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PURPOSE: In recent years, laparoscopic near-total gastrectomy (LnTG) has emerged as a surgical option for gastric cancer in the middle-third of the stomach. However, its application in locally advanced stages presents technical challenges. This study aims to provide a detailed analysis of the operative outcomes and long-term functional and oncological results of totally LnTG in combination with D2 lymphadenectomy for middle-third gastric cancer. PATIENTS AND METHOD: A prospective study was conducted on 79 patients who underwent totally LnTG and D2 lymphadenectomy for middle-third gastric cancer between January 2017 and December 2021. Short-term outcomes included operative characteristics, and the evaluation of gastroesophageal reflux and gastric remnant condition using endoscopy based on the Los Angeles (LA) and Residue-Gastritis-Bile classifications. Long-term oncological outcomes included overall survival and disease-free survival. RESULTS: Totally LnTG was successfully performed in 98.7% of patients without intraoperative complications or conversions to laparotomy. The mean operation time was 202.2±43.0 min, and the median blood loss was 50 (50;100) mL. The overall incidence of postoperative morbidities was 16.5%, with one patient experiencing a narrowing of the gastrojejunostomy, successfully treated by endoscopic balloon dilation. All patients had tumor-free resection margins, and there were no mortalities. The 5-year overall survival and disease-free survival rates were 80% and 55%, respectively. CONCLUSIONS: Totally LnTG is an effective and feasible approach for gastric cancer in the middle-third of the stomach, yielding favorable short-term outcomes and acceptable long-term results. Routine application of totally LnTG for middle-third gastric cancer is practical and promising.
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Introduction Lymph node (LN) metastasis happens even in early gastric cancer (GC) even in LN stations that are not adjacent to the primary tumor. Total or subtotal gastrectomy (TG or sTG) can be performed in the middle third of the GC if the negative proximal margin is maintained. These procedures differed in the extent of LN dissection; therefore, oncology considerations must be taken into consideration when selecting the appropriate procedure. Methods This was a cross-sectional study involving 98 patients suffering from middle-third GC. The metastatic lymph nodes (mLN) ratio was calculated in each case by the ratio between the number of mLN and the number of total LNs retrieved. We compare the difference in the total LN retrieved, number of mLN, and rate of positive LN (N+) between the two groups TG and sTG. Results The majority of patients had advanced GC (82.7% pT2-4). About 65.3% of patients had metastasis LN. The events of LN metastasis and skipped LN metastasis happened even in tumors contained in the submucosal layer. The metastasis rates in each LN station were also increasing in correlation with the depth of tumor invasion. For LN station No. 2, 4sa, 10, 11d (which are not mandatory) in sTG, the rate of mLN was 0% for the pT1-3 tumor, regardless of tumor longitudinal location. The rate of mLN for each station was higher in adjacent stations of the tumor (No. 1-3-5-7 in lesser curvature, No. 4sb-4d-6 in greater curvature, No.1-3-4sb in the anterior wall, No. 3-7-12a in the posterior wall). The total LN retrieved, number of mLN, and rate of positive LN were statistically higher in the TG group compared to the sTG group. However, the mean mLN ratios between the two groups were comparable (p = 0.116). Conclusion In accordance with the macroscopic and microscopic characteristics, we observed a stratified distribution of mLN in the middle third of the GC. With these early results, sTG combined with standard lymphadenectomy was an acceptable treatment for T1-T3 middle-third GC in terms of mLN distribution. Total No. 4sb LN dissection might also be reserved in gastrectomy for T1-T3 GC.