Totally Laparoscopic Total Gastrectomy: Experience of the First 106 Cases

Shigeru Tsunoda, MD, PhD, Hiroshi Okabe, MD, PhD, FACS, Kazutaka Obama, MD, PhD, Eiji Tanaka, MD, PhD, Shigeo Hisamori, MD, PhD, Yoshiharu Sakai, MD, PhD, FACS

Department of Surgery, Graduate School of Medicine, Kyoto University

INTRODUCTION: Although laparoscopic distal gastrectomy has gained widespread acceptance as a treatment option for gastric cancer, laparoscopic total gastrectomy remains in limited use due to the fact that lymphadenectomy at splenic hilum is rather complicated and esophagojejunostomy is technically more demanding. The objective of this study is to evaluate the short term outcomes of totally laparoscopic total gastrectomy (TLTG).

METHODS AND PROCEDURES: The records of 106 consecutive patients who underwent TLTG for gastric cancer between September 2006 and August 2012 were retrieved from prospective institutional database. Surgical outcomes of TLTG were retrospectively investigated. Postoperative morbidity was stratified by Clavien-Dindo classification system.

The indication of TLTG was T3(SS)N0 or earlier disease before April 2009. Subsequently, the indication range was extended to patients with more advanced diseases. Our TLTG consisted of D1+ or D2 lymphadenectomy in accordance with the Japanese Gastric Cancer Treatment Guidelines 2010 (ver. 3) and followed by intracorporeal esophagojejunostomy using a 45-mm linear stapler in functional end-to-end fashion or overlap method.

RESULTS: There were 64 male and 42 female patients with a median age of 68 (range, 30-89) years, and the median body mass index was 21.9 (14.0-29.6). According to the American Association of Anesthesiologists (ASA) scoring, 29 patients (27%) were graded in ASA 1, 69 patients (65%) were categorized in ASA 2 and 8 patients (8%) were classified as ASA 3.

The TNM stage of the tumor was as follows: IA, 41 (39%); IB, 8 (8%); IIA, 9 (8%); IIB, 19 (18%); IIIA, 11 (10%); IIIB, 8 (8%); IIIC, 5 (5%); IV, 4 (4%). Neoadjuvant chemotherapy (S-1 + CDDP +/- Docetaxel) was employed in 19 patients (18%).

As for the degree of lymphadenectomy, either D1+ (n=78, 74%) or D2 (n=28, 26%) was completed. Concomitant splenectomy was performed in 7 patients (7%) and pancreaticosplenectomy was done in 3 patients (3%). As a combined resection, 4 cholecystectomy, 2 nephrectomy, 1 aderenectomy, 1 colectomy and 1 anterior resection of rectum were performed as well. Esophagojejunostomy was done in functional end-to-end fashion in 93 patients (88%) and in overlap method in 12 patients (11%).

One patient (1%) underwent open conversion due to anastomotic trouble (involvement of naso-gastric tube in the anastomosis). The median operation time was 364 (range 211-624) minutes, the median intraoperative blood loss was 80 (range 0-550) ml, and the median total number of harvested lymph nodes was 55 (13-115). Postoperative complications occurred in 23 patients (22%) and major complications, classified as grades greater than Clavien-Dindo classification II, were observed in 8 patients (8%), including peripancreatic abscess (n=2), small bowel obstruction, leakage of esophagojejunostomy, pulmonary embolism, acute respiratory distress syndrome, aorto-anastomotic fistura and sudden cardio pulmonary arrest of a 89-year-old patient. The latter two patients (2%) died on the 31 and 3 postoperative day, respectively. The median postoperative hospital stay was 14 days.

CONCLUSIONS: Our results suggest TLTG is feasible and applicable for treatment of middle or upper gastric cancer. We await long term results to see oncological outcome.


Session: Poster Presentation

Program Number: P202

« Return to SAGES 2013 abstract archive