Masanori Tokunaga

Effect of individual fat areas on early surgical outcomes after open gastrectomy for gastric cancer

Obesity is generally considered a risk factor for postoperative morbidity following open gastrectomy. Body mass index (BMI) is widely accepted as an indicator of obesity, but does not necessarily reflect the distribution of fat. It is unclear how different types of fat may affect the operative procedure and outcome.

Laparoscopic esophagogastric circular stapled anastomosis: a modified technique to protect the esophagus.

Laparoscopic surgery is increasingly being applied to gastric cancer surgery, including proximal gastrectomy for the resection of cancer located in the upper gastric body. Despite the ease of use of stapling devices for end-to-end anastomosis, esophagogastric anastomosis is complicated by the narrow laparoscopic space, making the placement of an esophageal purse-string suture and anvil insertion into the fragile and contracted esophagus difficult. The aim of this study was to employ a novel esophagogastric anastomosis technique for laparoscopic surgery which may avoid esophageal breakdown. Eleven patients with early gastric cancer within the upper gastric body underwent laparoscopic proximal gastrectomy. The anvil of the stapler was introduced into the esophagus through a small gastrostomy, before transection of the esophagus. The esophageal-to-anterior gastric wall anastomosis was performed using a double-stapling technique, without the need to apply a purse-string suture. The mean operation time was 237 ± 15 min and estimated blood loss was 39 ± 21 ml. The postoperative course was uneventful in all 11 patients, with no anastomotic leakage observed. Two patients needed endoscopic balloon dilation of an anastomotic stricture 24 to 28 days postoperatively. This modified procedure of laparoscopic esophagogastric anastomosis after proximal gastrectomy for the resection of cancer is a simple, rapid, and atraumatic technique which reduces the risk of anastomotic insufficiency.

Intra-abdominal infectious complications following gastrectomy in patients with excessive visceral fat

BackgroundExcessive visceral fat may be a better predictor of the development of postoperative morbidity after gastrectomy than body mass index (BMI). The aim of the present study was to clarify the most appropriate fat parameter to predict pancreas-related infection and anastomotic leakage following gastrectomy.MethodsThe study was performed in 206 patients who underwent curative gastrectomy at the Shizuoka Cancer Center between April 2008 and March 2009. Relationships between fat parameters, including visceral fat area (VFA), and early surgical outcomes were investigated. The risk factors for pancreas-related infection and anastomotic leakage were identified using univariate and multivariate analyses.ResultsThere was no strong association between any of the fat parameters and operating time, intraoperative blood loss, the number of lymph nodes retrieved, or the duration of the postoperative hospital stay. Pancreas-related infection occurred in 18 patients (8.7%), whereas anastomotic leakage was observed in 10 patients (4.9%). Of all the fat parameters, only VFA was found to be an independent risk factor for both pancreas-related infection and anastomotic leakage, with odds ratios (95% confidence intervals) of 1.015 (1.005–1.025) and 1.010 (1.000–1.021), respectively.ConclusionsExcessive visceral fat, represented by the VFA, was found to be an independent risk factor for both pancreas-related infection and anastomotic leakage following gastrectomy.

Left-sided approach for suprapancreatic lymph node dissection in laparoscopy-assisted distal gastrectomy without duodenal transection

Laparoscopy-assisted distal gastrectomy (LADG) with extended lymph node dissection has not yet been widely adopted for the treatment of gastric cancers because of the perceived complexity of the procedure. Suprapancreatic lymph node dissection is one of the most important and demanding procedures in this approach. The techniques of duodenal transection within the abdominal cavity or taping of the common hepatic or splenic artery had traditionally been adopted for suprapancreatic nodal dissection during open surgery. In 2005, we developed a new laparoscopic procedure to safely and simply perform suprapancreatic lymph node dissection in LADG. We introduced a left-sided approach for the dissection of lymph nodes in the left gastropancreatic fold, where the body of the stomach is turned over and lifted ventrally to expose the left gastropancreatic fold through the opened lesser sac, without duodenal transection, and the suprapancreatic lymph nodes are resected en bloc in reverse order, i.e., including the lymph nodes along the proximal splenic artery (station 11p), around the celiac artery (station 9), and along the common hepatic artery (station 8a). Between April 2005 and December 2007, a total of 391 patients with cT1,2 gastric cancer underwent this surgical approach. In all patients, surgery was completed safely with favorable outcomes; mean operating time was 239 min and mean blood loss was 63 ml. The complication rate was 4.6% (18/391); there were ten conversions (2.6%) and no mortality. The aim of the present study was to describe the surgical technique of our new approach for LADG with extended lymph node dissection and to evaluate the treatment outcomes achieved by this technique.

Survival Benefit of Pylorus-Preserving Gastrectomy in Early Gastric Cancer

BACKGROUND Pylorus-preserving gastrectomy (PPG) is performed in some patients for the treatment of early gastric cancer. The aim of this study was to investigate longterm survival for patients having PPG with extensive lymph node dissection, except for the suprapyloric nodes, for early gastric cancer. STUDY DESIGN From January 1995 to December 2006, 305 patients underwent PPG if they met the following criteria: cT1 (mucosa or submucosa), cN0 gastric cancer in the middle body of the stomach. Overall 5-year survival, cancer-related mortality, and freedom from recurrence were assessed retrospectively. RESULTS The median followup period was 61 months (range 27 to 144 months). Seven patients died, and the overall 5-year survival probability was 98%. Gastric cancer-related mortality was 0% and none of the patients had evidence of tumor recurrence. The accuracy of the preoperative diagnosis of T1 gastric cancer using endoscopy or endoscopic ultrasonography was 95.7%. CONCLUSIONS PPG may provide a longterm survival benefit for patients with clinically diagnosed T1 (mucosa or submucosa), cN0 gastric cancer in the middle body of the stomach, only when the accuracy of preoperative diagnosis can be assured.

Effects of reconstruction methods on a patient’s quality of life after a proximal gastrectomy: subjective symptoms evaluation using questionnaire survey

Background and aimsProximal gastrectomy is typically indicated in early gastric cancer of the upper third of the stomach. Esophagogastrostomy (EG) and jejunum interposition (JI) are often selected as reconstruction methods, although the more appropriate method of the two is unknown.Materials and methodsOne hundred and seven patients, who underwent a proximal gastrectomy followed by either an EG or a JI, were sent a questionnaire of 33 questions about subjective symptoms. Eighty-three patients (45 in the JI group and 38 in the EG group) returned the questionnaire. Results were compared between the two groups to identify the appropriate reconstruction method after a proximal gastrectomy. Also, changes in a patient’s body weight after surgery were compared.ResultsEarly and late dumping syndromes and gastroesophageal reflux associated symptoms were equally observed between the two groups. However, abdominal discomfort after meals (P = 0.008), continuous gastric fullness (P = 0.028), and hiccups between meals (P = 0.022) were often observed in the JI group. The loss of body weight was not significantly different between the two groups.ConclusionEG is a better reconstruction method compared to a JI after a proximal gastrectomy when evaluating subjective symptoms. Prospective study is warranted to clarify the better reconstruction method following proximal gastrectomy in terms of both subjective and objective symptoms.

Increased fat content and body shape have little effect on the accuracy of lymph node retrieval and blood loss in laparoscopic distal gastrectomy for gastric cancer.

BackgroundFat volume and large abdominal shape are known to disrupt the procedures of lymph node retrieval used in gastric cancer surgery. The present study examined the effect of increasing fat content on surgical outcomes, including estimated blood loss and the number of lymph nodes retrieved during gastrectomy.MethodsOf 154 patients, 50 underwent the conventional open procedure (OPEN) and 104 underwent laparoscopy-assisted distal gastrectomy (LADG). The BMI-related factors of total fat, subcutaneous fat, and visceral fat area, as well as the peritoneum–celiac axis distance were calculated by computed tomography. Regression analysis was used to determine the effects of BMI-related factors that obstruct the surgical procedures on the specific outcomes of estimated blood loss and the number of lymph nodes retrieved.ResultsIn the OPEN, but not in the LADG, increases in all BMI-related factors were related to increases in estimated blood loss. The increases in BMI, subcutaneous fat, and the peritoneum-celiac axis distances were related to decreased numbers of retrieved lymph nodes only in the OPEN. Only the factor of visceral fat at the celiac level was modestly associated with a decreased number of dissected lymph node in both groups.ConclusionsThe present study demonstrated that increased fat content and large body shape have little effect on the number of lymph nodes retrieved and blood loss in LADG. However, for patients undergoing conventional open distal gastrectomy, increased fat content and large body shape do impact on the amount of blood lost and the number of lymph nodes retrieved.

Hepatic resection for the treatment of liver metastases in gastric carcinoma: review of the literature.

This article presents a review of the literature on hepatic resection for the treatment of liver metastases in gastric carcinoma, and discusses the indications, mortality rates, prognostic factors and long-term results. Reports on hepatectomy for liver metastases from gastric cancer are rare, the results are disappointing, and further studies are required.

Treatment of thoracic esophageal carcinoma invading adjacent structures

T4 esophageal cancer is defined as the tumor invading adjacent structures, using tumor–node–metastasis (TNM) staging. For clinically T4 thoracic esophageal carcinoma, multimodality therapy, that is, neoadjuvant chemoradiotherapy (CRT) followed by surgery or definitive CRT, has generally been performed. However, the prognosis of patients with these tumors remains poor. Another strategy is needed to achieve curative treatment. In the present article, the treatment strategies employed to date are reviewed. Furthermore, the strategies for these malignancies are reassessed, based on our experiences. R1/2 and R0 resections are regarded as those with residual and no tumor after surgery. The present data show that patients who underwent R1/2 resection after neoadjuvant CRT experienced little survival benefit, while complete response (CR) cases after definitive CRT had comparatively better results. Therefore, curative surgery should not be attempted without down‐staging, and definitive CRT should be the initial treatment. Then surgery is indicated for the eradication of residual cancer cells. Close surveillance is essential for early detection of relapse even after CR, because the operation will gradually become increasingly difficult due to post‐CRT fibrosis. In conclusion, multimodality therapy consists of definitive CRT followed by R0 resection, which can be the treatment of choice for T4 esophageal carcinoma. These challenging treatments have the potential to constitute the most effective therapeutic strategy. (Cancer Sci 2007; 98: 937–942)

Can Superextended Lymph Node Dissection be Justified for Gastric Cancer with Pathologically Positive Para-aortic Lymph Nodes?

BackgroundThe prognosis of patients with gastric cancer and para-aortic lymph node (PALN) metastasis is poor. Recent Japanese randomized trials concluded that prophylactic PALN dissection is not effective for curable advanced gastric cancer. However, the value of curative resection in patients with pathologically positive PALN is not determined yet.MethodsWe retrospectively identified 178 patients with pathologically positive PALN who underwent curative resection at the Cancer Institute Hospital from 1980 to 2004. Patient characteristics were analyzed and independent prognostic factors for death were identified by Cox proportional hazard model.ResultsPartial gastrectomy was the most frequently performed procedure (142 of 178). Postoperative morbidity and mortality rates were 30 and 2%, respectively, with a 5-year survival rate of 13.0%. Multivariate analysis revealed the total number of positive nodes (hazard ratio, 1.804; 95% confidence interval, 1.221–2.665) and macroscopic type (hazard ratio, 1.697; 95% confidence interval, 1.138–2.530) as independent prognostic factors, while age, sex, histology, pathological tumor depth, and degree of PALN dissection were not statistically significant. The 5-year survival rate increased to 28.6% in patients with ≤15 positive nodes and macroscopic type other than type 4.ConclusionsProphylactic PALN dissection can not be justified in curable advanced gastric cancer. However, R0 resection including PALN retrieval might be beneficial in patients with pathologically positive PALN, providing patients are carefully selected and operations are performed safely.