Postoperative Complications of Laparoscopy-assisted Gastrectomy in Early Gastric Cancer: The Importance of Precise Preoperative Staging

PURPOSE: Although laparoscopy-assisted gastrectomy (LAG) has become a popular treatment option for early gastric cancer, information about postoperative complications is limited in the literature and their risk factors vary among investigators. We analyzed the complications and their risk factors of LAG. METHODS: We performed LAGs in 92 gastric cancer patients from July 2006 to December 2009. LAG indication was gastric cancer preoperatively diagnosed as cT1N0. Clinical and operative data and perioperative complications were retrospectively reviewed. According to the surgical experience, cases were divided into early (1~40) and late (41~92) groups because operative times stabilized after the 40th case. RESULTS: There were no open conversion or mortality cases. Complications occurred in 11 patients. Two of them were non-surgical complications: postoperative delirium and cerebral infarction. Surgical complications were ischemic necrosis of transverse colon, duodenal stump leakage, anastomotic bleeding, leakage and stenosis. Univariate analysis proved that lymph node metastasis, and comorbidities were related to complication rate (P=0.000, P=0.032). Multivariate analysis proved that lymph node metastasis was the most important risk factor of complication (P=0.001). Surgical experience was not related to complication rate (12.5% in early period and 11.5% in late period, P=1.000). CONCLUSION: Complication rate of LAG was acceptable (11.9%). According to this study, unexpected lymph node metastasis is thought to be the most important risk factor for complications of LAG. Therefore, it is possible to accomplish lower complication rates in this procedure with careful patient selection through accurate preoperative evaluation.

Omental Infarction Following Laparoscopy-assisted Gastrectomy (LAG) for Gastric Cancer

PURPOSE: Omental infarction (OI) following laparoscopy-assisted gastrectomy (LAG) for gastric cancer could become more common in the future because the indications for LAG are expected to expand. The aim of this study was to determine the clinical characteristics of OI following LAG. MATERIALS AND METHODS: Three hundred ninety patients who underwent LAG for T1 or T2 gastric cancer from April 2003 to November 2007 were enrolled. OI was diagnosed by two radiologists using the patients' abdominal 16 row-detector CT scans. The clinicopathologic characteristics were retrospectively evaluated in the omental infarction (OI) group and the non-omental infarction (non-OI) group using the gastric cancer database of Dong-A University Medical Center and the medical records. RESULTS: Nine omental infarctions (2.3%) of 390 LAGs were diagnosed. All the OIs could be discriminated from omental metastasis on the initial or follow up CT images. The location of the omental infarctions was on the epigastrium in 3 patients and in the left upper quadrant in 3 patients. The mean size of the OIs was 4.1 cm. Most patients with OI had no signs or symptoms. The body mass index of the OI group was higher than that of the non-OI group (P=0230), and OI was more common in patients who underwent total gastrectomy than in the patients who underwent subtotal gastrectomy (P=0.0011). CONCLUSION: Laparoscopy-assisted gastrectomy (LAG) with partial omentectomy for gastric cancer can be a cause of secondary OI. Omental infarction after LAG has different clinical characteristics and CT findings that those of other omental infarctions or postoperative omental metastases. Further multicenter study will be needed to evaluate in detail the clinical features of omental infarction after LAG.

The Learning Curve of Laparoscopy-assisted Distal Gastrectomy (LADG) for Cancer

PURPOSE: Laparoscopic surgery for gastric cancer was introduced in the past decade because it was considered less invasive than open surgery, and this results in less postoperative pain, faster recovery and an improved quality of life. Several studies have demonstrated the safety and feasibility of this procedure. We examined the outcome of performing laparoscopic surgery for gastric cancer over the last two year. MATERIALS AND METHODS: From April 2004 to December 2006, 329 patients with gastric adenocarcinoma underwent a laparoscopy-assisted distal gastrectomy with lymph node dissection. The data was retrospectively reviewed in terms of the clinicopathologic findings, the perioperative outcomes and the complications. RESULTS: The total patient group was comprised 196 men (59.6%) and 133 women (40.4%). The mean BMI was 23.6 and the mean tumor size was 2.7 cm. The mean number of harvested lymph node was 22.7, and this was 18.6 before 30 cases and 23.1 after 30 cases, and the difference was significant (P=0.02). The mean operation time was 180.9 min, and this was than 287.9 min before 30 cases and 170.2 min after 30 cases. After 30 cases, there was a significant improvement of the operation time (P<0.01). The mean incision length after 30 cases was shorter than that before 30 cases (P<0.01). Postoperative complications occurred in 24 (7.3%) of 329 patients and there was no conversion to open surgery. CONCLUSION: Even though the LADG was accompanied by a difficult learning curve, we successfully performed 329 LADG procedures over the past 2 years and we believe that LADG is a safe, feasible operation for treating most early gastric cancers (EGC).

Short-term Surgical Outcomes after Laparoscopic D2 Lymphadenectomy in Patients with Distal Gastric Cancer

PURPOSE: With advancements in laparoscopic surgery, there have been efforts to expand the indication for laparoscopic surgery up to advanced gastric cancer. However, scant data are available regarding the feasibility and advantages of laparoscopy-assisted distal gastrectomy (LADG) with standard radical D2 lymph node dissection. MATERIALS AND METHODS: Twenty-two patients who were preoperatively diagnosed with cT1N0M0 gastric cancer underwent LADG with standard D2 lymphadenectomy between February and August 2007. They were compared with patients who underwent conventional open D2 lymphadenectomy with respect to clinicopathologic features, surgical outcomes, and postoperative course. RESULTS: The mean operative time was significantly longer in the LADG group than in the open group (160+/-25 min vs. 135+/-21 min, P<0.001). However, surgical outcomes, such as surgical margin and number of retrieved lymph nodes (25.7+/-11.1 vs. 26.9+/-9.2, P=ns) were comparable between the groups. The LADG group exhibited quicker postoperative recovery, and both groups exhibited similar postoperative morbidity and mortality. CONCLUSION: LADG with D2 lymphadenectomy is feasible and safe, with short-term surgical outcomes comparable to those seen in open D2 lymphadenectomy. Further prospective clinical investigation will be needed to better evaluate the advantages of LADG with D2 lymphadenectomy.

Intraoperative Complications in Laparoscopy- assisted Distal Gastrectomy (LADG) for Gastric Cancer

PURPOSE: A laparoscopy-assisted distal gastrectomy (LADG) has recently become a viable alternative for the treatment of patients with early gastric cancer. Surgeons seeking to undertake, or currently practicing LADG, are concerned about the unpredictable intraoperative events that occur during a LADG. However, little information exists on the intraoperative complications during a LADG. The aims of this study were to investigate the intraoperative complications and identify the factors predictive of intraoperative bleeding during a laparoscopy-assisted distal gastrectomy (LADG), with a lymphadenectomy for gastric cancer greater than D1+beta. METHODS: Of the 219 patients, who underwent a laparoscopy- assisted gastrectomy for gastric cancer by a single surgeon, between April 2003 and January 2006, 128 were enrolled in this study. The operative procedure was divided into 5 steps. Various intraoperative complications, such as bleeding and perigastric organ injuries, occurring during the different operative steps were investigated by reviewing videotapes of the procedures. RESULTS: A total of 839 bleeding events were encountered during the procedure, with a mean of 6.6 per patient. The mean numbers of bleeding events during each step were significantly different, with greater numbers occurring during steps II and IV (P < 0.0001). A multiple logistical regression analysis identified male gender (P=0.002, odds ratio 3.870) and a higher body mass index (P=0.038, odds ratio 1.158) as independent predictors of higher intraoperative bleeding rates. CONCLUSION: Intraoperative bleeding was found to be the most common complication during a LADG for gastric cancer, with greater numbers of bleeding events occurring during steps II and IV. Gender and body mass index were independent covariates associated with the development of intraoperative bleeding during a LADG.

Laparoscopy Assisted Distal Subtotal Gastrectomy with Lymphadenectomy - 202 Consecutive Cases

PURPOSE: The number of laparoscopy-assisted distal gastrectomy procedures for the treatment of early gastric cancer patient to improve the quality of life has been gradually increasing. This study evaluated the technical feasibility, safety, and surgical results of LADG with lymphadenectomy by reviewing the initial experience. METHODS: From May 2003 to December 2005, 202 LADG with lymphadenectomy were performed on patients with a preoperative diagnosis of EGC. The clinicopathological features and surgical outcomes were analyzed. RESULTS: There were 128 males and 74 females with a mean age of 58 years (range 24~78). The mean operation time was 212 minutes (range 105~450) and the operation time has decreased gradually with increasing number of cases. There were 16 operative morbidities (7.9%) including three operative mortalities. The restoration of the bowel sound was noted at 3.1 postoperative days, soft diet was started at 4.4 postoperative days and the duration of the hospital stay was 7.7 days. There were 105 mucosal, 64 submucosal, 22 proper muscle, 4 subserosal and 7 serosal lesions. A total 163 patients were treated with D2, 37 with D1+beta and 2 with D1+alpha LN dissection. The mean number of lymph nodes retrieved was 35 (range=10~81). Lymph node metastasis was noted in 30 patients. CONCLUSION: This study shows that laparoscopic procedure can be applied safely and effectively for the patients with EGC. However, a prospective study comparing laparoscopy-assisted versus open gastrectomy for the short- and long-term surgical outcomes is needed.

Operative Outcome of Laparoscopy-assisted Gastrectomy with Lymph Node Dissection in 117 Consecutive Patients with Gastric Cancer: A Single-center Experience

PURPOSE: The aim of this study was to determine the feasibility and safety of laparoscopy-assisted gastrectomy (LAG) with lymph node dissection for gastric cancer according to the analysis of postoperative complications. METHODS: The authors attempted LAG with lymph node dissection in 117 consecutive patients with gastric cancer. The clinicopathologic characteristics of the patients, operative outcomes, preoperative comorbidities and postoperative morbidities and mortalities were evaluated using the stomach cancer database of Dong-A university hospital and medical charts. RESULTS: Among the 114 successful patients, 100 had early gastric cancer and 14 had advanced gastric cancer. The mean operation time was 259.2 minutes (range 150~415). The mean number of retrieved lymph nodes was 23.4 (range 6~66). The mean time to the first flatus and postoperative hospital stay were 3.7 and 10.0 days, respectively. The overall operative mortality rate, hospital death rate and the overall rate of postoperative complications were 0, 1.7 and 14.7%, respectively. The major and minor complication rate were 4.3 and 10.4%, respectively. CONCLUSION: LAG with lymph node dissection is technically feasible and receptive as surgical treatment for patients with gastric cancer, although various postoperative complications can arise in LAG as they do in open gastrectomy.

Laparoscopy-assisted Billroth I Gastrectomy Compared with Open Gastrectomy

PURPOSE: To compare laparoscopy-assisted Billroth I gastrectomy (LABIG) including standard lymph node dissection for patients with early gastric cancer was compared with open gastrectomy as a treatment method. METHODS: A prospective nonrandomized study was performed of early gastric cancer patients at Ewha Womans University Mok-Dong hospital from July 1999 to May 2001. Twenty patients (Group L) underwent LABIG including standard lymph node dissection. The control group (Group O) comprised 14 patients with conventional open radical subtotal gastrectomy and Billroth I anastomosis. RESULTS: In group L, pathologic reports revealed 18 early gastric cancers (stage IA 17 cases, IB 1 case), and 2 pm cancers (stage IB 1 case, stage II 1 case). In group O, there were 13 early gastric cancers (stage IA 12 cases, IB 1 case), and 1 pm cancer (stage IB). Significant differences (p<0.05) were present between group L and O in regards to mean operation time (277.5 vs 215.0 minutes), proximal margin (4.8 vs 7.0 cm), distal margin (4.4 vs 3.9 cm), number of harvested lymph nodes (25.6 vs 37.9), frequencies for pain control (7.2 vs 11.0 times), wound size (7.6 vs 20.0 cm) and postoperative hospital stay (13.7 vs 21.9 days). There were no differences in blood loss, transfusion, leukocyte count, time to diet, serum protein, or weight loss. Complications were seen in 2 cases in group L (enterocutaneous fistula, gastric atony), and 2 cases in group O (gastric atony, marginal ulcer with bleeding). CONCLUSION: LABIG with standard lymph node dissections is a safe and useful technique for the treatment of early gastric cancer with improved postoperative recovery as compared to open conventional gastrectomy.