What Happens After Discharge? A 2+ Year Follow-Up After Laparoscopic Subtotal Fenestrating and Reconstituting Cholecystectomy.

Laparoscopic subtotal cholecystectomy (LSC) is utilized to prevent complications in the difficult cholecystectomy. Medium-term outcomes are poorly studied for fenestrating and reconstituting operative techniques. A single-institution retrospective review was undertaken of all LSCs. A telephone survey was used to identify complications addressed at other institutions. We performed subgroup analyses by operative approach and of patients requiring postoperative endoscopic intervention (ERC). 28 patients met inclusion criteria. The median follow-up was 32.7 months. There were no bile duct injuries or reoperations. 21% of patients required a postoperative ERC and 50% were discharged home with a drain. Bile leaks were found to be more prevalent in the fenestrating LSC group (38% vs 0%, P = .003). The case series suggested more severe recurrent biliary disease in patients undergoing reconstituting LSC. Laparoscopic subtotal cholecystectomy appears to have satisfactory medium-term outcomes. The reconstituting LSC group trends toward more severe recurrent disease which warrants further investigation.

Defining risk factors for mortality after emergent hiatal hernia repair in the era of minimally invasive surgery.

BACKGROUND: Risk factors for mortality following emergent hiatal hernia (HH) repair in the era of minimally invasive surgery remain poorly defined. METHODS: Data was obtained from the National Inpatient Sample (NIS), National Readmissions Database, and National Emergency Department Sample for patients undergoing HH repair between 2010 and 2018. Univariate and multivariate logistic regression analyses reported with odds ratio (OR) and 95% confidence intervals (CI) were performed to identify factors associated mortality. RESULTS: Via the NIS, mortality rate was 2.2% (147 patients). Via the NEDS, the mortality rate was 3.6% (303 patients). On multivariate analysis, predictors of mortality included age (OR 1.05, CI: 1.04,1.07), male sex (OR 1.49, CI: 1.06,2.11), frailty (OR 2.49, CI: 1.65,3.75), open repair (OR 3.59, CI: 2.50,5.17), and congestive heart failure (OR 2.71, CI: 1.81,4.06). CONCLUSIONS: There are multiple risk factors for mortality after hiatal hernia repair. There is merit to a laparoscopic approach even in emergent settings.

Cessation of Routine Jejunostomy Tube Placement at Time of Minimally Invasive Ivor Lewis Esophagectomy and Impact on Body Mass Index.

Jejunostomy tubes are frequently placed at time of esophagectomy. The purpose of this study is to evaluate cessation of routine j-tube placement on postoperative body mass index (BMI), return to the emergency room, and time until adjuvant therapy. We performed a retrospective review of an institutional database for consecutive patients undergoing minimally invasive Ivor Lewis Esophagectomy from 2014-2021 (after January 2019, routine j-tube placement was abandoned). Data was analyzed using Pearson's Chi-squared tests and Student's t test with 2-sided significance level of P < 0.05. In total,179 patients were included, 95 underwent j-tube placement and 84 did not. Cohorts had comparable baseline BMI's (no j-tube: 30.48 vs j-tube: 28.64, P = 0.06) and anastomotic leak rates (2.4% vs 4.2%, P = 0.5). Patients with no jejunostomy tubes were more likely to receive total parenteral nutrition (14.3% vs 5.3%, P < 0.05), but were no more likely to require total parenteral nutrition at discharge and had comparable durations of TPN requirement (7 days vs 12 days, P = 0.53). There was no difference in mean BMI reduction at 2 weeks (2.54 vs 2.09, P = 0.49) and 3-6 months postoperatively (6.11 vs 4.45 P = 0.15). There was no difference in return to the emergency room (8.3% vs 8.4%, P = 0.98) or readmissions (13.1% vs 11.6%, P = 0.76). There was a no difference in mean time to adjuvant therapy (83.5 days vs 72.6 days, P = 0.67). At esophagectomy centers with low anastomotic leak rates, cessation of routine j-tube placement at time of minimally esophagectomy can be undertaken without increasing risk of readmission, time until initiation of adjuvant therapy, or significantly impacting postoperative BMI loss.

Crisis management checklist: lessons learned from the SARS-CoV-2 pandemic.

"Everyone has a plan until they get punched in the mouth." Never has this quote, uttered in response to a challenger's reported plan to take the title away from heavyweight champion Mike Tyson, rang truer than in the past 20 months as the global population wrestles with the fallout on the SARS-CoV-2 pandemic. While countless lives were disrupted both directly and indirectly during this time, members of the medical community bore the brunt of this fallout in their personal lives while being asked to perform above capacity in their professional lives simultaneously. Compounding this experience was the fact that injuries, illness, and death from other causes did not halt leaving many in the medical community, and community at large, to face personal tragedies in addition to the pandemic. Our goal is to create a series of discussions using the perspective of our surgical department that faced not only the fallout of the pandemic, but also the unexpected death of an influential mentor/physician and close family member to the department. Unfortunately, this pandemic is not the only time tragedy has struck a surgical department. For example, Louisiana State University and Hurricane Katrina in 2007, and a plane crash killing members of the University of Michigan transplant team. However, the pandemic is certainly the most globally widespread, relevant and recent. We leverage crisis-management strategies from other fields, responses from an internal survey, and thoughts from our surgical team on what worked during these crises, what did not, and how we can begin to create a strategic response for those unexpected moments where you get "punched in the mouth."

Achalasia and obesity: patient outcomes and impressions following laparoscopic Heller myotomy and Dor fundoplication.

PURPOSE: The optimal management of achalasia in obese patients is unclear. For those who have undergone Heller myotomy and fundoplication, the long-term outcomes and their impressions following surgery are largely unknown. METHODS: A retrospective review of patients who underwent laparoscopic Heller myotomy and Dor fundoplication (LHMDF) for achalasia was performed. From this cohort, Class 2 and 3 obese (BMI > 35 kg/m2) patients were identified for short- and long-term outcome analysis. RESULTS: Between 2003 and 2015, 252 patients underwent LHMDF for achalasia, and 17 (7%) patients had BMI > 35 kg/m2. Pre-operative Eckardt scores varied from 2 to 9, and at short-term (2-4 week) follow-up, scores were 0 or 1. Ten (58%) patients had available long-term (2-144 months) follow-up data. Eckardt scores at this time ranged from 0 to 6. Symptom recurrence was worse for patients with BMI > 40 kg/m2 compared to patients with BMI < 40 kg/m2. BMI was largely unchanged at long-term follow-up regardless of pre-intervention BMI. Most patients were satisfied with surgery but would have considered a combined LHMDF and weight-loss procedure had it been offered. CONCLUSION: LHMDF for achalasia in obese patients is safe and effective in the short term. At long-term follow-up, many patients had symptom recurrence and experienced minimal weight loss. Discussing weight-loss surgery at the time LHMDF may be appropriate to ensure long-term achalasia symptom relief.

Perioperative Outcomes and Quality of Life after Repair of Recurrent Hiatal Hernia Are Compromised Compared with Primary Repair.

Paraesophageal hernia repair (PEHR) is burdened by high recurrence rates that frequently lead to redo PEHR. Revisional surgery, because of higher complexity, higher risk of injury, and the intrinsic risk of recurrence, has increased likelihood of higher complication rates and decreased quality of life (QOL) postoperatively. We aimed to compare perioperative outcomes and QOL after revisional and primary PEHR. A retrospective review of all patients who underwent PEHR for a recurrent hernia between January 2011 and July 2016 was completed. These were matched with a contemporary cohort of patients who underwent primary PEHR by age, gender, and BMI. Perioperative measures were compared. The patients were invited to complete the Gastrointestinal Quality of Life Index (GIQLI) to assess response to surgical intervention. There were 24 patients (group 1) who underwent revisional PEHR, and they were matched to 48 patients (group 2) who had a primary hernia repair. Thirteen patients in group 1 responded to the survey (54%), whereas 21 patients' responses were received from group 2 (44%). Conversion rates, LOS, and mean Gastrointestinal Quality of Life Index scores were significantly different between the two groups. Reoperative procedures for paraesophageal and hiatal hernias are burdened by higher conversion rates and length of stay, with similar overall complication rates. Patients who are undergoing repair of a recurrent hernia should be preoperatively counseled, and should have realistic expectations of their GI QOL after surgery.

Preoperative anemia: a common finding that predicts worse outcomes in patients undergoing primary hiatal hernia repair.

BACKGROUND: The increased incidence of anemia in patients with hiatal hernias (HH) and resolution of anemia after HH repair (HHR) have been clearly demonstrated. However, the implications of preoperative anemia on postoperative outcomes have not been well described. In this study, we aimed to identify the incidence of preoperative anemia in patients undergoing primary HHR at our institution and sought to determine whether preoperative anemia had an impact on postoperative outcomes. METHODS: Using our IRB-approved institutional HH database, we retrospectively identified patients undergoing primary HHR between January 2011 and April 2017 at our institution. We identified patients with anemia, defined as serum hemoglobin levels less than 13 mg/dL in men and 12 mg/dL in women, measured within two weeks prior to surgery, and compared this group to a cohort of patients with normal preoperative hemoglobin. Perioperative outcomes analyzed included estimated blood loss (EBL), operative time, perioperative blood transfusions, failed postoperative extubation, intensive care unit (ICU) admission, postoperative complications, length of stay (LOS), and 30-day readmission. Outcomes were compared by univariable and multivariable analyses, with significance set at p < 0.05. RESULTS: We identified 263 patients undergoing HHR. The median age was 66 years and most patients were female (78%, n = 206). Seventy patients (27%) were anemic. In unadjusted analyses, anemia was significantly associated with failed postoperative extubation (7 vs. 2%, p = 0.03), ICU admission (13 vs. 5%, p = 0.03), postoperative blood transfusions (9 vs. 0%, p < 0.01), and postoperative complications (41 vs. 18%, p < 0.01). On adjusted multivariable analysis, anemia was associated with 2.6-fold greater odds of postoperative complications (OR 2.57; 95% CI 1.36-4.86; p < 0.01). CONCLUSIONS: In this study, anemia had a prevalence of 27% in patients undergoing primary HHR. Anemic patients had 2.6-fold greater odds of developing postoperative complications. Anemia is common in patients undergoing primary HHR and warrants consideration for treatment prior to elective repair.

Comprehensive Multicenter Graduate Surgical Education Initiative Incorporating Entrustable Professional Activities, Continuous Quality Improvement Cycles, and a Web-Based Platform to Enhance Teaching and Learning.

BACKGROUND: It is increasingly important for faculty to teach deliberately and provide timely, detailed, and formative feedback on surgical trainee performance. We initiated a multicenter study to improve resident evaluative processes and enhance teaching and learning behaviors while engaging residents in their education. STUDY DESIGN: Faculty from 7 US postgraduate training programs rated resident operative performances using the perioperative briefing, intraoperative teaching, debriefing model, and rated patient visits/academic performances using the entrustable professional activities model via a web-based platform. Data were centrally analyzed and iterative changes made based on participant feedback, individual preferences, and database refinements, with trends addressed using the Plan, Do, Check, Act improvement methodology. RESULTS: Participants (92 surgeons, 150 residents) submitted 3,880 assessments during July 2014 through September 2017. Evidence of preoperative briefings improved from 33.9% ± 2.5% to 95.5% ± 1.5% between April and September 2014 compared with April and September 2017 (p < 0.001). Postoperative debriefings improved from 10.6% ± 2.7% to 90.2% ± 2.5% (p < 0.001) for the same period. Meaningful self-reflection by residents improved from 28.6% to 67.4% (p < 0.001). The number of assessments received per resident during a 6-month period increased from 6.4 ± 6.2 to 13.4 ± 10.1 (p < 0.003). Surgeon-entered assessments increased from 364 initially to 685 in the final period, and the number of resident assessments increased from 308 to 445. We showed a 4-fold increase in resident observed activities being rated. CONCLUSIONS: By adopting recognized educational models with repeated Plan, Do, Check, Act cycles, we increased the quality of preoperative learning objectives, showed more frequent, detailed, and timely assessments of resident performance, and demonstrated more effective self-reflection by residents. We monitored trends, identified opportunities for improvement and successfully sustained those improvements over time, applying a team-based approach.

Increasing resident utilization and recognition of the critical view of safety during laparoscopic cholecystectomy: a pilot study from an academic medical center.

BACKGROUND: Laparoscopic cholecystectomy (LC) is a commonly performed surgical procedure; however, it is associated with an increased rate of bile duct injury (BDI) when compared to the open approach. The critical view of safety (CVS) provides a secure method of ductal identification to help avoid BDI. CVS is not universally utilized by practicing surgeons and/or taught to surgical residents. We aimed to pilot a safe cholecystectomy curriculum to demonstrate that educational interventions could improve resident adherence to and recognition of the CVS during LC. METHODS: Forty-three general surgery residents at Thomas Jefferson University Hospital were prospectively studied. Fifty-one consecutive LC cases were recorded during the pre-intervention period, while the residents were blinded to the outcome measured (CVS score). As an intervention, a comprehensive lecture on safe cholecystectomy was given to all residents. Fifty consecutive LC cases were recorded post-intervention, while the residents were empowered to "time-out" and document the CVS with a doublet photograph. Two independent surgeons scored the videos and photographs using a 6-point scale. Residents were surveyed pre- and post-intervention to determine objective knowledge and self-reported comfort using a 5-point Likert scale. RESULTS: In the 18-week study period, 101 consecutive LCs were adequately captured and included (51 pre-intervention, 50 post-intervention). Patient demographics and clinical data were similar. The mean CVS score improved from 2.3 to 4.3 (p < 0.001). The number of videos with CVS score >4 increased from 15.7 to 52 % (p < 0.001). There was strong inter-observer agreement between reviewers. The pre- and post-intervention questionnaire response rates were 90.7 and 83.7 %, respectively. A greater number of residents correctly identified all criteria of the CVS post-intervention (41-93 %, p < 0.001) and offered appropriate bailout techniques (77-94 %, p < 0.001). Residents strongly agreed that the CVS education should be included in general surgery residency curriculum (mean Likert score = 4.71, SD = 0.54). Residents also agreed that they are more comfortable with their LC skills after the intervention (4.27, σ = 0.83). CONCLUSION: The combination of focused education along with intraoperative time-out significantly improved CVS scores and knowledge during LC in our institution.

Long-term functional outcomes of laparoscopic resection for gastric gastrointestinal stromal tumors.

INTRODUCTION: Laparoscopic resection is rapidly becoming the treatment of choice for small- to medium-sized gastric gastrointestinal stromal tumors (GIST). While long-term oncologic data are available, quality of life outcomes are less known. METHODS: Our IRB-approved prospectively maintained database was retrospectively queried (2003-2013) for patients who underwent laparoscopic gastric GIST resection. Demographics along with perioperative and oncologic outcomes were collected and analyzed. Patients were contacted and asked to complete a quality of life survey consisting of Likert scales scored from 1 to 5. Patients also completed the Gastrointestinal Quality of Life Index (GIQLI). RESULTS: A total of 69 patients were identified and 36 patients (59.0% of eligible patients) responded to the survey. Median follow-up was 39 months. Patients most commonly reported no change in weight, appetite, early satiety, heartburn, persistent cough, dysphagia, and reflux medication dosing postoperatively. The median scores for chest pain and regurgitation were 4, falling in the "worsened" range. 8.33% of patients reported worsened chest pain and 11.11% of patients reported worsened regurgitation postoperatively. The GIQLI scores had a mean of 126.9 (range 77-141). CONCLUSION: While some patients reported a worsening in early satiety, most patients reported no change in symptoms postoperatively, and the GIQLI scores remained within the normal range. Laparoscopic resection of gastric GIST provides durable results with minimal effect on longer-term quality of life.

Minimally invasive esophagectomy provides significant survival advantage compared with open or hybrid esophagectomy for patients with cancers of the esophagus and gastroesophageal junction.

BACKGROUND: Minimally invasive esophagectomy (MIE) is increasingly being used to treat patients with cancer of the esophagus and gastroesophageal junction. We previously reported that oncologic efficacy may be improved with MIE compared with open or hybrid esophagectomy (OHE). We compared survival of patients undergoing MIE and OHE. STUDY DESIGN: Our contemporary series of patients who underwent MIE (2008 to 2013) was compared with a cohort undergoing OHE (3-hole [n = 39], Ivor Lewis [n = 16], hybrid [n = 13], 2000 to 2013). Summary statistics were calculated by operation type; Kaplan-Meier methods were used to compare survival. Cox regression was used to assess the impact of operation type (MIE vs OHE) on mortality, adjusting for age, sex, total lymph nodes, lymph node ratio (LNR), neoadjuvant chemoradiotherapy (CRT), and stage. RESULTS: The MIE (n = 104) and OHE (n = 68) groups were similar with respect to age and sex. The MIE group tended to have higher BMI, earlier stage disease, and was less likely to receive CRT. The MIE group experienced lower operative mortality (3.9% vs 8.8%, p = 0.35) and significantly fewer major complications. Five-year survival between groups was significantly different (MIE, 64%, OHE, 35%, p < 0.001). Multivariate analysis demonstrated that patients undergoing OHE had a significantly worse survival compared with MIE independent of age, LNR, CRT, and pathologic stage (hazard ratio 2.00, p = 0.019). CONCLUSIONS: This study supports MIE for EC as a superior procedure with respect to overall survival, perioperative mortality, and severity of postoperative complications. Several biases may have affected these results: earlier stage in the MIE group and disparity in timing of the procedures. These results will need to be confirmed in future prospective studies with longer follow-up.

Grit: a marker of residents at risk for attrition?

BACKGROUND: Attrition from general surgery residency remains constant at approximately 20% despite nearly a decade of work-hour reform and studies aiming to identify common risk factors. High rates of attrition from training have a wide impact, from the overall quality of trainees produced to implications on public health and the broader surgical work force. We set out to evaluate a novel character trait, grit, defined as passion and perseverance for long-term goals, as a marker and potential risk factor for resident attrition. METHODS: Twelve Accreditation Council for Graduate Medical Education-approved general surgery residency programs participated in a prospective, multi-institutional, survey-based analysis of grit and attrition during the 2012-2013 academic year. Participating individuals were blinded with regards to the primary outcome of the study. Participating institutions were blinded to the responses of their trainees. Participating residency programs were located in a variety of settings, from university-based health systems to community hospitals. RESULTS: Sixty-eight percent (68%) of residents (180 of 265) at participating institutions completed the study. The primary end point for this study was attrition from residency as a function of grit. Secondary end points included an evaluation of the utility of the grit score in surgical residents, variability of grit according to postgraduate year, sex, measurements of resident satisfaction with current program, lifestyle, and career goals. Finally, the study included an analysis of key resident support strategies. The attrition rate across 12 institutions surveyed was approximately 2% (5 residents). Of those five, three participated in our study. All three had below-median levels of grit. Those residents with below-median grit were more likely to contemplate leaving surgical residency. Given the low attrition rate, no variable surveyed reached statistical significance in our analysis. Key support strategies for residents responding included family, friends outside of residency, co-residents, and formal mentorship through their particular residency. CONCLUSION: In this preliminary underpowered study, grit appears to be a promising marker and risk factor for attrition from surgical residency. In an effort to retain residents, programs should consider screening for grit in current residents and directing support to those residents with below-median values, with a focus on building family, friend, and formal mentor relationships.

Gastroduodenal intussusception of a gastrointestinal stromal tumor (GIST): case report and review of the literature.

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors in adults. They frequently occur in the stomach. Gastric GISTs typically present as a gastrointestinal bleed but can sometimes cause obstructive symptoms such as nausea and vomiting. We present a patient with a gastric GIST and liver metastases who during treatment with iminitab therapy presented with an acute gastric outlet obstruction. A computed tomography scan revealed a gastroduodenal intussusception of the gastric GIST. The patient underwent a laparoscopic exploration and resection of the GIST. We reviewed the English language literature of GISTs that presented as a gastroduodenal intussusception and put our case in the context of the previously reported cases. We discuss the diagnostic and therapeutic challenges that arise when treating these patients.

Major perioperative morbidity does not affect long-term survival in patients undergoing esophagectomy for cancer of the esophagus or gastroesophageal junction.

INTRODUCTION: The incidence of cancer of the esophagus/GE junction is dramatically increasing but continues to have a dismal prognosis. Esophagectomy provides the best opportunity for long-term cure but is hampered by increased rates of perioperative morbidity. We reviewed our large institutional experience to evaluate the impact of postoperative complications on the long-term survival of patients undergoing resection for curative intent. METHODS: We identified 237 patients who underwent esophagogastrectomy, with curative intent, for cancer between 1994 and 2008. Complications were graded using the previously published Clavien scale. Survival was calculated using Kaplan-Meier methodology and survival curves were compared using log-rank tests. Multivariate analysis was performed with continuous and categorical variables as predictors of survival, and examined with logistic regression and odds ratio confidence intervals. RESULTS: There were 12 (5 %) perioperative deaths. The average age of all patients was 62 years, and the majority (82 %) was male. Complication grade did not significantly affect long-term survival, although patients with grade IV (serious) complications did have a decreased survival (p = 0.15). Predictors of survival showed that the minimally invasive type esophagectomy (p = 0.0004) and pathologic stage (p = 0.0007) were determining factors. There was a significant difference in overall survival among patients who experienced pneumonia (p = 0.00016) and respiratory complications (p = 0.0004), but this was not significant on multivariate analysis. CONCLUSIONS: In this single-institution series, we found that major perioperative morbidity did not have a negative impact on long-term survival which is different than previous series. The impact of tumor characteristics at time of resection on long-term survival is of most importance.

Combined hepatic arterial embolization and hepatic ablation for unresectable colorectal metastases to the liver.

Liver-directed therapy for hepatic metastases includes: intra-arterial techniques such as transarterial chemoembolization (TACE) and yttrium-90 resin ((90)Y) microsphere radioembolization and ablative technologies: cryoablation, radiofrequency ablation, and microwave ablation. Combining embolization techniques with liver ablation may enhance the therapeutic benefit of each and result in improved patient survival. We retrospectively reviewed our experience with combined intra-arterial therapies and ablation for unresectable hepatic colorectal metastases from 1996 to 2011. Patient demographics, tumor characteristics, specific liver-directed treatments, procedure-related morbidity and mortality, and overall survival were recorded. There were 17 (53%) males and 15 (47%) females. Average age for the group was 74.1 years (median, 75.5 years). Fifteen patients (46.9%) had a single hepatic metastasis. Eleven (34%) patients had bilobar tumor distribution and seven (22%) patients had vascular invasion of the portal vein or hepatic/caval venous structures. Seven (21%) tumors were greater than 5 cm in diameter. Twenty-seven (84.4%) patients received TACE and five (15.6%) received (90)Y. Fourteen (43%) were embolized before any ablation. Fifty-three per cent of patients required multiple hepatic ablation sessions. Median length of hospital stay was 1 day. There were no procedure-related mortalities and complications occurred in six (18.8%) patients. Mean follow-up for the group was 33 months. Kaplan-Meier 1-, 3-, and 5-year estimated survival was 93.8, 50.0, and 10.1 per cent, respectively. Median survival for the group was 46 months. Hepatic ablation and embolization techniques can be combined safely with minimal morbidity. In our series, we observed 5-year survival in 10 per cent of patients.

Laparoscopic approaches to gastric gastrointestinal stromal tumors: an institutional review of 57 cases.

INTRODUCTION: Gastrointestinal stromal tumors (GIST) are uncommon gastric neoplasms, which are typically treated by surgical excision. During the past 10 years, our institution has gained experience in resecting these tumors by minimally invasive methods. The purpose of this study is to review our experience with laparoscopic resection, report our short-term outcomes, and offer our perspective on the technical nuances involved in handling these neoplasms. METHODS: We retrospectively queried our prospectively maintained, institutional review board-approved database for all gastric GISTs resected from 2002 to 2012. We analyzed all cases that were resected via laparoscopy. Operative notes were reviewed for the technique employed. Data on tumor location, size, margin status, operative time, and blood loss were collected and analyzed. RESULTS: During the 10-year study period, 104 gastric GISTs were resected. Laparoscopy was attempted in 58 cases with only one conversion to an open procedure. Tumors were separated based on anatomic zones. Forty-seven tumors (82%) were located on the body or fundus of the stomach (18 on the posterior wall and 29 on the anterior wall). Five GISTs (9%) were located at the gastroesophageal junction (GEJ). Five tumors (9%) were located at the antrum. The mean tumor size was 3.8 cm with a mean estimated blood loss of 40 ml. We achieved R0 resection in 100% of the cases. Most tumors (96%) were amenable to wedge resection. Tumors at the extremes of the stomach required variations of technique to achieve resection. Intraoperative endoscopy was selectively utilized. CONCLUSIONS: As our experience with gastric GISTs has increased, laparoscopic resection has become our first-line treatment for most small- and moderate-sized tumors. By employing a structured approach to tumors along the entire stomach, laparoscopic resection of these tumors can be performed safely with adequate short-term results.