Sang-Hoon Ahn

Laparoscopic versus open gastrectomy for gastric cancer: Long-term oncologic results

BACKGROUND Data are lacking regarding the oncologic safety of laparoscopic gastrectomy (LG) for the treatment of gastric cancer. The aim of this study was to compare the long-term outcomes of LG with open gastrectomy (OG) for the treatment of gastric cancer. METHODS A total of 1,874 patients underwent curative distal or total gastrectomy for gastric adenocarcinoma between May 2003 and December 2009 and were included in this retrospective study. Recurrence-free survival and recurrence pattern were compared according to each tumor stage, and a subgroup analysis was performed in advanced gastric cancer patients who underwent D2 lymphadenectomy. RESULTS Of 1,874 patients, 816 were treated with OG and 1,058 with LG. No differences were observed in recurrence-free survival rates between the LG and the OG groups for any tumor stage. The number of harvested lymph nodes was similar between the two groups when analyzed according to tumor progression, operative procedure, and extent of lymphadenectomy. There were no differences between the 2 groups when we compared recurrence patterns after stratifying for tumor stage. The subgroup analysis in advanced gastric cancer patients who underwent D2 lymphadenectomy showed that there was no difference in the recurrence-free survival rates for any tumor stage between the 2 groups. Multivariate analysis indicated that the type of operative approach did not influence recurrence in either early or advanced gastric cancer patients. CONCLUSION LG for gastric cancer is an oncologically safe procedure with comparable long-term outcomes with OG.

Single-port laparoscopic distal gastrectomy with D1+β lymph node dissection for gastric cancers: report of 2 cases.

The use of single-port laparoscopic surgery for treating various diseases has increased rapidly. This approach can offer better cosmetic results and less incisional pain. We report the cases of single-port laparoscopic distal gastrectomy with D1+&bgr; lymph node dissection for 2 patients with gastric cancers.

The current status and future perspectives of laparoscopic surgery for gastric cancer

Gastric cancer is most common cancer in Korea. Surgery is still the main axis of treatment. Due to early detection of gastric cancer, the innovation of surgical instruments and technological advances, gastric cancer treatment is now shifting to a new era. One of the most astonishing changes is that minimally invasive surgery (MIS) is becoming more dominant treatment for early gastric cancer. These MIS are represented by endoscopic resection, laparoscopic surgery, robotic surgery, single-port surgery and natural orifice transluminal endoscopic surgery. Among them, laparoscopic gastrectomy is most actively performed in the field of surgery. Laparoscopy-assisted distal gastrectomy (LADG) for early gastric cancer (EGC) has already gained popularity in terms of the short-term outcomes including patients quality of life. We only have to wait for the long-term oncologic results of Korean Laparoscopic Gastrointestinal Surgery Study Group. Upcoming top issues following oncologic safety of LADG are function-preserving surgery for EGC, application of laparoscopy to advanced gastric cancer and sentinel lymph node navigation surgery. In the aspect of technique, laparoscopic surgery at present could reproduce almost the whole open procedures. However, the other fields mentioned above need more evidences and experiences. All these new ideas and attempts provide technical advances, which will minimize surgical insults and maximize the surgical outcomes and the quality of life of patients.

Single-incision laparoscopic total gastrectomy with D1+beta lymph node dissection for proximal early gastric cancer

Single-incision laparoscopic distal gastrectomy for early gastric cancer has recently been reported by a few centers in Korea and Japan. In this technical report, we describe the world’s first pure single-incision laparoscopic total gastrectomy with D1+beta lymph node dissection for proximal early gastric cancer.

Comparative Study of Diabetes Mellitus Resolution According to Reconstruction Type After Gastrectomy in Gastric Cancer Patients with Diabetes Mellitus

BackgroundThis study was conducted to investigate diabetes mellitus (DM) resolution after gastrectomy according to reconstruction type in gastric cancer patients.MethodsTwo hundred twenty-nine gastric cancer patients with DM who underwent gastrectomy with curative intent from May 2003 to December 2009 were enrolled. Changes in fasting blood sugar concentration and the dosage of oral hyperglycemic agents or insulin were compared between reconstruction types.ResultsThe numbers of patients who underwent distal gastrectomy with a Billroth I (BI), Billroth II (BII), Roux-en-Y gastrojejunostomy (RYGJ), or total gastrectomy with Roux-en-Y esophagojejunostomy (RYEJ) were 119 (51.7%), 54 (23.5%), 40 (17.4%), and 16 (6.9%), respectively. DM remitted in 45 (19.7%) patients: 18 BI patients (15.1%), 11 BII patients (20.3%), 8 RYGJ patients (20.0%), and 8 RYEJ patients (50.0%). DM improved in 85 (37.1%) patients: 41 BI patients (34.4%), 25 BII patients (46.2%), 15 RYGJ patients (37.5%), and 4 RYEJ patients (25.0%). The DM remission or improvement rate was higher in the duodenal bypass group (BII, RYGJ, RYEJ) than in the BI group (67.2% vs. 49.5%, P = 0.022), and the DM remission rate was higher in the RYEJ group than in the distal gastrectomy group (50.0% vs. 17.3%, P = 0.002).ConclusionsMany gastric cancer patients with DM who received a gastrectomy showed remission or improvement of DM. The duodenal bypass group had higher DM remission or improvement rate than the BI group, and the RYEJ group had the highest DM remission rate.

Laparoscopy-assisted gastrectomy with para-aortic lymphadenectomy after palliative chemotherapy for advanced gastric cancer with isolated para-aortic lymph node metastasis

Prophylactic para-aortic lymphadenectomy is not recommended in curable advanced gastric cancer. However, there are few reports on therapeutic para-aortic lymphadenectomy after palliative chemotherapy in far advanced gastric cancer. We report three cases of laparoscopy-assisted gastrectomy with para-aortic lymphadenectomy after palliative chemotherapy for the first time in Korea. Three gastric cancer patients with isolated para-aortic lymph node (PAN) metastasis showed partial response to capecitabine-based chemotherapy, and laparoscopy-assisted gastrectomy with para-aortic lymphadenectomy was performed with curative intent. The mean total operation time was 365 minutes (range, 310 to 415 minutes), and the mean estimated blood loss was 158 mL (range, 125 to 200 mL). The mean number of retrieved PAN was 9 (range, 8 to 11), and all pathologic results showed no metastasis of para-aortic region. All patients recovered and were discharged without any significant complications.

Clinical impact of tumor infiltration at the transected surgical margin during gastric cancer surgery

When transected surgical margins are involved by tumor cells during gastrectomy for gastric cancer, dissemination of tumor cells to the peritoneal cavity may be a concern.

Risk factors of postoperative pancreatic fistula in curative gastric cancer surgery.

Purpose Postoperative pancreatic fistula is a dreadful complication after gastric cancer surgery. The purpose of this study is to evaluate the actual incidence and risk factors of postoperative pancreatic fistula after curative gastrectomy for gastric cancer. Materials and Methods A total of 900 patients who underwent gastrectomy for gastric cancer (laparoscopic gastrectomy, 594 patients; open gastrectomy 306 patients) were enrolled between January 2009 and December 2010. Clinical outcomes, including postoperative pancreatic fistula grade based on the International Study Group on Pancreatic Fistula, were investigated. Results Overall, the postoperative pancreatic fistula rate was 3.3% (30/900) (1.5% in laparoscopic gastrectomy versus 6.9% in open gastrectomy, P<0.001). Patients who underwent D2 lymphadenectomy, total gastrectomy, splenectomy or distal pancreatectomy showed higher postoperative pancreatic fistula rates (4.7%, 13.8%, 13.6%, or 57.1%, respectively, P<0.001). Patients with postoperative pancreatic fistula had higher morbidity (46.7% versus 13.1%, P<0.001), delayed gas out (4.9 days versus 3.8 days, P<0.001), belated diet start (5.8 days versus 3.5 days, P<0.001) and longer postoperative hospital stay (13.7 days versus 6.8 days, P<0.001). On the multivariate analysis, total gastrectomy (odds ratio 9.751, 95% confidence interval: 3.348 to 28.397, P<0.001), distal pancreatectomy (odds ratio 7.637, 95% confidence interval: 1.668 to 34.961, P=0.009) and open gastrectomy (odds ratio 2.934, 95% confidence interval: 1.100 to 7.826, P=0.032) were the independent risk factors of postoperative pancreatic fistula. Conclusions Laparoscopic gastrectomy had an advantage over open gastrectomy in terms of the lower postoperative pancreatic fistula rate. Total gastrectomy and combined resection, such as distal pancreatectomy, should be performed carefully to minimize postoperative pancreatic fistula in gastric cancer surgery.

Clinicopathologic implications of immune classification by PD-L1 expression and CD8-positive tumor-infiltrating lymphocytes in stage II and III gastric cancer patients

We co-assessed PD-L1 expression and CD8+ tumor-infiltrating lymphocytes in gastric cancer (GC), and categorized into 4 microenvironment immune types. Immunohistochemistry (PD-L1, CD8, Foxp3, E-cadherin, and p53), PD-L1 mRNA in situ hybridization (ISH), microsatellite instability (MSI), and EBV ISH were performed in 392 stage II/III GCs treated with curative surgery and fluoropyrimidine-based adjuvant chemotherapy, and two public genome databases were analyzed for validation. PD-L1+ was found in 98/392 GCs (25.0%). The proportions of immune types are as follows: PD-L1+/CD8High, 22.7%; PD-L1−/CD8Low, 22.7%; PD-L1+/CD8Low, 2.3%; PD-L1−/CD8High, 52.3%. PD-L1+/CD8High type accounted for majority of EBV+ and MSI-high (MSI-H) GCs (92.0% and 66.7%, respectively), and genome analysis from public datasets demonstrated similar pattern. PD-L1−/CD8High showed the best overall survival (OS) and PD-L1−/CD8Low the worst (P < 0.001). PD-L1 expression alone was not associated with OS, however, PD-L1−/CD8High type compared to PD-L1+/CD8High was independent favorable prognostic factor of OS by multivariate analysis (P = 0.042). Adaptation of recent molecular classification based on EBV, MSI, E-cadherin, and p53 showed no significant survival differences. These findings support the close relationship between PD-L1/CD8 status based immune types and EBV+, MSI-H GCs, and their prognostic significance in stage II/III GCs.

Solo Intracorporeal Esophagojejunostomy Reconstruction Using a Laparoscopic Scope Holder in Single-Port Laparoscopic Total Gastrectomy for Early Gastric Cancer

Single-incision laparoscopic total gastrectomy for gastric cancer has recently been reported by Seoul National University Bundang Hospital. However, this is not a popular procedure primarily because of the technical difficulties involved in achieving consistent intracorporeal esophagojejunostomy. At Seoul National University Bundang Hospital, we recently introduced a simple, easy-to-use, low-profile laparoscopic manual scope holder that enables the maintenance of a stable field of view, the most demanding condition in single-port gastrectomy. In this technical report, we describe in detail the worlds first solo single-incision laparoscopic total gastrectomy with D1+ lymph node dissection and intracorporeal esophagojejunostomy for proximal early gastric cancer.