Laparoscopy-Assisted Gastrectomy As Additional Treatment After Endoscopic Submucosal Dissection for Early Gastric Cancer

H Mieno, S Sakuramoto, T Shibata, M Nemoto, K Yamashita, N Katada, S Kikuchi, M Watanabe. Depertment of Surgery, Kitasato University School of Medicine

Background: Recently, endoscopic submucosal dissection (ESD) has been aggressively used to treat early gastric cancer. The growing number of patients undergoing ESD has been accompanied by an increasing number of lesions for which ESD is found not to be indicated on histopathological examination. Laparoscopy-assisted gastrectomy (LAG) has thus assumed new importance as salvage surgery.
Objective: To study the safety and problems of LAG as additional treatment after ESD for early gastric cancer.
Methods: We studied 53 patients who underwent LAG as additional treatment after ESD for early gastric cancer from March 2003 through August 2009.
Results: The reasons for additional treatment were as follows: positive resection margin in 11 patients, cancer invading the second layer of the submucosa (sm2) in 26, vascular invasion in 19, presence of poorly differentiated components in 14, recurrence in 2, and passage disorder in 2. The surgical procedures were as follows: laparoscopy-assisted distal gastrectomy (LADG) in 33 patients, laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) in 7, laparoscopy-assisted total gastrectomy (LATG) in 4, and laparoscopy-assisted proximal gastrectomy (LAPG) in 9. Two patients had histopathological evidence of residual cancer. Lymph-node metastasis was diagnosed in 4 patients (7.5%), all of whom had differentiated sm2 cancer. Intramucosal microcancers not detected before surgery were found in 6 patients (11.3%). The operation times for LADG/LAPPG were 256.3 min. The bleeding volume was 98.5 mL, the postoperative hospital stay was 10.9 days, and the postoperative incidence of complications was 7.5%. For LATG/LAPG, the operation time was 328.9 min, the bleeding volume was 139.6 mL, the postoperative hospital stay was 14.1 days, and the postoperative incidence of complications was 14.4%. There was no postoperative recurrence.
Conclusions: After ESD, 15% of patients with sm2 cancer had lymph-node metastasis. Salvage surgery should be performed without hesitation in such patients. LAG was performed safely as additional treatment and may be the procedure of first choice for salvage surgery after ESD.
 

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