Techniques and complications of laparoscopy-assisted distal gastrectomy (LADG) for gastric cancer.

AIM: Recently, LADG has become a viable alternative for the treatment of patients with early gastric cancer. Surgeons who are seeking to undertake, or currently practicing LADG, are concerned about unpredictable intraoperative events that occur during LADG. The aims of this study were to investigate intraoperative and postoperative complications in laparoscopy-assisted distal gastrectomy (LADG) with more than D1+beta lymphadenectomy for gastric cancer. MATERIALS AND METHODS: Of 219 patients who underwent laparoscopy-assisted gastrectomy for gastric cancer by a single surgeon between April 2003 and January 2006, 128 patients were enrolled in this study. The operative procedure was divided into five steps. Various intraoperative complications, such as bleeding and perigastric organ injuries, that occurred during different operative steps were investigated by reviewing videotapes. RESULTS: A total of 839 events of bleeding were encountered during the procedure with a mean of 6.6 per patient. The mean number of bleeding during each step was significantly different and more bleedings occurred during steps II and IV (P<0.0001). Sixteen cases of complications other than bleeding occurred in 15 patients (11.7%), and they were all managed properly without conversion or reoperation. Postoperative morbidity and mortality rates were 15.6 and 0.7%, respectively. CONCLUSION: LADG with more than D1+beta lymphadenectomy is a technically feasible and acceptable surgical modality for gastric cancer. Intraoperative bleeding was found to be the most common complication during LADG for gastric cancer, and more bleedings occurred during steps II and IV.

Laparoscopic wedge resection for gastric GIST: long-term follow-up results.

AIM: Gastrointestinal stromal tumor (GIST) is the most common mesenchymal neoplasm of the gastrointestinal tract. Recently, many investigations have been conducted on various aspects of laparoscopic surgery for gastric GIST. However, no study has provided long-term follow up results of laparoscopic surgery for gastric GIST. The aims of this study were to assess the feasibility and safety of laparoscopic surgery for gastric GIST and to evaluate the oncologic validity of the procedure. MATERIALS AND METHODS: Between January 1998 and August 2005, 51 patients with submucosal tumor of the stomach were treated by laparoscopic surgery at our institution. Of 51 patients, 23 patients were confirmed as gastric GIST by immunohistochemistry (CD 117, c-kit gene product). Patients' clinicopathologic characteristics, operative outcomes, postoperative complications, and follow-up findings were analyzed retrospectively. RESULTS: The mean age of patients was 59.7 years, and 12 patients were women. Twelve patients (47%) presented with epigastric pain. The mean tumor size was 4.2+/-2.1 cm, and most tumors were located in the upper stomach (52.2%). The mean operative time was 104.3 min. No case of open conversion, reoperation and operative mortality occurred in the present study. Most patients had very low and low risk (60.6%), while only two patients had high risk malignancy. During a median follow-up period of 61 months (range, 7-98 months), there have been no recurrences or metastases. CONCLUSION: Laparoscopic wedge resection for gastric GIST is safe, and oncologically and technically feasible in the hands of an experienced laparoscopic gastric surgeon.

Surgical outcome of laparoscopy-assisted gastrectomy with extraperigastric lymph node dissection for gastric cancer.

AIM: The aim of this study was to determine the feasibility of laparoscopy-assisted gastrectomy (LAG) with extraperigastric lymph node dissection for gastric cancer. METHODS: The authors attempted LAG with extraperigastric lymph node dissection in 117 consecutive gastric cancer patients between May 1998 and January 2004. The clinico-pathologic characteristics, operative outcomes, post-operative morbidities and mortalities, and follow-up findings of patients with advanced gastric cancer were evaluated. RESULTS: LAG with extraperigastric lymph node dissection were successfully performed in 114 of 117 patients (success rate, 97%). Of these 114 successful cases, 100 cases were early gastric cancers and 14 cases were advanced gastric cancers. The mean operation time for the 114 cases was 259 (range 150-415) min, and the mean number of retrieved lymph nodes was 23 (range 6-66). Operative mortality, hospital death, and overall post-operative complication rates were 0, 1.7 and 14.7%, respectively. Follow-up was available in 110 of the 112 patients (two post-operative hospital deaths were excluded from the 114). Follow-up ranged from 6 to 74 months (median: 19). 108 patients remain alive without recurrence or port-site metastasis. CONCLUSIONS: LAG with extraperigastric lymph node dissection is a technically feasible and acceptable method for the surgical treatment of gastric cancer.

The elderly liver transplant recipient: a call for caution.

OBJECTIVE: To determine whether liver transplantation is judicious in recipients older than 60 years of age. SUMMARY BACKGROUND DATA: The prevailing opinion among the transplant community remains that elderly recipients of liver allografts fare as well as their younger counterparts, but our results have in some cases been disappointing. This study was undertaken to review the results of liver transplants in the elderly in a large single-center setting. A secondary goal was to define, if possible, factors that could help the clinician in the prudent allocation of the donor liver. METHODS: A retrospective review of a prospectively maintained single-institution database of 1,446 consecutive liver transplant recipients was conducted. The 241 elderly patients (older than 60 years) were compared with their younger counterparts by preoperative laboratory values, illness severity, nutritional status, and donor age. Survival data were stratified and logistic regression analyses were conducted. RESULTS: Elderly patients with better-preserved hepatic synthetic function or with lower pretransplant serum bilirubin levels fared as well as younger patients. Elderly patients who had poor hepatic synthetic function or high bilirubin levels or who were admitted to the hospital had much lower survival rates than the sicker younger patients or the less-ill older patients. Recipient age 60 years or older, pretransplant hospital admission, and high bilirubin level were independent risk factors for poorer outcome. CONCLUSIONS: Low-risk elderly patients fare as well as younger patients after liver transplantation. However, unless results can be improved, high-risk patients older than 60 years should probably not undergo liver transplantation.

Tumor angiogenesis as a prognostic predictor in colorectal carcinoma with special reference to mode of metastasis and recurrence.

Tumor angiogenesis has proved to be a useful prognostic determinant for patients with various solid tumors. In this study, we investigated the quantitative expression of angiogenesis in colorectal carcinoma to determine how angiogenesis correlates with clinicopathologic factors and prognosis. One hundred twenty-seven specimens resected from patients with primary colorectal carcinoma were investigated immunohistochemically using a polyclonal antibody against factor-VIII-related antigen, and areas with the highest vascular density at the invasive tumor margin were counted at 200 times magnification. The microvessel count, defined as angiogenesis density (AD), became significantly higher with increase in histologic grade (p = 0.02) and Dukes stage (p = 0.001). AD was also significantly higher in patients with lymph node metastasis (p = 0. 005), lymphatic invasion (p = 0.042), vascular invasion (p < 0.001), and liver metastasis (p = 0.0004) than in those without. In addition, patients with synchronous distant hematogenous metastasis in stage D disease showed significantly higher AD than patients with nonhematogenous metastasis (p = 0.006). When 27 cases of disease recurrence after surgical resection with curative intent were stratified according to mode of spread, AD in cases with a hematogenous pattern of relapse proved to be significantly higher than in cases with nonhematogenous spread (p < 0.001). No significant differences were, however, found in AD when they were subdivided as to operative nodal status (p = 0.39 and 0.08 in the node-negative and the node-positive group, respectively). Multivariate analysis indicated that AD was an independent prognostic factor (p = 0.0004) in colorectal carcinoma. Quantitative evaluation of tumor angiogenesis at the invasive tumor margin is suggested to be a good prognostic indicator and a useful predictor for hematogenous spread and recurrence in patients with colorectal carcinoma.

Intestinal anastomosis by use of the biofragmentable anastomotic ring: is it safe and efficacious in emergency operations as well?

PURPOSE: Although sutureless anastomosis by use of the biofragmentable anastomotic ring is now accepted as an alternative to conventional manual sutured or stapled methods in elective enterocolic surgery, its applicability to emergency enterocolic surgery has not yet been established. The aim of this prospective study was to determine whether the biofragmentable anastomotic ring anastomosis in emergency enterocolic surgery could be performed as safely as in elective surgery or as emergency handsewn anastomosis. METHODS: To evaluate the safety and efficacy of sutureless bowel anastomosis by use of the biofragmentable anastomotic ring in emergency enterocolic surgery, a prospective, randomized study was undertaken to compare the biofragmentable anastomotic ring with conventional handsewn anastomotic technique. One hundred nineteen patients who required emergency laparotomy were randomly assigned to two groups: 56 patients (47 percent) underwent 58 biofragmentable anastomotic ring anastomoses, and 63 patients (53 percent) underwent 65 sutured anastomoses. In addition, the safety and efficacy of the biofragmentable anastomotic ring in emergency surgery were compared with those of the biofragmentable anastomotic ring in 86 elective biofragmentable anastomotic ring anastomoses performed in 84 patients during the same period of time. RESULTS: Specific intraoperative complications related to use of biofragmentable anastomotic rings occurred in six patients (10.7 percent), and another new biofragmentable anastomotic ring anastomosis was constructed in one patient. These reflected learning-curve errors, but they did not adversely affect the outcome. No statistical differences were observed among the groups with respect to wound complications, postoperative bleeding, intra-abdominal abscess, intestinal obstruction, or postoperative death. As for anastomotic leakage, six patients, two in each group, had complications of anastomotic failure, wherein four colonic fistulas required a diversion and two enteric fistulas closed spontaneously. Although there were no statistically significant differences in incidence of leaks among groups (P = 0.4522), two fistulas in colocolic anastomoses, one in the suture group and the other in the biofragmentable anastomotic ring group, manifested the risk of primary anastomosis in emergency colon resection. Seven patients, three in the elective biofragmentable anastomotic ring group and two each in the emergency suture and biofragmentable anastomotic ring groups, died after the operation, but no deaths were directly attributed to the anastomotic technique used. CONCLUSION: The data suggest that the biofragmentable anastomotic ring is a safe and reliable alternative to conventional handsewn anastomosis in emergency enterocolic surgery, where the rapidity and security of anastomosis may be critical. Consideration, however, should be given to emergency primary colocolic or colorectal anastomosis, because of a high risk of anastomotic failure, although there are too few cases for a definite conclusion.