Takaya Tokuhara

Long-Term Oncologic Outcomes from Laparoscopic Gastrectomy for Gastric Cancer: A Single-Center Experience of 601 Consecutive Resections

BACKGROUND Laparoscopic gastrectomy (LG) is becoming increasingly popular for management of early gastric cancer (EGC). Although short-term efficacy is proven, reports on long-term effectiveness are still infrequent. STUDY DESIGN All patients with a diagnosis of gastric cancer undergoing LG from the beginning of our laparoscopic experience were included in the analysis. At our unit, LG is indicated for all cancers up to preoperative stage T2N1. RESULTS Six-hundred and one laparoscopic resections were included in the analysis. There were 392 men and 209 women. Mean age was 64.2 +/- 10.9 years. Distal gastrectomy was performed in 305 patients, pylorus-preserving gastrectomy in 148, segmental gastrectomy in 42, proximal gastrectomy in 53, total gastrectomy in 27, and wedge resection in 26. Histological staging revealed that 478 patients had stage IA disease, 47 had stage IB, 44 had stage IIA, 19 had stage IIB, 8 had stage IIIA, 3 had stage IIIB, and 2 had stage IIIC. Morbidity and mortality rates were 17.6% and 0.3%, respectively. Median follow-up was 35.9 months (range 3 to 113 months). Cancer recurrence occurred in 15 patients and metachronous gastric remnant cancer was detected in 6 patients. The 5-year overall and disease-free survival rates were 94.2% and 89.9%, respectively, for stage IA tumors, 87.4% and 82.7% for stage IB, 80.8% and 70.7% for stage IIA, and 69.6% and 63.1% for stage IIB. CONCLUSIONS In our experience, long-term oncological outcomes from LG for EGC are acceptable. Wherever expertise permits, LG should be considered as the primary treatment in patients with EGC.

Surgical outcomes from laparoscopic distal gastrectomy and Roux-en-Y reconstruction: evolution in a totally intracorporeal technique.

Introduction Laparoscopic gastrectomy is gaining popularity. Increasingly, Roux-en-Y reconstruction after distal gastrectomy is preferred because of reduced reflux and associated symptoms. Therefore, efficient and reliable techniques for intracorporeal Roux-en-Y reconstruction are in demand. Aims To determine the surgical outcomes from laparoscopic distal gastrectomy and Roux-en-Y reconstruction in the treatment of gastric cancer. Patients and Methods Laparoscopic gastrectomy is indicated for gastric cancer up to stage T1N1. Our technique for laparoscopic Roux-en-Y reconstruction incorporates intracorporeal-stapled gastrojejunostomy with extracorporeal hand-sewn jejunojejunostomy, or more recently, totally intracorporeal reconstruction. Results From 2003 to 2009, 82 patients underwent laparoscopic distal gastrectomy with Roux-en-Y reconstruction. The mean age of the patients was 64.6 years (range, 39 to 83 y) and the male:female ratio was 2.4:1. Most patients (85%) had stage I disease. The mean operation time was 354 minutes (SD 82.7). The conversion rate was 0%. The mean lymph node yield was 27.2 nodes (SD 12.4). Eleven patients had totally intracorporeal reconstruction. Overall, anastomotic leakage of the gastrojejunostomy occurred in 2 patients (2.4%) both requiring reoperation. There were 2 cases (2.4%) of duodenal stump leakage, which were treated conservatively. Postoperative stasis was encountered in 2 patients (2.4%). The mean follow-up was 21 months (range, 5 to 50 mo). None of the patients developed reflux symptoms or endoscopic evidence of reflux during follow-up. Recurrence occurred in 1 patient who was the only patient with metastasis to the third tier of lymph nodes. Conclusions Surgical outcomes from laparoscopic distal gastrectomy and Roux-en-Y reconstruction were acceptable in the context of early gastric cancer. Totally intracorporeal reconstruction was technically feasible, safe, and associated with no obvious drawbacks.

Intracorporeal stapled anastomosis following laparoscopic segmental gastrectomy for gastric cancer: technical report and surgical outcomes

BackgroundLimited gastrectomy for early gastric body cancers can offer a better functional outcome by preserving more remnant stomach. Intracorporeal stapled techniques result in cosmesis and avoid awkward anastomosis through a minilaparotomy.MethodsLaparoscopic segmental gastrectomy is indicated for early gastric cancers of the body of the stomach with no evidence of lymph node involvement. Laparoscopic pylorus-preserving gastrectomy is a specific type of segmental resection for lower-body lesions with dissection of lymph nodes in station 6. Intracorporeal gastrogastric anastomosis is performed by the delta-shaped technique using linear staplers.ResultsSince January 2008 we have performed 12 laparoscopic pylorus-preserving gastrectomies and 13 laparoscopic segmental gastrectomies. All procedures were completed by laparoscopy. One patient with minor anastomotic leakage was managed conservatively. Bleeding from the anastomosis was not encountered in any of the patients. One patient developed narrowing at the anastomotic site and was treated successfully by balloon dilatation. There was no stasis encountered in any of the patients.ConclusionsLaparoscopic segmental gastrectomy with acceptable surgical outcomes is technically feasible. Although the impact of such resections on oncological outcomes remains to be further evaluated, laparoscopic segmental gastrectomy represents a minimally invasive limited resection that maximizes the potential for a better quality of life following gastric cancer surgery.

Laparoscopic Technique and Initial Experience with Knotless, Unidirectional Barbed Suture Closure for Staple-Conserving, Delta-Shaped Gastroduodenostomy after Distal Gastrectomy

a a c h Since laparoscopy-assisted distal gastrectomy was first reported by Kitano and colleagues in 1994, laparoscopic gastrectomy (LG) for early gastric cancer (EGC) has been increasing rapidly and gaining popularity worldwide because it is associated with earlier patient recovery compared with open surgery. Improvements in instruments and aparoscopic technique have allowed for widespread accepance of LG, not only for various types of gastric resection ut also for totally laparoscopic procedures. In general, LG can be divided into laparoscopy-assisted and totally laparoscopic techniques. With laparoscopyassisted gastrectomy, although lymph node dissection is performed laparoscopically, transection of the stomach and the anastomosis are performed thorough an epigastric minilaparotomy. Performing the anastomosis in the narrow and restricted space is frequently difficult, especially for obese patients with thick abdominal walls or for patients with a small remnant stomach. Avoiding minilaparotomy also improves cosmesis, and performing all of the processes laparoscopically, including reconstruction of the digestive tract intracorporeally using laparoscopic linear stapling devices, offers the prospect of further improvements in quality of life. Recent results of retrospective studies have demonstrated the feasibility, safety, and efficiency of totally laparoscopic gastrectomy (TLG) when performed by high-volume laparoscopic surgeons, even with a relatively prolonged operating time. However, TLG as the disadvantages of technical difficulties in intracor-

Benefits of intracorporeal gastrointestinal anastomosis following laparoscopic distal gastrectomy

BackgroundLaparoscopic gastrectomy has recently been gaining popularity as a treatment for cancer; however, little is known about the benefits of intracorporeal (IC) gastrointestinal anastomosis with pure laparoscopic distal gastrectomy (LDG) compared with extracorporeal (EC) anastomosis with laparoscopy-assisted distal gastrectomy (LADG).MethodsBetween June 2000 and December 2011, we assessed 449 consecutive patients with early-stage gastric cancer who underwent LDG. The patients were classified into three groups according to the method of reconstruction LADG followed by EC hand-sewn anastomosis (LADG + EC) (n = 73), using any of three anastomosis methods (Billroth-I (B-I), Billroth-II (B-II) or Roux-en-Y (R-Y); LDG followed by IC B-I anastomosis (LDG + B-I) (n = 248); or LDG followed by IC R-Y anastomosis (LDG + R-Y) (n = 128)). The analyzed parameters included patient and tumor characteristics, operation details, and post-operative outcomes.ResultsThe tumor location was significantly more proximal in the LDG + R-Y group than in the LDG + B-I group (P < 0.01). Mean operation time, intra-operative blood loss, and the length of post-operative hospital stay were all shortest in the LDG + B-I group (P < 0.05). Regarding post-operative morbidities, anastomosis-related complications occurred significantly less frequently in with the LDG + B-I group than in the LADG + EC group (P < 0.01), whereas there were no differences in the other parameters of patients’ characteristics.ConclusionsIntracorporeal mechanical anastomosis by either the B-I or R-Y method following LDG has several advantages over at the LADG + EC, including small wound size, reduced invasiveness, and safe anastomosis. Although additional randomized control studies are warranted to confirm these findings, we consider that pure LDG is a useful technique for patients with early gastric cancer.

Evaluation of lymph node metastases in gastric cancer using magnetic resonance imaging with ultrasmall superparamagnetic iron oxide (USPIO): diagnostic performance in post-contrast images using new diagnostic criteria

BackgroundWe assessed the value of magnetic resonance imaging (MRI), using ultrasmall superparamagnetic iron oxide (USPIO) with new diagnostic criteria, in the evaluation of regional lymph node metastases in gastric cancer.MethodsThirty-one patients with gastric cancer were enrolled. 1000 lymph nodes were dissected during surgery, and of these, 519 nodes (51.9 %) were identified by currently used MRI imaging analysis. We evaluated lymph nodes on USPIO-post-contrast T2*-weighted images using the following two criteria: (1) we diagnosed the nodes on T2*-weighted images according to conventional criteria, where a node having an overall low signal intensity (pattern A) was nonmetastatic, while a node having partial (pattern B) or overall (pattern C) high signal intensity was metastatic; (2) we subdivided pattern B nodes on T1-weighted images using the new criteria, in which a node for which the high-intensity area on T2*-weighted images was not defined as adipose tissue on T1-weighted images (pattern B1) was metastatic, while a node for which the high-intensity area was defined as adipose tissue (pattern B2) was nonmetastatic.Results(1) The results using the conventional criteria were 96.2% sensitivity, 92.5% specificity, 76.3% positive predictive value (PPV), 99.0% negative predictive value (NPV), and 93.3% accuracy. (2) The results using the new criteria were 96.2% sensitivity, 98.3% specificity, 90.1% PPV, 99.0% NPV, and 97.1% accuracy.ConclusionThe assessment of lymph node metastases from USPIO-post-contrast MRI alone using the new criteria was useful in the diagnosis of regional lymph node metastases in gastric cancer.

Functional Outcomes According to the Size of the Gastric Remnant and the Type of Reconstruction Following Distal Gastrectomy for Gastric Cancer: An Investigation Including Total Gastrectomy

OBJECTIVE In gastric cancer, various methods of gastric resection have been devised according to the location of the primary tumor and the depth of invasion. Functional outcomes were compared among different types of reconstruction following open 2/3- or 4/5 distal gastrectomy for gastric cancer. METHODS Resection and reconstruction were performed by one of the following three methods, depending on the depth of cancer invasion and the date of the procedure relative to the introduction of Roux-en-Y reconstruction: distal 2/3 gastrectomy with Roux-en-Y reconstruction (1/3 Roux-en-Y, n = 30); distal 4/5 gastrectomy with Roux-en-Y reconstruction (1/5 Roux-en-Y, n = 15) and distal 2/3 gastrectomy with Billroth I reconstruction (1/3B1, n = 30). Open total gastrectomy with Roux-en-Y reconstruction (total gastrectomy with RY reconstruction, n = 30) was taken as the control procedure. RESULTS Comparison of postoperative/preoperative body weight ratios and food intake ratios revealed better preservation among patients with a larger remnant stomach (the 1/3 Roux-en-Y and 1/3B1 groups), regardless of the reconstruction. The gastric emptying pattern in larger remnant stomach groups was milder than in the 1/5 Roux-en-Y and total gastrectomy with RY reconstruction groups. Reflux esophagitis was often observed on endoscopy in the 1/3B1 group. CONCLUSIONS Better functional outcomes were observed in patients with a large remnant stomach regardless of the reconstruction.

Laparoscopic gastrointestinal anastomoses using knotless barbed absorbable sutures are safe and reproducible: a single-center experience with 242 patients

OBJECTIVE Intracorporeal reconstruction of the digestive tract is technically challenging. The V-Loc 180 wound closure device (Covidien) is a self-anchoring unidirectional barbed suture that obviates the need for knot tying. The aim of this prospective cohort study was to investigate the use of the novel suture in gastrointestinal enterotomy closure. METHODS The subjects comprised patients with malignant disease who were scheduled to undergo laparoscopic gastrectomy with curative intent. The barbed suture was used to close the entry hole for the linear stapler during intracorporeal reconstruction following laparoscopic gastric resection. The primary endpoint was the proportion of patients who developed anastomotic leakage at the site where the barbed suture was applied. RESULTS Between July 2012 and March 2015, 242 patients were enrolled. Of 362 anastomoses, the enterotomy hole at 256 sites was closed using the barbed suture. These 256 sites consisted of 95 gastroduodenostomies, 25 gastrogastrostomies, 13 gastrojejunostomies, 90 jejunojejunostomies, 17 esophagojejunostomies and 16 primary closures of the stomach following local gastric resection. There were no anastomosis-related complications, conversion to usual sutures, mechanical closure of the entry hole and reoperation due to adhesive obstructions or mortality over a median follow-up period of 17.8 months. CONCLUSIONS The use of the unidirectional barbed absorbable suture for gastrointestinal closure is safe and effective in laparoscopic gastrectomy.

Comparative analysis of station-specific lymph node yield in laparoscopic and open distal gastrectomy for early gastric cancer.

Background: Randomized trials and cohort studies show that laparoscopic distal gastrectomy (LDG) achieves similar oncological results to open distal gastrectomy (ODG). However, studies have consistently demonstrated lower lymph node yield (LNY) for laparoscopic lymphadenectomy. Analysis of station-specific LNY may be useful in evaluating the reasons behind this difference. Objectives: Comparison of station-specific LNY, surgical, and oncological outcomes between LDG and ODG for early gastric cancer. Methods: Patients who underwent R0 distal gastrectomy with histologically confirmed early gastric cancer were eligible for the study. All consecutive cases of LDG since the beginning of our experience with laparoscopic gastrectomy and synchronous cases of ODG with R0 resection were included in the study. Demographic, operative, histopathologic, and follow-up data were recorded in all patients. Results: A total of 259 cases of LDG and 95 cases of ODG were performed between 2000 and 2009. Patients undergoing LDG had longer operations but less bleeding (P<0.05). Postoperative complications were similar in both groups. The preoperatively planned extent of lymphadenectomy was D1 (stations 1, 3, 4sb, 4d, 5, 6, and 7), D1+ (D1with stations 8a and 9), or D2 (D1+ with stations 11p and 12a). During surgery, dissection of stations 3, 4d, 5, 6, and 7 was performed in all cases of LDG and ODG. Dissection of stations 1, 4sb, 8a, 9, 11p, and 12a was performed more frequently during ODG than during LDG. Consequently, the total LNY was 26.71 and 31.43 for LDG and ODG, respectively. Station-specific LNY was significantly lower for LDG than for ODG in the common hepatic artery nodes only (P<0.05). The mean follow-up was 43.6 months. Lymph node metastases, metastatic-to-resected lymph node ratio, recurrence, and cancer-related deaths were similar for LDG and ODG. Conclusions: LDG was associated with less extensive lymph node dissection compared with ODG. Station-specific LNY was similar in all nodal stations except for the common hepatic artery nodes. In our experience, laparoscopic sub-D2 lymphadenectomy was adequate in the context of early gastric cancer and represents the future of gastric cancer resection in Japan.

V-shaped lymph node dissection in laparoscopic distal gastrectomy; new technique of intra-abdominal dissection and surgical outcomes

BackgroundRecently, laparoscopic-assisted distal gastrectomy (LADG) has become popular for the treatment of early gastric cancer. Furthermore, the use of totally laparoscopic gastrectomy (TLG), a more difficult procedure than LADG, has been increasing in Japan. Laparoscopic-assisted distal gastrectomy is currently performed more frequently than laparoscopic distal gastrectomy (LDG) in hospitals in Japan.MethodReconstruction after LDG is commonly performed extra-abdominally and lymph node dissection of the lesser curvature is performed at the same time. We have developed a new method of intra-abdominal lymph node dissection for the lesser curvature.ResultsOur technique showed positive results, is easy to perform, and is reasonable in terms of general oncology theory.ConclusionIn oncological therapy, this technique could be a valuable surgical option for totally laparoscopic surgery.