Laparoscopic gastrectomy for adenocarcinoma: lymphadenectomy and resection margins

Introduction: The American Joint Committee for Cancer recommends harvest of at least 15 lymph nodes from gastrectomy for adenocarcinoma for accurate staging. Up to one-quarter of open gastrectomies (OG) have resections margins microscopically positive for malignant cells (R1). We examined the lymph node yield and R status for entirely laparoscopic gastrectomy (LG).
Patients & Methods: All gastrectomies for adenocarcinoma performed by a single attending surgeon at a university hospital, during April 2005 (first LG) to August 2007, were reviewed. Gastrectomies for stromal tumors were excluded. For LG, all anastomosis were done laparoscopically and the specimen was retrieved via a transverse, supra-pubic incision.
Results: There were 21 men and 8 women, median age 75 years (45-88). Eighteen patients (62%) had LG. For LG compared to OG, the primary tumour was in the proximal stomach (1 patient vs. 3 patients, respectively), body/antrum (16 vs. 5) or previous gastrojejunostomy (1 vs. 3); radiology indicated early cancer in 9 patients vs.1 patient. There were 12 subtotal LG and 6 total LG. Two sub-total LG were converted to OG because of failure to progress with dissection. Three total LG needed upper abdominal incision for esophagojejunal anastomosis, but dissection was completed entirely laparoscopically. For OG (excluding conversions), there were 4 sub-total and 7 total cases. At pathology, total number of nodes was similar for LG and OG (median, 24 [10-44] vs. 26 [8-95]; P=0.40). For LG, 2 patients (11%) had 25 nodes; for OG, 1 (9%) had 25 nodes. There was N0 disease for 8 (44%) LG and 4 (36%) OG. Four LG had R1 disease. For subtotal LG, R1 disease was present at the proximal resection margin (1 patient), distal resection margin (1) or both margins (1). For total LG, one patient at R1 at both margins. Three OG were done with palliative intent and categorized as R2 (gross residual disease). Two OG had R1 disease; both had total OG and R1 was present at the distal resection margin (1) or both margins (1).
Conclusion: Accurate lymph node staging (minimum 15 nodes) was achieved in 89% of laparoscopic gastrectomies. 22% of LG had R1 disease. In one subtotal LG, R1 status may have been avoided by total gastrectomy.

Session: Poster

Program Number: P256

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