Laparoscopy Assisted Proximal Gastrectomy in Gastric Cancer : Short Term Clinical Outocome and Functional Study

Tomotaka Shibata, Shinichi Sakuramoto, Hiroaki Mieno, Masayuki Nemoto, Nobue Futawatari, Keishi Yamashita, Natsuya Katada, Shirou Kikuchi, Masahiko Watanabe. Department of Surgery Kitasato University

Background
Laparoscopy assisted proximal gastrectomy (LAPG) has become prevalent for early gastric cancer (EGC) located in the upper stomach in Japan. However, standard reconstruction method is not defined.

Patients
From May 2006 through June 2011, LAPG was performed for 50 EGC patients. Esophagogastrostomy with Liner stapler (LS) was performed in the initial 25 patients and the 25 remaining patients underwent that with circular stapler (CS). Postoperative esophago-gastro-reflux was assessed by 24h pH monitoring (n=25) and/or multichannel intraluminal impedance (MII/pH)(n=11).

Esophago-gastrostomy
Esophagus was laparoscopically dissected and both right and left crura of the diagragum were exposed. Upper 3rd of the stomach was resected extra-corporeally with 5cm minilaparotomy. Esophago-jejunostomy was made by either LS or CS.
(1) For LS group, esophagogastrostomy was made using the ETS Flex stapler (Ethicon Endo-Surgery). After making small hole in the anterior wall of the stomach, the gastric remnant was returned to the abdomen with linear stapler inserted, where small hole was afterward added in the posterior wall of the esophagus to allow insertion of the linear stapler. The entry hole was sewn by hand. Toupet like partial fundoplication was added, if remnant stomach is large.
(2)For CS group, the esophagogastrostomy was performed using an Orvil package (Covidien) consisting of 25mm anvil with the head pretiled and the tip attached to an 18 Fr orogastric tube. Through the hole for cartridge insertion, circular stapler was introduced into the intra-stomach and allowed the spike to exit anterior proximal side proximally, and the circular stapler was closed. The entry hole was sewn by hand.

Results
(1) The mean operation time was 292±72 min. The mean estimated blood loss was 103±98ml. The mean total number of dissected lymph nodes were 24±12. There are no differences between LS and CS groups. Two patients with LS group had anastomotic leakage, but CS group had no leakage. On the other hand, patients with CS group had anastomotic stenosis, while LS group had no stenosis. All stenosis was successfully treated by pneumatic balloon dilatation endscopically.
(2) 24h pH monitoring or multichannel intraluminal impedance (MII/pH). Twenty eight percentage (7/25) of patens still sustained for secretion of acid gastric juice (% time pH<4 was above 50%). Pre operative esophageal % time<4 was 1.8±4.1 and post operative esophageal % time<4 was 5.7±9.5 (no significant difference). There were no differences between acid reflux in pre and post operation, but non-acid reflux was increasing in post operation.

Conclusions
Esophagogastrostomy with LS or CS could be a simple and useful technique for reconstruction after LAPG. Concerned issues were GERD for LS, and stenosis for CS.
 

View Poster