Manabu Ohashi

Long-term and surgical outcomes of laparoscopic surgery for gastric gastrointestinal stromal tumors

AbstractBackgroundnGastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the gastrointestinal tract. Surgical resection with a free margin is the gold standard treatment for these lesions.nObjectiveThe aim of this study was to evaluate the feasibility of performing laparoscopic resection for gastric GIST from the viewpoint of operative and long-term oncological outcomes.MethodsBetween 2005 and 2011, a total of 78 consecutive patients undergoing laparoscopic resection of gastric GISTs were enrolled in a retrospective single-center study. Patient and tumor characteristics, surgical procedures, risk classification, postoperative complications, mortality, recurrence, and survival time were collected from a database, and the descriptive statistics were estimated.ResultsPatients (Nxa0=xa078; 32 males and 46 females) with a median age of 63xa0years (range 31–82) were evaluated. The tumors were located at the cardia (10.3xa0%), upper stomach (59.0xa0%), middle stomach (23.1), and lower stomach (7.7xa0%). The mean size of the tumors was 34.7xa0±xa012.1xa0mm. The laparoscopic procedures included wedge resection (92.3xa0%), such as laparoscopy and endoscopy cooperative surgery (51.3xa0%), and gastrectomy (7.7xa0%). All cases exhibited a pathologically negative margin. The mean operative time was 147.5xa0±xa063.8xa0min, and the mean estimated amount of blood loss was 17.8xa0±xa047.9xa0ml. The mean length of hospitalization was 9.4xa0±xa012.8xa0days. The incidence of perioperative complications higher than grade III was 2.6xa0%, including two cases of anastomotic leakage. Regarding risk classification, low, intermediate and high were observed in 61, 6, and 11 cases, respectively. During a mean follow-up period of 45.3xa0±xa018.5xa0months, one patient experienced local recurrence in the omentum. Meanwhile, four patients died due to other diseases; all other patients survived.ConclusionsAdequate oncologic resection was achieved in all cases. Laparoscopic surgery is a feasible option for gastric GISTs <5xa0cm.

Feasibility of laparoscopic and endoscopic cooperative surgery for gastric submucosal tumors (with video)

BACKGROUND AND AIMSnLaparoscopic gastric resection is widely used for gastric submucosal tumors (SMTs). However, determining an appropriate resection line using only the laparoscopic approach is difficult. We developed a laparoscopic and endoscopic cooperative surgery (LECS) technique by combining laparoscopic gastric resection with endoscopic submucosal dissection, and we have used this procedure to resect gastric SMTs. In this study, the procedure is presented and its safety and feasibility for resecting gastric SMTs are evaluated.nnnMETHODSnThis retrospective study included 100 patients who underwent LECS for SMTs at the Department of Gastroenterological Surgery, Cancer Institute, between June 2006 and November 2014. The demographics, tumor histopathologic characteristics, and operative and follow-up data were reviewed.nnnRESULTSnComplete resection with negative surgical margins was achieved in all patients, and LECS was performed regardless of tumor location. The mean operation time was 174.3 minutes, with an estimated blood loss of 16.3xa0mL. In addition, the mean time until the initiation of oral intake was 1.4 days, and the mean postoperative hospital stay was 8.4 days. Moreover, no local or distant tumor recurrence was observed. The only severe adverse event was leakage, which was observed in 1 patient.nnnCONCLUSIONSnLECS was performed with a reasonable operation time, low blood loss, and minimal adverse events. Therefore LECS is safe and feasible for resecting gastric SMTs.

Does the Single-Stapling Technique for Circular-Stapled Esophagojejunostomy Reduce Anastomotic Complications After Laparoscopic Total Gastrectomy?

AbstractBackgroundLaparoscopic total gastrectomy (LTG) is used for early gastric cancer (EGC) in the upper stomach. However, the incidences of postoperative anastomotic complications such as leakage and stricture remain high.n This study investigated whether using a single-stapling technique (SST) instead of a hemi-double-stapling technique (HDST) for intracorporeal circular-stapled esophagojejunostomy could reduce anastomotic complications after LTG.MethodsThis retrospective study included 136 patients with EGC treated by LTG with intracorporeal circular-stapled esophagojejunostomy. Originally, HDST was used for esophagojejunostomy in 71 patients (original group). Thereafter, the esophagojejunostomy procedure was modified, and SST was used in a further 65 patients (modified group). The impact of the anastomotic procedure (SST or HDST) on anastomotic complications after LTG was determined by uni- and multivariate analyses.ResultsThe incidence of anastomotic complications was significantly lower in the modified group (7.7xa0%) than in the original group (22.5xa0%; Pxa0=xa00.017). The frequency of anastomotic leakage was lower in the modified group (3.1xa0%) than in the original group (9.9xa0%), although the difference was not statistically significant. Meanwhile, the frequency of anastomotic stricture was significantly less common in the modified group (6.2xa0%) than in the original group (18.3xa0%; Pxa0=xa00.032). Multivariate analysis showed that anastomotic procedure with SST was significantly associated with a lower rate of postoperative anastomotic complications (odds ratio [OR], 0.217; 95xa0% confidence interval [CI], 0.063–0.631; Pxa0=xa00.004), as was the operation time (OR, 0.237; 95xa0% CI 0.082–0.667; Pxa0=xa00.007).ConclusionsThe use of SST for intracorporeal circular-stapled esophagojejunostomy could reduce anastomotic complications after LTG.

Clinical Outcomes and Evaluation of Laparoscopic Proximal Gastrectomy with Double-Flap Technique for Early Gastric Cancer in the Upper Third of the Stomach

BackgroundA novel double-flap esophagogastrostomy technique developed to prevent reflux after proximal gastrectomy was applied to laparoscopic proximal gastrectomy (LPG), and the clinical outcomes of this technique (LPG-DFT) were evaluated and compared to those of laparoscopic total gastrectomy (LTG).MethodsThis retrospective study of 90 patients with early gastric cancer (EGC) in the upper third of the stomach compared surgical outcomes, postoperative endoscopic findings, and nutritional status between two procedure groups, LPG-DFT (nxa0=xa043) and LTG (nxa0=xa047). The association between morbidity and surgical procedure was analyzed by controlling for body mass index (BMI).ResultsMean operation time was significantly higher for LPG-DFT than LTG (386.5 vs. 316.3xa0min, Pxa0<xa00.001). The morbidity and the frequency of anastomotic complications were lower, although not significantly, for LPG-DFT than LTG (7.0 vs. 21.3%, Pxa0=xa00.073; and 4.7 vs. 17.2%, Pxa0=xa00.093). Median postoperative hospital stay was significantly shorter for LPG-DFT than LTG (10 vs. 13xa0days, Pxa0=xa00.002). The LPG-DFT procedure was identified as the most significant independent predictor of low morbidity after adjustment for BMI (Pxa0=xa00.028, ORxa0=xa00.232, 95% CI 0.047–0.862). LTG induced more severe reflux esophagitis than LPG-DFT (14.9% vs. 2.3%, Pxa0=xa00.06). The mean baseline weight, total protein, and hemoglobin were significantly higher with LPG-DFT than with LTG (Pxa0<xa00.05).ConclusionsLPG-DFT is a better surgical procedure for treating upper-third EGC than LTG in terms of morbidity, postoperative hospital stay, and postoperative nutritional status.

Feasibility of Gastrectomy with Standard Lymphadenectomy for Patients Over 85 Years Old with Gastric Cancer.

BackgroundThe feasibility of gastrectomy with standard lymphadenectomy for patients over 85xa0years of age is not known. This study investigated short- and long-term outcomes and the tolerability of gastrectomy with standard lymphadenectomy for patients over 85xa0years with gastric cancer.MethodsAltogether, 77 patients aged over 85xa0years underwent gastrectomy with lymphadenectomy for gastric cancer at the Cancer Institute Hospital, Japan from May 2000 to February 2012. Postoperative short-term outcomes and survivals were analyzed retrospectively. Standard lymphadenectomy was defined according to the Japanese Gastric Cancer Association guidelines. Lymphadenectomy without splenectomy during total gastrectomy was called “reduced” lymphadenectomy.ResultsDistal gastrectomy was performed in 51 patients, total gastrectomy in 20, remnant total gastrectomy in 5, and proximal gastrectomy in 1 patient. Gastrectomy with standard lymphadenectomy was initially planned for 50 (64.9xa0%) patients and completed in 42 (54.5xa0%) patients. The other 8 patients underwent reduced lymphadenectomy because they required R1 or R2 resection. There were no deaths. The morbidity rate was 55.8xa0% overall and 54.8xa0% with standard lymphadenectomy. The most frequent complication was intestinal hypoperistalsis (29.9xa0%). The mean postoperative hospital stay was 19xa0days (range 10–70xa0days). The median overall survival time was 46.8xa0months.ConclusionCoupled with comprehensive postoperative medical care due to the relative high morbidity risk, gastrectomy with standard lymphadenectomy for gastric cancer may be acceptable for relatively healthy patients over 85xa0years of age. Decisions to reduce the extent of lymphadenectomy during gastrectomy should not be based on advanced age alone.The feasibility of gastrectomy with standard lymphadenectomy for patients over 85xa0years of age is not known. This study investigated short- and long-term outcomes and the tolerability of gastrectomy with standard lymphadenectomy for patients over 85xa0years with gastric cancer. Altogether, 77 patients aged over 85xa0years underwent gastrectomy with lymphadenectomy for gastric cancer at the Cancer Institute Hospital, Japan from May 2000 to February 2012. Postoperative short-term outcomes and survivals were analyzed retrospectively. Standard lymphadenectomy was defined according to the Japanese Gastric Cancer Association guidelines. Lymphadenectomy without splenectomy during total gastrectomy was called “reduced” lymphadenectomy. Distal gastrectomy was performed in 51 patients, total gastrectomy in 20, remnant total gastrectomy in 5, and proximal gastrectomy in 1 patient. Gastrectomy with standard lymphadenectomy was initially planned for 50 (64.9xa0%) patients and completed in 42 (54.5xa0%) patients. The other 8 patients underwent reduced lymphadenectomy because they required R1 or R2 resection. There were no deaths. The morbidity rate was 55.8xa0% overall and 54.8xa0% with standard lymphadenectomy. The most frequent complication was intestinal hypoperistalsis (29.9xa0%). The mean postoperative hospital stay was 19xa0days (range 10–70xa0days). The median overall survival time was 46.8xa0months. Coupled with comprehensive postoperative medical care due to the relative high morbidity risk, gastrectomy with standard lymphadenectomy for gastric cancer may be acceptable for relatively healthy patients over 85xa0years of age. Decisions to reduce the extent of lymphadenectomy during gastrectomy should not be based on advanced age alone.

Role of Prealbumin as a Powerful and Simple Index for Predicting Postoperative Complications After Gastric Cancer Surgery

Preoperative factors, including nutritional status, may have strong correlations with postoperative morbidities. The current study evaluated preoperative prealbumin concentrations as a predictor of postoperative complications after gastric surgery. A retrospective study of 1798 patients who underwent gastrectomy for gastric adenocarcinoma was performed. Information was collected on basic patient characteristics, preoperative laboratory findings, and 30xa0day postoperative complications. The patients were divided into three groups based on prealbumin concentrations (≥22xa0mg/dL,xa0<22 toxa0≥15xa0mg/dL, and <15xa0mg/dL) for analysis. The overall complication rate was 21.7xa0%, and the infection rate was 16xa0%. Subgroup analysis based on prealbumin concentrations showed that complication rates were markedly elevated with decreasing concentrations of prealbumin. Multivariate analysis using a logistic regression model showed that both overall and infectious complications were strongly associated with male gender, elevated C-reactive protein (CRP), and decreased prealbumin levels (pxa0<xa00.05). Even in patients with a CRP level higher than 0.1xa0mg/dL, male gender and low prealbumin concentrations (<15xa0mg/dL) were significantly correlated with overall and infectious morbidities (pxa0<xa00.05). Preoperative prealbumin concentrations are useful predictors of short-term postoperative outcomes after gastrectomy.BackgroundPreoperative factors, including nutritional status, may have strong correlations with postoperative morbidities. The current study evaluated preoperative prealbumin concentrations as a predictor of postoperative complications after gastric surgery.MethodsA retrospective study of 1798 patients who underwent gastrectomy for gastric adenocarcinoma was performed. Information was collected on basic patient characteristics, preoperative laboratory findings, and 30xa0day postoperative complications. The patients were divided into three groups based on prealbumin concentrations (≥22xa0mg/dL,xa0<22 toxa0≥15xa0mg/dL, and <15xa0mg/dL) for analysis.ResultsThe overall complication rate was 21.7xa0%, and the infection rate was 16xa0%. Subgroup analysis based on prealbumin concentrations showed that complication rates were markedly elevated with decreasing concentrations of prealbumin. Multivariate analysis using a logistic regression model showed that both overall and infectious complications were strongly associated with male gender, elevated C-reactive protein (CRP), and decreased prealbumin levels (pxa0<xa00.05). Even in patients with a CRP level higher than 0.1xa0mg/dL, male gender and low prealbumin concentrations (<15xa0mg/dL) were significantly correlated with overall and infectious morbidities (pxa0<xa00.05).ConclusionsPreoperative prealbumin concentrations are useful predictors of short-term postoperative outcomes after gastrectomy.

Survival benefit of “D2-plus” gastrectomy in gastric cancer patients with duodenal invasion

BackgroundThe optimal extent of lymph node (LN) dissection for gastric cancer with duodenal invasion is yet to be clarified. This study sought to evaluate the significance of gastrectomy with D2-plus lymphadenectomy including posterior LNs along the common hepatic artery (no. 8p), hepatoduodenal ligament LNs along the bile duct (no. 12b) and those behind the portal vein (no. 12p), LNs on the posterior surface of the pancreatic head (no. 13), LNs along the superior mesenteric vein (no. 14v) and para-aortic LNs around the left renal vein (nos. 16a2 and 16b1) dissection.MethodsPatients with gastric cancer with duodenal invasion undergoing R0 gastrectomy from January 2000 to December 2015 were enrolled. The therapeutic value index (TVI) of each LN dissection was calculated by multiplying the incidence of metastasis to each LN station by the 5-year overall survival (OS) rate of the patients with metastasis to the station.ResultsIn total, 117 patients were eligible. The 5-year OS rates (and TVI) of the patients with metastasis to LNs were 40.4% (7.4) in no. 12b, 25.4% (6.8) in no. 13, 32.0% (6.1) in no. 14v, 50.0% (13.0) in no. 16a2 and 40.0% (10.0) in no. 16b1. None of the patients with metastasis in no. 8p or no. 12p survived 5xa0years or longer.ConclusionIn a potentially curative gastrectomy for gastric cancer with duodenal invasion, there may be some survival benefit in dissection of nos. 12b, 13, 14v, 16a2 and 16b1 LNs, while no benefit was seen in dissection of nos. 8p or 12p LNs.

Preserving infrapyloric vein reduces postoperative gastric stasis after laparoscopic pylorus-preserving gastrectomy

PurposeLaparoscopic pylorus-preserving gastrectomy (LPPG) is performed to preserve function in treating early gastric cancer. However, gastric stasis is a potential complication of LPPG that could decrease postoperative quality of life, possibly due to gastric edema of the pyloric cuff caused by venous stasis. We introduced an infrapyloric vein (IPV)-preserving LPPG (iLPPG) procedure to prevent pyloric cuff edema and thus minimize the incidence of gastric stasis and investigated the early clinical outcomes of iLPPG.MethodsWe reviewed 150 patients with gastric cancer who underwent LPPG between August 2011 and June 2013 at the Cancer Institute Hospital and analyzed postoperative complications, incidence of gastric stasis (requiring starvation longer than 72xa0h or an invasive treatment), and transient delayed gastric emptying (TDGE).ResultsOf the 150 patients, 56 underwent iLPPG and 94 underwent conventional LPPG without preservation of the IPV (cLPPG). Morbidity rates were 5.4% in the iLPPG group and 23.4% in the cLPPG group (Pxa0=xa00.003). The incidence of both gastric stasis and TDGE was significantly lower in the iLPPG group than in the cLPPG group (0 vs. 8.5%, Pxa0=xa00.03 and 0 vs. 7.4%, Pxa0=xa00.046, respectively). Median postoperative stay was significantly shorter in the iLPPG group compared to the cLPPG group (9 vs. 11xa0days, Pxa0<xa00.001, respectively).ConclusionsPreservation of the IPV might prevent the incidence of postoperative gastric stasis after LPPG, resulting in a shorter postoperative stay.

Use of endoscopy to determine the resection margin during laparoscopic gastrectomy for cancer

It can be difficult to determine the transection line during totally laparoscopic surgery for early gastric cancer owing to lack of tactile feedback. This retrospective cohort study aimed to assess the role of intraoperative endoscopy in determining the resection margin in totally laparoscopic gastrectomy.

Excellent Long-Term Prognosis and Favorable Postoperative Nutritional Status After Laparoscopic Pylorus-Preserving Gastrectomy

Laparoscopic pylorus-preserving gastrectomy (LPPG) has been introduced as a minimally invasive function-preserving operation for early gastric cancer (GC). This study aimed to investigate the surgical and prognostic outcomes after LPPG at the authors’ institution. This study analyzed 465 patients who underwent LPPG for cT1 N0 GC located in the middle part of the stomach between 2006 and 2012. Short- and long-term surgical outcomes including 5-year survival rates, postoperative nutritional data, and body weight change were retrospectively investigated. Regarding short-term surgical results, 14 (3%) of the 465 patients had severe complications classified as Clavien–Dindo grade 3a or above, and no mortality occurred (no in-hospital deaths). The median follow-up period was 1829 days (range 226–3197 days), and the 5-year overall survival and relapse-free survival rates were respectively 98% (95% confidence interval [CI] 96.1–99.0%) and 98% (95% CI 96.1–99.0%). Only two cases of postoperative recurrence were confirmed, and their recurrence sites were not in the remnant stomach or regional lymph nodes. The postoperative nutritional status, in terms of serum total protein, albumin, and hemoglobin levels, was well maintained, and the mean relative body weight (postoperative/preoperative) was 93.24xa0±xa07.29% after LPPG. For the first time, we have clarified the detailed long-term survival outcomes of LPPG for cT1 N0 GC. LPPG is an acceptable and favorable operative method for clinically diagnosed early-stage GC, in terms of long-term survival and postoperative nutrition.BackgroundLaparoscopic pylorus-preserving gastrectomy (LPPG) has been introduced as a minimally invasive function-preserving operation for early gastric cancer (GC). This study aimed to investigate the surgical and prognostic outcomes after LPPG at the authors’ institution.MethodsThis study analyzed 465 patients who underwent LPPG for cT1 N0 GC located in the middle part of the stomach between 2006 and 2012. Short- and long-term surgical outcomes including 5-year survival rates, postoperative nutritional data, and body weight change were retrospectively investigated.ResultsRegarding short-term surgical results, 14 (3%) of the 465 patients had severe complications classified as Clavien–Dindo grade 3a or above, and no mortality occurred (no in-hospital deaths). The median follow-up period was 1829 days (range 226–3197 days), and the 5-year overall survival and relapse-free survival rates were respectively 98% (95% confidence interval [CI] 96.1–99.0%) and 98% (95% CI 96.1–99.0%). Only two cases of postoperative recurrence were confirmed, and their recurrence sites were not in the remnant stomach or regional lymph nodes. The postoperative nutritional status, in terms of serum total protein, albumin, and hemoglobin levels, was well maintained, and the mean relative body weight (postoperative/preoperative) was 93.24xa0±xa07.29% after LPPG.ConclusionsFor the first time, we have clarified the detailed long-term survival outcomes of LPPG for cT1 N0 GC. LPPG is an acceptable and favorable operative method for clinically diagnosed early-stage GC, in terms of long-term survival and postoperative nutrition.