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.
Gastric adenocarcinoma (GA) is a leading cause of cancer-related deaths all over the world [
This study was conducted during the period from May 2013 to August 2016. It included 27 patients presented by GA to General Surgery Department, Tanta University Hospital, Egypt and Hamad General Hospital, Hamad Medical Corporation, Qatar. All the patients were submitted to full history taking and thorough clinical examination. All the patients had upper gastrointestinal endoscopy and the gastric cancer was biopsied. Histopathological examination confirmed the diagnosis of GA in all patients. Computed tomography (CT) scans of the chest, abdomen and pelvis were obtained to assess the local extent and to exclude distant spread of the tumor. When distant spread was suspected on CT scan, positron emission tomography/CT (PET/CT) was performed before proceeding to curative resection. The cT and cN stage of the tumor were assessed using endoscopic ultrasonography (EUA) in all patients. Baseline carcinoembryonic antigen (CEA) level was done for all patients.
Patients with early (cT1) and locally advanced (cT2, cT3) GA involving the distal two thirds of the stomach without distant metastasis (cM0) were included in the study. Exclusion criteria included cT4 tumors, cM1 tumors, recurrent tumors, tumors located in the proximal third of the stomach and other types of gastric cancers (lymphoma, carcinoid and gastrointestinal stromal tumors). Patients with previous upper abdominal surgery and those with American Society of Anaesthiologists (ASA) score more than 3, were also excluded.
All the cases were discussed in a multi-disciplinary team meeting and the decision was surgical resection for all of them. An informed written consent was obtained from every patient and the study design was approved by the research and ethical committees.
Patients fulfilling selection criteria were divided randomly into 2 groups using the closed envelop method:
・ Group A: included 15 patients. In this group, surgery started with staging laparoscopy and when intra-abdominal disease spread was excluded, the surgeon proceeded to midline laparotomy with distal gastrectomy and D2 LN dissection.
・ Group B: included 12 patients who were submitted to LDG with D2 LN dissection after exclusion of distant intra-abdominal tumor spread.
All patients received prophylactic antibiotics in the form of Ceftriaxone 2 gm and Metronidazole 500 mg intravenously on anesthesia induction. In group (B), the patient was placed in Llyod Davies position, the surgeon stood between the patients, legs with the assistant on the left side and the camera holder on the right side. A thirty degree 10-mm telescope was inserted through a 10-mm port placed 1-cm below the umbilicus. Two 12-mm trocars were inserted 5-cm below the right and left costal margin in the anterior axillary line for the surgeon’s hands. A 5-mm trocar is then inserted in the left mid-axillary line 2-cm below the costal margin for the assistant. Another 5-mm trocar is inserted 3 cm below the xiphoid process to the left of the midline for liver retraction.
The procedure started in all the cases by staging laparoscopy to exclude intra-abdominal spread [
gastric division was done, at least, 4 cm proximal to the gross margin of the tumor by repeated firings of the endo-GIA stapler [
hepato-renal space and the lesser sac and the wounds were closed in layers.
In group (A), the abdomen was accessed through a midline incision extending from the Xiphoid process to few centimeters below the umbilicus. The conduct of the procedure is the same as in the laparoscopic approach.
In both groups, the monopolar diathermy, the HarmonicTM Ultrasonic Shear (Johnson and Johnson Medical, Ethicon, Cincinnati, OH, USA) or the ForceTraidTM (Vallelab, Covidien, Minneapolis, USA) were used for dissection and haemostasis. The operative time, the intra-operative blood loss and any intra- operative complications were recorded.
Post-operatively, patients were put on Ceftriaxone 1 gm IV/24 hours and Metronidazole 500 mg IV/8 hours for 24 hours. Postoperative analgesia was provided in the form of Paracetamol 1 gm IV/6 hours and Morphine 5 mg SC/6 hours on-demand according to the severity of pain. After return of normal gastrointestinal motility, the nasogastric tube was removed and the patients were allowed oral intake with clear fluids increased gradually to full diet over the next few days. The abdominal drain was removed when patients tolerated clear oral fluids provided there was no leak. Patients were discharged home when they were self-dependent, with no or mild pain, tolerated oral intake with no surgical complications.
Postoperative pain severity was assessed using the Visual Analogue Scale (VAS) at 24 hours, 3 and 7 days after the surgery. Postoperative data collected included the severity of postoperative pain as assessed by the VAS, the number of narcotic analgesic injections needed on demand, the time of return of postoperative bowel motility, the postoperative complications, and the length of postoperative hospital stay.
Data were tabulated and analyzed using SPSS Statistics software package version 20. Metric and ordinal data were presented as range and median while nominal data were expressed as percentage. Mann-Whitney test was used to compare metric data while two sample t-test was used to compare ordinal data. P value of less than 0.05 was considered statistically significant.
This study included two matched groups of patients; Group A included 15 patients submitted to open distal gastrectomy and D2 LN dissection and Group B included 12 patients submitted to LDG and D2 LN dissection. The age of the patients in group A ranged from 41 to 67 years with a median of 54 years and male: female ratio of 9:6. In group B, the age ranged from 47 to 60 years with a median of 54.3 years and male: female ratio of 7:5. Associated co-morbidities and the ASA class of patients in the 2 groups were shown in
The operative time in group A ranged from 100 to 143 minutes with a median of 118.7 minutes. The intra-operative blood loss ranged from 120 to 180 ml with a median of 152.2 ml. The length of the safety margin ranged from 5.6 to 7.8 with a median of 6.52 cm from the proximal edge of gross tumor. The number of dissected LNs ranged from 18 to 33 with a median of 24.2 LNs. No operative complications were recorded. In group B, the operative time ranged from 185 to 255 minutes with a median of 210.2 minutes. The intra-operative blood loss ranged from 66 to 95 ml with a median of 78.3 ml. The length of the safety margin ranged from 5.2 to 7.1 cm with a median of 5.7 cm. The number of dissected LNs ranged between 17 and 31 with a median of 21.4 LNs. No conversion to laparotomy was needed. One patient developed intraoperative bleeding from the right gastric artery during lesser sac dissection. It was successfully controlled by vascular clips. The differences between the 2 groups in the median operative time and the median intra-operative blood loss were statistically significant
Variable | Group A (No. = 15) | Group B (No. = 12) | P value | ||
---|---|---|---|---|---|
No | % | No | % | ||
Age (years) ・ Range ・ Median | 41 - 67 54 | 47 - 60 54.3 | 0.904 | ||
Sex ・ Male ・ Female | 9 6 | 60 40 | 7 5 | 58.3 41.6 | 0.089 0.084 |
Co-Morbidities ・ Diabetes Mellitus ・ Hypertension ・ Arrhythmia ・ Coronary Artery Disease | 10 3 4 1 2 | 66.6 20 26.6 6.6 13.3 | 6 2 3 0 1 | 50 16.6 25 0 8.3 | 0.872 |
ASA Score ・ I ・ II ・ III | 3 8 4 | 20 53.3 26.6 | 3 6 3 | 25 50 25 | 0.311 0.171 0.094 |
(118.7 vs 210.2 minutes; P < 0.01 and 152.2 vs 78.3 ml; P < 0.01 respectively). On the other hand, the differences between the two groups in the median number of intraoperative complication, tumor grade, pT stage, tumor size, median length of the least safety margin and median number of dissected LNs were statistically insignificant (
Post-operatively, the number of narcotic doses ranged from 5 - 11 doses with a median of 5.9 doses in group A while in group B, the number of narcotic doses ranged from 4 - 6 doses with a median of 4.25 doses. The median VAS scale at 1, 3, and 7 days was 6.6, 4.7, and 2.9 for group A, and 5, 3.8, and 2.2 for group B respectively. The time to pass first flatus ranged from 2 - 4 days with a median of 2.7 days in group A while in group B, it ranged from 1 - 3 days with a median of 2.1 days. The length of hospital stay ranged from 6 - 10 days with a median of 7.2 days in group A while it ranged from 6 - 13 days with a median of 7.3 days in group B. The differences between the 2 groups in the median number of analgesic injections, median VAS at 3 and 7 postoperative days were statistically significant. (P = 0.04, 0.04, and 0.035 respectively). On the other hand, the difference between the two groups in the median length of hospital stay was found statistically insignificant (7.2 vs 7.3 days; P = 0.86) (
Post-operative complications in group A included 2 patients (13.3%) with wound infection and 1 patient (6.7%) with pneumonia. In group B, 1 patient (8.3%) developed pancreatitis in the third post-operative day that was treated conservatively and the patient was discharged on eighth post-operative day. Another patient (8.3%) developed post-operative leakage on day 6 from the site of gastro-jejunostomy as proven by the CT scan. Since this patient had low output leakage with no intra-abdominal collections, he was treated conservatively by ICU admission, total parenteral nutrition and supportive care. The fistula closed spontaneously with no need for further surgical intervention. The difference between the two groups in the median number of postoperative complications was statistically insignificant (3/15 vs 2/12; P = 0.77) (
All the patients were followed in the Surgical Outpatient Clinic 2 weeks post- operatively and they were referred to Oncology Department to receive their adjuvant therapy.
Three months, 6 months, 1 year, & 2 years follow up to all patients was done, and showed local recurrence in one patient (1 year post-operatively) and lung metastasis in another patient (6 months post-operatively). Both patients were in group B and were treated by palliative chemo-irradiation.
In this study, we report the short term outcomes and our early experience in
Variable | Group A (No. = 15) | Group B (No. =1 2) | P Value |
---|---|---|---|
Operative Time (minutes) ・ Range ・ Median | 100 - 143 118.7 | 185 - 255 210.2 | <0.01 |
Blood Loss (ml) ・ Range ・ Median | 120 - 180 152.2 | 66 - 95 78.3 | <0.01 |
Intraoperative complications (%) | 0 | 1 (8.3%) | 0.31 |
Variable | Group A (No. = 15) | Group B (No. = 12) | P value | ||
---|---|---|---|---|---|
No | % | No | % | ||
Pathologic Grade ・ Grade I ・ Grade II ・ Grade III | 3 7 5 | 20 46.65 33.35 | 2 6 4 | 16.65 50 33.35 | 0.226 0.176 0.394 |
T staging ・ pT1 ・ pT2 ・ pT3 | 2 8 5 | 13.35 53.35 33.3 | 1 6 5 | 8.35 50 41.65 | 0.411 0.171 0.444 |
Tumor size in cm ・ Range ・ Median | 3.7 - 5.8 4.2 | 3.5 - 4.9 3.9 | 0.532 | ||
Nearest resection Margin (cm) ・ Range ・ Median | 5.6 - 7.8 6.52 | 5.2 - 7.1 5.7 | 0.77 | ||
No. of Dissected LN ・ Range ・ Median | 18 - 33 24.2 | 17 - 31 21.4 | 0.126 |
Variable | Group A (N0 = 15) | Group B (N = 12) | P Value |
---|---|---|---|
Number of Narcotic Doses ・ Range ・ Median | 5 - 11 5.9 | 4 - 6 4.25 | 0.04 |
Median VAS Scale ・ 1 day ・ 3 days ・ 7 days | 6.6 4.7 2.9 | 5 3.8 2.2 | 0.081 0.04 0.035 |
Time to Pass First Flatus (days) ・ Range ・ Median | 2 - 4 2.7 | 1 - 3 2.1 | 0.15 |
Length of Hospital Stay (days) ・ Range ・ Median | 6 - 10 7.2 | 6 - 13 7.3 | 0.86 |
Variable | Group A (N = 15) No (%) | Group B (N = 12) No (%) | P Value |
---|---|---|---|
Number of Post-Operative Complications: ・ Pancreatitis ・ Wound Infection ・ Pneumonia ・ Leakage | 3 (20) 0 2 1 0 | 2 (16.6) 1 0 0 1 | 0.77 |
LDG for GA and compare these results with the standard open technique. The study population included two matched groups of patients with no statistically significant differences between the 2 groups in terms of age, sex, comorbid conditions, ASA class and tumor stage (
In all patients included in this study, we performed staging laparoscopy before proceeding to definitive surgical resection because we think that staging laparoscopy is a crucial step for detection of occult metastases undetectable on preoperative work-up, thus, avoiding patients with these metastases in the open group unnecessary laparotomies [
We excluded patients with previous upper abdominal surgeries because the underlying adhesions may increase the difficulty of the laparoscopy, affect the safety of laparoscopic dissection, and may increase the incidence of conversion to open surgery. Patients with tumors in the upper third of the stomach were also excluded as these patients will need more extensive resection in the form of subtotal or total gastrectomy and may need esophageal resection; techniques that need more complex steps during laparoscopy [
We adopted the rules of proper oncological resection of GA that include a minimum safety margin of 4 cm and D2 LN dissection [
Although laparoscopic surgery provides the patients with many advantages including smaller incisions, less postoperative pain, faster recovery and better cosmesis, the implementation of this technique in the field of gastric cancer surgery is not widely practiced because LG is technically demanding and needs extensive experience both in laparoscopic and oncologic surgery [
The main outcome of this study shows that LDG with D2 LN dissection for distal GA is safe and oncologically sound. Moreover, it provides the patients all the advantages of laparoscopic surgery including reduction of the postoperative pain and the duration of postoperative ileus in comparison to the open approach. These results agree with the results of many other studies [
In terms of operative findings, our study showed that, when compared with open surgery, laparoscopy produced significant reduction of median intraoperative blood loss (152.2 vs 78.3 ml; p < 0.01), although it was associated with a significant increase in the median operative time (118.7 vs 210.2 minutes; p < 0.01). Nevertheless, both groups did not show significant differences in the median number of the dissected LN or the median safety margin of excision as shown in
In the open surgery group, 3 patients developed postoperative complications which included 2 superficial wound infections and 1 pneumonia. In the laparoscopic surgery group, 2 patients developed complications postoperatively which included postoperative pancreatitis in 1 patient and postoperative leakage in the other. The difference between the two groups was statistically insignificant (P value = 0.77). While our results are supported by those of several authors [
In conclusion, based on the results of this study, LDG with D2 LN dissection performed for GA is safe, oncologically sound with short-term outcomes comparable to those of open surgery. Moreover, it provides the patients all the advantages of minimally invasive surgery. However, a study on a larger number of patients with a longer follow-up is needed for more valid results. Also, we believe that increasing the experience of the operating surgeons will results in better outcomes.
Abdelaziem, S., El-Bakary, T.A. and Abd Allah, H.S. (2017) Short Term Outcomes of Laparoscopic versus Open Distal Gastrectomy with D2 Lymph Nodes Dissection for Gastric Cancer: A Prospective Study. Surgical Science, 8, 334-347. https://doi.org/10.4236/ss.2017.88037