Minimally invasive surgery for gastric cancer in a single institution: clinical experience of 3,021 cases over 11 years

Young Suk Park, MD, Aung Myint Oo, Dong Joon Shin, Do Hyun Jung, Sang Yong Son, Sang Hoon Ahn, Do Joong Park, Hyung Ho Kim. Seoul National University of Bundang Hospital, Korea

BACKGROUND: This study aims to investigate changes in trends of minimally invasive surgery (MIS) for gastric cancer in a single institution in South Korea over 11 years and to anticipate the developmental direction of MIS.

METHODS: A total of 3021 minimally invasive gastric cancer surgeries were performed from May 2003 to January 2014 in Seoul National University Bundang Hospital. Changes in the pathological features, clinical outcomes, and surgical techniques were analyzed.

RESULTS: Among 3021 cases, 3000 (99.3%) laparoscopic and 21 (0.7%) robotic operations were included and 147 (4.8%) patients underwent for palliative surgeries such as bypass and diagnostic laparoscopy. We performed 96 (3.1%) cases of sentinel lymph node navigation surgery and 68 (2.5%) single incision laparoscopic surgeries. Laparoscopic curative gastrectomies (R0 resection, 2751 cases, 91.0%) were divided into 3 periods (1st period : 2003~2006, 2nd period : 2007~2010, 3rd period : 2011~2014.1). The proportion of advanced gastric cancer (AGC) cases increased from 15.7% in 1st period to 29.3% in 3rd period (p<0.001) and the number of retrieved lymph nodes were also increased from 36.9 ± 14.1 to 54.4 ± 21.5 (p<0.001). However, the duration of hospital stay was decreased from 8.2 ± 5.5 to 7.0 ± 5.8 days (p=0.078) and the complication rates remained same throughout the study period (17.7% in 1st period, 15.9% in 2nd, 16.9% in 3rd, p=0.664). 5-year overall survival rates were acceptable (stage IA: 95.9%, stage IB: 92.3%, stage IIA: 95.5%, stage IIB 85.9%, stage IIIA 83.8%, stage IIIB 61.2%, stage IIIC 36.3%).

Since the intracorporeal anastomosis after distal gastrectomy was first introduced in October 2010, its proportion rose up to 94.9% in 2013 without increasing of complication rates (12.0% (n=1090) in Billroth-I anastomosis vs 13.5% (n=266) in delta-shaped anastomosis, p=0.500, and 13.8% (n=319) in extracorporeal uncut Roux-en-Y anastomosis vs 16.2% (n=216) in intracorporeal uncut Roux-en-Y anastomosis, p=0.441). Operating time was significantly shorter in the intracorporeal anastomosis group (165.9 ± 53.1 min in B-I vs 149.0 ± 43.0 min in delta-shaped, p<0.001, and 198.3 ± 64.3 min in extracorporeal uncut Roux-en-Y vs 180.3 ± 63.6 min in intracorporeal uncut Roux-en-Y, p=0.001)

A total of 9 cases of laparoscopic para-aortic lymphadenectomy have been performed in patients with isolated para-aortic lymph node metastasis. The mean number of harvested para-aortic lymph nodes was 10.1 ± 10.1. Mean operating time and estimated blood loss were 311.9 ± 124.5 min and 215.6 ± 213.4 ml, respectively. There were 2 postoperative complications ( 1 pleural effusion, 1 ascites) with 1 intraoperative bleeding due to injury of small branch of lest renal vein.

CONCLUSIONS: The application of MIS for AGC has been gradually increased. Our experience showed that MIS for AGC is safe and feasible in terms of complications and oncologic outcomes. MIS for gastric cancer can be performed safely even in more advanced cases such as adjacent organ invasion or para-aortic lymph node metastasis. With the development of totally laparoscopic gastric cancer surgery, less invasive surgeries such as laparoscopic sentinel node navigation surgery and single incision laparoscopic surgery for gastric cancer will be the future trend.

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