Seiji Satoh

Laparoscopic versus open D2 gastrectomy for advanced gastric cancer: a retrospective cohort study

BackgroundThe oncologic safety and feasibility of laparoscopic D2 gastrectomy for advanced gastric cancer are still uncertain. The aim of this study is to compare our results for laparoscopic D2 gastrectomy with those for open D2 gastrectomy.MethodsBetween 1998 and 2008, a total of 336 patients with clinical T2, T3, or T4 tumors underwent laparoscopic (nxa0=xa0186) or open (nxa0=xa0150) gastrectomy involving D2 lymph node dissection with curative intent. To produce this study population, 123 patients in the open group who matched those of the laparoscopic group with regard to age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) score, tumor location, and clinical tumor stage were retrospectively selected. The short- and long-term outcomes of these patients were examined.ResultsLaparoscopic D2 gastrectomy was associated with significantly less operative blood loss and shorter hospital stay, but longer operative time, compared with open D2 gastrectomy. The mortality and morbidity rates of the laparoscopic group were comparable to those of the open group (1.1 % vs. 0, Pxa0=xa00.519, and 24.2 % vs. 28.5 %, Pxa0=xa00.402). The 5-year disease-free and overall survival rates were 65.8 and 68.1 % in the laparoscopic group and 62.0 and 63.7 % in the open group (Pxa0=xa00.737 and Pxa0=xa00.968). There were no differences in the patterns of recurrence between the two groups.ConclusionsThis study suggests that laparoscopic D2 gastrectomy provides reasonable oncologic outcomes with acceptable morbidity and low mortality rates. Although operation time is currently long, this approach is associated with several advantages of laparoscopic surgery, including quick recovery of bowel function and short hospital stay. Laparoscopic D2 gastrectomy may offer a favorable alternative to open D2 gastrectomy for patients with advanced gastric cancer.

Novel Integrated Robotic Approach for Suprapancreatic D2 Nodal Dissection for Treating Gastric Cancer: Technique and Initial Experience

BackgroundRobotic surgery for the treatment of gastric cancer has been reported, but the technique is not yet established. The objective of this study was to assess the feasibility and safety of our novel integrated procedure for robotic suprapancreatic D2 nodal dissection during distal gastrectomy.MethodsAt our hospital from January 2009 to December 2010, a total of 25 consecutive cases of gastric cancer were treated by robotic distal gastrectomy with intracorporeal Billroth I reconstruction. These patients were enrolled in a prospective study to assess the safety and feasibility of robotic distal gastrectomy with nodal dissection by our novel integrated approach, which consists of three elements: arm formation, the surgical approach, a cutting device. To evaluate the learning curves involved in this approach, clinicopathologic features and surgical outcomes were compared between the initial (nxa0=xa012) and late (nxa0=xa013) phases.ResultsAll operations were completed without the need for open or conventional laparoscopic surgery. The mean operating time was 361xa0±xa058.1xa0min (range 258–419xa0min), and blood loss recorded was 51.8xa0±xa038.2xa0ml (range 4–123xa0ml). The median number of retrieved lymph nodes was 44.3xa0±xa018.4 (range 26–95). R0 resection was accomplished in all cases. There were no deaths or complications related to pancreatic damage. Operating time and surgeon console time for the late phase were significantly shorter than those for the initial phase.ConclusionsOur novel robotic approach for D2 nodal dissection in gastric cancer is feasible and safe.

The delta-shaped anastomosis in laparoscopic distal gastrectomy: analysis of the initial 100 consecutive procedures of intracorporeal gastroduodenostomy

BackgroundWe developed a new method of intracorporeal gastroduodenostomy, the delta-shaped anastomosis, in which only endoscopic linear staplers are used. In this report, we present the short- and long-term outcomes of our initial experience with this procedure.MethodsWe retrospectively analyzed 100 consecutive gastric cancer patients who underwent the delta-shaped anastomosis procedure from May 2001 to November 2006. All of them underwent a laparoscopic distal gastrectomy with regional lymph node dissection. Quality of life was assessed with a questionnaire 6xa0months or more postoperatively, and the gastric remnant was evaluated by endoscopy one year following the surgery.ResultsEight surgeons successfully performed the delta-shaped anastomosis without any conversion to laparotomy. The learning curve for all surgeons was steep and the mean time for the anastomosis was 13xa0min. Only one patient developed an anastomotic leak, and the leak was minor. Sixty-five patients tolerated a 1500xa0kcal/day soft diet at the time of discharge. The mean follow-up period was 54.9xa0months. Only one patient reported symptoms indicative of dumping. Two patients were diagnosed with reflux esophagitis, and approximately 70% had evidence of bile reflux, but severe gastritis of the remnant stomach on endoscopy was uncommon.ConclusionsThe wide lumen of the delta-shaped anastomosis led to early, adequate postoperative oral intake without a significant incidence of dumping syndrome. The delta-shaped anastomosis is safe and simple and provides satisfactory postoperative results.

Robot-assisted Thoracoscopic Lymphadenectomy Along the Left Recurrent Laryngeal Nerve for Esophageal Squamous Cell Carcinoma in the Prone Position: Technical Report and Short-term Outcomes

BackgroundMeticulous mediastinal lymphadenectomy frequently induces recurrent laryngeal nerve palsy (RLNP). Surgical robots with impressive dexterity and precise dissection skills have been developed to help surgeons perform operations. The objective of this study was to determine the impact on short-term outcomes of robot-assisted thoracoscopic radical esophagectomy performed on patients in the prone position for the treatment of esophageal squamous cell carcinoma, including its impact on RLNP.MethodsA single-institution nonrandomized prospective study was performed. The patients (nxa0=xa036) with resectable esophageal squamous cell carcinoma were divided into two groups: patients who agreed to robot-assisted thoracoscopic esophagectomy with total mediastinal lymphadenectomy performed in the prone position (nxa0=xa016, robot-assisted group) without insurance reimbursement, and those who agreed to undergo the same operation without robot assistance but with health insurance coverage (nxa0=xa020, control group). These patients were observed for 30xa0days following surgery to assess short-term surgical outcomes, including the incidence of vocal cord palsy, hoarseness, and aspiration.ResultsRobot assistance significantly reduced the incidence of vocal cord palsy (pxa0=xa00.018) and hoarseness (pxa0=xa00.015) and the time on the ventilator (pxa0=xa00.025). There was no in-hospital mortality in either group. There were no significant differences between the two groups with respect to patient background, except for the use of preoperative therapy (robot-assisted group <control, pxa0=xa00.003). There were no significant differences in estimated blood loss, operating time, number of dissected lymph nodes, completeness of resection, or the incidence of the other complications, except for anastomotic leakage (pxa0=xa00.038).ConclusionRobot-assisted thoracoscopic esophagectomy with total mediastinal lymphadenectomy is feasible and safe. This method shows promise in preventing RLNP.

Potential advantages of robotic radical gastrectomy for gastric adenocarcinoma in comparison with conventional laparoscopic approach: a single institutional retrospective comparative cohort study

BackgroundWe have previously reported that laparoscopic approach improved short-term postoperative courses even for advanced gastric adenocarcinoma, but not morbidity, in comparison with open approach. The objective of this study was to determine the impact of the use of the surgical robot, da Vinci Surgical System, in minimally invasive radical gastrectomy on short-term outcomes.MethodsA single institutional retrospective cohort study was performed (UMIN000011749). Five hundred twenty-six patients who underwent radical gastrectomy were enrolled. Eighty-eight patients who agreed to uninsured use of the surgical robot underwent robotic gastrectomy, whereas the remaining 438 patients who wished for laparoscopic (lap) approach with health insurance coverage underwent conventional laparoscopic gastrectomy.ResultsIn the robotic group, morbidity (robotic vs lap 2.3 vs 11.4xa0%, pxa0=xa00.009) and hospital stay following surgery (robotic vs lap 14 [2–31] vs 15 [8–136]xa0days, pxa0=xa00.021) were significantly improved, even though operative time (pxa0=xa00.003) and estimated blood loss (pxa0=xa00.026) were slightly greater. In particular, local (robotic vs lap 1.1 vs 9.8xa0%, pxa0=xa00.007) rather than systemic (robotic vs lap 1.1 vs 2.5xa0%, pxa0=xa00.376) complication rates were attenuated using the surgical robot. Multivariate analyses revealed that non-use of the surgical robot (OR 6.174 [1.454–26.224], pxa0=xa00.014), total gastrectomy (OR 4.670 [2.503–8.713], pxa0<xa00.001), and D2 lymphadenectomy (OR 2.095 [1.124–3.903], pxa0=xa00.020) were the significant independent risk factors determining postoperative complications.ConclusionsThe use of the surgical robot might reduce surgery-related complications, leading to further improvement in short-term postoperative courses following minimally invasive radical gastrectomy.

Laparoscopic surgery for advanced gastric cancer: Current status and future perspectives

Laparoscopic gastrectomy has been widely accepted especially in patients with early-stage gastric cancer. However, the safety and oncologic validity of laparoscopic gastrectomy for advanced gastric cancer are still being debated. Since the late 90s, we have been engaged in developing a stable and robust methodology of laparoscopic radical gastrectomy for advanced gastric cancer, and have established laparoscopic distinctive technique for suprapancreatic lymph node dissection, namely the outermost layer-oriented medial approach. In this article, We present the development history of this method, and current status and future perspectives of laparoscopic gastrectomy for advanced gastric cancer based on our experience and a review of the literature.

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.

Impact of anastomotic complications on outcome after laparoscopic gastrectomy for early gastric cancer

The effects of anastomotic complications after laparoscopically assisted gastrectomy (LAG) have not been studied widely. The aims of this observational study were to identify potential factors that predict anastomotic complications and investigate the impact of anastomotic complications in patients undergoing gastrectomy for early gastric cancer.

Critical factors that influence the early outcome of laparoscopic total gastrectomy

BackgroundLaparoscopic distal gastrectomy (LDG) is a routinely performed procedure. However, clinical expertise in laparoscopic total gastrectomy (LTG) is insufficient, and it is only performed at specialized institutions. This study aimed to identify critical factors associated with complications after laparoscopic gastrectomy (LG), particularly LTG.MethodsA large-scale database was used to identify critical factors influencing the early outcomes of LTG. Of 1248 patients with resectable gastric cancer who underwent LG, 259 underwent LTG. Predictive risk factors were determined by analyzing relationships between clinical characteristics and postoperative complications. Major complications after LTG were analyzed in detail.ResultsMultivariate analysis of all LG procedures revealed LTG as a risk factor for complications. Morbidity in the LDG and LTG groups was 6.2xa0% (52 of 835 patients) and 22.4xa0% (58 of 259 patients), respectively. Major post-LTG complications included anastomotic leakages and pancreatic fistulae. The rate of anastomotic leakage was significantly higher in the LTG group (5.0xa0%) than in the LDG group (1.2xa0%); however, it showed a tendency to decrease in more recent cases. Pancreatic fistulae occurred frequently after LTG with D2 lymphadenectomy (LTG-D2), particularly in cases of concomitant pancreatosplenectomy. Obesity was also associated with pancreatic fistula formation after LTG with pancreatosplenectomy.ConclusionsCompared with LDG, LTG is a developing procedure. Advances in the surgical techniques associated with the LTG procedure will improve the short-term outcomes of esophagojejunostomy. With regard to LTG-D2, establishing optimal and safe #10 node dissection is one of the most urgent issues. Pancreatic fistula after LTG with pancreatosplenectomy must be investigated in the future.

Esophagogastric tube reconstruction with stapled pseudo-fornix in laparoscopic proximal gastrectomy: a novel technique proposed for Siewert type II tumors

PurposeThe incidence of adenocarcinoma of the esophagogastric junction is increasing, but laparoscopic proximal gastrectomy is not widely accepted due to the absence of a standardized technique of reconstruction. This report describes a novel technique of esophagogastric tube reconstruction in laparoscopic proximal gastrectomy for Siewert type II tumors.MethodsLaparoscopic proximal gastrectomy, sometimes with transhiatal distal esophagectomy, was performed. After a perigastric, suprapancreatic, and lower thoracic paraesophageal lymphadenectomy, a gastric tube of 35-mm width was prepared. An esophagogastric tube anastomosis with pseudo-fornix was made with a no-knife linear stapler to prevent postoperative reflux esophagitis.ResultsFifteen patients with Siewert type II tumors underwent this operation. They included six patients with early-stage cancer, six at high risk for transhiatal total gastrectomy due to several comorbidities, and three who needed palliative tumor resection. The mean operation time was 315xa0min. One postoperative anastomotic leak was treated conservatively, and three anastomotic stenoses were resolved with endoscopic balloon dilatation. Postoperative 1-year follow-up endoscopy revealed four cases of reflux esophagitis that were well controlled by medication.ConclusionsThis new technique of reconstruction was feasible. With the advantage of a gastric tube, a tension-free anastomosis was possible even for bulky tumors that needed lower esophagectomy. Although long-term follow-up and a larger number of patients are required to evaluate long-term functional outcomes and oncological adequacy, our procedure has the potential of becoming a treatment of choice for early-stage Siewert type II tumors and/or for some selected high-risk patients who need tumor resection.