Laparoscopic Gastrectomy for Cancer: Standard Techniques and Clinical Evidences

The first laparoscopy-assisted gastrectomy for gastric cancer was performed in Japan in 1991. In the ensuing 20 years, at first through a process of trial and error, then through the sharing of master surgeons’ accumulated experience, the procedure has been honed and refined to its current high level. From the beginning, it soon became evident that this much less invasive form of gastrectomy, in comparison with traditional open surgery, led to improved quality of life for postsurgical patients, and use of the procedure spread rapidly among gastric surgeons.  Early on, however, there were calls for the establishment of standard techniques and procedures to be followed, with a recognized need to improve the level of safety and the quality of lymph node dissection for local control in cancer treatment. Toward that end, the Laparoscopy-Assisted  Gastrectomy Club  was formed in 1999. In the following year, because both Japan and Korea experience a high rate of gastric cancer, specialists from those two nations came together to form the Japan–Korea  Laparoscopic  Gastrectomy  Joint Seminar, to facilitate and encourage the exchange of vital information. The result has been to achieve an evolving consensus among specialists in the field of endoscopic surgery in Japan and Korea with expertise that can be shared worldwide. A compilation of the current state-of-the-art is now presented in this volume, with accompanying DVD, which will be of great value to all endoscopic surgeons who perform laparoscopic gastrectomy.

• Language: English
• Publisher: Springer
• Release date: Jul 16, 2012
• ISBN: 9784431540038

Book preview

Seigo Kitano and Han-Kwang Yang (eds.)Laparoscopic Gastrectomy for CancerStandard Techniques and Clinical Evidences10.1007/978-4-431-54003-8_1© Springer 2012

1. Trends in Laparoscopic Gastrectomy in Japan

Seigo Kitano¹  

(1)

Oita University, 1-1, Idaigaoka, Hasama-machi, Oita 879-5593, Japan

Seigo Kitano

Email: [e-mail]

Abstract

Laparoscopic gastrectomy for gastric cancer was developed in Japan. Laparoscopic wedge resection of the stomach was developed in 1992, intragastric mucosal resection in 1993, and LADG in 1991. Each has become an important operation [1–3]. Because lymph node dissection is not performed during the first two procedures, these procedures apply only to lesions that display no danger of lymph node metastasis. Therefore, mucosal cancer not treatable by endoscopic submucosal dissection because of the location and size of the lesion can be treated by LADG. Lymph node dissection during LADG was first attempted for treatment of early gastric cancer, which requires preventive lymph node dissection.

1.1 Development of Laparoscopic Gastrectomy in Japan

Laparoscopic gastrectomy for gastric cancer was developed in Japan. Laparoscopic wedge resection of the stomach was developed in 1992, intragastric mucosal resection in 1993, and LADG in 1991. Each has become an important operation [1–3]. Because lymph node dissection is not performed during the first two procedures, these procedures apply only to lesions that display no danger of lymph node metastasis. Therefore, mucosal cancer not treatable by endoscopic submucosal dissection because of the location and size of the lesion can be treated by LADG. Lymph node dissection during LADG was first attempted for treatment of early gastric cancer, which requires preventive lymph node dissection.

The use of laparoscopic gastrectomy for treating gastric cancer has spread rapidly in Japan owing to the support of the instrument manufacturers, foundation of the technical authorization system which is presided over by the Japan Society of Endoscopic Surgery (JSES), and the activity of the Japan Laparoscopic Surgery Study Group (JLSSG) in establishing the standard operation and verifying its technical and oncological feasibility (Fig. 1.1). Laparoscopic gastrectomy has rapidly come into widespread use throughout the Asian region owing to the activities of the Japan–Korea Laparoscopic Surgery Study Group and the Asia Endosurgery Task Force (Fig. 1.2).

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Fig. 1.1

Laparoscopic surgery for gastric cancer

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Fig. 1.2

Study groups for promoting laparoscopy-assisted distal gastrectomy (LADG)

1.2 Present Status of Laparoscopic Gastrectomy in Japan

The JSES performs a national survey by questionnaire once each year. The tenth national survey in 2010 is shown in Fig. 1.1 [4]. According to the results of this survey, a total of 34,645 laparoscopic gastrectomies had been performed for gastric cancer since 1991, with 7,341 having been performed during 2009. This is an approximately tenfold increase over a 10-year period. The number of LADGs in which lymph node dissection was performed has increased markedly as well, with 5,866 of these operations undertaken during 2009.

With standardization of the laparoscopic gastrectomy technique, approximately 25% of gastrectomies for gastric cancer are being treated laparoscopically (Fig. 1.3). Hence, if the technical safety and the technical and oncological feasibility of this procedure are established by a randomized controlled trial (RCT) that compares laparoscopic gastrectomy to open gastrectomy, more gastric cancer patients can experience the benefits of the minimal invasiveness offered by laparoscopic gastrectomy.

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Fig. 1.3

Percentage of LADGs among all surgical treatments

1.3 Laparoscopic Distal Gastrectomy for Cancer

Gastric cancer is frequently located in the area starting from the angle of the lesser curvature and proceeding to the antrum of the stomach. Therefore, laparoscopic gastrectomy for gastric cancer starts with distal gastrectomy. Because the reconstruction method following distal gastrectomy is a complex procedure, it is performed by mini-laparotomy (LADG).

Initially, during the 1990s LADG was indicated as a treatment only for early gastric cancer, and lymph node dissection was limited to the perigastric and nos. 7, 8a, and 9 lymph nodes. This procedure is now termed D1, D1 + α (no. 7), and D1 + β (nos. 7, 8a, 9) lymph node dissection. During the 2000s, with the improvement in surgical skills the number of facilities that treat advanced cancer has increased. Therefore, D1 + β and D2 lymph node dissection are now being performed by laparoscopic techniques. According to the tenth national JSES survey, D1 + β and D2 lymph node dissection are performed during approximately 44 and 35% of LADGs, respectively (Fig. 1.4).

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Fig. 1.4

LADG, including lymph node dissection

Improved surgical skills resulted in increased safety during the performance of LADG. In the tenth national survey, the intraoperative and postoperative morbidity rates had decreased to 1.1 and 7.5%, respectively, compared to the corresponding figures of 2.9 and 15.5% in the sixth national survey (Table 1.1). The safety of LADG was demonstrated in the Phase I study performed by the Japan Clinical Oncological Group (JCOG) [5]. The development of laparoscopy coagulation shears, laparoscopy-specific operating instruments for dissection, a vessel sealing system, and reconstruction methods that make use of auto-suture devices have contributed to the overall improvement in safety.

Table 1.1

Complications of laparoscopy-assisted distal gastrectomy

(JSES, 10th national survey)

A number of retrospective studies and four RCTs comparing the minimal invasiveness of LADG with open distal gastrectomy have been performed. Meta-analyses of these studies have shown the minimal invasiveness of LADG [6]. Although there are only a few reports on long-term survival following LADG, multicenter joint research in Japan showed the oncological feasibility of LADG to treat early cancer [7]. The JCOG confirmed this result, and the JLSSG has confirmed the oncological feasibility of LADG for the treatment of advanced cancer.

1.4 Laparoscopic Total or Proximal Gastrectomy

Now that the skill set for LADG has been established, laparoscopic techniques are beginning to be used for total gastrectomy and proximal gastrectomy as well. However, a standard reconstruction technique has not yet been developed for either procedure.

Laparoscopy-assisted total gastrectomy is used to treat early proximal cancer and advanced cancer. The goal of this procedure is reconstruction; especially, it is necessary to establish a safe method of performing esophagojejunal anastomosis. According to the tenth national survey of the JSES, it has been performed so far in 3,216 cases. During 2009, it was performed in 1,103 cases, and the number of cases has been gradually increasing (Fig. 1.1). Further increase is expected in the future.

Laparoscopic proximal gastrectomy is performed when early proximal gastrectomy is not adaptable to endoscopic submucosal dissection. Reconstruction methods performed by laparoscopic techniques include reconstruction with a gastric tube, esophagogastric anastomosis, and jejunal interposition. From the standpoints of nutrition and technical safety, however, standardized techniques have not yet been established.

1.5 Laparoscopic Gastrectomy in the Future

Laparoscopic gastrectomy, whose use was initiated in Japan in 1991, has evolved into an operation for extended lymph node dissection and treatment of gastric cancer located in the proximal stomach. If the laparoscopic gastrectomy techniques can be standardized and its safety and technical and oncological feasibility are proved, use of this operative procedure will increase. It is likely that in the near future all patients with gastric cancer will be treated by minimally invasive operations such as laparoscopic gastrectomy.

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Ohgami M, Otani Y, Furukawa T et al (2000) Curative laparoscopic surgery for early gastric cancer: eight years experience. Nippon Geka Gakkai Zasshi 101:539–545 (in Japanese)PubMed

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Ohashi S (1995) Laparoscopic intraluminal (intragastric) surgery for early gastric cancer. Surg Endosc 9:169–171PubMedCrossRef

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Kitano S, Iso Y, Moriyama M et al (1994) Laparoscopy-assisted Billroth I gastrectomy. Surg Laparosc Endosc 4:146–148PubMed

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Kurokawa Y, Katai H, Fukuda H et al (2008) Phase II study of laparoscopy-assisted distal gastrectomy with nodal dissection for clinical stage I gastric cancer: Japan Clinical Oncology Group Study JCOG0703. Jpn J Clin Oncol 36:501–503CrossRef

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Hosono S, Arimoto Y, Ohtani H et al (2006) Meta-analysis of short-term outcomes after laparoscopy-assisted distal gastrectomy. World J Gastroenterol 12:7676–7683PubMed

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Kitano S, Shiraishi N, Uyama I et al (2007) A multicenter study on oncologic outcome of laparoscopic gastrectomy for early cancer in Japan. Ann Surg 245:68–72PubMedCrossRef

Seigo Kitano and Han-Kwang Yang (eds.)Laparoscopic Gastrectomy for CancerStandard Techniques and Clinical Evidences10.1007/978-4-431-54003-8_2© Springer 2012

2. Trends of Laparoscopic Gastrectomy in Korea

Han-Kwang Yang¹  

(1)

Department of Surgery, Seoul National University College of Medicine and Cancer Research Institute, Seoul, Korea

Han-Kwang Yang

Email: [e-mail]

Abstract

The incidence of early gastric cancer in Korea increased to 47.4% in 2004 and 57.7% in 2009 because of the development of diagnostic tools and increased health screening [1]. Following the successful introduction of laparoscopic gastrectomy for early gastric cancer by Kitano et al. in 1991, laparoscopic gastrectomy has become popular in the field of gastric cancer. The aims of laparoscopic surgery for gastric cancer are to minimize the surgical insult and to maximize the patients’ quality of life while not influencing radicality or survival.

2.1 Introduction

The incidence of early gastric cancer in Korea increased to 47.4% in 2004 and 57.7% in 2009 because of the development of diagnostic tools and increased health screening [1]. Following the successful introduction of laparoscopic gastrectomy for early gastric cancer by Kitano et al. in 1991, laparoscopic gastrectomy has become popular in the field of gastric cancer. The aims of laparoscopic surgery for gastric cancer are to minimize the surgical insult and to maximize the patients’ quality of life while not influencing radicality or survival. The advantages of laparoscopic surgery are less postoperative pain, less inflammatory reaction, rapid recovery of bowel function, short hospital stay, well-preserved immune function, better cosmesis, and a rapid return to normal social activity.

2.2 Laparoscopic Gastric Surgery in Korea

According to the Korean Laparoendoscopic Gastrointestinal Surgery Study Group (KLASS) survey, 3,083 (25.8% of total gastric cancer operations) laparoscopic gastric cancer surgeries were performed during 2009 (Fig. 2.1). The number in 2009 is almost five times the number performed during 2004. The cumulative number from 1995 to 2009 was about 14,731. Since 2006, when medical insurance began to cover them, laparoscopic procedures for gastric cancer have been widely adopted in Korea. Laparoscopic total gastrectomy was rapidly adopted since 2003 (20 cases in 2003, 112 cases in 2004, and 231 cases in 2008). However, laparoscopic function-preserving gastrectomy, which included laparoscopy-assisted pylorus-preserving gastrectomy and laparoscopy-assisted proximal gastrectomy, were performed infrequently. Hand-assisted laparoscopic surgery was rarely performed. In terms of the indications of laparoscopic gastric surgery for adenocarcinoma, 21 surgeons performed laparoscopic gastrectomy only for a T1 lesion, 17 surgeons extended their indications to T2 lesions, and two surgeons to more than T2.

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Fig. 2.1

Total number of laparoscopic gastric operations for gastric cancer in Korea

2.3 Standards of Practice in Laparoscopic Gastric Cancer Surgery in Korea

Fourteen gastric surgeons from 14 institutions participated in the survey of Standards of Practice in Laparoscopic Gastric Cancer Surgery in 2009. The results were presented at the fourth Korea–Japan Laparoscopic Gastric Cancer Surgery Joint Seminar. Regarding preoperative evaluation, endoscopic ultrasonography was performed in 71.4%, endoscopic clipping in 78.6%, and a nasogastric tube was inserted in 28.6%. The indications of laparoscopic gastrectomy were as follows: T2N0 in 42.9% (6/14) and T3 in 14.3%. For prevention of deep vein thrombosis, stockings were used in 92.3% and low-molecular-weight heparin was applied in 30.8%. In terms of the operation, the supine position was used in 71.4% and the semi-lithotomy position in 28.6%. Mini-laparotomy during laparoscopy-assisted distal gastrectomy (LADG) was performed in 92.9%, and the common wound length was about 5 cm. For anastomosis, 78.6% was extracorporeal; and the proportion of Billroth I and Billroth II was 7:2. D1+ β lymph node dissection was the most common, and the indications for D2 dissection were submucosal invasion, advanced gastric cancer, and lymph node enlargement. As for postoperative management, sips of water started at postoperative day (POD) 2.32 ± 0.46, and a soft diet started at POD 3.54 ± 0.63. The drain was removed at POD 3.92 ± 1.22. Pain killers were used up to POD 2.96 ± 1.35 and antibiotics up to POD 2.39 ± 1.33. Patient discharged on POD 6.54 ± 1.03.

2.4 Korean Studies on Laparoscopic Gastric Cancer Surgery

Many retrospective multicenter studies on laparoscopic gastric cancer surgery were conducted in Korea [2–8]. Two small randomized controlled trials (RCTs) comparing LADG and open distal gastrectomy (ODG) were reported [9, 10]. According to a Korean retrospective multicenter study, morbidity and mortality were 13.1 and 0.7%, respectively [3]. The KLASS proposed a multiinstitutional prospective randomized trial comparing LADG versus ODG for gastric cancer (KLASS Trial) after the feasibility and validity of these procedures had been evaluated by analyzing retrospective multicenter large series. According to the interim analysis of the KLASS trial, including 179 LADG and 163 ODG patients, there was no significant difference between the two groups in terms of age, sex, or comorbidity. Postoperative complication rates for the LADG and ODG groups were 10.5% (17/179) and 14.7% (24/163), respectively (P = 0.137). Postoperative mortality was 1.1% (2/179) in the LADG group and 0% (0/163) for the ODG patients (P = 0.497). There was no significant difference in the morbidity and mortality rates between LADG and ODG patients [11]. The KLASS trial completed the enrollment of patients in 2010 and will disclose level 1 evidence about the oncological feasibility of LADG for early gastric cancer. Another KLASS trial on LADG for advanced gastric cancer has started in Korea.

2.5 Education in Laparoscopic Gastric Surgery

As the number of laparoscopic gastric surgeries has increased rapidly, the importance of education regarding laparoscopic skills has heightened. There are various tools for education about laparoscopic gastric surgery such as the box trainer, cadaveric model, anesthetized pig model, and virtual reality systems. Because many domestic training workshop programs have been actively held in Korea, beginners can overcome a learning curve in laparoscopic gastric surgery easily and quickly.

2.6 International Collaboration for Laparoscopic Gastric Surgery

Active international joint meetings provide opportunities to network each nation. For example, The fifth Japan–Korea Laparoscopic Gastric Surgery Joint Seminar held in Nagasaki, February 2010, was a valuable gathering where leading Japanese and Korean laparoscopic gastric surgeons exchanged their experiences and state of the art skills. The participants agreed to publish an English-language textbook on laparoscopic gastric surgery and collaboration of clinical data in the future, with contributions from both Korea and Japan. In a Kanto LAG meeting in November 2009, there was a joint video session connected by high-speed Internet between the Kanto LAG group and KLASS. Internet video conferencing is convenient as well as economical.

2.7 Robotic Surgery

Robotic surgery may give surgeons a technical solution to overcoming the shortcomings of conventional laparoscopic surgery. These solutions consist of three-dimensional imaging, a steady camera platform, surgical instruments with hand-like motions, removing motion reversal, resting tremor filtration, and an ergonomically comfortable position for the surgeon. Robotic surgery was applied to gastric cancer earlier in Korea than in other country. Technical feasibilities of robotic gastrectomy for gastric cancer have been reported [12–14]. In Korea, about 50 daVinci robots have been introduced at leading hospitals and are currently being used for gastric procedures. Korean Robot Gastrecomy Study Group is conducting a clinical study to explore the role of robot in gastrectomy.

2.8 Conclusions

Laparoscopic gastrectomies are widely performed in Korea because of a high incidence of early gastric cancer. Short-term and long-term outcomes after laparoscopic surgery for gastric cancer have been actively reported, but we are awaiting for the results of multicenter RCTs, including the KLASS trial. Education, including domestic training workshops and international collaboration, promise to aid in the progression of advanced laparoscopic gastric surgery with robots and augmented reality surgery.

References

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Korean Gastric Cancer Association Information Committee (2007) 2004 nationwide gastric cancer report in Korea. J Korean Gastric Cancer Assoc 7:47–54

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Song KY, Hyung WJ, Kim HH et al (2008) Is gastrectomy mandatory for all residual or recurrent gastric cancer following endoscopic resection? A large-scale Korean multi-center study. J Surg Oncol 98:6–10PubMedCrossRef

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Kim W, Song KY, Lee HJ et al (2008) The impact of comorbidity on surgical outcomes in laparoscopy-assisted distal gastrectomy: a retrospective analysis of multicenter results. Ann Surg 248:793–799PubMedCrossRef

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Kim MC, Kim W, Kim HH et al (2008) Risk factors associated with complication following laparoscopy-assisted gastrectomy for gastric cancer: a large-scale Korean multicenter study. Ann Surg Oncol 15:2692–2700PubMedCrossRef

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Lee HJ, Kim HH, Kim MC et al (2009) The impact of a high body mass index on laparoscopy assisted gastrectomy for gastric cancer. Surg Endosc 23:2473–2479PubMedCrossRef

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Jeong GA, Cho GS, Kim HH et al (2009) Laparoscopy-assisted total gastrectomy for gastric cancer: a multicenter retrospective analysis. Surgery 146:469–474PubMedCrossRef

7.

Cho GS, Kim W, Kim HH et al (2009) Multicentre study of the safety of laparoscopic subtotal gastrectomy for gastric cancer in the elderly. Br J Surg 96:1437–1442PubMedCrossRef

8.

Song J, Lee HJ, Cho GS et al (2010) Recurrence following laparoscopy-assisted gastrectomy for gastric cancer: a multicenter retrospective analysis of 1,417 patients. Ann Surg Oncol 17:1777–1786PubMedCrossRef

9.

Lee JH, Han HS, Lee JH (2005) A prospective randomized study comparing open versus laparoscopy-assisted distal gastrectomy in early gastric cancer: early results. Surg Endosc 19:168–173PubMedCrossRef

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Kim YW, Baik YH, Yun YH et al (2008) Improved quality of life outcomes after laparoscopy-assisted distal gastrectomy for early gastric cancer: results of a prospective randomized clinical trial. Ann Surg 248:721–727PubMedCrossRef

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Kim HH, Hyung WJ, Cho GS et al (2010) Morbidity and mortality of laparoscopic gastrectomy versus open gastrectomy for gastric cancer: an interim report: a phase III multicenter, prospective, randomized Trial (KLASS Trial). Ann Surg 251:417–420PubMedCrossRef

12.

Song J, Oh SJ, Kang WH et al (2009) Robot-assisted gastrectomy with lymph node dissection for gastric cancer: lessons learned from an initial 100 consecutive procedures. Ann Surg 249:927–932PubMedCrossRef

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Kim MC, Heo GU, Jung GJ (2010) Robotic gastrectomy for gastric cancer: surgical techniques and clinical merits. Surg Endosc 24:610–615PubMedCrossRef

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Hur H, Kim JY, Cho YK et al (2010) Technical feasibility of robot-sewn anastomosis in robotic surgery for gastric cancer. J Laparoendosc Adv Surg Tech A 20(8):693–697PubMedCrossRef

Part 2

Indications for Laparoscopic