Comparison efficacy and safety of total laparoscopic gastrectomy and laparoscopically assisted total gastrectomy in treatment of gastric cancer.

BACKGROUND: The development of laparoscopic technology has provided a new choice for surgery of gastric cancer (GC), but the advantages and disadvantages of laparoscopic total gastrectomy (LTG) and laparoscopic-assisted total gastrectomy (LATG) in treatment effect and safety are still controversial. The purpose of this study is to compare the efficacy and safety of the two methods in the treatment of GC, and to provide a basis for clinical decision-making. AIM: To compare the efficacy of totally LTG (TLTG) and LATG in the context of radical gastrectomy for GC. Additionally, we investigated the safety and feasibility of the total laparoscopic esophagojejunostomy technique. METHODS: Literature on comparative studies of the above two surgical methods for GC (TLTG group and LATG group) published before September 2022 were searched in the PubMed, Web of Science, Wanfang Database, CNKI, and other Chinese and English databases. In addition, the following search keywords were used: Gastric cancer, total gastrectomy, total laparoscopy, laparoscopy-assisted, esophagojejunal anastomosis, gastric/stomach cancer, total gastrectomy, totally/completely laparoscopic, laparoscopic assisted/laparoscopy assisted/laparoscopically assisted, and esophagojejunostomy/esophagojejunal anastomosis. Review Manager 5.3 software was used for the meta-analysis after two researchers independently screened the literature, extracted the data, and evaluated the risk of bias in the included studies. RESULTS: After layer-by-layer screening, 258 pieces of literature were recovered, and 11 of those pieces were eventually included. This resulted in a sample size of 2421 instances, with 1115 cases falling into the TLTG group and 1306 cases into the LATG group. Age or sex differences between the two groups were not statistically significant, according to the meta-analysis, however the average body mass index of the TLTG group was considerably higher than that of the LATG group (P = 0.01). Compared with those in the LATG group, the incision length in the TLTG group was significantly shorter (P < 0.001), the amount of intraoperative blood loss was significantly lower (P = 0.003), the number of lymph nodes removed was significantly greater (P = 0.04), and the time of first postoperative feeding and postoperative hospitalization were also significantly shorter (P = 0.03 and 0.02, respectively). There were no significant differences in tumor size, length of proximal incisal margin, total operation time, anastomotic time, postoperative pain score, postoperative anal exhaust time, postoperative anastomosis-related complications (including anastomotic fistula, anastomotic stenosis, and anastomotic hemorrhage), or overall postoperative complication rate (P > 0.05). CONCLUSION: TLTG and esophagojejunostomy are safe and feasible. Compared with LATG, TLTG has the advantages of less trauma, less bleeding, easier access to lymph nodes, and faster postoperative recovery, and TLTG is also suitable for obese patients.

Perioperative outcomes of transvaginal specimen extraction laparoscopic total gastrectomy and conventional laparoscopic-assisted total gastrectomy.

BACKGROUND: Natural orifice specimen extraction surgery (NOSES) has emerged as a promising alternative compared to conventional laparoscopic-assisted total gastrectomy (LATG) for treating gastric cancer (GC). However, evidence regarding the efficacy and safety of NOSES for GC surgery is limited. This study aimed to compare the safety and feasibility, in addition to postoperative complications of NOSES and LATG. AIM: To discuss the postoperative effects of two different surgical methods in patients with GC. METHODS: Dual circular staplers were used in Roux-en-Y digestive tract reconstruction for transvaginal specimen extraction LATG, and its outcomes were compared with LATG in a cohort of 51 GC patients with tumor size ≤ 5 cm. The study was conducted from May 2018 to September 2020, and patients were categorized into the NOSES group (n = 22) and LATG group (n = 29). Perioperative parameters were compared and analyzed, including patient and tumor characteristics, postoperative outcomes, and anastomosis-related complications, postoperative hospital stay, the length of abdominal incision, difference in tumor type, postoperative complications, and postoperative survival. RESULTS: Postoperative exhaust time, operation duration, mean postoperative hospital stay, length of abdominal incision, number of specific staplers used, and Brief Illness Perception Questionnaire score were significant in both groups (P < 0.01). In the NOSES group, the postoperative time to first flatus, mean postoperative hospital stay, and length of abdominal incision were significantly shorter than those in the LATG group. Patients in the NOSES group had faster postoperative recovery, and achieved abdominal minimally invasive incision that met aesthetic requirements. There were no significant differences in gender, age, tumor type, postoperative complications, and postoperative survival between the two groups. CONCLUSION: The application of dual circular staplers in Roux-en-Y digestive tract reconstruction combined with NOSES gastrectomy is safe and convenient. This approach offers better short-term outcomes compared to LATG, while long-term survival rates are comparable to those of conventional laparoscopic surgery.

Proximal Gastrectomy is Associated with Lower Incidence of Anemia and Vitamin B12 Deficiency Compared to Total Gastrectomy in Patients with Upper Gastric Cancer.

Purpose: Proximal gastrectomy is an alternative to total gastrectomy (TG) for early gastric cancer (EGC) treatment in the upper stomach. However, its benefits in terms of perioperative and long-term outcomes remain controversial. The aim of this study was to compare the perioperative, body compositional, nutritional, and survival outcomes of patients undergoing proximal gastrectomy with double-tract reconstruction (PG-DTR) and TG for pathological stage I gastric cancer in upper stomach. Materials and Methods: The study included 506 patients who underwent gastrectomy for pathological stage I gastric cancer in the upper stomach between 2015 and 2019. Clinicopathological, perioperative, body compositional, nutritional, and survival outcomes were compared between the PG-DTR and TG groups. Results: The PG-DTR and TG groups included 197 (38.9%) and 309 (61.1%) patients, respectively. The PG-DTR group had a lower rate of early complications (p=0.041), lower diagnosis rate of anemia and vitamin B12 deficiency (all p<0.001), and lower replacement rate of iron and vitamin B12 compared to TG group (all p<0.001). The PG-DTR group showed reduced incidence of sarcopenia at 6-months postoperatively, preserved higher amount of visceral fat after surgery (p=0.032 and p=0.040, respectively), and showed a higher hemoglobin level (p=0.007). Oncologic outcomes were comparable between the groups. Conclusion: The PG-DTR for EGC located in the upper stomach offered advantages of fewer complications, lower incidence of anemia and vitamin B12 deficiency, less decrease in visceral fat volume, and similar survival compared to TG. Consequently, PG-DTR may be considered a superior alternative treatment option to TG.

Massive Gastric Juvenile Polyposis Associated With Intermittent Gastric Outlet Obstruction: A Case Report.

Juvenile polyposis syndrome is a condition distinguished by numerous hyperproliferative polyps that can affect the entire gastrointestinal tract, though they are uncommon in the stomach. We report a rare case of a 70-year-old woman with a three-year history of epigastric pain and severe bloating who was referred to our department for gastric outlet obstruction due to massive gastric juvenile polyps also causing gastroparesis. The patient was successfully treated with a total gastrectomy.

Risk factors of postoperative complications and their effect on survival after laparoscopic gastrectomy for gastric cancer.

Background: The association between postoperative complications and long-term survival after laparoscopic gastrectomy (LG) for gastric cancer (GC) remains uncertain. This study aimed to determine the incidence and risk factors of postoperative complications and evaluate their impact on survival outcomes in patients undergoing LG. Methods: A retrospective study was conducted on 621 patients who underwent LG for gastric adenocarcinoma between March 2015 and December 2021. Postoperative complications were classified according to the Clavien-Dindo classification, with major complications defined as Grade III or higher. Logistic regression models with stepwise backward procedure were used to identify risk factors for complications. To assess the impact of postoperative complications on survival, uni- and multi-variable Cox proportional hazard models were used for overall survival (OS) and disease-free survival (DFS). Results: Overall rate of postoperative complications was 17.6% (109 patients); 33 patients (5.3%) had major complications. Independent risk factors for major complications were Charlson comorbidities index (OR [95% CI], 1.87 [1.09-3.12], p-value = 0.018 for each one score increase), and type of anastomosis (OR [95% CI], 0.28 [0.09-0.91], p-value = 0.029 when comparing Billroth II with Billroth I). Multivariable analysis identified major complications as an independent prognostic factor to reduce OS (HR [95% CI], 2.32 [1.02-5.30], p-value = 0.045) and DFS (HR [95% CI], 2.63 [1.37-5.06], p-value = 0.004). Other prognostic factors for decreased survival outcomes were tumor size, presence of invasive lymph nodes, and T4a stage. Conclusions: Major complications rate of LG for GC was approximately 5.3%. Charlson comorbidities index and type of anastomosis were identified as risk factors for major postoperative complications. Major complications were demonstrated to pose adverse impact on survival outcomes.

PG I and PG II show unique value in diagnosing postoperative biochemical recurrence in patients with gastric cancer after total gastrectomy.

OBJECTIVE: To investigate the potential of group I pepsinogen (PG I) and group II pepsinogen (PG II) as diagnostic markers for recurrence in gastric cancer (GC) patients post-total gastrectomy. METHODS: Ninety-six patients who underwent total gastrectomy for GC between June 2022 and June 2023 were included in this study. Clinical data, serum samples, and ascites samples were collected. Patients were categorized based on recurrence status at the time of sample collection and the primary tumor site. PG I and PG II levels were determined using a chemiluminescent immunoassay, and their clinical utility following total gastrectomy for GC was evaluated via receiver operating characteristic (ROC) curve analysis. RESULTS: This study included 96 GC patients who underwent total gastrectomy, 55 of whom experienced postoperative recurrence (57.29%). The levels of serum PG I (27.86 (27.04, 30.97) vs. 26.05 (24.16, 27.09) ng/mL; P < 0.0001) and PG II (1.95 (1.23, 3.05) vs. 0.63 (0.47, 0.90) ng/mL; P < 0.0001) were significantly greater in the recurrent group compared to the non-recurrent group. The secretion of PG I and/or PG II by metastatic cancer cells correlated with the primary lesion site. When the cut-off value for serum PG I was 26.93 ng/mL, the area under the curve (AUC) for PG I was 0.77. When the cut-off value for serum PG II was 0.96 ng/mL, the AUC reached 0.90. The combined AUC was 0.97. CONCLUSION: These findings suggest that serum PG I and PG II are valuable biomarkers for identifying GC patients with biochemical recurrence post-total gastrectomy.

Analysis of the safety and efficacy of the self-pulling and latter transected technique in modified overlap anastomosis in total laparoscopic total gastrectomy.

Background: Laparoscopic total gastrectomy plus lymph node dissection is an effective treatment method for patients with gastric cancer. With the development and popularization of laparoscopic techniques in recent years, surgeons have become more skilled in laparoscopic techniques. Totally laparoscopic total gastrectomy (TLTG) has been developed; however, digestive tract reconstruction remains difficult, especially with anastomosis of the esophagus and jejunum. Using the self-pulling and latter transection (SPLT) method combined with a linear stapler has effectively solved the problem of narrow space in esophagojejunostomy. Here, we examined the safety and effectiveness of the SPLT technique in TLTG compared with SPLT with traditional esophagojejunostomy overlap anastomosis. Methods: We retrospectively analyzed all patients with gastric cancer admitted to the Department of Gastrointestinal Surgery of the Second Affiliated Hospital of Fujian Medical University from September 2020 to September 2023. In total, 158 patients met the inclusion criteria and were included. Patients were grouped according to whether the lower esophagus was transected after self-pulling. Patient demographics, tumor characteristics, surgical conditions, and postoperative results between the two groups were statistically analyzed. Results: A total of 158 patients were included in the study. All patients underwent TLTG and completed intracavitary anastomosis. There were 70 cases (44%) in the SPLT-Overlap group and 88 cases (56%) in the traditional overlap group. There was no significant difference in demographic and oncological characteristics between the two groups. The operation time (P = 0.002) and esophageal jejunum anastomosis time (P<0.001) were significantly shorter in the SPLT-Overlap group compared with the traditional overlap group. The intraoperative blood loss of the SPLT-Overlap group was 80.29 ± 36.36 ml, and the intraoperative blood loss of the traditional overlap group was 101.40 ± 46.68 ml. The difference was statistically significant (P=0.003). The SPLT-Overlap group also achieved a higher upper cutting edge (P =0.03). There was no significant difference between the two groups in terms of the incision size, postoperative hospital stay, time to first flatus, time to first liquid intake, drainage tube removal time, and esophagojejunal anastomotic diameter. There were 15 and 19 cases of short-term postoperative complications in the SPLT-Overlap and traditional Overlap groups, respectively. All patients received R0 resection, and no secondary surgery or death occurred. Conclusion: We applied SPLT to overlap anastomosis. Short-term, SPLT has good safety and feasibility in TLTG. It can effectively shorten the time of digestive tract reconstruction, simplify the reconstruction procedure, and make the digestive tract reconstruction simple and fast; at the same time, a safe cutting edge can be obtained.

Laparoscopic versus open total gastrectomy for T4a gastric cancer: a propensity score-matched analysis of long-term outcomes.

Evidence of implementation of laparoscopic total gastrectomy (LTG) for surgical T4a stage (sT4a) gastric cancer (GC) remains inadequate. This study aimed to compare short- and long-term outcomes of LTG versus open total gastrectomy (OTG) for sT4a GC. This retrospective cohort study was conducted using data from patients with sT4a GC underwent total gastrectomy from 2014 to 2020. Short-term outcomes included operative characteristics and postoperative complications. Long-term oncological outcomes focused on 3-, and 5-year overall survival (OS) and disease-free survival (DFS). Propensity score matching (PSM) was applied to reduce potential biases in baseline characteristics between groups. There was a total of 161 patients, in which 96 underwent LTG and 65 underwent OTG. After PSM, both groups consisted of 51 patients each, with balanced baseline characteristics. There were no significant differences between the two groups regarding blood loss, length of proximal resected margin, postoperative hospital stays, and overall and major postoperative complications. Most of the complications were classified as minor according to the Clavien-Dindo classification. Operating time was significantly longer in the LTG group (mean: 257 min vs. 231 min, p = 0.006). LTG was superior to OTG groups in time to flatus (mean: 3.0 days vs 3.9 days, p < 0.001). Five-year OS and DFS rates were similar between the two groups (44% and 33% vs. 43% and 28% in the LTG and OTG groups, respectively). Our findings indicate that LTG is a feasible and safe technique, exhibiting comparable long-term oncological outcomes to OTG for sT4a GC. LTG may be an acceptable alternative to OTG for the treatment of sT4a GC.

Effects of perioperative low-dose naloxone on the immune system in patients undergoing laparoscopic-assisted total gastrectomy: a randomized controlled trial.

BACKGROUND: Low immune function after laparoscopic total gastrectomy puts patients at risk of infection-related complications. Low-dose naloxone (LDN) can improve the prognosis of patients suffering from chronic inflammatory diseases or autoimmune diseases. The use of LDN during perioperative procedures may reduce perioperative complications. The purpose of this study was to examine the effects of LDN on endogenous immune function in gastric cancer patients and its specific mechanisms through a randomized controlled trial. METHODS: Fifty-five patients who underwent laparoscopic-assisted total gastrectomy were randomly assigned to either a naloxone group (n = 23) or a nonnaloxone group (n = 22). Patients in the naloxone group received 0.05 µg/kg-1.h- 1naloxone from 3 days before surgery to 5 days after surgery via a patient-controlled intravenous injection (PCIA) pump, and patients in the nonnaloxone group did not receive special treatment. The primary outcomes were the rates of postoperative complications and immune function assessed by NK cell, CD3+ T cell, CD4+ T cell, CD8+ T cell, WBC count, neutrophil percentage, and IL-6 and calcitonin levels. The secondary outcomes were the expression levels of TLR4 (Toll-like receptor), IL-6 and TNF-α in gastric cancer tissue. RESULTS: Compared with the nonnaloxone group, the naloxone group exhibited a lower incidence of infection (in the incision, abdomen, and lungs) (P < 0.05). The numbers of NK cells and CD8+ T cells in the naloxone group were significantly greater than those in the nonnaloxone group at 24 h after surgery (P < 0.05) and at 96 h after surgery (P < 0.05). Compared with those in the nonnaloxone group, the CD3 + T-cell (P < 0.05) and CD4 + T-cell (P < 0.01) counts were significantly lower in the naloxone group 24 h after surgery. At 24 h and 96 h after surgery, the WBC count (P < 0.05) and neutrophil percentage (P < 0.05) were significantly greater in the nonnaloxone group. The levels of IL-6 (P < 0.05) and calcitonin in the nonnaloxone group were significantly greater at 24 h after surgery. At 24 h following surgery, the nonnaloxone group had significantly greater levels of IL-6 (P < 0.05) and calcitonin than did the naloxone group. Compared with those in the naloxone group, the expression levels of TLR4 (P < 0.05) in gastric cancer tissue in the naloxone group were greater; however, the expression levels of IL-6 (P < 0.01) and TNF-α (P < 0.01) in the naloxone group were greater than those in the nonnaloxone group. CONCLUSION: Laparoscopic total gastrectomy patients can benefit from 0.05 ug/kg- 1. h- 1 naloxone by reducing their risk of infection. It is possible that LDN alters the number of cells in lymphocyte subpopulations, such as NK cells, CD3 + T cells, and CD4 + T cells, and the CD4+/CD8 + T-cell ratio or alters TLR4 receptor expression in immune cells, thereby altering immune cell activity. TRIAL REGISTRATION: The trial was registered at the Chinese Clinical Trial Registry on 24/11/2023 (ChiCTR2300077948).

Minimally Invasive Techniques for Gastrectomy.

Gastric adenocarcinoma is an aggressive disease and a leading cause of cancer-related deaths worldwide. Surgery entails either a total or a subtotal gastrectomy. These complex operations carry elevated morbidity and mortality with an extended recovery time. As such, research has focused on minimizing these risks and enhancing postoperative care. Robotic surgery is a newer platform that helps overcome some of the limitations of laparoscopy through three-dimensional vision, better mobility, and improved surgeon dexterity. As such, many surgeons have embraced robotics and advocated for their implementation in cancer surgery. This review will discuss the technical considerations of performing a robotic gastrectomy.

Transjugular intrahepatic portosystemic shunt for esophagojejunal variceal bleeding after total gastrectomy: A case report.

Esophagojejunal varices occurring after total gastrectomy are rare but potentially fatal in cases of variceal bleeding. Owing to their rarity, treatment strategies for this condition are not well established. Here, we describe the case of a 48-year-old woman who presented with hematemesis and melena. Four years prior, she underwent a total gastrectomy for gastric cancer. Esophagojejunal variceal bleeding supplied by a dilated jejunal vein, along with liver cirrhosis, was diagnosed as per endoscopy and computed tomography findings. Initial attempts at endoscopic therapy were unsuccessful. Subsequently, transjugular intrahepatic portosystemic shunt placement was performed to reduce the portal pressure gradient, resulting in the cessation of bleeding. At the 1-month follow-up endoscopy, the varices had resolved, and no rebleeding occurred during 6 months of follow-up. Transjugular intrahepatic portosystemic shunt placement may be considered as an effective treatment option for esophagojejunal variceal bleeding.

Robotic spleen­preserving suprapancreatic and splenic hilar lymph node dissection using the preemptive retropancreatic approach in total gastrectomy for gastric cancer.

Advanced gastric cancer that has not invaded the greater curvature is a good indication for total gastrectomy (TG) with spleen-preserving suprapancreatic and splenic hilar lymph node dissection (LND). However, the suprapancreatic and splenic hilar LND increases the area of dissection of the pancreas, and prolonged pressure drainage of the pancreas is required to maintain a clear operative view. This can lead to an increased risk of postoperative pancreatic complications. To report the efficacy of our novel preemptive retropancreatic approach (PRA) for the suprapancreatic and splenic hilar LND in robotic TG (RTG). We report our experience with nine patients with gastric cancer who underwent spleen-preserving splenic hilar LND using PRA during RTG at Hokkaido University from October 2018 to November 2021. The PRA involves initial dissection of the left side of the retropancreatic space, followed by the release of the adherence between the retroperitoneum surface and the pancreas (fusion fascia), which provides a good operative field and prevents contact with the pancreas during the suprapancreatic and splenic hilar LND in RTG. The median operating time was 488 min (254-564 min). The median intraoperative bleeding was 55 mL (0-115 mL). One patient had postoperative complications (above grade II of the Clavien-Dindo classification), but there were no postoperative pancreatic complications. The spleen-preserving suprapancreatic and splenic hilar LND using PRA could help to reduce the postoperative pancreatic complications associated with RTG.Trial registration number and date of registration The Hokkaido University Hospital institutional review board approved the data collection and analysis. The trial registration number and date of registration are No. 021-0022 and July 26, retrospectively registered.

Minimally Invasive Conversion Surgery for Unresectable Gastric Cancer with Splenic Metastasis and Splenic Vein Tumor Thrombus: A Case Report.

While the importance of conversion surgery has increased with the development of systemic chemotherapy for gastric cancer (GC), reports of conversion surgery for patients with GC with distant metastasis and tumor thrombus are extremely scarce, and a definitive surgical strategy has yet to be established. Herein, we report a 67-year-old man with left abdominal pain referred to our hospital following a diagnosis of unresectable GC. Esophagogastroduodenoscopy and contrast-enhanced abdominal computed tomography (CT) revealed advanced GC with splenic metastasis. A splenic vein tumor thrombus (SVTT) and a continuous thrombus to the main trunk of the portal vein were detected. The patient was treated with anticoagulation therapy and systemic chemotherapy comprising S-1 and oxaliplatin. One year following chemotherapy initiation, a CT scan revealed progressive disease (PD); therefore, the chemotherapy regimen was switched to ramucirumab with paclitaxel. After 10 courses of chemotherapy resulting in primary tumor and SVTT shrinkage, the patient underwent laparoscopic total gastrectomy (LTG) and distal pancreaticosplenectomy (DPS). He was discharged without complications and remained alive 6 months postoperatively without recurrence. In summary, the wait-and-see approach was effective in a patient with GC with splenic metastasis and SVTT, ultimately leading to an R0 resection performed via LTG and DPS.

The safety and feasibility assessment of overlap esophagojejunostomy with self-pulling and latter transection technique in totally laparoscopic total gastrectomy.

BACKGROUND: This study presented an innovative technique in totally laparoscopic total gastrectomy (TLTG) for overlap esophagojejunostomy (E-J), termed self-pulling and latter transection (SPLT) (overlap SPLT). It evaluated the effectiveness and short-term outcomes of this novel method through a comparative analysis with the established functional end-to-end (FETE) E-J incorporating SPLT. METHODS: From September 2018 to September 2023, this study enrolled 68 patients with gastric cancer who underwent TLTG with overlap SPLT anastomosis and 120 patients who underwent TLTG with FETE SPLT anastomosis. Clinicopathologic characteristics and surgical and postoperative outcomes data for overlap SPLT cases were gathered and retrospectively compared with those from FETE SPLT TLTG to evaluate the effectiveness and clinical safety. RESULTS: The duration of anastomosis for overlap SPLT was 25.3 ± 7.4 minutes, significantly longer than that for the FETE SPLT (18.1 ± 4.0 minutes, P = .031). Perioperatively, 1 anastomosis-related complication occurred in each group, but this did not constitute a statistically significant difference (P = .682). No statistically significant differences were found between the 2 groups in terms of operative time, postoperative hospital stay, operative cost, surgical margins, or number of lymph nodes removed. Postoperative morbidity rates were similar between the groups (4.4% vs 5.8%, P = .676). CONCLUSION: The overlap SPLT technique is regarded as a safe and feasible method for anastomosis. There were no apparent differences in complications between overlap SPLT and FETE SPLT, but overlap SPLT costed 1 additional stapler cartridge and required a longer duration.

Key nodal stations for predicting splenic hilar nodal metastasis in upper advanced gastric cancer without invasion of the greater curvature.

Background: Standard surgery for upper advanced gastric cancer without invasion of the greater curvature (UGC-GC) is spleen-preserving D2 total gastrectomy without dissection of the splenic-hilar nodes (#10). However, some patients with nodal metastasis to #10 survive more than 5 years due to nodal dissection of #10. If nodal metastasis to #10 is predictable based on the positivity of other nodes dissected by the current standard surgery without #10 nodal dissection, physicians may be able to consider #10 dissection. Methods: This study retrospectively reviewed data from the National Cancer Center Hospital in Japan between 2000 and 2012. We selected cases that met the following criteria: (1) D2 or more total gastrectomy with splenectomy, (2) UGC-GC, and (3) histological type is gastric adenocarcinoma. We performed univariate and multivariate analyses concerning lymph node stations associated with #10 metastasis. Results: A total of 366 patients were examined. A multivariate analysis revealed that #10 metastasis was associated with positivity of the nodes along the short gastric arteries (#4sa) and distal nodes along the splenic artery (#11d) (#4sa: p = 0.003, #11d: p = 0.016). When either key node was positive, the metastatic rate of #10 was 24.4%, and the therapeutic value index was 13.3. Conclusions: #4sa and #11d were key lymph nodes predicting #10 nodal metastasis in UGC-GC. When these key nodes are positive on computed tomography before surgery or according to a rapid pathological examination during surgery, dissection of #10 should be considered even if upper advanced tumors are not invading the greater curvature.

Strangulated Bowel Obstruction Due to Hiatal Hernia After Laparoscopic Total Gastrectomy.

Laparoscopic total gastrectomy results in more internal hernias than open surgery. However, there are few reports of incarcerated hiatal hernia after laparoscopic total gastrectomy. Here, we report a case of a 79-year-old male who underwent urgent surgical intervention for a strangulated intestinal obstruction due to an incarcerated hernia through the esophageal hiatus following laparoscopic total gastrectomy. In this case, an esophageal hiatal hernia was present before gastrectomy, but was not repaired. Additionally, the patient experienced significant weight loss after gastrectomy. Preoperative hiatal hernia and marked postoperative weight loss may pose risks.

Application of hand-sewn esophagojejunostomy in laparoscopic total gastrectomy.

OBJECTIVE: To investigate the clinical efficacy and prognostic implication of hand-sewn anastomosis in laparoscopic total gastrectomy (LTG). METHODS: Retrospective analysis is adopted to the clinicopathologic data of 112 patients with gastric cancer (GC) who went through LTG in the Department of General Surgery, the Second Affiliated Hospital of Anhui Medical University between October 2020 and October 2022. Among them, 60 individuals receiving medical care were split into the hand-sewn anastomosis group (Group H, N = 60); while, 52 individuals were split into the circular stapler anastomosis group (Group C, N = 52) The clinical efficacy and prognostic conditions of hand-sewn anastomosis are compared with those of circular stapler anastomosis in the application of LTG. RESULTS: The analysis results indicated that no notable difference was observed in intraoperative bleeding volume, time to first flatus (TFF), postoperative hospitalization duration and postoperative complications among the two groups (P > 0.05). Group H had shorter esophagojejunal anastomosis duration (20.0 min vs. 35.0 min) and surgery duration (252.6 ± 19.4 min vs. 265.9 ± 19.8 min), smaller incisions (5.0 cm vs. 10.5 cm), and lower hospitalization costs (58415.0 CNY vs. 63382.5 CNY) compared to Group C (P < 0.05). CONCLUSION: The clinical efficacy and the postoperative complications of hand-sewn esophagojejunostomy are basically equivalent in comparison to the circular stapler anastomosis in the application of LTG. Its advantage lies in shorter esophagojejunal anastomosis duration, shorter surgery duration, smaller incisions, lower hospitalization costs and wider adaptability of the location of the tumor.

Catheter-guided anvil insertion for circular stapler esophagojejunal anastomosis: a novel technique in laparoscopic total gastrectomy.

OBJECTIVE: This study evaluates feasibility, safety, and short-term outcomes of employing the catheter-guided stapler anvil insertion technique for esophagojejunal anastomosis using a circular stapler during laparoscopic total gastrectomy (LTG). MATERIALS AND METHODS: From September 2021 to April 2023, the catheter-guided stapler anvil insertion technique was employed in 80 patients undergoing laparoscopic total gastrectomy (LTG) for esophagojejunal anastomosis. A modified D2 dissection, according to the en bloc technique, was performed in the patients. Subsequently, a longitudinal incision, approximately 2 cm in length, was made on the anterior wall of the esophagus, about 2 cm above the tumor. The transection line was pre-marked with blue dye along the esophagus's minor axis, and the tail of the anvil was capped with a 10-cm length of catheter (F14 d4.7 mm). The surgeon secures the head of anvil and carefully inserts it into the esophagus, ensuring that only a 5-cm segment of the catheter remains outside the esophagus. A linear cutter was employed to transect and seal the lower end of the esophagus. Subsequently, esophagojejunostomy was performed under laparoscopic guidance using a circular stapler. RESULTS: Among patients undergoing esophagojejunal anastomosis with the new technique, postoperative complications included pneumonia or pleural effusion in 14 patients (17.5%), anastomotic stenosis in 3 patients (3.75%), abdominal infection in 2 patients (2.5%), and intestinal obstruction in 1 patient (1.25%). No instances of anastomotic leakage, anastomotic bleeding, or deaths were recorded. All patients experiencing complications improved with conservative treatment, without the need for secondary surgery. CONCLUSION: The catheter-guided stapler anvil insertion technique is demonstrated to be a safe and effective method for esophagojejunostomy, potentially reducing the occurrence of anastomotic leakage.

Safety and Limitations of Laparoscopic Total Gastrectomy for Gastric Cancer: A Comparative Analysis of Short and Long-term Outcomes With Open Surgery.

BACKGROUND/AIM: Laparoscopic gastrectomy is a standard treatment strategy for gastric cancer (GC); however, the clinical impact of laparoscopic total gastrectomy (LTG) on survival outcomes remains unclear. We compared the short- and long-term results of LTG with those of open total gastrectomy (OTG). PATIENTS AND METHODS: Patients undergoing total gastrectomy with lymph node dissection for Stage I/II/III GC between 2010 and 2020 were retrospectively analyzed. Patients were classified into those undergoing LTG (n=143, LTG group) and OTG (n=173, OTG group). The primary outcome was relapse-free survival (RFS). RESULTS: The LTG group exhibited a higher prevalence of early T and N factors, with pStage I/II/III distribution skewed toward early-stage in a ratio of 86/24/33 compared to 38/65/69 in the OTG group (p<0.001), respectively. Longer operation time (p<0.001), less blood loss (p<0.001), fewer grade 3-4 complications (p<0.001), and shorter hospital stay (p<0.001) were observed in the LTG than in the OTG group. LTG was associated with survival benefits for patients without indication for adjuvant chemotherapy [5-year RFS rate, 96.3% vs. 73.2%; hazard ratio (HR)=0.24; 95% confidence interval (CI)=0.10-0.56; p<0.001]. Among the eligibility criteria for adjuvant chemotherapy (Stage II/III excluding pT1 and pT3N0), while the LTG group received more frequently doublet-agent administration (56.5% vs. 11%, p<0.001), conversely, the OTG group exhibited slightly better long-term survival rates (5-year RFS rate, 33.9% vs. 50.2%; HR=1.31; 95%CI=0.82-2.10; p=0.251). CONCLUSION: LTG contributed to favorable short-term outcomes and demonstrated improved long-term outcomes in early-stage GC; however, careful consideration of indications is warranted for advanced GC cases.