• Journal of Gastric Cancer
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• 제12권3호
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• pp.133-139
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• 2012

Laparoscopic gastrectomy has become widely used as a minimally invasive technique for the treatment of gastric cancer. When it was first introduced, most surgeons preferred a laparoscopic-assisted approach with a minilaparotomy rather than a totally laparoscopic procedure because of the technical challenges of achieving an intracorporeal anastomosis. Recently, with improved skills and instruments, several surgeons have reported the safety and feasibility of a totally laparoscopic gastrectomy with intracorporeal anastomosis. This review describes the recent technical advances in intracorporeal anastomoses using circular and linear staplers that allow for totally laparoscopic distal, total, and proximal gastrectomies. Data that demonstrate advantages in early surgical outcomes of a total laparoscopic method compared to laparoscopic-assisted operations are also discussed.

• Journal of Gastric Cancer
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• 제20권1호
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• pp.72-80
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• 2020

Purpose: Proximal gastrectomy (PG) is a function-preserving surgery in cases of proximally located early-stage gastric cancer. Because gastroesophageal reflux is a major pitfall of this operation, we devised a modified esophagogastrostomy (EG) anastomosis to fix the distal part of the posterior esophageal wall to the proximal part of the anterior stomach wall to produce an anti-reflux mechanism; we named this the SPADE operation. This study aimed to show demonstrate the clinical outcomes of the SPADE operation and compare them to those of previous PG cases. Materials and Methods: Case details of 56 patients who underwent PG between January 2012 and March 2018 were retrospectively reviewed: 30 underwent conventional esophagogastrostomy (CEG) anastomosis using a circular stapler, while 26 underwent the SPADE operation. Early postoperative clinical outcome-related reflux symptoms, endoscopic findings, and postoperative complications were compared in this case-control study. Results: Follow-up endoscopy showed more frequent reflux esophagitis cases in the CEG group than in the SPADE group (30% vs. 15.3%, P=0.19). Similarly, bile reflux (26.7% vs. 7.7%, P=0.08) and residual food (P=0.01) cases occurred more frequently in the CEG group than in the SPADE group. In the CEG group, 13 patients (43.3%) had mild reflux symptoms, while 3 patients (10%) had severe reflux symptoms. In the SPADE group, 3 patients (11.5%) had mild reflux symptoms, while 1 had severe reflux symptoms (absolute difference, 31.8%; 95% confidence interval, 1.11-29.64; P=0.01). Conclusions: A novel modified EG, the SPADE operation, has the potential to decrease gastroesophageal reflux following a PG.

• Journal of Gastric Cancer
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• 제21권2호
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• pp.169-178
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• 2021

Purpose: The aim of this study was to investigate the oncologic safety and identify potential candidates for proximal gastrectomy (PG) in upper third advanced gastric cancer (AGC) and esophagogastric junction (EGJ) cancers. Materials and Methods: Among 5,665 patients who underwent gastrectomy for gastric adenocarcinoma between January 2011 and December 2017, 327 patients who underwent total gastrectomy with standard lymph node (LN) dissection for upper third AGC and Siewert type II EGJ cancers were enrolled. We analyzed the correlation between the metastatic rates of distal LNs (No. 4d, 5, 6, and 12a) around the lower part of the stomach and the clinicopathological characteristics. We identified subgroups with no metastasis to the distal LNs. Results: The metastatic rate of distal LNs in proximal AGC and Siewert type II EGJ cancers was 7.0% (23 of 327 patients). On multivariate analysis, pathological T stage (P=0.001), tumor size (P=0.043), and middle third invasion (P=0.003) were significantly associated with distal LN metastases. Pathological 'T2 stage' (n=88), or 'T3 stage with ≤5 cm tumor size' (n=87) showed no metastasis in distal LNs, regardless of middle third invasion. Pathological T3 stage with tumor size > 5 cm (n=61) and T4 stage (n=91) had metastasis in the distal LNs. Conclusions: In the upper third AGC and Siewert type II EGJ cancer, pathological T2 and small-sized T3 stage groups are possible candidates for PG in cases without distal LN metastasis. Further validation studies are required for clinical application.

• Journal of Gastric Cancer
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• 제22권2호
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• pp.135-144
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• 2022

Purpose: This study aimed to compare the surgical and oncological outcomes between totally laparoscopic pylorus-preserving gastrectomy (TLPPG) with intracorporeal anastomosis and laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) with extracorporeal anastomosis. Materials and Methods: A retrospective analysis was performed in 258 patients with cT1N0 gastric cancer who underwent laparoscopic pylorus-preserving gastrectomy using two different anastomosis methods: TLPPG with intracorporeal anastomosis (n=88) and LAPPG with extracorporeal anastomosis (n=170). The following variables were compared between the two groups to assess the postoperative surgical and oncological outcomes: proximal and distal margins, number of resected lymph nodes (LNs) in total and in LN station 6, operation time, postoperative hospital stay, and postoperative morbidity including delayed gastric emptying (DGE). Results: The average length of the proximal margin was similar between the TLPPG and LAPPG groups (2.35 vs. 2.73 cm, P=0.070). Although the distal margin was significantly shorter in the TLPPG group than in the LAPPG group (3.15 vs. 4.08 cm, P=0.001), no proximal or distal resection margin-positive cases were reported in either group. The average number of resected LN was similar in both groups (36.0 vs. 33.98, P=0.229; LN station 6, 5.72 vs. 5.33, P=0.399). The operation time was shorter in the TLPPG group than in the LAPPG (200.17 vs. 220.80 minutes, P=0.001). No significant differences were observed between the two groups in terms of postoperative hospital stay (9.38 vs. 10.10 days, P=0.426) and surgical complication rate (19.3% vs. 22.9%), including DGE (8.0% vs. 11.8%, P=0.343). Conclusions: The oncological safety and postoperative complications of TLPPG with intracorporeal anastomosis are similar to those of LAPPG with extracorporeal anastomosis.

• Journal of Gastric Cancer
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• 제19권1호
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• pp.49-61
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• 2019

Purpose: The perigastric vagus nerve may play an important role in preserving function after gastrectomy, and intraoperative neurophysiologic tests might represent a feasible method of evaluating the vagus nerve. The purpose of this study is to assess the feasibility of neurophysiologic evaluations of the function and viability of perigastric vagus nerve branches during gastrectomy. Materials and Methods: Thirteen patients (1 open total gastrectomy, 1 laparoscopic total gastrectomy, and 11 laparoscopic distal gastrectomy) were prospectively enrolled. The hepatic and celiac branches of the vagus nerve were exposed, and grabbing type stimulation electrodes were applied as follows: 10-30 mA intensity, 4 trains, $1,000{\mu}s/train$, and $5{\times}$frequency. Visible myocontractile movement and electrical signals were monitored via needle probes before and after gastrectomy. Gastrointestinal symptoms were evaluated preoperatively and postoperatively at 3 weeks and 3 months, respectively. Results: Responses were observed after stimulating the celiac branch in 10, 9, 10, and 6 patients in the antrum, pylorus, duodenum, and proximal jejunum, respectively. Ten patients responded to hepatic branch stimulation at the duodenum. After vagus-preserving distal gastrectomy, 2 patients lost responses to the celiac branch at the duodenum and jejunum (1 each), and 1 patient lost response to the hepatic branch at the duodenum. Significant procedure-related complications and meaningful postoperative diarrhea were not observed. Conclusions: Intraoperative neurophysiologic testing seems to be a feasible methodology for monitoring the perigastric vagus nerves. Innervation of the duodenum via the celiac branch and postoperative preservation of the function of the vagus nerves were confirmed in most patients.

• Journal of Gastric Cancer
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• 제1권3호
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• pp.168-173
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• 2001

Purpose: A positive esophageal margin is encountered in a total gastrectomy not infrequently. The aim of this retrospective review was to evaluate whether a positive esophageal margin predisposes a patient to loco-regional recurrence and whether it has an independent impact on long-term survival. Materials and Methods: A retrospective review of 224 total gastrectomies for adenocarcinomas was undertaken. The Chisquare test was used to determine the statistical significance of differences, and the Kaplan-Meier method was used to calculate survival rates. Significant differences in the survival rates were assessed using the log-rank test, and independent prognostic significance was evaluated using the Cox regression method. Results: The prevalence of esophageal margin involvement was $3.6\%$ (8/224). Univariate analysis showed that advanced stage (stage III/IV), tumor size ($\geq$5 cm), tumor site (whole or upper one-third of the stomach), macroscopic type (Borrmann type 4), esophageal invasion, esophageal margin involvement, lymphatic invasion, and venous invasion affected survival. Multivariate analysis demonstrated that TNM stage, venous invasion, and esophageal margin involvement were the only significant factors influencing the prognosis. All patients with a positive esophageal margin died with metastasis before local recurrence became a problem. A macroscopic proximal distance of more than 6 cm of esophagus was needed to be free of tumors, excluding one exceptional case which involved 15 cm of esophagus. Conclusion: All of the patients with a positive proximal resection margin after a total gastrectomy had advanced disease with a poor prognosis, but they were not predisposed to anastomotic recurrence. Early detection and extended, but reasonable, surgical resection of curable lesions are mandatory to improve the prognosis.

• Journal of Gastric Cancer
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• 제15권2호
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• pp.132-138
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• 2015

Single-incision laparoscopic total gastrectomy for gastric cancer has recently been reported by Seoul National University Bundang Hospital. However, this is not a popular procedure primarily because of the technical difficulties involved in achieving consistent intracorporeal esophagojejunostomy. At Seoul National University Bundang Hospital, we recently introduced a simple, easy-to-use, low-profile laparoscopic manual scope holder that enables the maintenance of a stable field of view, the most demanding condition in single-port gastrectomy. In this technical report, we describe in detail the world's first solo single-incision laparoscopic total gastrectomy with D1+ lymph node dissection and intracorporeal esophagojejunostomy for proximal early gastric cancer.

• Journal of Gastric Cancer
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• 제23권2호
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• pp.253-263
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• 2023

Purpose: Although chylous ascites is a frequent complication of radical gastrectomy for gastric cancer, proper diagnostic criteria and optimal treatment strategies have not been established. This study aimed to identify the clinical features of chylous ascites and evaluate the treatment outcomes. Materials and Methods: We retrospectively analyzed the data of patients who underwent radical gastrectomy between 2013 and 2019. Diagnosis was made when milky fluid or elevated triglyceride levels (≥100 mg/dL) appeared in the drains without a preceding infection. The clinical features, risk factors, and treatment outcomes were assessed according to the initial treatment modalities for fasting and non-fasting groups. Results: Among the 7,388 patients who underwent radical gastrectomy for gastric cancer, 156 (2.1%) experienced chylous ascites. The median length of hospital stay was longer in patients with chylous ascites than in those without (median [interquartile range]: 8.0 [6.0-12.0] vs. 6.0 [5.0-8.0], P<0.001). Low body mass index (adjusted odds ratio [aOR]=0.9; P<0.001), advanced gastric cancer (aOR=1.51, P=0.024), open surgery (reference: laparoscopic surgery; aOR=1.87, P=0.003), and extent of surgical resection (reference: subtotal gastrectomy, total gastrectomy, aOR=1.5, P=0.029; proximal gastrectomy, aOR=2.93, P=0.002) were associated with the occurrence of chylous ascites. The fasting group (n=12) was hospitalized for a longer period than the non-fasting group (n=144) (15.0 [12.5-19.5] vs. 8.0 [6.0-10.0], P<0.001). There was no difference in grade III complication rate (16.7% vs. 4.2%, P=0.117) or readmission rate (16.7% vs. 11.1%, P=0.632) between the groups. Conclusions: A fat-controlled diet and medication without fasting provided adequate initial treatment for chylous ascites after radical gastrectomy for gastric cancer.

• Journal of Gastric Cancer
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• 제6권1호
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• pp.1-5
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• 2006

목적: 근위부 위절제술 후 식도-위 문합술을 시행받은 환자에서 문합부 협착, 역류성 식도염 등이 드물지 않게 발생한다. 저자들 역시 이러한 합병증을 경험하였고 이를 극복하기 위한 방법으로 공장간치술을 시행하였으며 식도-위 문합술과 공장간치술 간의 경과 관찰을 통해 보다 나은 재건 술식을 찾고자 하였다. 대상 및 방법: 1998년 6월부터 2002년 12월까지 울산의대 서울아산병원 외과에서 상부위암 혹은 위상부의 위장관기질종양으로 진단받고 근위부 위절제술을 시행한 환자를 대상으로 재건 술식에 따른 수술시간, 수술 후 증상, 체중변화, 추적관찰 시 시행한 내시경 소견 등을 비교하였다. 결과: 대상 환자 총 33명의 평균연령은 59세였고, 남녀 비는 3 : 1이었다. 식도-위 문합술을 시행한 환자는 25명, 공장간치술을 시행한 환자는 8명이었다. 통과장애, 속쓰림, 신트림, 구토 등의 증상을 관찰하였으며 식도-위 문합술 환자에서 통과장애 12예, 구토 3예, 속쓰림 4예, 신트림 4예가 관찰되었으며, 공장간치술 환자에서는 통과장애 12예, 구토 3예가 있었고, 속쓰림과 신트림은 관찰되지 않았다. 수술 후 체중변화는 1개월 후 수술 전 체중의 90%까지 감소한 경우가 식도-위 문합술 환자에서 7예, 공장간치술 환자에서 없었다. 수술 후 추적 내시경 검사 결과 역류성 식도염이 관찰된 경우는 식도-위 문합술 환자에서 9예, 공장간치술 환자에서 0예였다. 문합부위 협착으로 인해 풍선 확장술이 필요하였던 경우가 식도-위 문합술 환자에서 4예, 공장간치술 환자에서 1예가 있었다. 결론: 상부 위절제 시 재건방법으로 역류성 식도염 및 여러 소화기 증상을 예방하기 위해 공장간치술이 식도-위문합술의 대안이 될 수 있다고 생각한다. 하지만 통계적 유의성을 가지기 위해 더 많은 대상군이 포함되어야 할 것이다.

• Journal of Gastric Cancer
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• 제15권1호
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• pp.53-57
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• 2015

Laparoscopic distal gastrectomy has become widespread as a treatment for early gastric cancer in eastern Asia, but a standard method for setting the stomach transection line has not been established. Here we report a novel method of setting this line based on anatomical landmarks. At the start of the operation, two anatomical landmarks along the greater curvature of the stomach were marked with ink: the proximal landmark at the avascular area between the last branch of the short gastric artery and the first branch of the left gastroepiploic artery, and the distal landmark at the point of communication between the right and left gastroepiploic arteries. Just before specimen retrieval, the stomach was transected from the center of these two landmarks toward the lesser curvature. Then, about two-third of the stomach was reproducibly resected, and gastroduodenostomy was successfully performed in 26 consecutive cases. This novel method could be used as a standard technique for setting the transection line in laparoscopic distal gastrectomy.