparoscopic gastrectomy associated with regional lymph node dissection, a total of 209 patients undergoing gastrectomy associated with lymph node dissection who consequently obtained complete resection for advanced gastric cancer were subjected to the retrospective analysis to evaluate clinical outcome. Results: The mean period of postoperative observation was 1,068 days. The final stages of the 209 cases were as follows: 83 in IB, 56 in II, 46 in IIIA, and 24 in IIIB. The 5-year survival rate was 89.1% in stage IB, 93.1% in stage II, 52.5% in stage IIIA, and 46.5% in stage IIIB, respectively. A total of 27 patients (12.9%) had recurrence. Postoperative recurrence of gastric carcinoma occurred in peritoneal dissemination in 13 patients, liver in 7, distant lymph nodes in 6, ovary in 3, lung in 2, skin in 1, and meninges in 1 patient. There were neither port-site metastases nor locoregional recurrence. Conclusion: The characteristics and the rate of postoperative recurrence after laparoscopic gastrectomy for advanced gastric cancer were not greatly different from those of the open conventional procedure. Although further observation is required to finally conclude long-term survival, laparoscopic radical gastrectomy may possibly be indicated for patients with advanced gastric cancer.