Short-Term Outcomes of Laparoscopic Total Gastrectomy Performed by a Single Surgeon Experienced in Open Gastrectomy: Review of Initial Experience

PURPOSE: Laparoscopic total gastrectomy (LTG) is more complicated than laparoscopic distal gastrectomy, especially during a surgeon's initial experience with the technique. In this study, we evaluated the short-term outcomes of and learning curve for LTG during the initial cases of a single surgeon compared with those of open total gastrectomy (OTG). MATERIALS AND METHODS: Between 2009 and 2013, 134 OTG and 74 LTG procedures were performed by a single surgeon who was experienced with OTG but new to performing LTG. Clinical characteristics, operative parameters, and short-term postoperative outcomes were compared between groups. RESULTS: Advanced gastric cancer and D2 lymph node dissection were more common in the OTG than LTG group. Although the operation time was significantly longer for LTG than for OTG (175.7±43.1 minutes vs. 217.5±63.4 minutes), LTG seems to be slightly superior or similar to OTG in terms of postoperative recovery measures. The operation time moving average of 15 cases in the LTG group decreased gradually, and the curve flattened at 54 cases. The postoperative complication rate was similar for the two groups (11.9% vs. 13.5%). No anastomotic or stump leaks occurred. CONCLUSIONS: Although LTG is technically difficult and operation time is longer for surgeons experienced in open surgery, it can be performed safely, even during a surgeon's early experience with the technique. Considering the benefits of minimally invasive surgery, LTG is recommended for early gastric cancer.ope

Determination of Additional Surgery after Non-Curative Endoscopic Submucosal Dissection in Patients with Early Gastric Cancer: A Practically Modified Application of the eCura System

Background: Additional surgery after non-curative endoscopic submucosal dissection (ESD) may be excessive as few patients have lymph node metastasis (LNM). It is necessary to develop a risk stratification system for LNM after non-curative ESD, such as the eCura system, which was introduced in the Japanese gastric cancer treatment guidelines. However, the eCura system requires venous and lymphatic invasion to be separately assessed, which is difficult to distinguish without special immunostaining. In this study, we practically modified the eCura system by classifying lymphatic and venous invasion as lymphovascular invasion (LVI). Method: We retrospectively reviewed 543 gastric cancer patients who underwent radical gastrectomy after non-curative ESD between 2006 and 2019. LNM was evaluated according to LVI as well as size >30 mm, submucosal invasion ≥500 µm, and vertical margin involvement, which were used in the eCura system. Results: LNM was present in 8.1% of patients; 3.6%, 2.3%, 7.4%, 18.3%, and 61.5% of patients with no, one, two, three, and four risk factors had LNM, respectively. The LNM rate in the patients with no risk factors (3.6%) was not significantly different from that in patients with one risk factor (2.3%, p = 0.523). Among patients with two risk factors, the LNM rate without LVI was significantly lower than with LVI (2.4% vs. 10.7%, p = 0.027). Among patients with three risk factors, the LNM rate without LVI was lower than with LVI (0% vs. 20.8%, p = 0.195), although not statistically significantly. Based on LNM rates according to risk factors, patients with LVI and other factors were assigned to the high-risk group (LNM, 17.4%) while other patients as a low-risk group (LNM, 2.4%). Conclusions: Modifying the eCura system by classifying lymphatic and venous invasion as LVI successfully stratified LNM risk after non-curative ESD. Moreover, the high-risk group can be simply identified based on LVI and the presence of other risk factors.ope

Adverse Effects of Ligation of an Aberrant Left Hepatic Artery Arising from the Left Gastric Artery during Radical Gastrectomy for Gastric Cancer: a Propensity Score Matching Analysis

Purpose: No consensus exists on whether to preserve or ligate an aberrant left hepatic artery (ALHA), which is the most commonly encountered hepatic arterial variation during gastric surgery. Therefore, we aimed to evaluate the clinical effects of ALHA ligation by analyzing the perioperative outcomes. Materials and methods: We retrospectively reviewed the data of 5,310 patients who underwent subtotal/total gastrectomy for gastric cancer. Patients in whom the ALHA was ligated (n=486) were categorized into 2 groups according to peak aspartate aminotransferase (AST) or alanine aminotransferase (ALT) levels: moderate-to-severe (MS) elevation (≥5 times the upper limit of normal [ULN]; MS group, n=42) and no-to-mild (NM) elevation (<5 times the ULN; NM group, n=444). The groups were matched 1:3 using propensity score-matching analysis to minimize confounding factors that can affect the perioperative outcomes. Results: The mean operation time (P=0.646) and blood loss amount (P=0.937) were similar between the 2 groups. The length of hospital stay was longer in the MS group (13.0 vs. 7.8 days, P=0.022). No postoperative mortality occurred. The incidence of grade ≥ IIIa postoperative complications (19.0% vs. 5.1%, P=0.001), especially pulmonary complications (11.9% vs. 2.5%, P=0.003), was significantly higher in the MS group. This group also showed a higher Comprehensive Complication Index (29.0 vs. 13.9, P<0.001). Conclusions: Among patients with a ligated ALHA, those with peak AST/ALT ≥5 times the ULN showed worse perioperative outcomes in terms of hospital stay and severity of complications. More precise perioperative decision-making tools are needed to better determine whether to preserve or ligate an ALHA.ope

Intracorporeal esophagojejunostomy using a linear stapler in laparoscopic total gastrectomy: comparison with circular stapling technique

Background: Laparoscopic total gastrectomy for gastric cancer is feasible but less commonly performed compared to laparoscopic distal gastrectomy due to technical difficulties such as reconstruction. There is no standard esophagojejunal anastomosis technique in laparoscopic total gastrectomy due to a lack of evidence. Methods: We retrospectively analyzed data from 213 patients with gastric cancer who underwent laparoscopic total gastrectomy from October 2012 to December 2016. Of these, 109 and 104 patients underwent esophagojejunostomy with linear and circular stapling, respectively. We compared short-term postoperative outcomes, including surgical complications and anastomosis costs between both groups. Results: The mean operation time in the linear stapler group was longer than the circular stapler group (Linear stapler, 235.3 ± 57.9 vs. Circular stapler, 217.1 ± 55.8 min; P = 0.021); however, D2 lymph node dissection was performed more in the linear stapler group (Linear stapler, 36.7% vs. Circular stapler, 23.1%; P = 0.030). There were two anastomosis leakages in each group (Linear stapler, 1.8% vs. Circular stapler, 1.9%; P > 0.999). Anastomosis stenosis only occurred in the circular stapler group (Linear stapler, 0% vs. Circular stapler, 7.7%; P = 0.003). Although the linear stapling technique used more stapler cartridges (Linear stapler, 7.6 ± 1.1 vs. Circular stapler, 4.8 ± 0.9; P < 0.001), costs related to anastomosis were lower in the linear stapler group (Linear stapler, 1,904,679 ± 342,116 vs. Circular stapler, 2,246,150 ± 427,136KRW; P < 0.001). Conclusions: Esophagojejunostomy with the linear stapling technique reduces anastomosis stenosis in laparoscopic total gastrectomy. It can be recommended as a safe and more cost-effective method for esophagojejunal anastomosis.ope

Intracorporeal Esophagojejunostomy during Reduced-port Totally Robotic Gastrectomy for Proximal Gastric Cancer: a Novel Application of the Single-Site ® Plus 2-port System

Purpose: Intracorporeal esophagojejunostomy during reduced-port gastrectomy for proximal gastric cancer is a technically challenging technique. No study has yet reported a robotic technique for anastomosis. Therefore, to address this gap, we describe our reduced-port technique and the short-term outcomes of intracorporeal esophagojejunostomy. Materials and methods: We conducted a retrospective review of patients who underwent a totally robotic reduced-port total or proximal gastrectomy between August 2016 and March 2020. We used an infra-umbilical Single-Site® port with two additional ports on both sides of the abdomen. To transect the esophagus, a 45-mm endolinear stapler was inserted via the right abdominal port. The common channel of the esophagojejunostomy was created between the apertures in the esophagus and proximal jejunum using a 45-mm linear stapler. The entry hole was closed with a 45-mm linear stapler or robot-sewn continuous suture. All anastomoses were performed without the aid of an assistant or placement of stay sutures. Results: Among the 40 patients, there were no conversions to open, laparoscopic, or conventional 5-port robotic surgery. The median operation time and blood loss were 254 min and 50 mL, respectively. The median number of retrieved lymph nodes was 40.5. The median time to first flatus, soft diet intake, and length of hospital stay were 3, 5, and 7 days, respectively. Three (7.5%) major complications, including two anastomosis-related complications and a case of small bowel obstruction, were treated with an endoscopic procedure and re-operation, respectively. No mortality occurred during the study period. Conclusions: Intracorporeal esophagojejunostomy during reduced-port gastrectomy can be safely performed and is feasible with acceptable surgical outcomes.ope

Adverse Prognostic Impact of Postoperative Complications After Gastrectomy for Patients With Stage II/III Gastric Cancer: Analysis of Prospectively Collected Real-World Data

Background: The impact of postoperative complications on the prognosis of gastric cancer remains controversial. This study aimed to evaluate the relationship between postoperative complications and long-term survival in patients undergoing gastrectomy for stage II/III gastric cancer. Methods: Some 939 patients underwent curative gastrectomy for stage II/III gastric cancer were identified from real-world data prospectively collected between 2013 and 2015. We divided patients according to the presence of serious complications, specifically, Clavien-Dindo grade III or higher complications or those causing a hospital stay of 15 days or longer. Results: Serious complications occurred in 125 (13.3%) patients. Patients without serious complications (64.3%) completed adjuvant chemotherapy significantly more than patients with serious complications (37.6%; p<0.001). The 5-year overall survival(OS) rate was 58.1% and recurrence-free survival(RFS) rate was 58.1% in patients with serious complications, which were significantly worse than those of patients without serious complications (73.4% and 74.7%, respectively; p<0.001 for both). In stage II, once patients completed adjuvant chemotherapy adequately, the OS and RFS of patients with serious complications did not differ from those without serious complications. However, in stage III, the patients with serious complications showed a worse OS even after completion of adequate adjuvant chemotherapy. Conclusion: Serious complications after gastrectomy had a negative impact on the prognosis of stage II/III gastric cancer patients. Serious complications worsen the survival in association with inadequate adjuvant chemotherapy. Efforts to reduce serious complications, as well as support adequate chemotherapy through proper management of serious complications, would improve the prognosis of stage II/III gastric cancer patients.ope

2/3기 위암 환자에서 위 절제술 후 합병증이 예후에 미치는 부정적인 영향: 전향적으로 수집된 실제 임상 데이터의 분석

연구적 배경: 위암 환자의 예후에 대한 수술 후 합병증의 영향은 후 향적 분석에서 누락 된 데이터와 전향적 연구에서 환자 선택 편견으로 인해 논란의 여지가 있다. 본 연구는 전향적으로 수집된 실제 임상 데이터를 사용하여 2기와 3기 위암에 대해 위 절제술을 받은 환자의 대규모 코호트에서 수술 후 합병증과 장기 생존 사이의 관계를 분석하는 것을 목표로 했다. 방법: 본 연구는 2013년부터 2015년까지 2기와 3기 위암으로 위 절제술을 받은 939명의 환자를 대상으로 하였다. 재원 기간이 15일 이상인 합병증 또는 Clavien-Dindo 3등급 이상을 나타내는 serious 합병증에 따라 환자를 나누었다. 생존 결과를 그룹간에 비교하였다. Results: serious 합병증 발생률은 13.3%였다. 수술 후 보조 화학 요법의 생략, 지연 또는 중단으로 정의된 보조 화학 요법의 부적절성은 serious 합병증이 없는 환자 (n = 291, 35.7 %; p < 0.001)보다 serious 합병증이 있는 환자 (n = 78, 62.4 %)에서 더 높았다. 수술 후 평균 추적 관찰 시간은 52개월 (7-71) 이었다. serious 합병증이 있는 환자의 5년 전체 생존 (OS) 및 재발 없는 생존 (RFS)은 각각 58.1 % 및 58.1 %였고, serious 합병증이 없는 환자의 5년 OS 및 RFS은 각각 73.4, 74.7 % (p < 0.001 for OS and RFS)였다. 2기에서, 적절한 보조 화학 요법 하에서 심각한 합병증이 있는 환자는 적절한 보조 화학 요법 하에서 심각한 합병증이 없는 환자와 유사한 OS 및 RFS를 가졌다 (각각 p = 0.495, p = 0.936). 3기에서, 적절한 보조 화학 요법 하에서 심각한 합병증이 없는 환자는 적절한 보조 화학 요법 하에서 심각한 합병증이 있는 환자보다 전체 생존율이 더 우수 하였다 (p = 0.013). Conclusion: 전향적으로 수집된 실제 임상 데이터에 기반한 본 연구는 위 절제술 후 serious 합병증이 2기와 3기 위암 환자의 예후에 부정적인 영향을 미친다는 것을 나타낸다. serious 합병증은 보조 화학 요법의 부적절성에 영향을 미쳐 생존 결과를 악화시킨다. 장기 생존 결과를 높이려면 심각한 합병증을 줄이기 위한 노력이 필요하다. 또한 적절한 화학 요법을 받도록 serious 합병증이 있는 환자를 적시에 치료하는 것이 중요하다. Background: The impact of postoperative complications on the prognosis of gastric cancer patients remains controversial. This study aimed to evaluate the relationship between postoperative complications and long‐term survival in a large cohort of patients undergoing gastrectomy for stage II/III gastric cancer. Methods: A total of 939 patients who underwent curative gastrectomy for stage II/III gastric cancer were identified from prospectively collected real-world data between 2013 and 2015. We divided patients according to the presence of serious complications, specifically, Clavien-Dindo grade III or higher complications or complications causing a hospital stay of 15 days or longer. Results: Serious complications occurred in 125 (13.3%) patients, of which 86 (9.2%) experienced Clavien-Dindo grade III or higher complications and 39 (5.2%) exhibited complications causing to a hospital stay of 15 days or longer. Patients without serious complications (n=523, 64.3%) completed adjuvant chemotherapy significantly more adequately than patients with serious complications (n=47, 37.6%; p<0.001). The 5-year overall survival (OS) rate was 58.1% and the recurrence-free survival (RFS) rate was 58.1% in patients who had serious complications, which were significantly worse than those of patients without serious complications (73.4% and 74.7%, respectively; p<0.001 for OS and RFS). In stage II, once patients completed adjuvant chemotherapy adequately, the OS and RFS of patients with serious complications did not differ from those without serious complications (p=0.495, p=0.936, respectively). However, in stage III, the patients with serious complications showed a worse OS even after completion of adequate adjuvant chemotherapy (p=0.013). Conclusion: Analysis of prospectively collected real-world data revealed that serious complications after gastrectomy had a negative impact on the prognosis of patients with stage II/III gastric cancer. Serious complications worsen the survival outcomes in association with inadequate adjuvant chemotherapy. Efforts to reduce serious complications, as well as support adequate chemotherapy through proper management of serious complications, will improve the long-term survival of stage II/III gastric cancer patients.open석

[특집] 통일에 대비한 인적자원개발정책에 관한 소고

1. 들어가는 말 2. 통일과 인적자원개발 3. 북한의 일반교육 및 직업교육정책 4. 통일에 대비한 인적자원개발을 위한 정책 방향 5. 정책 과제 6. 현 단계 실행 대

D2 Lymph Node Dissections during Reduced-port Robotic Distal Subtotal a Gastrectomy and Conventional Laparoscopic Surgery Performed by a Single Surgeon in a High-volume Center: a Propensity Score-matched Analysis

Purpose: Various studies have indicated that reduced-port robotic gastrectomies are safe and feasible for treating patients with early gastric cancer. However, there have not been any comparative studies conducted that have evaluated patients with clinically advanced gastric cancer. Therefore, we aimed to compare the perioperative outcomes of D2 lymph node dissections during reduced-port robotic distal subtotal gastrectomies (RRDGs) and conventional 5-port laparoscopic distal subtotal gastrectomies (CLDGs). Materials and methods: We retrospectively evaluated 118 patients with clinically advanced gastric cancer who underwent minimally invasive distal subtotal gastrectomies with D2 lymph node dissections between February 2016 and November 2019. To evaluate the patient data, we performed a 1:1 propensity score matching (PSM) according to age, sex, body mass index, American Society of Anesthesiologists physical status classification score, and clinical T status. The short-term surgical outcomes were also compared between the two groups. Results: The PSM identified 40 pairs of patients who underwent RRDG or CLDG. The RRDG group experienced a significantly longer operation time than the CLDG group (P<0.001), although the RRDG group had significantly less estimated blood loss (P=0.034). The number of retrieved extraperigastric lymph nodes in the RRDG group was significantly higher than that of the CLDG group (P=0.008). The rate of postoperative complications was not significantly different between the two groups (P=0.115). Conclusions: D2 lymph node dissections can be safely performed during RRDGs and the perioperative outcomes appear to be comparable to those of conventional laparoscopic surgeries. Further studies are needed to compare long-term survival outcomes.ope