Background
The safety of robotic gastrectomy (RG) for gastric cancer in daily clinical settings and the process by which surgeons are introduced and taught RG remain unclear. This study aimed to ...evaluate the safety of RG in daily clinical practice and assess the learning process in surgeons introduced to RG.
Methods
Patients who underwent RG for gastric cancer at Kyoto University and 12 affiliated hospitals across Japan from January 2017 to October 2019 were included. Any morbidity with a Clavien–Dindo classification grade of II or higher was evaluated. Moreover, the influence of the surgeon’s accumulated RG experience on surgical outcomes and surgeon-reported postoperative fatigue were assessed.
Results
A total of 336 patients were included in this study. No conversion to open or laparoscopic surgery and no in-hospital mortality were observed. Overall, 50 (14.9%) patients developed morbidity. During the study period, 14 surgeons were introduced to robotic procedures. The initial five cases had surprisingly lower incidence of morbidity compared to the following cases (odds ratio 0.29), although their operative time was longer (+ 74.2 min) and surgeon’s fatigue scores were higher (+ 18.4 out of 100 in visual analog scale).
Conclusions
RG was safely performed in actual clinical settings. Although the initial case series had longer operative time and promoted greater levels of surgeon fatigue compared to subsequent cases, our results suggested that RG had been introduced safely.
We report a new method of esophagogastrostomy after proximal gastrectomy, side overlap with fundoplication by Yamashita (SOFY) in 2017. Recently, even better treatment results can be obtained by ...modifying the SOFY method. We describe the technical details of the modified SOFY (mSOFY) after laparoscopic proximal gastrectomy. The stomach was dissected in the short axis direction and the esophagus was dissected in the left and right direction. After the proximal gastrectomy, the bilateral diaphragmatic crus were dissected to enhance gastric elevation. After confirming that the esophagus overlapped more than 5 cm at the center of the remnant stomach (we call it SOFY check), the remnant stomach was suture‐fixed to the dissected diaphragmatic crus. The right wall of the esophageal stump and the remnant stomach were anastomosed using the full length of a 45 mm‐linear stapler. The entry hole was closed in a direction that did not widen the anastomotic hole. Both sides of the esophagus, remnant stomach, and diaphragmatic crus were suture‐fixed on the cranial side 1–2 cm away from the anastomosis. Moreover, the left wall and lower end of the esophagus was suture‐fixed to the remnant stomach. The preserved dorsal esophageal wall is pressed and flattened by pressure from the pseudofornix, which is the reflux prevention mechanism. The mSOFY method had favorable treatment outcomes. In conclusion, mSOFY can be one of the safe and feasible reconstruction methods after laparoscopic proximal gastrectomy.
The modified SOFY (mSOFY) is a novel esophagogastrostomy method that can prevent reflux after proximal gastrectomy. It had favorable treatment outcomes and can be easily performed laparoscopically.
Background
Presently, there is no consensus as to what procedure of intracorporeal esophagojejunostomy (EJS) in totally laparoscopic total gastrectomy (TLTG) is best to reduce postoperative ...complications. The aim of this study was to demonstrate the superiority of linear stapled reconstruction in terms of anastomotic-related complications for EJS in TLTG.
Methods
We collected data on 829 consecutive gastric cancer patients who underwent TLTG reconstructed by the Roux-en-Y method with radical lymphadenectomy between January 2010 and December 2016 in 13 hospitals. The patients were divided into two groups according to reconstruction method and matched by propensity score. Postoperative EJS-related complications were compared between the linear stapler (LS) and the circular stapler (CS) groups.
Results
After matching, data from 196 patients in each group were analyzed. The overall incidence of EJS-related complications was significantly lower in the LS group than in the CS group (4.1% vs. 11.7%,
p
= 0.008). The incidence of EJS anastomotic stenosis during the first year after surgery was significantly lower in the LS group than in the CS group (1.5% vs. 7.1%,
p
= 0.011). The incidence of EJS bleeding did not differ significantly between the groups, although no bleeding was observed in the LS group (0% vs. 2.0%,
p
= 0.123). The incidence of EJS leakage did not differ significantly between the groups (2.6% vs. 3.6%,
p
= 0.771).
Conclusion
The use of linear stapled reconstruction is safer than the use of circular stapled reconstruction for intracorporeal EJS in TLTG because of its lower risks of stenosis.
Side overlap esophagogastrostomy to prevent reflux after proximal gastrectomy Yamashita, Yoshito; Yamamoto, Atsushi; Tamamori, Yutaka ...
Gastric cancer : official journal of the International Gastric Cancer Association and the Japanese Gastric Cancer Association,
07/2017, Letnik:
20, Številka:
4
Journal Article
Background
Internal hernia (IH) is one of the critical complications after gastrectomy with Roux-en-Y reconstruction, which can be prevented by closing mesenteric defects. However, only few studies ...have investigated the incidence of IH after laparoscopic total gastrectomy (LTG) with Roux-en-Y reconstruction for gastric cancer till date. This study aimed to assess the efficacy of defect closure for the prevention of IH after LTG.
Methods
This multicenter, retrospective cohort study collected data from 714 gastric cancer patients who underwent LTG with Rou-en-Y reconstruction between 2010 and 2016 in 13 hospitals. We evaluated the incidence of postoperative IH by comparing closure and non-closure groups of Petersen’s defect, jejunojejunostomy mesenteric defect, and transverse mesenteric defect.
Results
The closure group for Petersen’s defect included 609 cases, while the non-closure group included 105 cases. The incidence of postoperative IH in the closure group for Petersen’s defect was significantly lower than it was in the non-closure group (0.5% vs. 4.8%,
p
< 0.001). The closure group for jejunojejunostomy mesenteric defect included 641 cases, while the non-closure group included 73 cases. The incidence of postoperative IH in the closure group of jejunojejunostomy mesenteric defect was significantly lower than that in the non-closure group (0.8% vs. 4.1%,
p
= 0.004). Out of 714 patients, 41 underwent retro-colic reconstruction. No patients in the transverse mesenteric defect group developed IH.
Conclusion
Mesenteric defect closure after LTG with Roux-en-Y reconstruction may reduce postoperative IH incidence. Endoscopic surgeons should take great care to prevent IH by closing mesenteric defects.
Purpose
To define the role of surgery for metastatic/recurrent lesions after resection of primary gastrointestinal stromal tumors (GISTs).
Methods
Based on data obtained from the Kinki GIST registry, ...patients with recurrence or metastasis were divided into a surgical treatment group (ST group), comprised those treated with surgery in addition to tyrosine kinase inhibitor (TKI) therapy; and a drug treatment group (DT group), comprised those treated with TKI therapy alone. We compared the baseline characteristics and survival outcomes of the groups.
Results
Metastasis or recurrence developed in 93 of the 737 patients with GISTs treated between 2003 and 2007, 50 (53.8 %) of whom were assigned to the ST group and 43 (46.2 %) to the DT group. In the ST group, the 5-year overall survival rate was significantly higher for patients who underwent R0/R1 resection than for those who underwent R2 resection (82.2 vs. 47.0 %,
p
= 0.018). Survival time after recurrence was correlated with the duration of total TKI therapy in both the ST and DT groups (
r
= 0.766 and
r
= 0.932, respectively,
p
< 0.001).
Conclusions
Continuous TKI therapy appears to be important primarily for the prognostic improvement of patients with recurrent/metastatic GISTs. R0/R1 resection may have benefits when combined with TKI therapy for patients with stable disease or disease responsive to TKI therapy, less than four metastatic lesions, and lesions <100 mm in total.
Purpose: The purpose of the present study was to evaluate whether trastuzumab has antitumor effect against pancreatic cancer and whether
this effect is concordant with levels of HER-2, which is ...reportedly overexpressed in pancreatic cancer. We also investigated
whether the effect is potentiated in combined therapy with gemcitabine.
Experimental Design: Using immunohistochemistry and FACScan, we analyzed HER-2 expression in 16 pancreatic cancer cell lines. The in vitro antiproliferative effect of trastuzumab, alone and in combination with gemcitabine, was examined by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium
bromide assay. The in vitro antibody-dependent cell-mediated cytotoxicity of trastuzumab was investigated by 51 Cr release assay. The in vivo antitumor effect of trastuzumab, alone and in combination with gemcitabine, was evaluated in nude mouse xenograft growth.
The survival benefit was evaluated in a Capan-1 orthotopic implanted nude mouse model.
Results: HER-2 expression of 2+ or more was observed in 10 and of 3+ in 2 of the 16 cell lines. No in vitro growth-inhibitory effect of trastuzumab was found in any cell line, but trastuzumab induced antibody-dependent cell-mediated
cytotoxicity in proportion to HER-2 expression level. Trastuzumab inhibited tumor growth in Capan-1 (HER-2: 3+) xenografts
and prolonged survival in the orthotopic model. These effects were increased by combined therapy with gemcitabine. In contrast,
trastuzumab exhibited no antitumor effect against PANC-1 (HER-2: 1+) or SW1990 (HER-2: 2+) xenografts.
Conclusions: The antitumor effect of trastuzumab in pancreatic cancer with high HER-2 expression was shown in vitro and in vivo . Clinical application of trastuzumab is expected in pancreatic cancer with 3+ HER-2 expression.
Background
Radical esophagectomy is the cornerstone of curative treatment for patients with resectable esophageal squamous cell carcinoma (ESCC). Patient survival after surgery for ESCC is mainly ...associated with pathological tumor progression. Recently, the impact of baseline immune-nutritional status of various types of patients with cancer on survival has been highlighted. The purpose of the present study was to investigate the association between the baseline prognostic nutritional index (PNI) and postoperative short- and long-term results after esophagectomy for patients with ESCC.
Methods
In total, 202 patients with ESCC who underwent radical esophagectomy at our institution between 2002 and 2010 were enrolled. PNI was calculated as 10× serum albumin (g/dL) + 0.005 × total lymphocyte counts (per mm
3
). Receiver operating characteristic (ROC) curves were generated for multiple logistic regression analysis using 5-year overall survival as the endpoint to determine an optimal PNI cutoff value, in which patients were classified into two groups: high PNI and low PNI. We evaluated the significance of PNI on postoperative morbidity and long-term survival using univariate and multivariate analyses.
Results
The mean PNI was 48.9 ± 4.6 (range 37.2–64.0). The area under the ROC curve in multiple logistic regression analysis was 0.5367. The projected 5-year survival rate was optimal at a PNI of 44.1. Hence, the PNI cutoff point was set at 44, with subjects classified by PNI level into the low (PNI <44) or high (PNI ≥44) PNI groups. Of 202 patients, 173 (85.7 %) and 29 (14.3 %) were classified as having high and low PNI, respectively. No significant differences were noted between the two groups regarding patient background, including age, sex, pT, pN, and pStage, or postoperative complications. However, overall survival (OS) and relapse-free survival (RFS) were significantly worse in the low PNI group than in the high PNI group. The 5-year OS and RFS rates in the high PNI vs. low PNI groups were 67.2 vs. 41.2 % (
P
= 0.007) and 61.5 vs. 38.8 % (
P
= 0.008), respectively. Multivariate analysis revealed that PNI was a significant prognostic factor for both OS (hazard ratio, 1.826; 95 % confidence interval, 1.015–3.285;
P
= 0.044) and RFS (hazard ratio, 1.862; 95 % confidence interval, 1.121–3.095;
P
= 0.016).
Conclusion
Preoperative PNI is an independent prognostic marker of both OS and RFS for patients with potentially curative ESCC. A careful follow-up for tumor recurrence after surgery is required for ESCC patients with low PNI.
Side overlap esophagogastrostomy to prevent reflux after proximal gastrectomy Yamashita, Yoshito; Yamamoto, Atsushi; Tamamori, Yutaka ...
Gastric cancer : official journal of the International Gastric Cancer Association and the Japanese Gastric Cancer Association,
07/2017, Letnik:
20, Številka:
4
Journal Article
Recenzirano
Odprti dostop
Background
No optimal method of reconstruction for proximal gastrectomy has been established because of problems associated with postoperative reflux and anastomotic stenosis. It is also important ...that the reconstruction is easily performed laparoscopically because laparoscopic gastrectomy has become widely accepted in recent years.
Methods
We have developed a new method of esophagogastrostomy, side overlap with fundoplication by Yamashita (SOFY). The remnant stomach is fixated to the diaphragmatic crus on the dorsal side of the esophagus. The esophagus and the remnant stomach are overlapped by a length of 5 cm. A linear stapler is inserted in two holes on the left side of the esophageal stump and the anterior gastric wall. The stapler is rotated counterclockwise on its axis and fired. The entry hole is closed, and the right side of the esophagus is fixated to the stomach so that the esophagus sticks flat to the gastric wall. The surgical outcomes of the SOFY method were compared with those of esophagogastrectomy different from SOFY.
Results
Thirteen of the 14 patients in the SOFY group were asymptomatic without a proton pump inhibitor, but reflux esophagitis was observed in 5 of the 16 patients in the non-SOFY group and anastomotic stenosis was observed in 3 patients. Contrast enhancement findings in the SOFY group showed inflow of Gastrografin to the remnant stomach was extremely good, and no reflux into the esophagus was observed even with patients in the head-down tilt position.
Conclusions
SOFY can be easily performed laparoscopically and may overcome the problems of postoperative reflux and stenosis.
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