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Short Term Outcomes of Laparoscopic versus Open Distal Gastrectomy with D2 Lymph Nodes Dissection for Gastric Cancer: A Prospective Study  [PDF]
S. Abdelaziem, Tamer A. El-Bakary, Hamdy S. Abd Allah
Surgical Science (SS) , 2017, DOI: 10.4236/ss.2017.88037
Abstract: Background: Laparoscopic distal gastrectomy (LDG) for gastric adenocarcinoma (GA) is gaining more acceptances worldwide. Its results are still controversial. This study aimed to assess short term outcomes of LDG and compare it to the standard open distal gastrectomy. Patients and Methods: 27 patients with GA of the distal 2/3 of the stomach were included and divided into 2 groups; Group A: 15 patients submitted to open distal gastrectomy with D2 lymph node (LN) dissection, and Group B: 12 patients submitted to LDG with D2 LN dissection. Results: The median age was 54 and 54.3 years in group A and B respectively. The median operative time was 118.7 and 210.2 minutes in group A and B respectively. The median safety margin was 6.52 and 5.7 cm in group A and B respectively while the median number of excised LN was 24.2 and 21.4 in group A and B respectively. One patient in group B had intraoperative bleeding that was controlled laparoscopically. No conversion to open surgery needed in group B. The median number of narcotic doses was 5.9 and 4.25 in group A and B respectively. The median length of hospital stay was 7.2 days in group A and 7.3 days in group B. Three patients in group A and 2 patients in group B had postoperative complications and all were treated successfully conservatively. Conclusion: LDG with D2 LN dissection is oncologically safe with short-term outcomes comparable to those of the open surgery. Gaining more surgeons’ experience is necessary to improve these results.
Single Incision Laparoscopic Total Gastrectomy and D2 Lymph Node Dissection for Gastric Cancer Using a Four-Access Single Port: The First Experience  [PDF]
Metin Ertem,Emel Ozveri,Hakan Gok,Volkan Ozben
Case Reports in Surgery , 2013, DOI: 10.1155/2013/504549
Abstract: Single incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) have been developed to reduce the invasiveness of laparoscopic surgery. SILS has been frequently applied in various clinical settings, such as cholecystectomy, colectomy, and sleeve gastrectomy. So far, there have been four reports on single incision laparoscopic distal gastrectomy and one report on single incision laparoscopic total gastrectomy with D1 lymph node dissection for gastric cancer. In this report, we present our single incision laparoscopic total gastrectomy with D2 lymph node dissection technique using a four-hole single port (OctoPort) in a patient with gastric cancer. 1. Introduction In recent years, laparoscopic gastrectomy has been increasingly performed in the surgical management of gastric cancer. In some Asian countries, especially in Japan and Korea, this procedure has become a standard therapy for early stage gastric cancer [1, 2]. Kitano et al. [1] reported excellent long-term outcomes of laparoscopic gastrectomy in a retrospective multicenter study for early gastric cancer. Experienced surgeons are trying to extend this laparoscopic approach to certain advanced gastric cancer using more aggressive techniques. Furthermore, single incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) have been developed to reduce the invasiveness of laparoscopic surgery. SILS has been frequently applied in various clinical settings, such as cholecystectomy, colectomy, and sleeve gastrectomy [3–6]. So far, there have been four reports on single incision laparoscopic distal gastrectomy and one report on single incision laparoscopic total gastrectomy with D1 lymph node dissection for gastric cancer [7–11]. Here, we report the first experience in single incision laparoscopic total gastrectomy with D2 lymph node dissection technique in a patient with gastric cancer. 2. Case Report A 63-year-old man presented to our clinic with the complaints of recent weight loss, indigestion, and abdominal discomfort. During diagnostic work-up, upper endoscopy and biopsy revealed adenocarcinoma located in the corpus of the stomach and endoscopic ultrasonography showed the invasion of the cancer in the submucosal layer. Abdominal CT and PET-CT demonstrated that there was no regional lymph node involvement or distant metastasis. The patient’s body mass index was 22.1?kg/m2. Based on these findings, total gastrectomy was scheduled. Operative Technique. Under general anesthesia, the patient was placed in a supine position with
Lymph Node Dissection in Curative Gastrectomy for Advanced Gastric Cancer  [PDF]
Shigeyuki Tamura,Atsushi Takeno,Hirofumi Miki
International Journal of Surgical Oncology , 2011, DOI: 10.1155/2011/748745
Abstract: Gastric cancer is one of the most common causes of cancer-related death worldwide. Surgical resection with lymph node dissection is the only potentially curative therapy for gastric cancer. However, the appropriate extent of lymph node dissection accompanied by gastrectomy for cancer remains controversial. In East Asian countries, especially in Japan and Korea, D2 lymph node dissection has been regularly performed as a standard procedure. In Western countries, surgeons perform gastrectomy with D1 dissection only because D2 is associated with high mortality and morbidity compared to those associated with D1 alone but does not improve the 5-year survival rate. However, more recent studies have demonstrated that western surgeons can be trained to perform D2 lymphadenectomies on western patients with a lower morbidity and mortality. When extensive D2 lymph node dissection is preformed safely, there may be some benefit to D2 dissection even in western countries. In this paper, we present an update on the current literature regarding the extent of lymphadenectomy for advanced gastric cancer. 1. Introduction Gastric cancer is one of the most common causes of death worldwide [1]. Although the prognosis of patients with advanced gastric cancer has improved with the introduction of effective chemotherapy [2] or adjuvant radiotherapy [3], surgical resection remains the primary therapeutic modality for curable advanced cancer. With regard to surgical procedure, dissection of regional LN is regarded an important part of en bloc resection for gastric cancer. However, there are significant differences in the extent of lymphadenectomy preformed by surgeons in different countries. In Japan, D2 dissection has been recommended as standard practice since the 1960s [4]. East Asian surgeons, especially Japanese and Korean surgeons, routinely performed gastrectomy with D2 dissection. However, most Western surgeons perform gastrectomy with only D1 dissection, because D1 was associated with less mortality and morbidity than D2 in prospective randomized trials preformed in the Netherland and the UK concluded that there was no survival benefit for D2 over D1 lymph node dissection [5, 6]. However, there were significant problems with these studies, including a high morbidity and mortality rate in the D2 group associated with inadequate surgical training, with inadequate dissection of D2 and with the frequent performance of distal pancreatectomy and splenectomy in the D2 group, which is now considered unnecessary [7]. More recent studies have demonstrated that western surgeons at
Learning Curve for D2 Lymphadenectomy in Gastric Cancer  [PDF]
Alexis Luna,Pere Rebasa,Sandra Montmany,Salvador Navarro
ISRN Surgery , 2013, DOI: 10.1155/2013/508719
Abstract: Background. D2 lymphadenectomy is a demanding technique which is associated with high morbidity in the West. We report our experience with D2 lymphadenectomy after a training period in Japan. Methods. Prospective, descriptive study in 133 consecutive patients undergoing radical gastrectomy for gastric adenocarcinoma from 2005 to 2011. We analysed the number of lymph nodes removed, observed morbidity/mortality compared with the predictions of POSSUM and O-POSSUM, survival, and disease-free interval for patients with D1 and D2 lymphadenectomy. Results. The morbidity rate in patients with D1 lymphadenectomy was 59.4%. For D2 it was 47.7%. The mortality rate in patients with D1 was 6.7%. In the D2 group it was 6.8%. Median survival was 42.9 months in D1 and 55 months in D2. The disease-free interval was 49 months for D1 and 58 months for D2. Conclusion. The learning curve for D2 lymphadenectomy presents acceptable rates of morbidity and mortality, providing that the technique is learnt at a center with extensive experience. 1. Introduction Deciding on the type of lymphadenectomy to perform in gastric cancer is a controversial matter. Groups in Asia contend that lymph node involvement in gastric cancer in the absence of distant metastases is a localized disease and that curative surgical treatment should be performed. They advocate D2 lymphadenectomy on the grounds that it improves staging and locoregional control of disease. In the West, lymph node involvement tends to be considered a systemic disease with low likelihood of cure. In the last two decades, the literature has shown that the results of gastric cancer surgery are far better in Asia, where D2 lymphadenectomy is considered the standard five-year survival rates in Japan are around 50–60% [1], compared with the figures of 10–30% reported in the West [2]. D2 lymphadenectomy is a demanding technique, especially in patients with higher body mass index, as is generally the case in the West. Patients in our setting also tend to be older and more likely to present comorbidity. As a result, D1 lymphadenectomy is considered the standard in the West, although certain groups now advocate D2 lymphadenectomy [3]. The evidence available to compare D1 and D2 lymphadenectomy is limited and has serious shortcomings. Most of the literature consists of retrospective cohort studies with substantial bias; only two methodologically sound, prospective, randomized, and multicenter studies have been published, but both present serious problems regarding treatment selection. Studies performed in Japan are retrospective and
Totally Laparoscopic Total Gastrectomy with D2 Lymphadenectomy for Advanced Gastric Cancer  [PDF]
Hironobu Takano, Yuma Ebihara, Yo Kurashima, Soichi Murakami, Toshiaki Shichinohe, Satoshi Hirano
Surgical Science (SS) , 2015, DOI: 10.4236/ss.2015.66038
Abstract: Introductions: Gastrectomy, which is the standard surgical procedure for gastric cancer, has gradually come to be performed laparoscopically. Laparoscopic distal gastrectomy (LDG) has been adopted gradually and performed for advanced gastric cancer. However, laparoscopic total gastrectomy (LTG) has not been as widely accepted as LDG due to technical difficulties, especially with reconstruction and proper D2 lymphadenectomy. The purpose of the current study was to determine the utility of TLTG with concomitant splenectomy and D2 lymphadenectomy (TLTGS) for advanced gastric cancer (AGC). Materials and Methods: Between January 2006 and May 2014, 10 consecutive patients who underwent TLTGS for AGC and 76 patients who underwent TLTG with D1 lymphadenectomy were included in this study. These two groups were compared in terms of perioperative results, with assessment of intraoperative and postoperative outcomes. Results: There were no significant differences in patients’ characteristics between the two groups. Operative time was longer in the TLTGS group than in the TLTG group. However, the rate of patients with postoperative complications including major complications was not different between the groups, and no patient in the TLTGS group had anastomotic leakage or pancreatic fistula. Conclusions: In the short-term, TLTGS had good postoperative outcomes and was useful and acceptable for AGC.
Effect of obesity on intraoperative bleeding volume in open gastrectomy with D2 lymph-node dissection for gastric cancer
Hirochika Makino, Chikara Kunisaki, Hirotoshi Akiyama, Hidetaka A Ono, Takashi Kosaka, Ryo Takagawa, Yasuhiko Nagano, Syoichi Fujii, Hiroshi Shimada
Patient Safety in Surgery , 2008, DOI: 10.1186/1754-9493-2-7
Abstract: Between January 2005 and March 2007, 100 patients with preoperatively diagnosed gastric cancer who underwent open gastrectomy with D2 lymph-node dissection were enrolled in this study. Of these, 61 patients underwent open distal gastrectomy (ODG) and 39 patients underwent open total gastrectomy (OTG). Patients were classified as having a high body-mass index (BMI; ≥ 25.0 kg/m2; n = 21) or a normal BMI (<25.0 kg/m2; n = 79). The visceral fat area (VFA) and subcutaneous fat area (SFA) were assessed as identifiers of obesity using FatScan software. Patients were classified as having a high VFA (≥ 100 cm2; n = 34) or a normal VFA (<100 cm2; n = 66). The relationship between obesity and short-term patient outcomes after open gastrectomy was evaluated. Patients were classified as having high intraoperative blood loss (IBL; ≥ 300 ml; n = 42) or low IBL (<300 ml; n = 58). Univariate and multivariate analyses were used to identify predictive factors for high IBL.Significantly increased IBL was seen in the following: patients with high BMI versus normal BMI; patients with gastric cancer in the upper third of the stomach versus gastric cancer in the middle or lower third of the stomach; patients who underwent OTG versus ODG; patients who underwent splenectomy versus no splenectomy; and patients with high VFA versus low VFA. BMI and VFA were significantly greater in the high IBL group than in the low IBL group. There was no significant difference in morbidity between the high IBL group and the low IBL group. Multivariate analysis revealed that patient age, OTG and high BMI or high VFA independently predicted high IBL.It is necessary to perform operative manipulations with particular care in patients with high BMI or high VFA in order to reduce the IBL during D2 gastrectomy.Obesity is associated with substantial technical difficulties and increased patient morbidity after open gastrectomy [1,2]. The body-mass index (BMI) has been widely used as an indicator of the extent of obes
D2 dissection in laparoscopic and open gastrectomy for gastric cancer  [cached]
Ming Cui,Jia-Di Xing,Wei Yang,Yi-Yuan Ma
World Journal of Gastroenterology , 2012, DOI: 10.3748/wjg.v18.i8.833
Abstract: AIM: To evaluate the radicalness and safety of laparoscopic D2 dissection for gastric cancer. METHODS: Clinicopathological data from 209 patients with gastric cancer, who underwent radical gastrectomy with D2 dissection between January 2007 and February 2011, were analyzed retrospectively. Among these patients, 131 patients underwent laparoscopy-assisted gastrectomy (LAG) and 78 underwent open gastrectomy (OG). The parameters analyzed included operative time, blood loss, blood transfusion, morbidity, mortality, the number of harvested lymph nodes (HLNs), and pathological stage. RESULTS: There were no significant differences in sex, age, types of radical resection [radical proximal gastrectomy (PG + D2), radical distal gastrectomy (DG + D2) and radical total gastrectomy (TG + D2)], and stages between the LAG and OG groups (P > 0.05). Among the two groups, 127 cases (96.9%) and 76 cases (97.4%) had 15 or more HLNs, respectively. The average number of HLNs was 26.1 ± 11.4 in the LAG group and 24.2 ± 9.3 in the OG group (P = 0.233). In the same type of radical resection, there were no significant differences in the number of HLNs between the two groups (PG + D2: 21.7 ± 7.5 vs 22.4 ± 9.3; DG + D2: 25.7 ± 11.0 vs 22.3 ± 7.9; TG + D2: 30.9 ± 13.4 vs 29.3 ± 10.4; P > 0.05 for all comparisons). Tumor free margins were obtained in all cases. Compared with OG group, the LAG group had significantly less blood loss, but a longer operation time (P < 0.001). The morbidity of the LAG group was 9.9%, which was not significantly different from the OG group (7.7%) (P = 0.587). The mortality was zero in both groups. CONCLUSION: Laparoscopic D2 dissection is equivalent to OG in the number of HLNs, regardless of tumor location. Thus, this procedure can achieve the same radicalness as OG.
Fatores prognósticos nas gastrectomias com linfadenectomia D2 por adenocarcinoma gástrico
Castro, Osvaldo Antonio Prado;Malheiros, Carlos Alberto;Rodrigues, Francisco César Martins;Ilias, Elias Jirjoss;Kassab, Paulo;
ABCD. Arquivos Brasileiros de Cirurgia Digestiva (S?o Paulo) , 2009, DOI: 10.1590/S0102-67202009000300005
Abstract: background: lymphatic spread is more common in gastric cancer than the hematogenic one. thus, the locoregional dissection type d2 seems to be important. aim: to evaluate the overall survival after d2 gastrectomy for gastric adenocarcinoma and to determine the most important prognostic factors, including those with independent statistical value. methods: prospective study with 125 patients operated between august 1997 and october 2005. the technique employed followed strictly the protocol of the national cancer center - tokyo. results: there were 73 men and 52 women with ages ranging 28 to 84 years (mean of 58.96 ± 14.01). seventy per cent of the lesions were located at the distal portion of the stomach, 20% were proximal and 10% comprised the whole organ. the stage distributions were: i - 37 cases (29.6%), ii - 20 cases (16%), iii - 37 cases (29.6%), and iv - 31 cases (24.8%). it was performed the amount of 73 subtotal gastrectomies and 52 totals. the morbidity rate was 26.4%, mainly, due to leakage and pulmonary complications. the overall mortality rate was 9.6%. after a mean follow-up of 48 months, 68 (54.4%) patients were dead, representing an overall survival rate of 45.6%. univariate and multivariate statistical analysis revealed that: tumors comprising the whole stomach, beyond the serosal layer (t3 or t4), with more than seven metastatic lymph nodes (n2 or n3), with distant metastasis (m1), and belonging to the stage iii or iv of the disease, were related to a poor prognosis. conclusions: less than a half of the patients were alive after a mean follow-up of almost four years; the tnm stage system was the main prognostic factor, ergo, the extension of the lesions, the stage of the disease, metastatic occurrence and mainly the lymph node involvement were define as an independent prognostic factors.
Adjuvant Chemotherapy for Elderly Patients with Gastric Cancer after D2 Gastrectomy  [PDF]
Ying Jin, Miao-zhen Qiu, De-shen Wang, Dong-sheng Zhang, Chao Ren, Long Bai, Hui-yan Luo, Zhi-qiang Wang, Feng-hua Wang, Yu-hong Li, Rui-hua Xu
PLOS ONE , 2013, DOI: 10.1371/journal.pone.0053149
Abstract: Background A phase III clinical trial has already shown the survival benefits of postoperative chemotherapy in gastric cancer. However, there are limited published data concerning the elderly. This study aims to investigate the use of adjuvant chemotherapy for gastric cancer after D2 gastrectomy among the elderly and identify its impact on survival. Methods We retrospectively reviewed 360 patients who had undergone D2 gastrectomy, aged 65 years or older, with non-metastatic gastric cancer in a single institution. We analyzed the predictors and survival benefits of adjuvant chemotherapy use in the elderly. Further, we analyzed the survival benefits of adjuvant chemotherapy by dividing the patients into groups according to disease stages and chemotherapeutic regimens. Results Among the 360 patients, only 34.7% of patients received adjuvant chemotherapy. Age, tumor location, lymph node involvement and tumor invasion were associated with the receipt of adjuvant chemotherapy. Adjuvant chemotherapy improved the overall survival for non-metastatic elderly patients (HR 0.60, 95%CI 0.42–0.83, P = 0.003). Significant survival benefits were found with adjuvant chemotherapy in stage III patients (HR 0.67, 95%CI 0.47–0.97, P = 0.033), but not in stage I patients or in stage II patients (HR 0.52, 95%CI 0.21–1.30 P = 0.161). Compared to adjuvant chemotherapy without platinum, no significant survival benefits were observed with platinum-containing chemotherapy (HR 0.84, 95%CI 0.49–1.45, P = 0.530). Besides adjuvant chemotherapy, other independent prognostic factors of survival included tumor location, tumor size, histologic grade, depth of tumor invasion, and lymph node status. Conclusions This study demonstrated the survival benefits of adjuvant fluoropyrimidine-based chemotherapy among the elderly patients with non-metastatic gastric cancer after D2 gastrectomy. However, due to the limitations of this study, further well-designed prospective studies with large populations are needed to confirm these findings and identify the patients that can tolerate and benefit from adjuvant chemotherapy.
Time-related improvement of survival in resectable gastric cancer: the role of Japanese-style gastrectomy with D2 lymphadenectomy and adjuvant chemotherapy
Juan J Grau, Ramon Palmero, Maribel Marmol, Jose Domingo-Domenech, Mariano Monzo, Jose Fuster, Oscar Vidal, Constantino Fondevila, Juan C Garcia-Valdecasas
World Journal of Surgical Oncology , 2006, DOI: 10.1186/1477-7819-4-53
Abstract: We retrospectively analyze the outcome of 426 consecutive patients from 1975 to 2002, divided into 2 time-periods (TP) cohort: Before 1990 (TP1, n = 207) and 1990 or after (TP2; n= 219). Partial gastrectomy and D1-lymphadenetomy was predominant in TP1 and total gastrectomy with D2-lymphadenectomy it was in TP2. Adjuvant chemotherapy consisted of mitomycin C (MMC), 10–20 mg/m2 iv 4 courses or MMC plus Tegafur 500 mg/m2 for 6 months.Positive nodes were similar in TP2/TP1 patients with 56%/59% respectively. Total gastrectomy was done in 56%/45% of TP2/TP1 respectively. Two-drug adjuvant chemotherapy was administered in 65%/18% of TP2/TP1 respectively. Survival at 5 years was 66% for TP2 versus 42% for TP1 patients (p < 0.0001). Survival by stages II, IIIA y IIIB for TP2 versus TP1 patients was 70 vs. 51% (p = 0.0132); 57 vs. 22% (p = 0.0008) y 30 vs. 15% (p = 0.2315) respectively. Multivariate analysis showed that age, stage of disease and period of treatment were independent variables.The global prognosis and that of some stages have improved in recent years with case RGC patients treated with surgery and adjuvant chemotherapy.For many authors, gastric carcinoma remains one of the leading causes of cancer death worldwide, second only to lung carcinoma [1,2]. Five-year relative survival of patients from European countries ranges from 10 to 30% [3,4], similar to that reported in USA (15 to 28%) [5]. Local and regional gastric carcinoma showed a 5-year relative survival of 55–59% and 20–22% respectively [6]. In this latter subgroup of patients the surgical treatment of choice consisted of gastrectomy combined with regional lymph node dissection. The relevance of radical surgery, extending lymph node dissection as wide as possible has been highlighted. The experience of an expert surgeon has been shown to improve clinical outcome in some tumors [7]. In the statistical outcome of two European trials, one from the United Kingdom and the other, The Netherlands, comparing D1
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